Chinese family care partners of older adults in Canada have grit: A qualitative study

AIM

To explain the process taken by Chinese family care partners of older adults in the Greater Toronto Area, Canada, to access health and social services in their communities. The research question was: What mechanisms and structures impact the agency of Chinese family care partners of older adults, in the process of assisting them to access health and social services?

DESIGN

This qualitative study was informed by critical realism.

METHODS

Chinese family care partners of older adults in the Greater Toronto Area, Canada, were interviewed from August 2020 to June 2021. Transcripts underwent thematic analysis.

FINDINGS

Twenty-eight Chinese family care partners expressed a firm commitment to maintain caregiving conditions and to judiciously access health and social services. Their commitment was made up of three parts: (a) legislative and cultural norms of family, work, and society; (b) their perseverance to fill gaps with limited social and financial resources; (c) the quality of their relationship to, and illness trajectory of the older adults. The social structures created tension in how Chinese family care partners made decisions, negotiated resources, and ultimately monitored and coordinated timely access with older adults.

CONCLUSION

Participants' commitment and perseverance were conceptualized as "grit," central to their agency to conform to legislative and cultural norms. Moreover, findings support grit's power to motivate and sustain family caregiving, in order for older adults to age in place as long as possible with finite resources.

IMPLICATIONS FOR THE PROFESSION

This study highlights the importance of cultural awareness education for nurses, enabling continuity of care at a systems level and for a more resilient healthcare system.

IMPACT

Family care partners' grit may be crucial for nurses to harness when together, they face limited access to culturally appropriate health and social services in a system grounded in values of equity and inclusion, as in Canada.

REPORTING METHOD

When writing this manuscript, we adhered to relevant EQUATOR guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ).

PATIENT OR PUBLIC INVOLVEMENT AND ENGAGEMENT

No patient or public involvement.

Prevalence of Anemia and Its Association with Frailty, Physical Function and Cognition in Community-Dwelling Older Adults: Findings from the HOPE Study

OBJECTIVES

The prevalence of anemia and its impact on frailty and physical function amongst the multiethnic older populations in the Southeast Asian (SEA) countries are often not well studied. Singapore, a nation comprised of multiethnic communities, is one of the most rapidly aging population globally. We aim to evaluate the prevalence of anemia and its impact on frailty, and physical function in Healthy Older People Everyday (HOPE)- an epidemiologic population-based study on community-dwelling older adults in Singapore.

DESIGN

Cross-sectional study.

SETTING

Community.

PARTICIPANTS

480 adults ≥ 65 years old.

MEASUREMENTS

Data were collected from interviewers-administered questionnaires on socio-demographics, FRAIL scale, Mini-Mental State Examination, EQ-5D, Barthel Index, and Lawton index. Hemoglobin concentration and physical assessments, including anthropometry, grip strength, timed up-and-go (TUG) were measured.

RESULTS

The overall prevalence of anemia was 15.2% (73 out of 480). The Indian ethnic group had the highest prevalence of anemia (32%, OR=3.02; 95%CI= 1.23-7.41) with the lowest hemoglobin concentration compared to the overall population (13.0±1.3g/L and 13.5±1.4g/L, p=0.02). Hemoglobin levels and anemia were significantly associated with frailty (OR=2.28; 95% CI=1.02-5.10), low grip strength (OR=1.79; 95% CI=1.01-3.03), ≥ one IADL impairment (OR=2.35; 95% CI=1.39-3.97). Each 1 g/dL increase in hemoglobin was associated with a 6% decrease in frailty odds after adjusting for potential covariates (OR = 0.94, 95% CI: 0.90-0.99). There was a significant difference in the mean TUG between the non-anemic (11.0±3.4 seconds) and anemic (12.3±6.0 seconds, p=0.01) counterparts, but no difference in the number of falls.

CONCLUSION

In our multiethnic Asian population, anemia was adversely associated with frailty, decreased muscle strength, and IADL impairment. Health policies on anemia screening should be employed to avoid or potentially delay or reverse these adverse outcomes associated with anemia. Recognition, evaluation, and treatment of anemia amongst this vulnerable population is warranted.

Diagnostic value of bronchoalveolar lavage and bronchial washing in sputum-scarce or smear-negative cases with suspected pulmonary tuberculosis: a randomized study

OBJECTIVES

Bronchoalveolar lavage (BAL) and bronchial washing (BW) are two major methods used to obtain high-quality respiratory specimens from patients with suspected pulmonary tuberculosis (TB) but a sputum-scarce or smear-negative status. We aimed to compare the value of BAL and BW in the diagnosis of TB in such patients.

METHODS

We enrolled patients with suspected pulmonary TB but with a sputum-scarce or smear-negative status who were referred for bronchoscopy between October 2013 and January 2016. Participants were randomized into the BAL and BW groups for evaluation. The primary outcome was the diagnostic yield for TB detection. Secondary outcomes included culture positivity, positivity of nucleic acid amplification tests (NAATs) for Mycobacterium tuberculosis and procedure-related complications.

RESULTS

A total of 94 patients were assessed and 91 (43 in the BAL group, 48 in the BW group) were analysed. Twenty-one patients (48.8%) in the BAL group and 30 (62.5%) in the BW group had a final diagnosis of pulmonary TB. The detection rate of M. tuberculosis by culture or NAAT was significantly higher in BAL specimens than in BW specimens (85.7% vs 50.0%, p 0.009). The procedure-related complications were hypoxic events, 2/43 (4.7%) in the BAL group and 5/48 (10.4%) in the BW group; and post-bronchoscopic fever, 3/43 (7.0%) in the BAL group and 4/48 (8.3%) in the BW group.

DISCUSSION

As long as it is tolerable, BAL rather than BW, should be used to obtain specimens for the diagnosis of pulmonary TB in sputum-scarce or smear-negative cases.

Factors associated with food insecurity among older homeless adults: results from the HOPE HOME study

BACKGROUND

The US homeless population is aging. Older adults and those living in poverty are at a high risk of food insecurity.

METHODS

We conducted a cross-sectional analysis of baseline data from a population-based study of 350 homeless adults aged ≥50. We assessed food security and receipt of food assistance. We used multivariable logistic regression to examine factors associated with very low food security.

RESULTS

The majority of the cohort was male and African American. Over half (55.4%) met criteria for food insecurity, 24.3% reported very low food security. Half (51.7%) reported receiving monetary food assistance. In the multivariable model, those who were primarily sheltered in the prior 6 months, (multi-institution users [AOR = 0.44, 95% CI: 0.22-0.86]) had less than half the odds of very low food security compared with those who were unsheltered. Depressive symptoms (AOR = 3.01, 1.69-5.38), oral pain (AOR = 2.15, 1.24-3.74) and cognitive impairment (AOR = 2.21, 1.12-4.35) were associated with increased odds of very low food security.

CONCLUSIONS

Older homeless adults experience a high prevalence of food insecurity. To alleviate food insecurity in this population, targeted interventions must address specific risk groups.

Hepatitis B virus infection in Taiwan: The role of NTCP rs2296651 variant in relation to sex

Sodium taurocholate cotransporting polypeptide (NTCP) is a functional receptor for hepatitis B virus (HBV) infection. NTCP rs2296651 is believed to be an Asian-specific variant responsible for HBV susceptibility. We investigated the relationship between rs2296651 and HBV infection in Taiwan based on stratification by gender and menopausal status. We recruited 10 017 Taiwan Biobank participants aged 30-70 years with complete genetic data and sociodemographic information. Gender-stratified multivariate logistic regression models were used to determine the relationship between NTCP variant and HBV infection. Among individuals with HBV infection, the genotype frequencies of GG, AG and AA in women were 0.85, 0.15 and 0 while those in men were 0.82, 0.18 and 0, respectively. The multivariate-adjusted odds ratios (OR) of HBV infection were 0.77 (95% CI 0.59-0.99) in women and 0.98 (95% CI 0.79-1.20) in men. The adjusted OR was 0.87 (CI 0.63-1.19) in premenopausal and 0.59 (0.36-0.97) in postmenopausal women. We found that genetic variation in the HBV receptor gene (NTCP) was significantly associated with a decreased risk of HBV infection in Taiwanese women.

Bronchial angles are associated with nodular bronchiectatic non-tuberculous mycobacteria lung disease

BACKGROUND

The nodular bronchiectatic (NB) form of non-tuberculous mycobacteria (NTM) lung disease usually involves the right middle lobe (RML) and the left upper lobe lingular segment. However, the reason underlying this preference is not known.

METHODS

Fifty patients with NB NTM lung disease who had both positive NTM culture(s) and NB lesions in the RML or lingular segment on computed tomography (CT) of the chest, and 100 healthy subjects matched for sex, age, height and body weight with normal chest CT, were randomly selected. Using reconstructed curved multiplanar reformation (MPR) images, the lengths, diameters and angles of the RML and lingular bronchi were measured.

RESULTS

Of the 150 individuals, 64% were female; the mean age was 55 years. The angles of the bronchi were significantly more acute in patients than in healthy subjects, both in the RML (patients, mean 46.75° ± standard deviation 8.87° vs. healthy subjects, mean 51.73° ± 7.76°; P = 0.001) and in the lingular segments (patients, mean 26.94° ± 8.16° vs. healthy subjects, mean 34.65° ± 9.75°; P < 0.001). In addition, the angles of the bronchi in the involved segments were more acute than those in the non-involved segments, both in the RML and the lingular segments. There were no differences in the lengths and bronchi diameters between groups.

CONCLUSIONS

An acute angle (obtuse slope) of RML/lingular bronchi could be an anatomical risk factor for NB NTM lung disease.

The Relationship between Inflammatory Markers, Leptin and Adiponectin in Chronic Hemodialysis Patients

Chronic inflammation is prevalent in dialysis patients. We investigated the relationship between inflammation and newly identified adipokines: leptin and adiponectin in this population. A total of 129 chronic hemodialysis patients were collected. Serum high sensitivity C-reactive protein (CRP), interleukin-6 (IL-6), leptin and adiponectin levels were determined as well as other metabolic variables. Correlation studies and multiple regression analysis were performed among variables. Our results showed that hemodialysis patients had elevated levels of inflammatory markers, leptin and adiponectin. Diabetic subjects had higher serum CRP and lower albumin levels than non-diabetics. Serum CRP levels were positively correlated with IL-6 levels and negatively correlated with albumin levels. Serum leptin levels were directly related to CRP levels while adiponectin levels were inversely related to CRP levels. A significant negative correlation was observed between serum leptin and adiponectin levels. Serum IL-6 levels were the single independent factor affecting CRP levels. Body mass index can predict both serum leptin and adiponectin levels. We conclude that hemodialysis patients are at an increased risk of chronic inflammation and diabetes patients are even more susceptible to this status. Both serum leptin and adiponectin levels are associated with inflammatory markers. As adipose tissue is the major secreting site of these adipokines, our results suggest that adipose tissue plays an important role in the pathogenesis of chronic inflammation in dialysis patients.

Gallstone disease associated with increased risk of arterial stiffness in a Taiwanese population

Arterial stiffness has similar risk factors to gallstone disease (GSD). However, there are few studies on the association between arterial stiffness and GSD. The aim of this study was to determine the relationship between arterial stiffness and GSD in a Taiwanese population. We enroled 6211 subjects from a health examination centre after excluding those who received medications for diabetes, hypertension and hyperlipidemia or had a history of cardiovascular disease, cerebrovascular disease, cancer, cholecystectomy or ankle-brachial index of ⩽ 0.9 or⩾1.3. Increased arterial stiffness was defined as right brachial-ankle pulse wave velocity (baPWV) ⩾1400 cm s^-1. The diagnosis of GSD was based on ultrasonographic findings. The prevalence of increased arterial stiffness was 47.2 and 31.9 % in subjects with and without GSD (P<0.001). A multiple linear regression analysis revealed that GSD, age, systolic blood pressure, fasting plasma glucose and current smoking were positively associated with baPWV, whereas male gender, BMI, habitual exercise and HDL-C were negatively related to baPWV after adjusting for other clinical variables. In conclusion, subjects with GSD are associated with an increased risk of arterial stiffness.

Incidence of toxic optic neuropathy with low-dose ethambutol

OBJECTIVE

To investigate the incidence of ethambutol (EMB) induced optic neuropathy prescribed at a relatively low dose of ≤ 15 mg/kg/day for the treatment of tuberculosis (TB) or Mycobacterium avium complex (MAC) lung disease.

DESIGN

Patients diagnosed with TB or MAC lung disease received multidrug regimens including EMB at a single institution from August 2003 to July 2009. Visual monitoring was performed at baseline and at regular follow-up. The incidence of EMB-induced visual disturbances was evaluated.

RESULTS

Of the 415 patients included in the study, three (0.7%) developed toxic optic neuropathy over the 6-year period. Of the 289 patients prescribed a dose of ≤ 15 mg/kg/day EMB, only one (0.3%) developed toxic optic neuropathy.

CONCLUSIONS

The incidence of EMB-induced optic neuropathy among Koreans is estimated to be 0.7%, and can be reduced with lower doses of EMB.

Effect of flap design on periodontal healing after impacted third molar extraction: a systematic review and meta-analysis

The extraction of an impacted third molar violates the surrounding soft and bony tissues. The surgeon's access to the tooth, for which there are various surgical approaches, has an important impact on the periodontium of the adjacent second molar. The aim of this review was to analyze the relationships between the different flap techniques and postoperative periodontal outcomes for the mandibular second molars (LM2) adjacent to the impacted mandibular third molars (LM3). An electronic search of MEDLINE and other databases was conducted to identify randomized controlled trials fulfilling the eligibility criteria. To assess the impact of flap design on the periodontal condition, the weighted mean difference of the probing depth reduction (WDPDR) and the weighted mean difference of the clinical attachment level gain (WDCAG) at the distal surface of LM2 were used as the primary outcomes. The results showed that, overall, the different flap techniques had no significant impact on the probing depth reduction (WDPDR -0.14mm, 95% confidence interval -0.44 to 0.17), or on the clinical attachment level gain (WDCAG 0.05mm, 95% confidence interval -0.84 to 0.94). However, a subgroup analysis revealed that the Szmyd and paramarginal flap designs may be the most effective in reducing the probing depth in impacted LM3 extraction, and the envelope flap may be the least effective.

Fetal Development: Voice Processing in Normotensive and Hypertensive Pregnancies

Recent observation of maternal voice recognition provides evidence of rudimentary memory and learning in healthy term fetuses. However, such higher order auditory processing has not been examined in the presence of maternal hypertension, which is associated with reduced and/or impaired uteroplacental blood flow. In this study, voice processing was examined in 40 fetuses (gestational ages of 33 to 41 weeks) of hypertensive and normotensive women. Fetuses received 2 min of no sound, 2 min of a tape-recorded story read by their mothers or by a female stranger, and 2 min of no sound while fetal heart rate was recorded. Results demonstrated that fetuses in the normotensive group had heart rate accelerations during the playing of their mother's voice, whereas the response occurred in the hypertensive group following maternal voice offset. Across all fetuses, a greater fetal heart rate change was observed when the amniotic fluid index was above compared to below the median (i.e., 150 mm), indicating that amniotic fluid volume may be an independent moderator of fetal auditory sensitivity. It was concluded that differential fetal responding to the mother's voice in pregnancies complicated by maternal hypertension may reflect functional elevation of sensorineural threshold or a delay in auditory system maturation, signifying functional differences during fetal life or subtle differences in the development of the central nervous system.

Determinants of recurrence after successful treatment of Mycobacterium avium complex lung disease

BACKGROUND

The long-term treatment outcomes of Mycobacterium avium complex (MAC) lung disease (LD) have not been adequately evaluated.

OBJECTIVE

We evaluated the determinants of microbiological recurrence after successful treatment for MAC LD.

DESIGN

The medical records of 295 MAC LD patients treated with combination chemotherapy from 2004 to 2013 were reviewed. The clinical data, microbiological study results and chest computerised tomography findings were collected for each patient.

RESULTS

Ninety-one patients who maintained negative sputum conversion during treatment and had a minimum 10-month follow-up period after treatment were included. The median duration of follow-up was 25 months. Seventy-one (78.0%) patients remained microbiologically disease-free, while 20 (22.0%) had microbiological recurrence after successful treatment. Age, sex and body mass index were not associated with microbiological recurrence. Longer intervals between initial diagnosis and administration of medication (P = 0.024), increased number of involved lobes (P = 0.033) and failure of sputum conversion within 6 months of initiating treatment (P = 0.017) were significantly associated with microbiological recurrence.

CONCLUSION

Microbiological recurrence after successful anti-MAC chemotherapy was associated with the time interval between initial diagnosis and administration of medication, number of lobes involved and time to sputum conversion during treatment.

Pursuing Quality in the Application of Bladder Cancer Quality of Life Research

Patient-reported outcomes (PRO), including health-related quality of life (HRQOL) measures, represent important means for evaluating patients' health outcomes and for guiding health care decisions made by patients, practitioners, investigators, and policy makers. In spite of the large number of studies examining HRQOL in patients with bladder cancer, very few review articles investigated this topic. Because these review studies report mixed results, incorporating bladder cancer HRQOL measures into standard urological practice is not a viable option. In this non-systematic review of the literature and commentary we note some general concerns regarding PRO research, but our primary focus is on the HRQOL methodology within the context of two types of bladder cancer: muscle invasive and non-muscle invasive bladder cancer. Considering bladder cancer HRQOL as the interaction of four areas of the assessment process (i.e., what model of HRQOL to choose, what instruments are available to fit the choice, how interpretation of the resulting data fits the model, and how to derive some utility from the chosen model) and the two types of disease (i.e., muscle invasive and non-muscle invasive) may move us toward a better understanding of bladder cancer HRQOL. Establishing a useful model of perceived general health or specific symptoms is the first and most important step in developing the responsive bladder cancer HRQOL measures necessitated by clinical settings.

Risk factors for deterioration of nodular bronchiectatic Mycobacterium avium complex lung disease

SETTING The long-term natural course of Mycobacterium avium complex (MAC) disease with nodular bronchiectasis, the most common pulmonary non-tuberculous mycobacterial disease, is not well described.

OBJECTIVE

To identify risk factors for the deterioration of nodular bronchiectatic MAC lung disease over a 5-year follow-up period.

DESIGN

Clinical and laboratory data of 67 patients with nodular bronchiectatic MAC lung disease were collected. Chest computerised tomographic images were used to count the number of lung segments involved at diagnosis and measure subcutaneous fat thickness during follow-up.

RESULTS

The 34 patients who showed deterioration had significantly lower body mass index (BMI) (P = 0.004) and % predicted forced vital capacity (P = 0.032), higher numbers of lung segments involved (P < 0.001) and MAC-positive sputum cultures (P = 0.028), and thinner chest subcutaneous fat during follow-up (P < 0.001) than patients without deterioration. In particular, patients with both BMI <21.0 kg/m(2) and more than four lung segments involved had a 240-fold increased risk of deterioration (P < 0.001).

CONCLUSION

Patients with poor nutritional status and extensive lung involvement tend to experience deterioration of nodular bronchiectatic MAC lung disease.

Clinicopathologic and prognostic significance of c-MYC copy number gain in lung adenocarcinomas

BACKGROUND

c-MYC copy number gain (c-MYC gain) has been associated with aggressive behaviour in several cancers. However, the role of c-MYC gain has not yet been determined in lung adenocarcinomas classified by genetic alterations in epidermal growth factor receptor (EGFR), KRAS, and anaplastic lymphoma kinase (ALK) genes. We investigated the clinicopathologic and prognostic significance of c-MYC gain for disease-free survival (DFS) and overall survival (OS) according to EGFR, KRAS, and ALK gene status and stages in lung adenocarcinomas.

METHODS

In 255 adenocarcinomas resected in Seoul National University Bundang Hospital from 2003 to 2009, fluorescence in situ hybridisation (FISH) with c-MYC probe and centromeric enumeration probe 8 (CEP8) was analysed using tissue microarray containing single representative core per each case. EGFR (codon 18 to 21) and KRAS (codon 12, 13, and 61) mutations were analysed by polymerase chain reaction and direct sequencing method from formalin-fixed, paraffin-embedded tissue sections. ALK rearrangement was determined by FISH method. c-MYC gain was defined as >2 copies per nucleus, chromosome 8 gain as ⩾3 copies per nucleus, and gain of c-MYC:CEP8 ratio (hereafter, c-MYC amplification) as ⩾2.

RESULTS

We observed c-MYC gain in 20% (51 out of 255), chromosome 8 gain in 5.5% (14 out of 255), c-MYC amplification in 2.4% (6 out of 255), EGFR mutation in 49.4% (118 out of 239), KRAS mutation in 5.7% (7 out of 123), and ALK rearrangement in 4.9% (10 out of 205) of lung adenocarcinomas. c-MYC gain was observed in 19% (22 out of 118) of patients with lung adenocarcinomas with an EGFR mutation, but not in any patients with a KRAS mutation, or an ALK rearrangement. c-MYC gain (but not chromosome 8 gain or c-MYC amplification) was an independent poor-prognostic factor in the full cohort of lung adenocarcinoma (P=0.022, hazard ratio (HR)=1.71, 95% confidence interval (CI), 1.08-2.69 for DFS; P=0.032, HR=2.04, 95% CI, 1.06-3.91 for OS), as well as in stage I subgroup (P=0.023, HR=4.70, 95% CI, 1.24-17.78 for DFS; P=0.031, HR=4.65, 95% CI, 1.15-18.81 for OS), and in EGFR-mutant subgroup (P=0.022; HR=2.14; 95% CI, 1.11-4.10 for DFS).

CONCLUSIONS

c-MYC gain (but not chromosome 8 gain or c-MYC amplification) was an independent poor-prognostic factor for DFS and OS in lung adenocarcinomas, both in full cohort and stage I cancer, and possibly for DFS in EGFR-mutant adenocarcinomas. Additional studies are required to determine if patients with lung adenocarcinoma with c-MYC gain are candidates for additional first-line treatment to mitigate their increased risk for disease progression and death.

Influence of previous tuberculosis treatment history on acid-fast bacilli smear and culture conversion

SETTING

A teaching hospital in the Republic of Korea, 2003-2009.

OBJECTIVE

To evaluate the effect of previous tuberculosis (TB) treatment history on sputum smear and culture conversion.

DESIGN

Data, including sputum acid-fast bacilli (AFB) results at baseline and at weeks 2, 4, 8, 12, 16, 20 and 24, were collected from patients with AFB sputum smear-positive and culture-confirmed pulmonary TB. Patients with multidrug-resistant TB or those with poor adherence were excluded. AFB conversion was compared between patients with a previous history of anti-tuberculosis treatment and those without.

RESULTS

The median age of the 208 patients was 49.0 years; 58.3% were male, while 43 (20.7%) had a history of previous anti-tuberculosis treatment. Patients with a history of previous treatment had significantly lower sputum smear-negative conversion at 2 weeks of treatment compared with patients without (70.0% vs. 44.8%, P = 0.005). However, the two groups did not differ in culture conversion and in smear conversion at 4, 8, 12, 16, 20 and 24 weeks of anti-tuberculosis treatment.

CONCLUSION

Patients with a history of previous anti-tuberculosis treatment are more likely to have positive sputum AFB smear at 2 weeks of treatment. However, sputum culture conversion is not affected by previous treatment history.

Prevalence of haematuria positively associated with urine albumin excretion in Type 2 diabetes

AIMS

Some guidelines or studies consider haematuria an indication for renal biopsy or a potential cause of albuminuria that precludes accurate assessment of urinary albumin excretion. This study examined the justification of excluding haematuria in interpreting urinary albumin excretion in patients with Type 2 diabetes and its associations with other diabetes-related variables.

METHODS

Between May and November 2008, patients with Type 2 diabetes at a single centre with data on urinary albumin excretion and urinalysis in the same urine sample were recruited. Urinary albumin excretion was determined by urine albumin/creatinine ratio in spot urine. Diagnosis of haematuria was made by positive urine occult blood from 1+ to 4+ and/or presence of more than nine red blood cells/ml in urinalysis. Demographic, anthropometric, clinical and laboratory variables and diabetes-associated complications were analysed.

RESULTS

In total, 743 patients were enrolled. Prevalence of haematuria among patients with normoalbuminuria, microalbuminuria, or macroalbuminuria was 8.7% (n = 13), 16.1% (n = 67) and 35.8% (n = 64), respectively. Urine albumin/creatinine ratio was significantly higher, while macroalbuminuria was more common in patients with haematuria (n = 144) than in those without (n = 599). Multiple regression analysis identified urine albumin/creatinine ratio (odds ratio 1.33, P = 0.01) and macroalbuminuria (odds ratio 2.66, P = 0.01) as the only independent predictors of haematuria. Moreover, urine albumin/creatinine ratio was an independent predictor of haematuria in the macroalbuminuria subgroup (odds ratio 1.30, P = 0.04).

CONCLUSIONS

Increased urine albumin/creatinine ratio and macroalbuminuria were the only independent predictors of haematuria in patients with Type 2 diabetes, raising questions on the justifications of excluding haematuria in interpreting urinary albumin excretion in patients with Type 2 diabetes and including haematuria as an indication for renal biopsy in those with macroalbuminuria.

Risk factors influencing the outcome of peptic ulcer bleeding in end stage renal diseases after initial endoscopic haemostasis

Background and Aims:  Patients suffering from peptic ulcer (PU) bleeding who have end-stage renal disease (ESRD) may encounter more adverse outcomes. The primary objective is to investigate the risk factors that influence the outcomes of ESRD and chronic kidney disease (CKD) patients with PU bleeding after successful initial endoscopic haemostasis. Methods:  A total of 540 patients with PU bleeding after initial endoscopic haemostasis in a tertiary hospital were investigated retrospectively. They were sorted into three groups after randomised age-matched adjustment: ESRD group (n = 90), CKD group (n = 90) and control group (n = 360). Main outcome measurements were rebleeding, requirement for blood transfusion and surgery, length of hospital stay and mortality. Results:  The rebleeding rates were 43% for the ESRD group vs. 21% for the CKD group vs. 12% for the control group (overall p = < 0.001). Multivariate analysis showed the predictors of rebleeding were ESRD, time to endoscope, and non-high-dose proton-pump inhibitors (PPI) users. The risk factors for bleeding-related mortality were presence of moderate degree of CKD and ESRD group, time to endoscope, and Rockall score. All-cause mortality was related to presence of moderate degree of CKD and ESRD group, platelet count, time to endoscope, Rockall score and length of hospital stay. Conclusions:  ESRD patients who suffered from PU bleeding were at risk of excessive rebleeding and mortality with frequent occurrence of delayed rebleeding. This study suggests that early endoscopy for initial haemostasis and high-dose intravenous PPI are associated with the reduction of rebleeding risk especially in patients with high Rockall scores.

Crystallization mechanisms of phase change (GeSbSn)(100-x)Co(x) optical recording films

In this study, the (GeSbSn)(100-x0Co(x) films (x = 0-13.3) were deposited on natural oxidized silicon wafer and glass substrate by dc magnetron co-sputtering of GeSbSn and Co targets. The ZnS-SiO2 films were used as protective layers. The thicknesses of the (GeSbSn)(100-x)Co(x) films and protective layer were 100 nm and 30 nm, respectively. We investigated the effects of Co addition on the thermal property, crystallization kinetics, and crystallization mechanism of the GeSbSn recording film. The crystallization temperatures of (GeSbSn)(100-x)Co(x) films were decreased with Co content. It was found that the activation energy of the (GeSbSn)(100-x)Co(x) films will decrease from 1.53 eV to 0.55 eV as Co content increased from 0 at.% to 13.3 at.%.

Kruger strict morphology and post-thaw progressive motility in cryopreserved human spermatozoa

The purpose of this prospective study was to evaluate Kruger strict morphology and conventional semen analysis in predicting cryosurvival and the progressive motility recovery rate of frozen spermatozoa. Our study included 56 semen samples with >10 million spermatozoa per ejaculate. The main outcome measures were conventional semen analysis, strict morphology analysis by the Kruger method, cryosurvival rate and post-thaw sperm motility. A significant reduction in sperm motility after cryopreservation was demonstrated. The freeze-thawing process caused a 66% reduction in rapid progressive motile spermatozoa, a 45% reduction in slow progressive motile spermatozoa and a 2% reduction in nonprogressive motile spermatozoa. The cryosurvival and progressive motility recovery rates were not correlated with parameters of conventional semen analysis, such as sperm concentration, motility, WHO morphology and total motile count, but the progressive motility recovery rate was significantly correlated with the percentage of spermatozoa exhibiting Kruger normal morphology (P = 0.028). The recovery rate of rapidly progressive motility was profoundly decreased compared with slow progressive motility following the frozen-thaw procedure of semen. Kruger strict morphology assessment was a better predictor of the progressive motility recovery rate following the freezing-thaw procedure than parameters of conventional semen analysis.

The impact of previous tuberculosis history on T-SPOT.TB® interferon-gamma release assay results

SETTING

Seoul National University Bundang Hospital, a tertiary referral hospital in Korea.

OBJECTIVE

To evaluate whether previous tuberculosis (TB) history has a long-term effect on T-SPOT.TB® results after anti-tuberculosis treatment.

DESIGN

We retrospectively reviewed 489 adults (age ≥18 years) who underwent T-SPOT.TB as part of their evaluation between January 2008 and July 2009.

RESULTS

Among 489 subjects analysed, 369 were finally included. Active TB was diagnosed in 121/369 (32.8%). T-SPOT.TB was positive in 110 (90.9%) active TB patients. Of the 248 subjects without active TB, T-SPOT.TB positivity was significantly different between the 51 patients with a previous TB history and the 197 without (84.3% vs. 26.9%, P < 0.001). The difference in T-SPOT.TB positivity between the 51 non-active TB patients with a TB history and the 121 active TB patients was not statistically significant (84.3% vs. 90.9%, P = 0.208). Among the 51 non-active TB individuals with a TB history, the mean time since anti-tuberculosis treatment was 22.7 years (range 1-59); this had no correlation with total region of difference 1 (RD1) spot-forming cells (r = -0.076, P = 0.597).

CONCLUSION

T-SPOT.TB has a limited role in the diagnosis of TB infection in individuals with a previous history of TB.

Concurrent intracardiac metastasis in a patient with intestinal perforation

The administration of anaesthesia to subjects with intracardiac lesions poses the potential for cardiac complications. Cardiac metastases should be identified in susceptible cases and transthoracic echocardiography performed to elucidate the nature of the cardiac lesions. We describe a case of an intracardiac metastasis in a 65-year-old subject with a small bowel tumour leading to intestinal perforation and presenting for surgical treatment. Oncological assessment of the situation, in conjunction with the anaesthetic risks, led to abandonment of surgery and palliative treatment.

Comparison of propofol and the combination of propofol and alfentanil during bronchoscopy: a randomized study

BACKGROUND

propofol is an excellent sedative agent for use in patients undergoing bronchoscopy. The addition of an opioid to propofol can be advantageous because of the antitussive effect of the opioid and the possible improvement in sedation quality. However, it may increase the risk of hypoxaemia. To investigate the effect of the addition of alfentanil to propofol, we performed a prospective study to compare propofol-only sedation with propofol-alfentanil combination sedation in patients undergoing bronchoscopy.

METHODS

patients were randomly assigned either to the propofol-only (group P, n=32) or to the propofol-alfentanil combination group (group PA, n=32). The average peripheral oxygen saturation (SpO(2) ) and the lowest SpO(2) during the sedation were compared. Patient and bronchoscopist satisfaction as well as the degree of coughing were compared using a 100 mm visual analogue scale, where 0 indicated the least and 100 indicated the most satisfied.

RESULTS

group P had the higher average SpO(2) (%) during the procedure than group PA (97.8 ± 1.6 and 96.4 ± 1.1, P<0.01) as well as the lowest SpO(2) (%) (95.4 ± 2.7 and 94.0 ± 2.4, P<0.05). Patient satisfaction (92.2 ± 13.5 and 92.3 ± 18.2), bronchoscopist satisfaction (76.6 ± 18.1 and 72.8 ± 19.1), and degree of cough (73.4 ± 22.7 and 72.2 ± 18.5; group P and group PA, respectively) were not different between the groups.

CONCLUSIONS

the combination of propofol and alfentanil resulted in a greater respiratory depression than propofol alone; furthermore, the addition of an opioid did not improve the quality of sedation. In conclusion, we do not recommend sedation with propofol and alfentanil during bronchoscopy.

Time interval to conversion of interferon-gamma release assay after exposure to tuberculosis

The proper interval for repeating an interferon-γ release assay (IGRA) among tuberculosis contacts with initially negative results is unknown. The interval for IGRA conversion after exposure to patients with active pulmonary tuberculosis in an outbreak setting was evaluated. In a platoon of 32 soldiers, four active pulmonary tuberculosis patients, in addition to one index patient, were diagnosed during a contact investigation. For the other 27 contacts, a tuberculin skin test (TST) and QuantiFERON® TB-Gold In-Tube (QFT-GIT) assay were performed. For soldiers with a negative result on the initial QFT-GIT assay, the test was repeated at 2, 4, 8, 14, 18 and 30 weeks until positive conversion occurred. When conversion was identified, the subject was treated for latent tuberculosis infection. Initially, 17 (63.0%) soldiers gave positive QFT-GIT results, whereas 21 (77.8%) showed positive TST results. Among 10 participants with initially negative QFT-GIT results, three showed conversion at 2 weeks, three at 4 weeks and three at 14 weeks. Conversion did not occur during the 30-week observation period in one contact. Based on the tuberculosis exposure time-points among the contacts, IGRA conversion generally occurred 4-7 weeks after exposure, although it could occur as late as 14-22 weeks after exposure.

Identifying LRRC16B as an oncofetal gene with transforming enhancing capability using a combined bioinformatics and experimental approach

Oncofetal genes are expressed in embryos or fetuses, are downregulated or undetectable in adult tissues, and then re-expressed in tumors. Known oncofetal genes, such as AFP, GCB, FGF18, IMP-1 and SOX1, often have important clinical applications or pivotal biological functions. To find new oncofetal-like genes, we used the public information of expressed sequence tags to systematically analyze gene expression patterns and identified a novel oncofetal-like gene, LRRC16B. It increased the proliferation, anchorage-independent growth and tumorigenesis of transformed cells in xenografts, possibly through its effects on cyclin B1 protein levels. These findings exemplify the feasibility of using bioinformatics to find new oncofetal-like genes and suggest that more genes with important functional roles will be uncovered in the candidate gene list.

Narrow-band imaging with magnifying endoscopy for the screening of esophageal cancer in patients with primary head and neck cancers

BACKGROUND AND STUDY AIM

Although narrow-band imaging (NBI) in endoscopy can improve detection of early-stage esophageal malignancies in patients with head and neck cancers, false-positive results may be obtained in areas with nonspecific inflammatory changes. This study evaluated the feasibility of primary screening with NBI and magnification for the presence of esophageal malignancies in these cancer patients.

PATIENTS AND METHODS

Sixty-nine patients with documented head and neck cancers were enrolled from April 2008 to January 2009. All patients underwent a meticulous endoscopic examination of the esophagus using a conventional white-light system followed by re-examination using the NBI system and final confirmation with NBI plus magnification.

RESULTS

Twenty-one patients (30.4 %) were confirmed to have esophageal neoplasia. Among these 21, 16 (76.2 %) had synchronous lesions, 9 (42.9 %) were asymptomatic, and 10 (47.6 %) had early-stage neoplasia. The incidence of multiple esophageal neoplasia was 57.1 %. NBI was more effective than conventional endoscopy in detecting neoplastic lesions (35 lesions in 21 patients vs. 22 lesions in 18 patients) and was particularly effective in patients with dysplasia (13 lesions in 9 patients vs. 3 lesions in 3 patients). The sensitivity and accuracy of detection were 62.9 % and 64.4 % for conventional endoscopy, 100 % and 86.7 % for NBI alone, and 100 % and 95.6 % for NBI with high magnification, respectively.

CONCLUSIONS

Compared with current approaches, NBI followed by high magnification significantly increases the accuracy of detection of esophageal neoplasia in patients with head and neck cancers. The result warrants conducting prospective randomized controlled study to confirm its efficacy.

Real-time polymerase chain reaction in bronchial aspirate for rapid detection of sputum smear-negative tuberculosis

SETTING

The real-time polymerase chain reaction (RT-PCR) has increasingly been used for the detection of various micro-organisms, including mycobacteria.

OBJECTIVE

To determine the role of RT-PCR in confirming the diagnosis of tuberculosis (TB) when acid-fast bacilli (AFB) smear results in sputum samples were not available (i.e., no sputum or negative smear results).

DESIGN

We analysed the data of consecutive patients whose bronchial aspirate (BA) was tested for RT-PCR for the diagnosis of TB from January 2006 to April 2008. Computed tomography (CT), bronchoscopy and tissue biopsies were performed in all patients for confirmatory diagnosis, and BA was collected for microbiological analyses and RT-PCR. Final diagnoses were based on microbiological or clinicopathological criteria.

RESULTS

Final diagnoses were made in 136 patients, and TB was confirmed in 77 (including 65 culture-positive patients). RT-PCR was positive in 51.9% (40/77) of the confirmed TB patients. More TB patients (20.8%) were detected using RT-PCR than using BA-AFB stain (40 vs. 20, P < 0.001). Of the 77 TB patients, 44 (57.1%) were detected within a few days using a combination of BA-AFB and RT-PCR.

CONCLUSION

Real-time RT-PCR of bronchial aspirate seems to be useful for the rapid diagnosis of TB in suspects with smear-negative TB sputum or no sputum.

M(1)-like muscarinic acetylcholine receptors regulate fast-spiking interneuron excitability in rat dentate gyrus

Cholinergic transmission through muscarinic acetylcholine receptors (mAChRs) plays a key role in cortical oscillations. Although fast-spiking (FS), parvalbumin-expressing basket cells (BCs) are proposed to be the cellular substrates of gamma oscillations, previous studies reported that FS nonpyramidal cells in neocortical areas are unresponsive to cholinergic modulation. Dentate gyrus (DG) is an independent gamma oscillator in the hippocampal formation. However, in contrast to other cortical regions, the direct impact of mAChR activation on FS BC excitability in this area has not been investigated. Here, we show that bath-applied muscarine or carbachol, two mAChR agonists, depolarize DG BCs in the acute brain slices, leading to action potential firing in the theta-gamma bands in the presence of blockers of ionotropic glutamate and gamma-aminobutyric acid type A receptors at physiological temperatures. The depolarizing action persists in the presence of tetrodotoxin, a voltage-gated Na(+) channel blocker. In voltage-clamp recordings, muscarine markedly reduces background K(+) currents. These effects are mimicked by oxotremorine methiodide, an mAChR-specific agonist, and largely reversed by atropine, a non-selective mAChR antagonist, or pirenzepine, an M(1) receptor antagonist, but not by gallamine, an M(2/4) receptor antagonist. Interestingly, in contrast to M(1)-receptor-mediated depolarization, M(2) receptor activation by the specific agonist arecaidine but-2-ynyl ester tosylate down-regulates GABA release at BC axons-the effect is occluded by gallamine, an M(2) receptor antagonist. Overall, muscarinic activation results in a net increase in phasic inhibitory output to the target cells. Thus, cholinergic activation through M(1)-like receptor enhances BC activity and promotes the generation of nested theta and gamma rhythms, thereby enhancing hippocampal function and associated performance.

Nested PCR in lung tissue for diagnosis of pulmonary tuberculosis

Diagnosis of pulmonary tuberculosis (TB) is difficult in cases with an unusual presentation and often requires a lung biopsy. The goal of this study was to determine the clinical usefulness of nested PCR on lung tissue for the diagnosis of pulmonary TB. Clinical and laboratory data were reviewed from patients who underwent diagnostic lung biopsies, followed by nested TB PCR on formalin-fixed paraffin-embedded lung tissue specimens. The diagnostic yield and clinical impact of nested PCR were investigated. Of the 223 patients studied, 142 were diagnosed with TB. Microbiologically confirmed TB was identified in 71 patients. Compared to culture results, the sensitivity, specificity, positive predictive value and negative predictive value of nested PCR were 85%, 99%, 98% and 88%, respectively. Nested PCR was more sensitive than acid-fast bacilli smear of respiratory specimens and histopathological findings. The PCR results provided an early diagnosis and initiation of treatment for TB. However, negative PCR results did not lead to discontinuation of unnecessary TB treatment in patients on medication. In conclusion, nested PCR on lung tissue specimens is a useful diagnostic test for pulmonary TB in patients with an unusual presentation.

PRIMARY B CELL LYMPHOMA OF THE PENIS: SUCCESSFUL TREATMENT WITH ORGAN PRESERVATION

Malignant lymphoma uncommonly manifests in the genitourinary tract. Primary penile lymphoma is extremely rare. A 77-year-old male presented with primary malignant B-cell lymphoma of the penis with the chief complaint of a painless and itching nodule on the penile glans for more than 2 months. The pathologic examination with immunohistochemical stain of penile biopsy revealed malignant B cell lymphoma, mixed cellular type. The physical examination and the computed tomography scan of chest, abdomen, and pelvis showed no evidence of superficial, thoracic, abdominal, or pelvic lymphadenopathy. This case was treated with local excision and systemic chemotherapy with good cosmetic and functional results. There was absence of recurrence 16 months after therapy.

A pilot examination of social context and everyday physical activity among adults receiving Community Mental Health Services

OBJECTIVE

Community mental health center (CMHC) clients include a variety of people with moderate to severe mental illnesses who also report a number of physical health problems. Physical activity (PA) has been identified as one intervention to improve health among this population; however, little is known about the role of social context in PA. The purpose of this study was to examine the role of social context in everyday PA among CMHC clients.

METHOD

Data were collected from CMHC clients in two cultures using accelerometery and experience sampling methods. Data were analyzed using hierarchical linear modeling.

RESULTS

Independence in housing nor culture was significantly associated with levels of PA. Being alone was significantly negatively related to PA level.

CONCLUSION

Social isolation appears to be negatively related to PA at the level of everyday life. Physical activity interventions with this population should consider including social components as a part of PA.

Nutritional deficit as a negative prognostic factor in patients with miliary tuberculosis

The effects of malnutrition on outcomes in miliary tuberculosis (MTB) are not well described. The aim of the present study was to find predictors for the development of acute respiratory failure (ARF) and survival in MTB patients, focusing on parameters reflecting nutritional condition. Out of the patients from three hospitals who had microbiologically or histopathologically confirmed tuberculosis, 56 patients presenting with typical disseminated pulmonary nodules on radiographs were retrospectively enrolled. A four-point nutritional risk score (NRS) was defined according to the presence of four nutritional factors: low body mass index (BMI; <18.5 kg x m(-2)), hypoalbuminaemia (<30.0 g x L(-1)), hypocholesterolaemia (<2.33 mmol x L(-1)) and severe lymphocytopenia (<7 x 10(5) cells x L(-1)). The male to female ratio was 1:3. ARF developed in 25% of patients (14 out of 56), with a 50% fatality rate. A high NRS (> or =3 points) was an independent risk factor for the development of ARF and fatality. In 90-day survival analysis, ARF, severe lymphocytopenia, hypocholesterolaemia, low BMI and higher NRS were risk factors for poor outcome. In multivariate analysis, only high NRS was an independent risk factor for 90-day survival rate in patients with MTB. A high nutritional risk score was a good predictor of poor outcome in miliary tuberculosis patients. Additional approaches to recover the nutritional deficits may become a focus in future management of miliary tuberculosis.

O17. The development of 'time release' nail enamels

In our recent studies on the effects of plasticizers on nail enamel films, we developed a high interest in a phenomenon that we named as 'internal flow'[1]. During the film forming process there is an area that develops beneath the film surface where the film components remain dynamic and mobile. The time frame during which the film maintains this status is directly related to the balance of the resins, plasticizers, polymers and solvents utilized. We found that the longer this 'internal flow' persists, the better the nail enamel wears. At Tevco, we have been able to control the rate at which the solvents and plasticizers flash off the substrate during the film forming process by regulating the interactions and the levels of film constituents. This 'time release' action is the foundation of our study. This study shows that the alkyl adipates are an integral component in controlling the film's internal flow through time release. As plasticizers, these materials, when in proper balance with other components, can create a film surface that is crack-and scuff-resistant. Finally, the substrate in this study is the human nail. The film we developed has to adhere and provide consistent performance over a wide range of temperatures, oil content and the surface abrasion of human nails. We have found that by utilizing adhesion promoters in conjunction with our optimized internal flow time release formula, our film meets all required criteria and generally outperforms conventional quick dry films. In conclusion, we have been able to optimize the film characteristics of conventional quick dry nail enamels. By controlling the internal flow of the film, we can enhance the performance criteria generally expected by consumers in nail enamels.

Role of the virulence plasmid pR99 and the metalloprotease Vvp in resistance of Vibrio vulnificus serovar E to eel innate immunity

Vibrio vulnificus biotype 2 serovar E (VSE) is a bacterial pathogen that produces a haemorrhagic septicaemia called vibriosis in eels. Its ability to grow in blood is conferred by a recently described virulence plasmid [Lee CT, Amaro C, Wu KM, Valiente E, Chang YF, Tsai SF, et al. A common virulence plasmid in biotype 2 Vibrio vulnificus and its dissemination aided by a conjugal plasmid. Journal of Bacteriology, submitted for publication.]. In this study, we analyzed the role of this plasmid together with the role played by the metalloprotease (Vvp) in the interaction between bacteria and eel innate immunity. To this end, we compared and statistically analyzed the differences in resistance to serum and mucus factors (complement, selected antimicrobial peptides, transferrin and lysozyme) and also to phagocytosis/opsonophagocytosis between one VSE strain and its derivatives: a plasmid-cured strain and a vvp-deficient mutant. The wild-type and the metalloprotease-deficient strains were resistant to both the bactericidal action of fresh serum and the phagocytosis and opsonophagocytosis by eel phagocytes, confirming that Vvp is not involved in resistance to eel innate immunity. In contrast, the cured strain was sensitive to both the bactericidal action of eel serum activated by the alternative pathway and phagocytosis/opsonophagocytosis. Since no plasmid-encoded ORF, with homology to known genes, is related to the resistance to innate immunity [Lee CT, Amaro C, Wu KM, Valiente E, Chang YF, Tsai SF, et al. A common virulence plasmid in biotype 2 Vibrio vulnificus and its dissemination aided by a conjugal plasmid. Journal of Bacteriology, submitted for publication.], this function could be codified by one or more new genes. Further studies are underway to characterize the plasmid-encoded system responsible for V. vulnificus resistance to the innate immune system of eels.

"Full house" proliferative glomerulonephritis: an unreported presentation of subacute infective endocarditis

A severely ill 65-year-old man presented with symptoms of shortness of breath, edema and vasculitidic purpura over his lower extremities. He had severe mitral regurgitation which had not been surgically treated. Hematologic examination demonstrated leukocytosis with profound anemia. Other blood tests revealed impaired renal function, hypoalbuminemia, hypocomplementemia and mixed-type cryoglobulinemia. Urinalysis showed proteinuria, hematuria and pyuria, typical of a nephritic sediment. Renal biopsy indicated diffuse proliferative glomerulonephritis and a "full house" deposition in immunofluorescence study (positive for C3, C4, C1q, IgG, IgA and IgM), resembling the pathologic findings in class IV lupus nephritis. Although subacute bacterial endocarditis was initially suspected owing to a history of a predisposing valvular heart disease, probable vegetation shown by cardiac sonography and a clinical picture suggestive of a chronic infection, it was thought unlikely due to the entire afebrile course and initial sterile blood cultures. However, the blood cultures repeated 2 weeks after admission grew 3 sets of viridans streptococci. Following a course of penicillin and gentamicin treatment, his renal function, anemia and abnormal urine sediments improved gradually. Diffuse proliferative glomerulonephritis is well known to occur in infective endocarditis. However, the "full house" immunostaining in immunofluorescence study has never been reported. This case adds a new entity to the differential diagnosis of "full house" immune complex-related glomerulonephritis and exemplifies the need to maintain a high index of suspicion for underlying infectious disorders when facing glomerulonephritic or vasculitic syndrome.

An immortalized rat ventral mesencephalic cell line, RTC4, is protective in a rodent model of stroke

One therapeutic approach to stroke is the transplantation of cells capable of trophic support, reinnervation, and/or regeneration. Previously, we have described the use of novel truncated isoforms of SV40 large T antigen to generate unique cell lines from several primary rodent tissue types. Here we describe the generation of two cell lines, RTC3 and RTC4, derived from primary mesencephalic tissue using a fragment of mutant T antigen, T155c (cDNA) expressed from the RSV promoter. Both lines expressed the glial markers vimentin and S100beta, but not the neuronal markers NeuN, MAP2, or beta-III-tubulin. A screen for secreted trophic factors revealed substantially elevated levels of platelet-derived growth factor (PDGF) in RTC4, but not RTC3 cells. When transplanted into rat cortex, RTC4 cells survived for at least 22 days and expressed PDGF. Because PDGF has been reported to reduce ischemic injury, we examined the protective functions of RTC4 cells in an animal model of stroke. RTC4 or RTC3 cells, or vehicle, were injected into rat cortex 15-20 min prior to a 60-min middle cerebral artery ligation. Forty-eight hours later, animals were sacrificed and the stroke volume was assessed by triphenyl-tetrazolium chloride (TTC) staining. Compared to vehicle or RTC3 cells, transplanted RTC4 cells significantly reduced stroke volume. Overall, we generated a cell line with glial properties that produces PDGF and reduces ischemic injury in a rat model of stroke.

Low serum concentrations of anti-tuberculosis drugs and determinants of their serum levels

SETTING

Low serum concentrations of anti-tuberculosis drugs have occasionally been associated with treatment failure.

OBJECTIVE

To determine the prevalence of low serum concentrations of anti-tuberculosis drugs and to identify the determinants of drug concentrations.

DESIGN

Venous blood was obtained 2 h after drug ingestion, and serum levels of isoniazid (INH), rifampicin (RMP), ethambutol (EMB), pyrazinamide (PZA), acetyl INH and 25-desacetyl RMP were analysed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Patients with human immunodeficiency virus co-infection and gastrointestinal disease or diarrhoea were excluded.

RESULTS

Among 69 enrolled TB patients, the prevalence of a low 2 h serum concentration of at least one anti-tuberculosis drug was 46.4%. Prevalences of a low concentration of INH, RMP, EMB or PZA were 15.2%, 23.5%, 22.4% and 4.5%, respectively. By multivariate linear regression analysis, the serum concentrations of INH, RMP and PZA were positively associated with dose per kg of body weight (P < 0.05). Moreover, INH concentration was associated with acetyl INH/INH ratio (beta = -8.588, P < 0.001) and EMB concentration was associated with calculated creatinine clearance (beta = -0.025, P < 0.001).

CONCLUSION

Low concentrations of anti-tuberculosis drugs are common, and although the clinical significance of low concentrations remains uncertain, it may be necessary to optimise drug doses by therapeutic drug monitoring, especially in patients with an inadequate clinical response to chemotherapy.

Haemoptysis due to chronic tuberculosis vs. bronchiectasis: comparison of long-term outcome of arterial embolisation

OBJECTIVE

To evaluate the factors that influence the outcome of bronchial arterial embolisation (BAE) in chronic tuberculosis (TB). In cases of chronic TB, non-bronchial systemic arteries (NBSA) provide a significant source of massive or recurrent haemoptysis.

DESIGN

Medical records and radiological findings of 30 consecutive TB patients who underwent BAE were retrospectively analysed and compared with those of 19 bronchiectasis patients.

RESULTS

Chronic TB patients had higher numbers of total feeding vessels (4.40 + or - 3.85 vs. 1.79 + or - 1.51, P = 0.007) and NBSA (1.57 + or - 1.63 vs. 0.42 + or - 0.61, P = 0.005) than the bronchiectasis patients. The number of embolisations required for obliterating feeding vessels (3.87 + or - 2.48 vs. 1.95 + or - 1.47, P = 0.004), and the incidence of incomplete embolisation (30% vs. 5.3%, P = 0.033) were also higher in the TB patients. Moreover, recurrence after BAE was more frequent in the TB patients (17/30, 56.7% vs. 5/19, 26.3%, P = 0.037). Male sex, past history of haemoptysis and incomplete embolisation during BAE were associated with higher recurrence of haemoptysis in chronic TB patients. The existence of a fungus ball or significant pleural thickening (> or =10 mm) was not found to influence the recurrence rate of haemoptysis.

CONCLUSION

The haemoptysis recurrence rate was higher in chronic TB than in bronchiectasis; this was found to be related to incomplete feeding vessel embolisation.

Determinants of diagnostic bronchial washing in peripheral lung cancers

OBJECTIVE

To establish clinical determinants affecting the diagnostic yield of bronchial washing.

SETTING

We performed bronchial washing in 241 consecutive patients with bronchoscopically invisible lung tumours. Of these, 150 patients known to have lung cancer were enrolled for the final analysis.

DESIGN

A multi-centre study.

RESULTS

Bronchial washing provided a diagnosis of lung cancer in 30 of the 150 patients (20%). Tumour size > or = 3 cm (P = 0.005), the location of the tumour within 8 cm of the carina (P = 0.003), and exposed type bronchus sign of tumour (P < 0.001) were factors affecting diagnostic bronchial washing for bronchoscopically invisible lung cancers. However, multivariate logistic regression revealed that exposed type bronchus sign was the sole determinant (OR 19.22, 95% CI 4.23-87.46, P < 0.001).

CONCLUSION

Bronchial washing is a useful procedure for the diagnosis of bronchoscopically invisible lung cancers. As the tumour-bronchus relationship is the most important determinant of a diagnostic yield, the routine use of bronchial washing should be considered for tumours with exposed type bronchus sign.

Lidar observations of the diurnal variations in the depth of urban mixing layer: a case study on the air quality deterioration in Taipei, Taiwan

An aerosol light detection and ranging (LIDAR) system was used to measure the depth of the atmospheric mixing layer over Taipei, Taiwan in the spring of 2005. This paper presents the variations of the mixing height and the mixing ratios of air pollutants during an episode of air quality deterioration (March 7-10, 2005), when Taipei was under an anti-cyclonic outflow of a traveling high-pressure system. It was found that, during those days, the urban mixing height reached its daily maximum of 1.0-1.5 km around noon and declined to 0.3-0.5 km around 18:00 (LST). In terms of hourly averages, the mixing height increased with the ambient temperature linearly by a slope of 166 m/degrees C in daytime. The consistency between the changes in the mixing height and in the ambient temperature implied that the mixing layer dynamics were dominated by solar thermal forcing. As the cap of the mixing layer descended substantially in the afternoon, reduced dispersion in the shallow mixing layer caused the concentrations of primary air pollutants to increase sharply. Consequently, the pollutant concentration exhibited an anti-correlation with the mixing height. While attentions are usually focused on the pollution problems occurring in a morning inversion layer, the results of this study indicate that the air pollution and its health impacts could be even more severe as the mixing layer is getting shallow in the afternoon.

Hyperhomocysteinaemia and vascular access thrombosis among chronic hemodialysis patients in Taiwan: a retrospective study

Vascular access thrombosis (VAT) is an important cause of morbidity for chronic haemodialysis (HD) patients. Some risk factors for VAT have been well-defined for chronic HD patients from western countries. However, only a few such factors have been confirmed for Taiwanese patients. This study attempted to determine the association between hyperhomocysteinaemia and the incidence of VAT for chronic HD patients in Taiwan. We retrospectively enrolled a total of 196 patients into this study during 2003. The patients were separated into VAT (n = 142) and control (n = 54) group. The participants of the VAT group were identified as those having one or more VAT, and the participants of the control group were those with no VAT in the past. The mean follow-up period was 48 months. The mean serum homocysteine levels were 29.5 +/- 9.6 and 29.1 +/- 9.5 micromol/l for the VAT (n = 142) and the control (n = 54) group, respectively. There was no significant difference in the level of homocysteine between the VAT and the control group (p = 0.70). Female chronic HD patients had significantly greater mean total homocysteine levels than male (30.89 micromol/l, 95% CI 28.84-32.94 vs. 28.06 micromol/l, 95% CI 26.32-29.82, respectively, p = 0.038). That synthetic graft was a significant risk factor for VAT was determined using multivariate logistic regression analysis. There was no association between serum total homocysteine levels and the incidence of VAT in chronic HD patients in Taiwan.

Hypokalemic paralysis due to Gitelman syndrome: a family study

Hypokalemic paralysis is rarely seen as the presenting feature in patients with Gitelman syndrome. We report a Chinese man who presented with periodic paralysis, in whom molecular analysis revealed compound heterozygous inheritance of three mutations of the thiazide-sensitive sodium chloride cotransporter. Family history revealed intrafamilial variation in phenotypes. Gitelman syndrome should be considered as a cause of hypokalemic paralysis, and molecular analysis may help establish the diagnosis.

Increased renal calcium and magnesium transporter abundance in streptozotocin-induced diabetes mellitus

Diabetes is associated with renal calcium and magnesium wasting, but the molecular mechanisms of these defects are unknown. We measured renal calcium and magnesium handling and investigated the effects of diabetes on calcium and magnesium transporters in the thick ascending limb and distal convoluted tubule in streptozotocin (STZ)-induced diabetic rats. Rats were killed 2 weeks after inducing diabetes, gene expression of calcium and magnesium transporters in the kidney was determined by real-time polymerase chain reaction, and the abundance of protein was assessed by immunoblotting. Our results showed that diabetic rats had significant increase in the fractional excretion for calcium and magnesium (both P < 0.01), but not for sodium. Reverse transcriptase-polymerase chain reaction revealed significant increases in messenger RNA abundance of transient potential receptor (TRP) V5 (223 +/- 10%), TRPV6 (177 +/- 9%), calbindin-D28k (231 +/- 8%), and TRPM6 (165 +/- 8%) in diabetic rats. Sodium chloride cotransporter was also increased (207 +/- 10%). No change was found in paracellin-1 (cortex: 108 +/- 8%; medulla: 110 +/- 10%). Immunofluorescent studies of renal sections showed significant increase in calbindin-D28k (238 +/- 10%) and TRPV5 (211 +/- 10%), but no changes in paracellin-1 in Western blotting (cortex: 110 +/- 7%; medulla: 99 +/- 7%). Insulin administration completely corrected the hyperglycemia-associated hypercalciuria and hypermagnesiuria, and reversed the increase of calcium and magnesium transporter abundance. In conclusion, our results demonstrated increased renal calcium and magnesium transporter abundance in STZ-induced diabetic rats, which may represent a compensatory adaptation for the increased load of calcium and magnesium to the distal tubule.

Prognostic factors for surgical resection in patients with multidrug-resistant tuberculosis

Although surgical lung resection could improve prognosis in some patients with multidrug-resistant tuberculosis (MDR-TB), there are no reports on the optimal candidates for this surgery. The aim of the present study was to elucidate the prognostic factors for surgery in patients with MDR-TB. Patients who underwent lung resection for the treatment of MDR-TB between March 1993 and December 2004 were included in the present study. Treatment failure was defined as greater than or equal to two of the five cultures recorded in the final 12 months of treatment being positive, any one of the final three cultures being positive, or the patient having died during treatment. The variables that affected treatment outcomes were identified through univariate and multivariate logistic regression analysis. In total, 79 patients with MDR-TB were included in the present study. The treatment outcomes of 22 (27.8%) patients were classified as failure. A body mass index <18.5 kg x m(-2), primary resistance, resistance to ofloxacin and the presence of a cavitary lesion beyond the range of the surgical resection were associated with treatment failure. Low body mass index, primary resistance, resistance to ofloxacin and cavitary lesions beyond the range of resection are possible poor prognostic factors for surgical lung resection in multidrug-resistant tuberculosis patients.

Lack of association between COPD and transforming growth factor-beta1 (TGFB1) genetic polymorphisms in Koreans

OBJECTIVE

Many genetic variations have been suggested as genetic risk factors for the development of chronic obstructive pulmonary disease (COPD), including single nucleotide polymorphisms in the transforming growth factor-beta1 (TGFB1) gene. We attempted to elucidate the association between TGFB1 genetic polymorphisms and COPD among Koreans.

DESIGN

The genotypes of 102 male patients with COPD and 159 volunteers with similar distributions of age, sex and smoking intensity, as well as normal pulmonary function, were determined for three previously associated TGFB1 single nucleotide polymorphisms (SNPs), -10807G/A (rs2241712) and -509T/C (rs1800469), located in or near the promoter, and 29T/C (rs1982073), located in exon 1 of the TGFB1 gene.

RESULTS

No significant associations between COPD and the three TGFB1 SNPs could be identified. In addition, the haplotypes composed of three TGFB1 SNPs were not associated with the presence of COPD.

CONCLUSION

These results differ from previous reports involving Caucasians, and might reflect racial differences in the pathogenesis of COPD.

Recombinant human erythropoietin independence in chronic hemodialysis patients: clinical features, iron homeostasis and erythropoiesis

AIMS

Recombinant human erythropoietin (r-HuEPO) is widely used to correct renal anemia in uremic patients. Interestingly, some chronic hemodialysis (HD) patients can maintain high hemoglobin level without the need of r-HuEPO. The aim of this study is to investigate clinical features, iron metabolism and erythropoiesis of these r-HuEPO-independent HD patients.

METHODS

r-HuEPO independence was defined in dialysis patients as hemoglobin greater than 12 g/dl and no use of r-HuEPO for at least 6 months. An age- and sex-matched group was selected for comparison. Their underlying diseases, duration of hemodialysis therapy, efficacy of dialysis (Kt/V), normalized protein catabolic rate (nPCR) and body mass index (BMI) were recorded. Laboratory data including: hemoglobin, albumin, high sensitivity C-reactive protein, serum iron, total iron binding capacity, transferrin saturation, ferritin, intact parathyroid hormone, soluble transferrin receptor (sTfR), serum EPO, cortisol, testosterone, aluminum and leptin levels were measured. Renal sonography was also performed in each patient to evaluate renal cyst formation.

RESULTS

About 2.3% of all HD patients (21/888; M : F = 18 : 3) were r-HuEPO-independent. These patients had significantly longer HD duration and higher serum EPO and sTfR levels, and lower transferrin saturation rate than dependent groups. Correlation analysis revealed that hemoglobin level strongly correlated with HD duration, serum sTfR and EPO levels. Levels of sTfR were positively related with serum EPO levels and BMI. Multivariate regression analysis showed that level of sTfR was the only independent factor related to r-HuEPO independence.

CONCLUSION

R-HuEPO independence is rare among chronic hemodialysis patients. Factors contributing to this dependence are complex and multiple. Level of serum sTfR parallels erythropoiesis and is the most significant factor associated with r-HuEPO independence in chronic HD patients.