44909639
Do glucocorticoids decrease mortality in acute respiratory distress syndrome? A meta-analysis.
BACKGROUND AND OBJECTIVES
Glucocorticoids have been shown to improve survival when used in patients with septic shock. The aim of this study was to analyse the role of glucocorticoids in decreasing mortality in acute respiratory distress syndrome (ARDS) both in the acute and the fibroproliferative phases.


METHODS
We searched the MEDLINE database for relevant studies published between 1980 and 2006, and included studies if the study design was a randomized controlled trial or observational study (comparing historical controls). The study population included patients with ARDS treated with glucocorticoids. We calculated the odds ratio and 95% confidence intervals (CI) for the outcome of mortality.


RESULTS
Six trials met the inclusion criteria; three investigated the role of steroids in early stage disease (n = 300) and three investigated the role of steroids in late stage disease (n = 235). The odds of glucocorticoids decreasing mortality in patients with early ARDS were 0.57 (95% CI: 0.25-1.32) with a number needed to treat of 10 for benefit (818 harm to 5 benefit) whereas the odds of glucocorticoids decreasing mortality in patients with late ARDS was 0.58 (95% CI: 0.22-1.53) with a number needed to treat of 15 for harm (6 harm to 21 benefit). However, there was significant heterogeneity.


CONCLUSIONS
Current evidence does not support a role for corticosteroids in the management of ARDS in either the early or late stages of the disease. More research is required to establish the role of steroids in specific subgroups of patients with severe sepsis and early ARDS who have relative adrenal insufficiency and patients with late ARDS 7-14 days after the onset of disease.
39024721
Efficacy and safety of iodopovidone in chemical pleurodesis: a meta-analysis of observational studies.
The search for an 'ideal' agent for pleurodesis continues. Iodopovidone is a topical antiseptic and has been shown to be safe and effective in many studies. The aim of this study was to evaluate the efficacy and safety of iodopovidone as an agent for chemical pleurodesis. We performed a systematic review of all the observational trials which have used iodopovidone for chemical pleurodesis. Six studies including 265 patients who had undergone chemical pleurodesis with iodopovidone were included for this analysis. Iodopovidone was used for variety of indications, which included pleural effusion (157 patients), and pneumothorax (108 patients). Pleurodesis was performed through tube thoracostomy in 144 patients and through thoracoscopy in 121 patients. The success rate of pleurodesis varied from 64.2% to 100%, and summary success rate of all the studies was 90.6% (95% confidence intervals [CI], 86.4-93.8). The success rate was independent for the procedure (tube thoracostomy [126/144; 87.5%, 95% CI 80.9-92.4] or thoracoscopy [114/121; 94.2%, 95% CI 88.4-97.6]) used for performing pleurodesis or for the indication (pleural effusion [139/157; 88.5%, 95% CI 82.5-93.1] or pneumothorax [101/108; 93.5%, 95% CI 87.1-97.4]). The only significant complication reported was chest pain of varying degree. Systemic hypotension was reported in three patients in only one study. There were no deaths related to chemical pleurodesis with iodopovidone. Overall, this review supports the safety and efficacy of iodopovidone as an agent for chemical pleurodesis in cases of recurrent pleural effusions and pneumothoraces regardless of their etiology.
33491888
Noninvasive ventilation in ARDS caused by Mycobacterium tuberculosis: report of three cases and review of literature
12010523
What are high-flow and low-flow oxygen delivery systems?
To the Editor:

We read with interest the article, “A Pilot Study of Normobaric Oxygen Therapy in Acute Ischemic Stroke.”1 However, we have certain reservations with the terminology and the method of oxygen delivery used by the authors.

First, regarding the terminology of “high-flow” oxygen used by the authors, the authors mention the flow rates but not the oxygen delivery system used. An oxygen delivery system is a device used to administer, regulate, and supplement oxygen to a subject to increase the arterial oxygenation. In general, the system entrains oxygen and air to prepare a fixed concentration required for administration. Oxygen delivery systems are generally classified as low-flow or variable-performance devices and high-flow or fixed-performance devices.2 Low-flow systems provide oxygen at …
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.
7910812
Hypertension, hypokalemia, and thiazide-induced diabetes: a 3-way connection.
Reduction in the dose of diuretics to treat essential hypertension occurred with the recognition that higher doses of thiazides cause hypokalemia, glucose intolerance, and hyperuricemia but little additional reduction in blood pressure.1 Subsequently, large randomized, controlled trials have demonstrated a higher incidence of diabetes mellitus with thiazide diuretics compared with other antihypertensive drugs.2 A meta-analysis done with 143153 participants without diabetes mellitus in 22 clinical trials showed that thiazide diuretics and β-blockers had similarly high risks of developing new-onset diabetes mellitus, followed by placebo and calcium channel blockers; the most protective were angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors.3 This detrimental effect on glucose tolerance together with the growing epidemic of diabetes and obesity has reined in the wider use of thiazides despite being effective and inexpensive antihypertensive drugs with strong cardiovascular benefits.

Whether thiazide-induced diabetes mellitus has the same adverse prognostic significance as spontaneously occurring diabetes mellitus is not known with certainty.2 If thiazide diuretics unmask the presence of underlying diabetes mellitus, then the earlier detection of diabetes with more aggressive hypertension, lipid, and metabolic control may in fact, instead of being harmful, be protective. There is also some evidence that, although new-onset diabetes mellitus is associated with cardiovascular mortality, treatment of such patients with diuretics has survival benefits. In a long-term analysis of the Systolic Hypertension in Elderly Program with a mean follow-up of 14.3 years, the long-term fatality rate was higher in those with had diabetes mellitus at baseline, followed by patients who developed diabetes during follow-up.4 However, diabetes mellitus …
26142710
Pregnancy concomitant with metastatic adult granulosa cell tumor
IntroductionMetastatic adult granulosa cell tumor of the ovary is rarely encountered with pregnancy.Case report and resultsPrimigravida (26 years) presented at 20 weeks of gestation with acute abdomen and clinical evidence of supraclavicular lymphadenopathy and ascites. She was diagnosed of adult granulosa cell tumor (AGCT) of the right ovary following right salpingoophrectomy done 1 month prior to conception. Fine needle aspiration cytology of supraclavicular lymph node, revealed it to be a metastatic AGCT. Chemotherapy was given antepartum and she delivered a healthy preterm baby at 30 weeks. Subsequently, she had optimal debulking surgery following 6 cycles of cisplatin-based chemotherapy. Baby at 10 months of age was with normal milestones.ConclusionsThe case is an unusual presentation of metastatic adult granulosa cell tumor at child bearing age. Although rapidly progressing, successful prolongation of pregnancy till 30 weeks of gestation was possible with the judicious use of chemotherapy. Fetal and maternal outcomes were favorable.
36005104
Volume Overload in Dialysis: The Elephant in the Room, No One Can See
interests of the authors. However, considering the totality of the evidence, I am less convinced that this marker is superior to other volume markers. First, there are few head-to-head studies comparing BIA to other established markers of volume. Second, there is no range that defines ‘normal’. Unlike blood pressure (BP) or cholesterol, there is no target that has been established. The normal values are obtained from healthy subjects whose body composition differs substantially from those on dialysis. Extrapolating from healthy subjects to those with ESRD on hemodialysis does not appear scientifically valid. Third, there is no study to my knowledge that demonstrates convincingly that compared to probing dry weight without BIA, BIA-guided dry weight reduction results in improved outcomes. Most data provided to support the use of BIA are associative and observational. A large amount of observational data does not prove causation. We therefore have to be cautious in interpreting these data as ‘strongly indicative of fluid overload’. Nearly all markers of volemia suffer from the same shortcomings. These shortcomings include lack of normative data, and data being largely observational and associative in nature. As an example, several observational studies suggest that B-type natriuretic peptide (BNP), NT-proBNP or other natriuretic peptides are associated with volume state among people with ESRD on dialysis [2–10] . However, only one study has been reported to date that relates the change in BNP to an intervention of probing dry weight [11] . In this study, a direct relationship existed at baseline between BNP and interdialytic ambulatory BP. Since interdialytic ambulatory BP is reVolume overload is the invisible threat to the health of dialysis patients. Currently, Medicare incentivizes the measurement of the dose of dialysis (urea reduction ratio) but has no measure of volume. Perhaps this is because the few who can recognize the epidemic nature of volume excess cannot agree on how to define it. Whereas, some have proposed interdialytic weight gain (IDWG) as a marker of volume, the in-depth review of Hecking et al. [1] quite clearly and importantly makes the distinction that IDWG should not be confused with hypervolemia. One has to wonder how IDWG got confused with dry weight in the first place. It appears that epidemiologists decided to use IDWG as a proxy of dry weight because of its ready availability in large databases. IDWG is a marker that is convenient; it can be measured easily and it can be related to outcomes such as all-cause mortality. This analysis was performed and a relationship emerged between IDWG and all-cause mortality. But establishing a relationship between IDWG and mortality does not establish causality. It could be numerous other factors, measured and unmeasured, associated with IDWG which may be causally related to mortality. Factors such as missing or cutting short dialysis, not taking medications as prescribed, and consuming a diet rich in phosphorus and potassium are some confounding factors that may also be associated with IDWG but may be more plausibly related to mortality. The authors discuss several markers of volume excess. Although several exist, one marker, bioimpedance analysis (BIA), is discussed in great detail. This is understandable given both the academic and intellectual property Published online: July 6, 2013 Nephrology American Journal of
26375371
Determinants and prognostic significance of electrocardiographic left ventricular hypertrophy criteria in chronic kidney disease.
BACKGROUND AND OBJECTIVES
The diagnosis of left ventricular hypertrophy (LVH) has prognostic value in the general population. However, among those with chronic kidney disease (CKD), the determinants of electrocardiographic (EKG) LVH and its prognostic value are not clear.


DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS
A cross-sectional study was performed among 387 consenting consecutive patients from a veterans hospital with a longitudinal follow-up.


RESULTS
The overall prevalence of EKG-LVH by the Sokolow-Lyon criteria was 8% and by the Cornell voltage-duration product was 11%. Compared with non-CKD controls, CKD patients had unadjusted odds ratio (OR) for LVH by Cornell criteria of 2.52 (95% CI 1.18 to 5.42). Significance was lost after adjustment. The unadjusted OR for LVH by Sokolow-Lyon criteria was 2.24 (95% CI 0.95 to 5.33). This OR remained statistically insignificant after multivariate adjustment. Anemia, proteinuria, and 24-hour ambulatory systolic BP were associated with EKG-LVH regardless of diagnostic criteria. After a 7.5-year median follow-up, the hazard ratio for all-cause mortality was not associated with EKG-LVH diagnosed by the Sokolow-Lyon criteria; however, multivariable adjustments made EKG-LVH significant. A statistically significant relationship was seen between mortality and Cornell criteria; however, multivariable adjustments made EKG-LVH nonsignificant.


CONCLUSIONS
The Sokolow-Lyon and Cornell EKG-LVH criteria cannot be used interchangeably to diagnose LVH or determine prognosis. Among those with CKD, ambulatory systolic BP predicts all-cause mortality. Moreover, the duration and severity of BP elevation presumably reflected in EKG-LVH diagnosed by Sokolow-Lyon criteria is also of prognostic significance; the Cornell criteria do not carry independent prognostic information.
5428839
Blood pressure components and the risk for end-stage renal disease and death in chronic kidney disease.
BACKGROUND AND OBJECTIVES
Mean arterial pressure has been used in clinical trials in nephrology to randomly assign and treat patients, yet the pulsatile component of BP is recognized to influence outcomes in older people. I examined the unique contributions of systolic (SBP) and diastolic BP (DBP) on the risk for ESRD and death in patients with chronic kidney disease (CKD).


DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS
A single-center, prospective cohort study was conducted of 218 veterans with CKD (22% black, 4% women, mean age 68 yr, clinic BP 154.1 +/- 25.1/85.2 +/- 13.9 mmHg, 48% with diabetes).


RESULTS
During follow-up of up to 7 yr, 63 patients had ESRD and 102 patients died. Compared with those with controlled SBP (<130 mmHg), patients with moderate control (130 to 149 mmHg) had hazard ratio of 3.87 and those with poor control hazard ratio of 9.09 for ESRD. DBP had no direct ability to predict ESRD. For all-cause mortality, a J-shaped relationship was seen for SBP and an inverse relationship was seen for DBP. Considered jointly in the Cox model, a higher SBP and lower DBP improved the prediction of all-cause mortality compared with either BP component alone. The presence of J curve was especially pronounced in patients with advanced CKD, absence of clinical proteinuria, or age >65 yr.


CONCLUSIONS
In older patients with CKD, SBP predicts ESRD and a higher SBP and lower DBP predicts all-cause mortality. Lower BP of <110/70 mmHg is a marker of higher mortality in older individuals with advanced CKD.