39931674
Is the patient brain-dead?
A 45 year old male working as a labourer in the agricultural sector was brought to the emergency room with complaints of difficulty in opening the eye-lids, dysphagia, dysphonia, dyspnea, and progressive weakness in all four limbs, after awakening from sleep. At presentation, patient had no spontaneous respiratory efforts and was deeply cyanosed. Endotracheal intubation was performed immediately and the patient was mechanically ventilated. Physical examination revealed an afebrile patient with a heart rate of 130 beats/minute and blood pressure of 160/100 mm Hg. He was comatose with absent motor responses to painful stimuli, complete ptosis, external, and internal ophthalmoplegia. Deep tendon reflexes and plantars were absent. Fang marks typical of snakebite were noted in the right middle finger. Patient was started on anti-snake venom (Haffkine Institute, Mumbai) at a dose of 100 mL stat followed by 50 mL at 6 hours, deep venous thrombosis and stress ulcer prophylaxis along with supportive care. Arterial blood gas analysis, serum electrolytes, liver, and renal function tests done were within normal limits. After initiation of …
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
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.
207670106
Competing Risk Factor Analysis of End-Stage Renal Disease and Mortality in Chronic Kidney Disease
Background: Death and dialysis are competing outcomes in patients with chronic kidney disease (CKD). The factors associated with end-stage renal disease (ESRD) versus death in this population are unknown. The purpose of our study was to evaluate the competing risk of ESRD versus mortality and to evaluate the risk factors associated with these two outcomes. Methods: We prospectively recruited 220 consecutive patients at a Veterans Administration Medical Center attending a renal clinic who met the definition of CKD (estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 or urine protein/creatinine ratio of >0.22 g/g). Using age, race, proteinuria, eGFR, systolic blood pressure, and coronary artery disease as predictors, we calculated the competing end-points of ESRD or death using a competing Cox regression model. Results: The cumulative incidence for ESRD was 17.6% and death 18.5% during follow-up that lasted up to 7 years. ESRD was predicted by younger age (hazard ratio (HR) 0.91/year), black race (HR 2.75), higher systolic blood pressure (HR 1.02/mm Hg), proteinuria (HR 1.37/log urine protein/creatinine ratio) and low eGFR (0.014/log eGFR ml/min/1.73 m2). Death was predicted by older age (HR 1.07/year), lower eGFR (HR 0.43/log eGFR ml/min/1.73 m2), proteinuria (HR 1.26/log urine protein/creatinine ratio) and coronary artery disease (HR 2.52). The coefficients were statistically different for age (p < 0.001), log eGFR (p < 0.001) and systolic blood pressure (p = 0.04) for ESRD and death outcomes. Conclusions: The risk for mortality is similar to the risk of ESRD in the CKD population of veterans seen by nephrologists. Risk factors for ESRD and death appear to differ in this population. Certain clinical and demographic factors may discriminate between the end-points of death or dialysis and may influence decisions about planning for ESRD.
19667728
Protection against malignant conversion in SENCAR mouse skin by all trans retinoic acid: inhibition of the ras p21-processing enzyme farnesyltransferase and Ha-ras p21 membrane localization.
Many studies have shown that all trans retinoic acid (RA) exhibits significant protective effects against mouse skin tumor promotion and spontaneous as well as enhanced malignant conversion. In a recently completed study, we showed that under treatments in which papillomas on SENCAR mouse skin are induced at low and high probabilities to convert to malignant carcinomas, RA affords significant protection against both tumor promotion and subsequent malignant conversion. More than 95% of these mouse skin papillomas and carcinomas have been shown to contain point mutation at the 61 codon of Ha-ras oncogene. The ras oncogene encodes a p21 protein that, in its mutated form, transforms mammalian cells only when p21 is at the inner surface of the plasma membrane, by a series of enzymatic reactions in which the initial step is catalyzed by farnesyltransferase (FTase). In this study, we assessed whether the protective effect of RA against malignant conversion involves the inhibition of ras p21 processing in those tumors that contain the activated ras oncogene. The FTase activity and the levels of cytosolic and membrane-bound Ha-ras p21 were determined in all papillomas and carcinomas obtained from acetone- or RA-treated animals. No matter how the data were analyzed and what comparisons were considered, in all the protocols used, compared with controls, papillomas and carcinomas obtained from RA-treated groups showed significantly decreased (P < 0.01-0.001) FTase activity. Furthermore, the tissue samples from RA-treated groups in different protocols also showed significantly diminished membrane localization of Ha-ras p21, with a concomitant increase in cytosolic Ha-ras p21 levels. The analysis of these data also showed that in all the protocols used, the increased FTase activity and membrane localization of Ha-ras p21 were associated with the induction of papillomas and their subsequent malignant conversion to squamous cell carcinomas. Taken together, these results indicate a strong correlation between the inhibition of ras p21 farnesylation because of a decrease in FTase activity by RA and its protective effect against malignant conversion of papillomas to carcinomas. Based on the results of this study, it is tempting to suggest that clinical trials evaluating the preventive or therapeutic potential of retinoids may be directed more toward those clinical malignancies that are known to contain the activated ras oncogene.
27037028
Nocturia, nocturnal activity, and nondipping.
Patients with chronic kidney disease have less than expected decline in blood pressure during sleep (nondipping) and commonly experience the vexing symptom of nocturia. To better understand the relationship among nocturia, nighttime physical activity, and nondipping, we studied 98 patients with chronic kidney disease on 2 occasions, 1 month apart, with 24-hour ambulatory blood pressure monitoring and simultaneous activity monitoring with wrist actigraphy. Patients with nocturia had greater actigraphically recorded nighttime physical activity compared to those with no nocturia. The drop in activity from wake to sleep was reduced to a similar extent whether the patients had nocturia once or twice, but patients who had nocturia >/=3 times had the least reduction from wake to sleep activity (P<0.001 versus those with less degrees of nocturia). Those with nocturia had a lesser drop in systolic ambulatory blood pressure during sleep compared with those without nocturia. The average fall in sleep systolic blood pressure was 9.8 mm Hg (95% CI: 8.0 to 11.6 mm Hg) in those without nocturia compared with 3.4 mm Hg (95% CI: 2.7 to 4.1 mm Hg) in those with any severity of nocturia (P<0.001 for difference). Nondipping in patients with nocturia was mediated by nighttime physical activity. These differences were independent of estimated glomerular filtration rate, albuminuria, or use of diuretics. Thus, nocturia, which may reflect impaired renal tubular function, is associated with nondipping in patients with chronic kidney disease and appears to be mediated by increased nocturnal activity. Whether nocturia itself or the resulting nondipping associated with nocturia is of prognostic importance for cardiorenal events in patients with chronic kidney disease should be tested in future studies.
1101762
Prognostic significance of between-arm blood pressure differences.
Blood pressure (BP) recordings often differ between arms, but the extent to which these differences are reproducible and whether the differences have prognostic importance is unknown. We enrolled 421 consecutive patients from a medicine and a renal clinic at a veterans' hospital. Three BP recordings were obtained in each arm using an oscillometric device in a sequential manner and repeated in 1 week. Patients were followed for all-cause mortality <or=7 years. The right arm had 5.1-mm Hg higher systolic BP that attenuated by approximately 2.2 mm Hg a week later. Systolic BP dropped 6.9 mm Hg over 1 week and by an additional 5.3 mm Hg in patients with chronic kidney disease. Accounting for the visit and arm effect improved the reproducibility of the BP measurements. The intraclass correlation coefficient was 0.74, which improved to 0.88 after accounting for visit and 0.93 after accounting for arm. The crude mortality rate was 6.33 per 100 patient-years. Every 10-mm Hg difference in systolic BP between the arms conferred a mortality hazard of 1.24 (95% CI: 1.01 to 1.52) after adjusting for average systolic BP and chronic kidney disease. BP differences between arms are reproducible and carry prognostic information. Patients should have evaluation of BP in both arms at the screening visit.
45622499
Buzz in the axilla: a new physical sign in hemodialysis forearm graft evaluation.
The value of physical signs in predicting flow rates or polytetrafluoroethylene (PTFE) hemodialysis graft survival is not well known. Simultaneous physical examination and flow measurements were performed in 67 dialysis patients with PTFE grafts over a period of 1 month. Physical signs included the presence and location of a palpable thrill, location and auscultatory nature of the bruit, and presence or absence of a pulsation. Patients were followed up for 1 year to detect the time to failure defined by angioplasty, clotting, or surgical revision. There was a fair correlation between physical signs and graft flow rates. In a multivariate model, systolic blood pressure, location of the thrill, and patient age were the best predictors of graft flow. During follow-up, there were 68 graft failures (30 grafts, angioplasty alone; 38 grafts, thrombosis followed by interventional or surgical revisions). The median survival of a graft without a thrill in the axilla was 154 days compared with 321 days when a thrill was present (P = 0.05, log-rank test). Dialysis graft physical examination is a useful test to predict graft flows, as well as graft failure. The single best test is the location of the thrill along the venous limb of the graft. Average flow rates for no thrill, thrill but distal to the midarm, and axillary buzz were approximately 500, 750, and 1,000 mL/min, respectively. This single physical sign also correlated with subsequent graft failure and should be incorporated into physical examinations of all dialysis grafts.