45728668
Pulmonary mucormycosis: two of a kind.
Mucormycosis is an uncommon infection caused by fungi of the class Zygomycetes, suborder Mucorales. It occurs predominantly in the immunodeficient host, the most common risk factor being diabetes mellitus. Pulmonary mucormycosis is a disease that is localized in the lungs or mediastinum. It usually presents in a fulminant manner, although a chronic presentation can also occur. We describe two cases of pulmonary mucormycosis in patients with diabetes mellitus, one with an acute and the other with a chronic presentation. A high level of clinical suspicion, combined surgical and medical therapy, and control of patient's underlying immunosuppression are the key to a successful outcome.
26068481
Efficacy and safety of iodopovidone pleurodesis through tube thoracostomy.
OBJECTIVE
To evaluate the efficacy and safety of iodopovidone as an agent for pleurodesis through tube thoracostomy in patients with recurrent pleural effusions and pneumothorax.


METHODS
This was a prospective study in which pleurodesis was performed with a solution of 20 mL 10% iodopovidone and 80 mL normal saline solution infused through a tube thoracostomy and left in the pleural cavity for 4 h.


RESULTS
A total of 64 patients (34 men) with a mean (+/-SD) age of 47.1 +/- 15.4 years were included. There were 37 cases of pleural effusion and 27 of pneumothorax. A complete response (neither reaccumulation of fluid nor recurrence of pneumothorax) was obtained in 32 (86.5%) patients with pleural effusion and 25 (92.6%) patients with pneumothorax. A second procedure (i.e. repeated pleurodesis) was attempted successfully in four patients in the pleural effusion group. All patients experienced chest pain to a varying degree as recorded on a Visual Analogue Scale (median 50.5, range 10-95). Seven patients developed fever and one immunocompromised patient developed empyema following the procedure. There were no recurrences at a median follow up of 5 months (range 3-15 months) in the pleural effusion group, and 13 months (range 6-24 months) in the pneumothorax group.


CONCLUSIONS
Iodopovidone can be used as an effective and safe agent for (chemical) pleurodesis (through tube thoracostomy), which is inexpensive and readily available.
3038618
Is the mortality higher in the pulmonary vs the extrapulmonary ARDS? A meta analysis.
BACKGROUND AND AIM
ARDS can occur from the following two pathogenetic pathways: a direct pulmonary injury (ARDSp); and an indirect injury (ARDSexp). The predisposing clinical factor can influence the pathogenesis and clinical outcome of ARDS. This metaanalysis was aimed at evaluating whether there is any difference in mortality between the two groups.


METHODS
We searched the MEDLINE, EMBASE, and CINAHL databases for relevant studies published from 1987 to 2007, and included studies that have reported mortality in the two groups of ARDS. We calculated the odds ratio (OR) and 95% confidence interval (CI) to assess mortality in patients with ARDSp vs patients with ARDSexp and pooled the results using three different statistical models.


RESULTS
Our search yielded 34 studies. In all, the studies involved 4,311 patients with 2,330 patients in the ARDSp group and 1,981 patients in the ARDSexp group. The OR of mortality in ARDSp group compared to the ARDSexp group was 1.11 (95% CI, 0.88 to 1.39), as determined by the random-effects model; 1.04 (95% CI, 0.92 to 1.18), as determined by the fixed-effects model; and 1.04 (95% CI, 0.92 to 1.18), as determined by the exact method, indicating that mortality is similar in the two groups. The mortality was no different whether the studies were classified as prospective (OR, 1.15; 95% CI, 0.87 to 1.51) or retrospective (OR, 1.01; 95% CI, 0.61 to 1.69); small (OR, 1.11; 95% CI, 0.77 to 1.60) or large (OR, 1.1; 95% CI, 0.82 to 1.49); or observational (OR, 1.10; 95% CI, 0.82 to 1.49) or interventional (OR, 0.97; 95% CI, 0.79 to 1.19). There was methodological and statistical heterogeneity (I(2), 50.9%; 95% CI, 21.3 to 66.2%; chi(2) statistic, 67.22; p = 0.0004).


CONCLUSIONS
The results of this study suggest that there is no difference in mortality between these two groups. Further studies should focus on specific etiologies within the subgroups rather than focusing on the broader division of ARDSp and ARDSexp.
22528299
Pulmonary hypertension as a presenting manifestation of allergic bronchopulmonary aspergillosis.
The case of a 46-year-old lady who presented with respiratory failure and pulmonary hypertension in the absence of clinical signs of asthma or bronchiectasis, and in whom a diagnosis of allergic bronchopulmonary aspergilloma [ABPA] was made subsequently on the basis of radiological and laboratory investigations is reported. Symptomatic and objective improvement was seen with corticosteroid therapy. To the best of the authors' knowledge, such an occurrence has not been reported previously. This case highlights the importance of keeping a high index of suspicion while investigating a patient with pulmonary hypertension in whom the aetiology is not apparent on initial evaluation. Identification of the disease, in its early-stage, can prevent progression to bronchiectasis and fibrotic lung disease, and thus, patients can be saved from the morbidity related to end-stage disease.
45999589
Noninvasive ventilation in acute heart failure.
33491888
Noninvasive ventilation in ARDS caused by Mycobacterium tuberculosis: report of three cases and review of literature
25462829
Blood Pressure Recordings within and outside the Clinic and Cardiovascular Events in Chronic Kidney Disease
Background: Blood pressure (BP) measured outside the clinic correlates better with cardiovascular outcomes in patients with essential hypertension. To assess the role of out-of-clinic BP recordings in predicting cardiovascular events in patients with chronic kidney disease (CKD), a prospective cohort study was conducted in 217 veterans with CKD. Methods: BP was measured outside the clinic at home and by 24-hour ambulatory recordings, and in the clinic by ‘routine’ and standardized methods. Patients were followed over a median of 3.4 years to assess the combined end-point of total mortality, myocardial infarction or stroke. Results: Average (±SD) home BP was 147.0 ± 21.4/78.3 ± 11.6 mm Hg, 24-hour ambulatory BP 133.5 ± 16.6/73.1 ± 11.1 mm Hg and in-clinic BPs were 155.2 ± 25.6/84.7 ± 14.2 mm Hg by the standardized method, and 144.5 ± 24.2/75.4 ± 14.7 mm Hg by the ‘routine’ method. A 1 SD increase in systolic BP increased the hazard ratio (HR) of the composite end-point by 1.16 (95% CI 0.89–1.50) for routine BP, 1.57 (95% CI 1.19–2.09) for standardized BP, 1.66 (95% CI 1.27–2.17) for home BP, and 1.42 (95% CI 1.10–1.84) for 24-hour ambulatory BP recording. The HR of the composite end-point was only significant for hypertension defined by 24-hour ambulatory BP monitoring (HR 2.22 (95% CI 1.23–4.01)). Adjusted for the propensity scores, BP measured by the ambulatory technique was not an independent predictor of cardiovascular events. Non-dipping was associated with increased cardiovascular risk, but not when adjusted for other risk factors. Conclusion: Risk factors that differentiate hypertension or non-dipping appear to confer a cardiovascular risk in CKD.
7762587
The role of statins in chronic kidney disease.
Chronic kidney disease is associated with cardiovascular event rates that are at least as high as in patients with established atherosclerotic cardiovascular disease or in those with diabetes mellitus. Chronic kidney disease is therefore considered a cardiovascular disease risk equivalent. Treatment of dyslipidemia, which is very common in this population and reflects the pattern seen in the metabolic syndrome, reduces cardiovascular events in patients with chronic kidney disease. Thus, patients with chronic kidney disease should be evaluated and treated for dyslipidemia. Dyslipidemia is a risk factor for the development of impaired kidney function. Dyslipidemia is also associated with progressive renal disease in subjects with no overt renal disease, as well as those with diabetic and nondiabetic kidney disease. Although definitive randomized controlled trials are lacking, the collective evidence suggests that treatment of dyslipidemia is associated with less decline in renal function. The use of potent statins in high doses can lead to transient proteinuria via impairment of proximal tubular receptor--mediated endocytosis, in a dose-dependent manner. Over the long term, however, the use of statins results in a reduction in proteinuria and in the rate of decline of renal function. Several large definitive trials that are currently underway to examine the safety and efficacy of statins in cardiovascular and renal protection should provide more definitive answers on the role of these drugs in this very high risk population.
35998479
Exploring the paradoxical relationship of hypertension with mortality in chronic hemodialysis.
Hypertension is seen in 85% of patients on hemodialysis (HD) in the United States. Although it is amply clear that high blood pressure (BP) has a continuous, graded, and etiologically significant relationship with cardiovascular outcomes in the general population, studies in HD patients have found an inverse relationship between high BP and outcomes. Thus, those patients with high BP have a lower mortality compared to those with low BP. It is intellectually troublesome to find such an association because high BP, which was such an important risk factor for cardiovascular disease before onset of dialysis suddenly, becomes a protective factor. In patients with chronic kidney disease who are not yet on HD, we strive to lower BP more aggressively than what we target those with uncomplicated essential hypertension. If these observations—‘‘reverse epidemiology’’ or ‘‘risk factor paradox’’—are etiologically significant, should we be complacent about treating high BP in HD? The objective of this analysis is to review the data to explain these apparently troublesome observations. POOR ASSESSMENT OF BP: REGRESSION DILUTION BIAS
10346616
Mechanisms of cataractogenesis in the presence of magnesium deficiency.
Senile cataract is the most common cause of bilateral blindness and results from the loss of transparency of the lens. Maintenance of the unique tissue architecture of the lens is vital for keeping the lens transparent. Membrane transport mechanisms utilizing several magnesium (Mg)-dependent ATPases, play an important role in maintaining lens homeostasis. Therefore, in Mg-deficiency states, ATPase dysfunctions lead to intracellular depletion of K(+) and accumulation of Na(+) and Ca(2+). High intracellular Ca(2+) causes activation of the enzyme calpain II, which leads to the denaturation of crystallin, the soluble lens protein required for maintaining the transparency of the lens. Mg deficiency also interferes with ATPase functions by causing cellular ATP depletion. Furthermore, Mg deficiency enhances lenticular oxidative stress by increased production of free radicals and depletion of antioxidant defenses. Therefore, Mg supplementation may be of therapeutic value in preventing the onset and progression of cataracts in conditions associated with Mg deficiency.
8887497
Does ferric gluconate lower epoetin requirements in hemodialysis patients with high ferritin levels?
The 6-week Dialysis Patients' Response to IV Iron with Elevated Ferritin (DRIVE) study demonstrated that the administration of intravenous iron improved anemia in patients on hemodialysis who had high ferritin levels (500–1,200 ng/ml [1,124–2,696 pmol/l]) and were receiving adequate epoetin doses, disproving previous beliefs that intravenous iron does not benefit patients with ferritin levels >500 ng/ml. This commentary discusses the DRIVE-II study, an observational 6-week extension study reported by Kapoian et al. that was designed to measure the impact of prior iron administration on subsequent epoetin dose. The extension study found that the epoetin dose requirement decreased significantly in patients who had received intravenous iron during DRIVE, but did not change in control patients. Although the results are promising, long-term studies with hard end points such as stroke, myocardial infarction, hospitalization for heart failure, and death are needed to confirm the safety of the intravenous iron regimen.