43401092
Failure of NIV in acute asthma: case report and a word of caution
Noninvasive ventilation (NIV) is the provision of ventilatory support without the need for an invasive airway, and has revolutionized the management of patients with diverse forms of respiratory failure. The advantages of NIV include improved patient comfort and reduced need for sedation, while avoiding the complications of endotracheal intubation, including upper airway trauma, sinusitis, otitis, and nosocomial pneumonia. In selected patients, NIV has also been shown to improve survival. The role of NIV in acute severe asthma is at best controversial. In this case report, we describe a patient with acute severe asthma who was initially managed and failed with NIV, and was successfully managed with invasive ventilation. We also review the pathophysiological mechanisms of benefit of NIV in acute severe asthma, and the current literature on the use of NIV in acute asthma. In conclusion, a trial of NIV in acute asthma may be justified in carefully selected and monitored patients who do not respond to initial medical therapy. However, as its role is not clear and as the condition of an asthmatic patient may deteriorate abruptly, extreme caution is advisable to recognize failure of NIV as in the case presented here. Facilities for immediate endotracheal intubation and next level of treatment should be readily available.
33491888
Noninvasive ventilation in ARDS caused by Mycobacterium tuberculosis: report of three cases and review of literature
45999589
Noninvasive ventilation in acute heart failure.
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.
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.
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.
36745510
Iron sucrose causes greater proteinuria than ferric gluconate in non-dialysis chronic kidney disease.
Non-dextran intravenous (i.v.) iron preparations seem to differentially affect proteinuria in patients with chronic kidney disease. To study effects of ferric gluconate and iron sucrose on proteinuria, we conducted a crossover trial in 12 patients with stage 3-4 chronic kidney disease. These patients were randomized to receive the same dose of either drug 1 week apart. Urine samples were obtained immediately before and at frequent intervals after the drug. The urine total protein/creatinine ratio was significantly greater after iron sucrose than ferric gluconate treatment with the effect noted within 15 min post-infusion. Furthermore, when iron sucrose was given first, a significantly greater protein/creatinine ratio was seen subsequently with ferric gluconate than with the reverse order of treatment. The urine albumin/creatinine ratio was also significantly greater with iron sucrose than with ferric gluconate. There was no significant difference, however, between the two i.v. irons in the measured urine N-acetyl-beta-D-glucosaminidase/creatinine ratio. Although our study showed that acutely, iron sucrose increased proteinuria, the long-term effects of repeated i.v. non-dextran iron on kidney function requires further study.
22178651
Prognostic Value of Circadian Blood Pressure Variation in Chronic Kidney Disease
Background: Reduced circadian variation in blood pressure (BP) has been associated with cardiovascular morbidity, mortality and accelerated progression of kidney disease, but its independent prognostic value remains unknown. Methods: Using 2 definitions, one based on dipping and the other based on BP pattern (assessed by cosinor rhythmometry), we studied the prognosis of circadian BP variation among 322 patients, 179 (56%) of whom had chronic kidney disease (CKD). Results: During a follow-up period extending for up to 8.7 years, 116 (36%) patients died and 57 (32%) patients with CKD developed end-stage renal disease (ESRD). Compared to 106 patients (33%) who were dippers, the unadjusted hazard ratio (HR) for death among non-dippers was 2.03 (95% CI 1.30–3.16, p = 0.002). However, this HR became nonsignificant [1.39 (95% CI 0.89–2.19), p = 0.15] when adjusted for age and 24-hour average systolic BP. Although non-dipping was marginally associated with ESRD [HR 1.98 (95% CI 0.996–3.92), p = 0.051], even this association was weakened when adjusted for overall 24-hour systolic BP (HR 1.67, p = 0.15). Similar to the dipping definition, the BP pattern-based definition was significantly associated with mortality (p = 0.005) but not with ESRD (p = 0.68). Compared to those ‘in-phase,’ the HR for death among those ‘out-of-phase’ was 1.86 (95% CI 1.25–2.75, p = 0.002). Although this HR when adjusted for overall mean BP remained significant, when further adjusted for age, it too became nonsignificant. Conclusion: Among elderly veterans with or without CKD, circadian variation in BP is associated with mortality, but not ESRD. However, after accounting for common clinical risk factors, this association of circadian BP variation with mortality or ESRD is abolished.
5649152
Differential distribution of pigment-protein complexes in the Thylakoid membranes of Synechocystis 6803
AbstractThylakoids in Synechocystis 6803, though apparently uniform in appearance in ultrastructure, were found to consist of segments which were functionally dissimilar and had distinct proteomes. These thylakoid segments can be isolated from Synechocystis 6803 by successive ultracentrifugation of cell free extracts at 40,000×g (40 k segments), 90,000×g (90 k segments) and 150,000×g (150 k segments). Electron microscopy showed differences in their appearance. 40 k segments looked feathery and fluffy, whereas the 90 k and 150 k thylakoid membrane segments appeared tiny and less fluffy. The absorption spectra showed heterogeneous distribution of pigment-protein complexes in the three types of segments. The photochemical activities of Photosystem I (PSI) and Photosystem II (PSII) showed unequal distributions in 40 k, 90 k and 150 k segments which were substantiated with low temperature fluorescence measurements. The ratio of PSII/PSI fluorescence emission at 77 K (λex = 435 nm) was highest in 150 k segments indicating higher PSII per unit PSI in these segments. The chlorophyll fluorescence lifetimes in the membranes, determined with a time-correlated single-photon counting technique, could be resolved in three components: τ1 
 = <40 ps, τ2 
 = 425–900 ps and τ3 
 = 2.4–3.2 ns. The percentage contribution of the fastest component (τ1) decreased in the order 40 k > 90 k > 150 k segments whereas that of the other two components showed a reversed trend. These studies indicated differential distribution of pigment-protein complexes in the three membrane segments suggesting heterogeneity in the thylakoids of Synechocystis 6803.
21105377
Is continuous veno-venous hemofiltration for acetaminophen-induced acute liver and renal failure worthwhile?
We describe a patient with acute liver and renal failure secondary to acetaminophen and chronic alcohol abuse who was treated aggressively with oral acetylcysteine, continuous renal replacement therapy, glucose and branched-chain amino acid intravenous feeding and ventilatory support. The patient had a predicted mortality of > 95% without liver transplantation however, with intensive ventilatory, renal, and nutritional support he made a complete recovery. We discuss the benefits of aggressive supportive therapy and suggest that continuous renal replacement therapy may allow gentle fluid removal, excellent control of cerebral edema and intravenous feeding that may favorably influence prognosis.
24044013
Evaluation of kidney function in patients with acute renal failure using high-performance liquid chromatography: a case report.
Accurate measurement of glomerular function rate (GFR) in the setting of acute renal failure is difficult to achieve with current clinical methods, such as measuring plasma creatinine concentration and 24-hour urine creatinine clearance. High-performance liquid chromatography was used to measure GFR directly in a critically ill patient with acute renal failure. This approach involved evaluating the elimination kinetics of nonionic contrast material administered intravenously for radiologic imaging. It required no additional patient exposure to radiographic contrast media and enabled caregivers to determine kidney function accurately in the presence of worsening clinical status and delayed changes in plasma creatinine. This and other methods for more accurate measurement of GFR in patients with acute renal failure may provide the foundation for clinical studies that assess the severity and management of acute renal failure.