Disrupting the Conserved Salt Bridge in the Trimerization of Influenza A Nucleoprotein

Antiviral drug resistance in influenza infections has been a major threat to public health. To develop a broad-spectrum inhibitor of influenza to combat the problem of drug resistance, we previously identified the highly conserved E339...R416 salt bridge of the nucleoprotein trimer as a target and compound 1 as an inhibitor disrupting the salt bridge with an EC₅₀ = 2.7 μM against influenza A (A/WSN/1933). We have further modified this compound via a structure-based approach and performed antiviral activity screening to identify compounds 29 and 30 with EC₅₀ values of 110 and 120 nM, respectively, and without measurable host cell cytotoxicity. Compared to the clinically used neuraminidase inhibitors, these two compounds showed better activity profiles against drug-resistant influenza A strains, as well as influenza B, and improved survival of influenza-infected mice.

[Structural equation model analysis of infectious disease-specific health literacy scale in China]

Objective: To explore the relationship between different dimensions of infectious disease-specific health literacy scale in China. Methods: Structural equation model (SEM) was employed to assess the psychometric properties of the infectious disease-specific health literacy scale. Based on the database from a randomly selected sample of 4 499 adult residents in three provinces in China, from March to May 2015. AMOS 21.0 software was used to build the SEM for data analyses. Results: SEM analyses showed a good model fit of data, with the following satisfied parameters: goodness-of-fit index was 0.969, adjusted goodness-of-fit index was 0.962, root mean square residual was 0.038, root mean square error of approximation was 0.038, standardized root mean square residual was 0.032, Tacker-Lewis index/non-normed fit index was 0.926, comparative fit index was 0.934, normed fit index was 0.925, relative fit index was 0.915, incremental fit index was 0.934, parsimony goodness-of-fit index was 0.782, parsimony-adjusted normed fit index was 0.817, parsimony-adjusted comparative fit index was 0.825 and critical N was 702. The established SEM showed that the total influence path coefficient of "infectious disease-related knowledge and values" on the "infectious disease prevention" , "management or treatment of infectious diseases" and "identification of infection sources" were 0.771, 0.744 and 0.843, respectively. The total influence path coefficients of "identification of infection sources" , "infectious disease prevention" on "management or treatment of infectious diseases" were 0.164 and 0.535, respectively. The effect of "infectious disease-related knowledge and values" on "management or treatment of infectious diseases" appeared the greatest (55.4%), followed by "infectious disease prevention" (28.6%) and "identification of infection sources" (2.7%). Conclusion: This SEM could be optimistically used for planning and evaluation of health education and promotion programs on infectious diseases prevention.

Experimental Evidence of Kinetic Effects in Indirect-Drive Inertial Confinement Fusion Hohlraums

We present the first experimental evidence supported by simulations of kinetic effects launched in the interpenetration layer between the laser-driven hohlraum plasma bubbles and the corona plasma of the compressed pellet at the Shenguang-III prototype laser facility. Solid plastic capsules were coated with carbon-deuterium layers; as the implosion neutron yield is quenched, DD fusion yield from the corona plasma provides a direct measure of the kinetic effects inside the hohlraum. An anomalous large energy spread of the DD neutron signal (∼282  keV) and anomalous scaling of the neutron yield with the thickness of the carbon-deuterium layers cannot be explained by the hydrodynamic mechanisms. Instead, these results can be attributed to kinetic shocks that arise in the hohlraum-wall-ablator interpenetration region, which result in efficient acceleration of the deuterons (∼28.8  J, 0.45% of the total input laser energy). These studies provide novel insight into the interactions and dynamics of a vacuum hohlraum and near-vacuum hohlraum.

Polymorphisms of TGFB1, TLE4 and MUC22 are associated with childhood asthma in Chinese population

OBJECTIVE

To investigate whether the genetic variants of TGFB1, TLE4, MUC22 and IKZF3 are associated with the development of asthma in Chinese children.

METHODS

572 adolescent asthma patients and 590 age-matched healthy controls were included in this study. A total of four SNPs were genotyped, including rs2241715 of TGFB1, rs2378383 of TLE4, rs2523924 of MUC22, and rs907092 of IKZF3. Allele frequencies of the patients and the control group were compared by the Chi-square test. The Student t test was used to analyse the relationship between genotypes and clinical feature of the patients.

RESULTS

Patients were found to have significantly different frequencies of allele A of rs2241715, allele G of rs2378383 and allele A of rs2523924 as compared with the controls (40.4% vs. 45.9%, p=0.01 for rs2241715; 17.2% vs. 13.4%, p=0.01 for rs2378383; 15.3% vs. 11.9%, p=0.02 for rs2523924). For patients with severe asthma, those with genotype AA/AG of rs2241715 had remarkably higher FEV1% as compared with those with genotype GG (59.1±4.3% vs. 55.4±3.7%, p<0.001). Moreover, those with genotype GG/GA of rs2378383 had remarkably lower FEV1% as compared with those with genotype AA (54.6±2.9% vs. 58.6±4.1%, p<0.001).

CONCLUSIONS

Genes TGFB1, TLE4 and MUC22 are associated with the risk of childhood asthma in Chinese population. Our results associating TGFB1 and TLE4 with clinical features of asthma suggest potential application of these parameters in the management of asthma children.

Physiological analysis and transcriptome comparison of two muskmelon (Cucumis melo L.) cultivars in response to salt stress

Melon (Cucumis melo L.) is an important vegetable crop that ranks second in salt tolerance among the Cucurbitaceae. Previous studies on the two muskmelon cultivars 'Bing XueCui' (BXC) and 'Yu Lu' (YL) revealed that they had different characteristics under salt stress, but the molecular basis underlying their different physiological responses is unclear. Here, we combined a physiological study with a genome-wide transcriptome analysis to understand the molecular basis of genetic variation that responds to salt stress in the melon. BXC performed better under salt stress than YL in terms of biomass and photosynthetic characteristics, because it exhibited less reduction in transpiration rate, net photosynthesis rate, and stomatal conductance under 150-mM NaCl stress than YL. A transcriptome comparison of the leaves of the cultivars revealed that 1171 genes responded to salt stress in BXC while 1487 genes were identified as salt-stress-responsive in YL. A real-time polymerase chain reaction analysis of 12 of the responsive genes revealed that there was a strong, positive correlation with RNA sequencing data. The genes were involved in several pathways, including photosynthesis, the biosynthesis of secondary metabolites, metabolism, and plant hormone signal transduction, and their expression levels differed between the two cultivars in response to salt stress. This study provides a molecular perspective of two melon cultivars in response to salt stress, and its results could be used to investigate the complex molecular mechanisms underlying salt tolerance in the melon.

Glutathione S-transferase pi polymorphism contributes to the treatment outcomes of advanced non-small cell lung cancer patients in a Chinese population

We analyzed the association between polymorphisms in three glutathione S-transferase genes (GSTP1, GSTM1, and GSTT1) and the treatment outcome for advanced non-small cell lung cancer (NSCLC). We recruited 284 NSCLC patients at advanced stage from Department of Radiotherapy in Peace Hospital Attached to Changzhi Medical College between May 2009 and May 2011, who had received cisplatin-based chemotherapy. The GSTP1, GSTM1, and GSTT1 genotyping for was determined using DNA pyrosequencing on an ABI Prism 3100 DNA analyzer. In the Cox proportional hazards model, the IIe/Val and Val/Val genotypes of GSTP1 were associated with lower risk of disease progression compared with the IIe/IIe genotype, and the HRs (95%CIs) were 0.37 (0.18-0.74) and 0.15 (0.06-0.35), respectively. The IIe/Val and Val/Val genotypes significantly decreased risk of death from all causes in patients with NSCLC, and the HRs (95%CIs) were 0.52 (0.29-0.92) and 0.37 (0.17- 0.79), respectively No significant association was observed between GSTM1 and GSTT1 polymorphisms and progression-free survival and overall survival in the NSCLC patients. In summary, we suggest that GSTP1 polymorphisms might influence the treatment outcome of advanced NSCLC patients, and our results could help improve individualized therapy.

Dual Targeting of 3-Hydroxy-3-methylglutaryl Coenzyme A Reductase and Histone Deacetylase as a Therapy for Colorectal Cancer

Statins are 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase (HMGR) inhibitors decreasing serum cholesterol and have shown promise in cancer prevention. In this study, we demonstrated the oncogenic role of HMGR in colorectal cancer (CRC) by disclosing increased HMGR activity in CRC patients and its enhancement of anti-apoptosis and stemness. Our previous studies showed that statins containing carboxylic acid chains possessed activity against histone deacetylases (HDACs), and strengthened their anti-HDAC activity through designing HMGR-HDAC dual inhibitors, JMF compounds. These compounds exerted anti-cancer effect in CRC cells as well as in AOM-DSS and Apc^Min/+ CRC mouse models. JMF mostly regulated the genes related to apoptosis and inflammation through genome-wide ChIP-on-chip analysis, and Ingenuity Pathways Analysis (IPA) predicted their respective regulation by NR3C1 and NF-κB. Furthermore, JMF inhibited metastasis, angiogenesis and cancer stemness, and potentiated the effect of oxaliplatin in CRC mouse models. Dual HMGR-HDAC inhibitor could be a potential treatment for CRC.

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HMGR is an oncotarget of CRC.

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JMF3086 targeting HMGR and HDACs is effective therapy in different preclinical CRC models.

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JMF3086 down-regulated inflammatory, proliferation, stemness and anti-apoptotic genes but up-regulated tumor suppressor genes.

Addition of chemotherapeutic and molecular targeted agents stepwise prolongs the survival of metastatic colorectal cancer (CRC), implying the importance of new drugs discovery. Furthermore, combination therapy is a rational approach to improve the anti-cancer efficacy. Here, we demonstrate HMGR is a target for CRC and design a dual HMGR and HDAC inhibitor JMF3086. It inhibits tumor progression, metastasis and stemness in several preclinical models, conferring a significant benefit above lovastatin plus SAHA. JMF3086 also potentiates the effect of oxaliplatin, an important chemotherapeutic agent of CRC. These results provide a rationale for clinical studies of JMF3086 to advance the survival of metastatic CRC.

Mitochondrial DNA variants as genetic risk factors for Parkinson disease

BACKGROUND AND PURPOSE

Investigation of the relationship between mitochondrial DNA (mtDNA) variants and Parkinson disease (PD) remains an issue awaiting more supportive evidence. Moreover, an affirming cellular model study is also lacking.

METHODS

The index mtDNA variants and their defining mitochondrial haplogroup were determined in 725 PD patients and 744 non-PD controls. Full-length mtDNA sequences were also conducted in 110 cases harboring various haplogroups. Cybrid cellular models, composed by fusion of mitochondria-depleted rho-zero cells and donor mitochondria, were used for a rotenone-induced PD simulation study.

RESULTS

Multivariate logistic regression analysis revealed that subjects harboring the mitochondrial haplogroup B5 have resistance against PD (odds ratio 0.50, 95% confidence interval 0.32-0.78; P = 0.002). Furthermore, a composite mtDNA variant group consisting of A10398G and G8584A at the coding region was found to have resistance against PD (odds ratio 0.50, 95% confidence interval 0.33-0.78; P = 0.001). In cellular studies, B4 and B5 cybrids were selected according to their higher resistance to rotenone, in comparison with cybrids harboring other haplogroups. The B5 cybrid, containing G8584A/A10398G variants, showed more resistance to rotenone than the B4 cybrid not harboring these variants. This is supported by findings of low reactive oxygen species generation and a low apoptosis rate in the B5 cybrid, whereas a higher expression of autophagy was observed in the B4 cybrid particularly under medium dosage and longer treatment time with rotenone.

CONCLUSIONS

Our studies, offering positive results from clinical investigations and cybrid experiments, provide data supporting the role of variant mtDNA in the risk of PD.

Resveratrol could reverse the expression of SIRT1 and MMP-1 in vitro

Intervertebral disc degeneration is the main cause of lumbago disease, in which the extracellular matrix structure and moisture in the nucleus pulposus is lost continuously. In this study, we aimed to detect differential expression of silence mating type information regulation 2 homolog 1 (SIRT1) and matrix metalloproteinase-1 (MMP-1) in human intervertebral disc nucleus pulposus cells and to explore the effects of SIRT1 and MMP-1 on the development of the intervertebral disc degeneration. Intervertebral disc nucleus pulposus specimens from 41 patients who underwent lumbar protrusion resection at HuiZhou Municipal Central Hospital, during the period from October 2011 to December 2013, were studied in comparison with 23 control cases from patients who underwent fractured lumbar resection. In degenerated human intervertebral disc nucleus pulposus cells, the expression of SIRT1 is decreased and MMP-1 is increased compared with that of the control cells. Resveratrol could reverse these effects, thereby increasing the expression of SIRT1 (0.87 ± 0.07 vs 0.54 ± 0.04), Coll2α1 (0.90 ± 0.08 vs 0.38 ± 0.01), and aggrecan (0.69 ± 0.07 vs 0.42 ± 0.05) and decreasing the expression of MMP-1 (0.61 ± 0.03 vs 0.93 ± 0.08). These results suggest that resveratrol could possibly reverse the process of intervertebral disc degeneration and thus could be applied as a potential drug for the disease.

Abstract B95: Statin hydroxamates, novel inhibitors targeting histone deacetylases and HMG-CoA reductase, suppress colorectal carcinogenesis associated with colitis

We synthesized statin hydroxamates (JMF3086, JMF3171, and JMF3173), which are small molecules that simultaneously inhibit histone deacetylases (HDACs) and 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGR). These statin hydroxamates were found to be cytotoxic in numerous human cancer cell lines, but not in normal cells, and to induce caspase-dependent apoptosis in HCT116 colon cancer cells. A genome-wide ChIP-on-chip analysis demonstrated that JMF3086 downregulated the expression of inflammatory and stemness genes and upregulated tumor suppressor genes. Gene Ontology (GO) and Ingenuity Pathway Analysis (IPA) predicted that several of the inflammatory genes were regulated by NF-κB and that the apoptosis-related genes were regulated by NR3C1. The oral administration of statin hydroxamates prevented dextran sulfate sodium (DSS)-induced acute colitis and azoxymethane (AOM)/DSS-induced colorectal cancer (CRC) in mice by inhibiting inflammation. JMF3086 and JMF3173 exerted a therapeutic effect in mice with CRC by inducing apoptosis. CRC metastasis to the lungs was inhibited by JMF3086. A positive correlation was detected between the inhibition of HMGR and HDACs and the preventive or therapeutic effects of JMF3086. In addition, the self-renewal and stemness of colorectal cancer stem cells were inhibited by the statin hydroxamates both in vitro and in vivo. Thus, statin hydroxamates show potential as lead compounds for the future development of cancer prevention and treatment.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B95.

Citation Format: Tzu-Tang Wei, Yi-Ting Lin, Pei-Ming Yang, Jhih-Bin Chen, Jim-Min Fang, Ching-Chow Chen. Statin hydroxamates, novel inhibitors targeting histone deacetylases and HMG-CoA reductase, suppress colorectal carcinogenesis associated with colitis. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B95.

Chloroplast ultrastructure regeneration with protection of photosystem II is responsible for the functional 'stay-green' trait in wheat

CN17 is a functional stay-green wheat variety that exhibits delayed leaf senescence and enhanced photosynthetic competence. To better understand these valuable traits, levels of chlorophyll a and b, soluble proteins, unsaturated fatty acids, and other components of CN17 were assayed. In addition, chloroplast ultrastructure, chloroplast number, and differences in gene expression between CN17 and a control variety, MY11, were examined. By 21 d post-anthesis (DPA), CN17 leaves exhibited a significantly higher maximal photochemical efficiency for photosystem II (PSII) (F(v) /F(m) ) and a significantly higher efficiency of excitation capture by open PSII reaction centres (F(v) '/F(m) '). In addition, chlorophyll degradation in CN17 was delayed by approximately 14 d, and was not blocked as observed in cosmetic stay-green phenotypes. The soluble protein content (Ps) of CN17 was higher than MY11 at all timepoints assayed, and the ratio of unsaturated to saturated fatty acids was significantly higher. CN17 also exhibited isolated granal lamellae associated with vesicles and diminished peroxidation, and between 35 and 42 DPA, a sharp decrease in chloroplast number was detected. Taken together, these results strongly support the hypothesis that chloroplast ultrastructure regeneration is responsible for the functional stay-green trait of CN17, and gene expression data provide insight into the mechanistic details.

Successful endovascular treatment of carotid aneurysms in a patient with vascular Ehlers-Danlos syndrome

BACKGROUND

Patients with vascular Ehlers-Danlos syndrome (EDS) can develop internal carotid artery (ICA) aneurysms. Any surgical procedure is hazardous and often unrewarding because of fragile blood vessels. Endovascular treatment may be an alternative approach to the treatment of ICA aneurysms in patients with vascular EDS.

CASE

A 23-year-old woman with vascular EDS developed a cervical right ICA aneurysm and a left petrous ICA aneurysm, which were successfully treated with endovascular interventions without major complications.

CONCLUSION

This case report suggests that endovascular treatment of ICA aneurysms is feasible and can be achieved in patients with vascular EDS.

A new drug design targeting the adenosinergic system for Huntington's disease

Background

Huntington's disease (HD) is a neurodegenerative disease caused by a CAG trinucleotide expansion in the Huntingtin (Htt) gene. The expanded CAG repeats are translated into polyglutamine (polyQ), causing aberrant functions as well as aggregate formation of mutant Htt. Effective treatments for HD are yet to be developed.

Methodology/Principal Findings

Here, we report a novel dual-function compound, N⁶-(4-hydroxybenzyl)adenine riboside (designated T1-11) which activates the A_2AR and a major adenosine transporter (ENT1). T1-11 was originally isolated from a Chinese medicinal herb. Molecular modeling analyses showed that T1-11 binds to the adenosine pockets of the A_2AR and ENT1. Introduction of T1-11 into the striatum significantly enhanced the level of striatal adenosine as determined by a microdialysis technique, demonstrating that T1-11 inhibited adenosine uptake in vivo. A single intraperitoneal injection of T1-11 in wildtype mice, but not in A_2AR knockout mice, increased cAMP level in the brain. Thus, T1-11 enters the brain and elevates cAMP via activation of the A_2AR in vivo. Most importantly, addition of T1-11 (0.05 mg/ml) to the drinking water of a transgenic mouse model of HD (R6/2) ameliorated the progressive deterioration in motor coordination, reduced the formation of striatal Htt aggregates, elevated proteasome activity, and increased the level of an important neurotrophic factor (brain derived neurotrophic factor) in the brain. These results demonstrate the therapeutic potential of T1-11 for treating HD.

Conclusions/Significance

The dual functions of T1-11 enable T1-11 to effectively activate the adenosinergic system and subsequently delay the progression of HD. This is a novel therapeutic strategy for HD. Similar dual-function drugs aimed at a particular neurotransmitter system as proposed herein may be applicable to other neurotransmitter systems (e.g., the dopamine receptor/dopamine transporter and the serotonin receptor/serotonin transporter) and may facilitate the development of new drugs for other neurodegenerative diseases.

Toll-like receptor 2 gene polymorphism and its relationship with SCS in dairy cattle

Toll-like receptor 2 (TLR2) plays an important role in the innate immune response to a variety of pathogens. In this study, bovine TLR2 gene was taken as a candidate gene for mastitis resistance. Through PCR-SSCP analysis and sequencing, three missense mutations at T385 G, G398A, and G1884A were detected in the coding region that encoded extracellular domain. Altogether 240 dairy cattle of three breeds (Holstein, Simmental, and Sanhe cattle) were genotyped and allele frequencies were determined. The effects of TLR2 polymorphisms on somatic cell score (SCS) were analyzed and significant association was found between T385 G and SCS. The mean of genotype GG was significantly lower than those of genotype TT and TG. No significant associations were found with SCS for G398A and G1884A. Information provided in this research will be useful in further studies to determine the role of TLR2 gene in the mastitis resistance.

BMP-7 and CBFA1 in allograft bone in vivo bone formation and the influence of gamma-irradiation

An initial study showed that morselized human bone grafts were osteoconductive and osteoinductive when implanted in nude rat tibial window defects, and 25 kGy of gamma-irradiation significantly reduced those properties. The mechanism of the osteoinductivity and the influence of gamma-irradiation required further investigation. In this study we assessed the paraffin sections of seven morselized human bone grafts implanted into rat tibial defects for 3 weeks after being treated with 0, 15, or 25 kGy gamma-radiation respectively. Osteoclast-like cell counting and protein expressions of bone morphogenetic protein-7 (BMP-7), core binding factor alpha1 (CBFA1), and proliferating cell nuclear antigen (PCNA) were investigated and the positive signals were quantitatively analyzed. More new bone formation was observed in the 0 and 15 kGy groups compared with 25 kGy groups. The newly formed bones were found mainly from the intact cortex into the defects bridged by the implanted grafts. A dense staining of BMP-7 and CBFA1 was noted in the osteoblast-like cells in those areas. The BMP-7 and CBFA1 staining was also seen in the cells surrounding the implanted grafts in the centre areas of the defects in distance from the intact cortex. Quantitative analysis of immunohistochemical staining of the centre areas of the defects showed that gamma-irradiation (15 and 25 kGy) significantly reduced the expression of CBFA1 and BMP-7. In conclusion, morselized human bone grafts may contain some factors, which induced osteoblast lineage differentiation and bone formation and gamma-irradiation damages those bone inducing factors.

Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy

OBJECTIVE

To determine whether measurement of cardiac troponin T (cTnT) concentration in newly diagnosed peripartum cardiomyopathy (PPCM) can be used to predict persistent left ventricular dysfunction after a 6-month follow-up.

PATIENTS AND METHODS

This was a prospective, multiple-centre clinical trial that studied 106 patients with newly diagnosed PPCM surviving over 6 months. cTnT concentration was measured within 2 weeks of the onset of PPCM.

RESULTS

Serum cTnT concentration was negatively correlated with left ventricular ejection fraction (LVEF) at follow-up (LVEF, r = -0.518, p = 0.0001). Analysis by receiver operator characteristic curve yielded an area under the curve of 0.764 (95% CI 0.669 to 0.860, p = 0.0001, vs null hypothesis value 0.5) for cTnT, and a cTnT concentration cut off of >0.04 ng/ml, predicting persistent left ventricular dysfunction with a sensitivity of 54.9% and a specificity of 90.9%. Among 106 recruited patients, there were 33 patients with cTnT concentrations >0.04 ng/ml and 73 patients with cTnT concentrations < or =0.04 ng/ml. After a 6-month follow-up, there was significantly smaller LVEF (35.42% (13.04% vs 50.16% (10.48%, p = 0.0001) and more persistent left ventricular dysfunction (84.8% vs 31.5%, OR = 12.17 (95% CI 4.17 to 35.57), p = 0.001) in patients with cTnT >0.04 ng/ml than in patients with cTnT < or =0.04 ng/ml.

CONCLUSION

Serum cTnT concentration measured within 2 weeks of the onset of PPCM was correlated negatively with LVEF at follow-up. This marker offers a simple, quick, inexpensive, non-invasive method for predicting a persistent LVEF of < or =50%. A cTnT concentration of >0.04 ng/ml predicted persistent left ventricular dysfunction with a sensitivity of 54.9% and a specificity of 90.9%.

Successful outpatient treatment of renal vein thrombosis by low-molecular weight heparins in 3 patients with nephrotic syndrome

Renal vein thrombosis (RV Thromb) is a serious complication ofnephrotic syndrome. Anticoagulation is usually recommended as the treatment of choice. This study reports 3 nephrotic patients diagnosed to have RVThromb combined with thromboembolic events. Low-molecular weight heparin (LMWHep) was given subcutaneously every 12 hours following the diagnosis of RVTromb, which continued at the outpatient clinic after an average of 11 in-hospital days. The patients visited the nephrology outpatient clinic every other week and underwent magnetic resonance image (MRI) studies at 6-week intervals for follow-up of patency of the involved renal vein. LMWHep was discontinued when MRI showed this patency. The average outpatient treatment period was 74 days. There was no recurrent RVThromb in the follow-up course of 6 months after discontinuation of LMWHep. Kidney function was preserved, as indicated by image studies and serial renal function tests. LMWHep produced a more predictable anti-coagulant effect, a superior bioavailability, a longer half-life and a dose-independent effect than unfractionated heparin and coumadin. These benefits made the outpatient treatment of RVThromb possible. Our report recommends outpatient treatment of RVThromb by LMWHep because it is feasible, effective and safe.

Comparison of rate control and rhythm control in patients with atrial fibrillation after percutaneous mitral balloon valvotomy: a randomised controlled study

OBJECTIVE

To compare rate control and rhythm control strategies in patients with atrial fibrillation (AF) after percutaneous mitral balloon valvotomy (PMV).

METHODS

183 patients with AF after successful PMV, with AF duration <or= 12 months and post-PMV left atrial (LA) size <or= 45 mm, were studied in a prospective, randomised trial. The primary end point was improvement in AF-related symptoms. Secondary study end points were 6 min walk tests, quality of life (QOL), normalisation of LA size, number of hospital admissions and duration of hospital stay.

RESULTS

Over one year, 2% patients in the rate control group had sinus rhythm, as compared with 96% of patients in the rhythm control group (p < 0.001). A greater proportion of patients reported improvement in symptoms in the rhythm control group than in the rate control group (p < 0.0001 at every visit time). Walking distance in a 6 min walk test, QOL and LA size normalisation were better in the rhythm control group than in the rate control group. The strategy of rhythm control was associated with similar numbers of hospital admissions but with longer duration of hospital admissions. Drug-related side effect did not differ between the rate control and rhythm control groups. During the follow-up period, no patients in either group had embolic or transitory ischaemic neurological events.

CONCLUSIONS

In patients with AF after PMV, AF duration <or= 12 months and post-PMV LA size <or= 45 mm, sinus rhythm was easy and safe to achieve and maintain. Moreover, patients benefited from restoration and maintenance of sinus rhythm in terms of improved AF-related symptoms, 6 min walk tests and QOL, and of LA size normalisation. Rhythm control should therefore be considered as the preferred initial therapy for this group of patients. The optimal strategy to treat AF after PMV should be individualised.

Lanthanum carbonate (Fosrenol®) efficacy and tolerability in the treatment of hyperphosphatemic patients with end-stage renal disease

AIMS

High serum phosphorus levels are a common problem in patients receiving long-term dialysis treatment. Lanthanum carbonate (Fosrenol) is a new non-aluminum, non-calcium phosphate binder developed for the treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD). We report data from a recent trial, which, for the first time, assessed the efficacy and tolerability of lanthanum carbonate treatment, compared with placebo, in Chinese patients with ESRD.

PATIENTS AND METHODS

Following a one- to three-week washout phase and a four-week, open-label lanthanum carbonate dose-titration phase, male and female hemodialysis patients were randomized (1:1) to receive either lanthanum carbonate or placebo for four weeks. The primary efficacy parameter of the study was the control of serum phosphorus levels (< or =1.8 mmol/l [< or = 5.6 mg/dl]). Secondary endpoints included the profile of serum phosphorus during titration and parathyroid hormone, calcium, and calcium x phosphorus (Ca x P) product levels. The safety and tolerability of lanthanum carbonate were assessed by monitoring adverse events throughout the study.

RESULTS

Mean serum phosphorus level at the end of washout was 2.5 +/- 0.5 mmol/l (7.7 +/- 1.5 mg/dl; n=73), and there was no evidence of a difference in levels between the treatment groups pre-randomization. At the end of the study, lanthanum carbonate-treated patients had significantly lower phosphorus levels (1.6 +/- 0.5 mmol/l [5.1 +/- 1.5 mg/dl]; n=30) than those receiving placebo (2.3 +/- 0.4 mmol/l [7.2 +/- 1.3 mg/dl]; n=31; p < 0.001). In addition, a significantly higher proportion of patients receiving lanthanum carbonate had controlled serum phosphorus levels (60%) compared with the placebo group (10%; p < 0.001). Ca x P product levels were also significantly lower in the lanthanum carbonate group at the end of randomized treatment (p < 0.001). Lanthanum carbonate was well tolerated; only one serious adverse event was reported, which was unrelated to treatment.

CONCLUSIONS

Lanthanum carbonate was shown to be an effective and well-tolerated phosphate binder for the treatment of hyperphosphatemia in Chinese patients with ESRD. This finding supports the results of previous US and European studies, which have also shown that lanthanum carbonate treatment effectively controls serum phosphorus levels.

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.

Incidental primary hyperparathyroidism in a hypercalcaemic woman with tuberculous peritonitis

We report on a 51-year-old woman with initial hypercalcaemia and unknown ascites. In spite of unyielding laparoscopy, laparotomy showed findings compatible with tuberculous peritonitis (TBP). Unexpectedly, a series of examinations eventually revealed the concurrence of hyperparathyroidism due to a parathyroid adenoma. Anti-tuberculous regimen was given and was uneventful. However, hypercalcaemia was not decreased but sustained at a high level even after anti-tuberculous therapy for 3 months. Parathyroidectomy was performed with subsequent normalisation of hypercalcaemia. The aetiology of hypercalcaemia in a patient with an explored disease able to cause this electrolyte abnormality such as TBP may be a coexistent occult parathyroid adenoma.

Hypercalcaemia and haemophagocytic syndrome: rare concurrent presentations of disseminated tuberculosis in a dialysis patient

Tuberculosis remains an important cause of infection in chronic haemodialysis patients. Frequent extrapulmonary involvement, non-specific presentation and limited diagnostic tools usually make early diagnosis difficult. Herein, we report on an 83-year-old female patient who had been on regular heamodialysis therapy for 15 years, who presented with asymptomatic hypercalcaemia and pancytopenia. Haemophagocytic syndrome was documented during the admission period. Mycobacterium tuberculosis was cultured from bone marrow 1 month after her demise. This case report highlights the non-specific manifestations of extrapulmonary tuberculosis in dialysis patients and the limited value of conventional diagnostic methods. We would like to recommend aggressive intervention and early tissue aspiration from possible infectious sites when tuberculosis cannot be completely ruled out. Disseminated tuberculosis should be considered as an indication of hypercalcaemia where haemophagocytic syndrome occurs simultaneously.

Successful treatment of crescentic glomerulonephritis associated with adult-onset Henoch-Schoenlein purpura by double-filtration plasmapheresis

Henoch-Schoenlein purpura (HSP) crescentic glomerulonephritis with acute renal failure in adults is extremely rare. The condition carries a grave renal outcome if it is not appropriately managed. Oral corticosteroids, intravenous methylprednisolone pulse therapy and plasmapheresis with concomitant plasma replacement have been used alone or in various combinations to treat patients with HSP nephritis, yet the effects are uncertain. We describe a 33-year-old man with oliguric acute renal failure in the setting of HSP crescentic glomerulonephritis that is refractory to intravenous methylprednisolone pulse therapy (1,000 mg/day for 3 days) with maintained oral prednisolone (1 mg/kg/day) and oral cyclophosphamide (2 mg/kg/day) for 3 weeks, resulting in successful recovery of renal function after 9 sessions of simple double-filtration plasmapheresis treatment without concomitant plasma replacement. There was no recurrence of vasculitic events within 18 months. In this case, we emphasize that simple double-filtration plasmapheresis without concomitant plasma replacement is an effective and safe modality therapy for adult patients with HSP crescentic glomerulonephritis and acute renal failure, especially when conventional therapy has failed.

Thermal drying of wastewater sludge with crack formation

We examined in this work the drying characteristics of wastewater sludge. The drying flux of the constant-rate period for sludge cake could be up to 40% higher than that from a sand bed. Owing to the considerable volume shrinkage of cake, cracks would form and develop on the crack surface, which yielded three-dimensional but rather than the one-dimensional cake structure assumed in conventional drying theories. The crack length was fully developed in the first 30 min of drying, while the width of crack increased linearly with time. Using these data the drying flux from the cracks was estimated. Enhanced drying flux was noticeable which depended on the crack shape and the crossflow velocity.

[Random amplified polymorphic DNA analysis of Cryptosporidium species and strains]

OBJECTIVE

To analyse the genetic heterogeneity of 8 isolates of Cryptosporidium belonging to three species (Cryptosporiduim muris, Cryptosporiduim parvum and Cryptosporidium meleagridis) using RAPD technique.

METHODS

DNA extracts of the 8 isolates were amplified by PCR using 26 out of 200 primers. The amplified products were separated by agar electrophoresis followed by staining with ethidium bromide.

RESULTS

RAPD analysis revealed; 1. Obvious differences among species were found, the average genetic distance being 7.037; 2. Certain differences among different isolates of the same species were found, the average genetic distance being 5.162.

CONCLUSION

RAPD could differentiate the common and respective gene fragments of the 8 isolates of Cryptosporidium.

Tuberculous peritonitis in uremic patients

AIMS

To identify clinical features and treatment response of tuberculous peritonitis (TBP) in a uremic population, a retrospective case-control study was performed.

MATERIALS AND METHODS

Thirteen uremic patients with TBP (Group I: 62.7 +/- 6.8 years, male 54%) collected between January 1986 and January 2002 were compared with another two age- and sex-matched controls: 19 non-azotemic patients with TBP (Group II: 62.9 +/- 7.3 years, male 47%) and 30 uremic patients without TBP (Group III: 61.1 +/- 8.7 years, male 47%). Clinical information and data of ascites and blood examinations were evaluated.

RESULTS

Significant differences between Groups I and II were found in comorbidity, hypertension, anorexia, percentages of neutrophil and lymphocyte from blood and ascites, and serum calcium (sCa), phosphorus and albumin-adjusted calcium (sAACa). However, no significant differences in duration of symptoms, coexistent pulmonary tuberculosis (p = 0.061), duration or complications of therapy and mortality (p = 0.13) were detected. Significant differences between Groups I and III were found in peripheral white cell counts and percentages of neutrophil and lymphocyte as well as in serum creatinine (sCr), albumin, sCa, sAACa and intact parathyroid hormone (iPTH).

CONCLUSIONS

Non-specific symptoms make the diagnosis of TBP in a uremic population difficult. However, neutrophil predominance in blood and ascites, hypoalbuminemia, relatively lower sCr and hypercalcemia with suppressed serum iPTH were found to be characteristic. In TBP uremic patients, therapy complications were not common and there was a tendency for higher mortality, largely due to septic shock.

Nosocomial blood-stream infection in patients with end-stage renal disease: excess length of hospital stay, extra cost and attributable mortality

Patients with end-stage renal disease undergoing haemodialysis are at high risk of nosocomial blood-stream infection (BSI), but data on the associated costs in this patient population are not available. Therefore, we conducted a retrospective matched (1:2) case-control study of such patients undergoing haemodialysis from January 1998 to December 1998 in a medical centre in southern Taiwan to determine the excess length of hospital stay, attributable mortality, and the extra cost caused by nosocomial BSI. The excess length of hospital stay was 30 days for cases vs. 16 days for controls (P<0.001), the mortality rate was 26.3% for cases vs. 0 for controls (P=0.003) (attributable mortality being 26.3%), and the median of overall costs was 131,584 dollars NT for cases vs. 65,282 dollars NT for controls (P<0.001). Based on these findings, we believe that an effective programme to minimize nosocomial BSI in this patient population would greatly reduce their medical and economic burdens.

Biomonitoring trace element atmospheric deposition using lichens in China

Concentrations of 32 elements, Ag, As, Au, Ba, Ca, Ce, Co, Cr, Cs, Eu, Fe, Hf, K, La, Lu, Mo, Na, Nd, Ni, Rb, Sb, Sc, Se, Sm, Sr, Ta, Tb, Th, U, W, Yb, and Zn were determined by instrumental neutron activation analysis (INAA) in the early preserved epiphytic lichens (Parmotrema recticulatum) from the remote southwestern China area in the 1960s, 1980s and 1990s. The concentrations of Ag, As, Ce, Cr, Cs, Eu, Fe, Hf, La, Nd, Ni, Sc, Se, Sm, Tb, U, Yb and Zn were dropped down by the temporal prolongation. The elemental concentration levels obtained from the organisms indicate that the extent of heavy metal atmospheric deposition among the sampling sites has been declining during the past decades.

Implications of sonographic identification of duplex kidney in adults

BACKGROUND

Duplication of the renal pelvis and ureter constitutes the most common anomalies of the upper urinary tract. Most patients are asymptomatic and don't need treatment. However, the associated anomaly and acquired renal disease may cause morbidity and mortality. The aim of this study was to investigate the prevalence of duplex kidney in sonographic examinations and the predictive capability of this method. An analysis of patients with urography-confirmed duplication anomaly was also performed.

METHODS

During a period of 9 year (from 1988 to 1996), sonographic examination records of 19,287 patients were reviewed. Patients with a diagnosis of duplex kidney were enrolled. Their clinical characteristics and radiological images were recorded and evaluated.

RESULTS

One hundred and sixty-three patients were found by sonography to have duplex kidney, for an prevalence of 0.85%. Urography studies were done on 64 (39.2%) patients, and 42 patients were proven to have duplex kidney. The positive predictive rate of sonography was 65.6%. Eighty percent of patients with duplex kidney had associated ureteral duplication. No associated anomalies were found. Four patients had urolithiasis, and 3 patients had recurrent urinary tract infection. One patient had coexisting uroepithelial malignancy, and 1 patient had refractory gross hematuria.

CONCLUSIONS

Duplex kidney is an uncommon finding during adult sonographic examinations. The sensitivity and specificity of sonography in identifying this anomaly are controversial. An experienced hand with good knowledge of the anomaly and its sonographic signs is helpful in more accurately diagnosing this anomaly.

Neglected bilateral femoral neck fractures in a patient with end-stage renal disease before chronic dialysis

Bilateral femoral neck fractures are rarely reported in patients with end-stage renal disease before chronic dialysis. We report on a 39-year-old woman with neglected bilateral femoral neck fractures, who presented with severe uremic complications prior to chronic dialysis. Three years before admission, she had injured herself in a trivial slip with subsequent bilateral hip pain. She had progressively waddled since then. Pelvic X-ray taken after admission revealed bilateral femoral neck fractures. Bilateral hip hemiarthroplasties were subsequently performed. Displaced femoral neck fractures were found intraoperatively. Pathologic findings and results of examinations supported the coexistence of osteoporosis and high turnover renal osteodystrophy, rendering this woman at high risk of bilateral femoral neck fractures. Therefore, preventing a simple fall or trivial accident and treating renal osteodystrophy and osteoporosis are paramount in patients with chronic renal failure even before the start of dialysis therapy. We also emphasize the need to seek any possible underlying metabolic bone disease once a patient presents with unusual fractures.

Parathyroidectomy can improve bone mineral density in patients with symptomatic secondary hyperparathyroidism

HYPOTHESIS

The recovery of osteoporosis or bone mineral density (BMD) after parathyroidectomy and autotransplantation can be improved in patients with symptomatic secondary hyperparathyroidism.

DESIGN

Case series.

SETTING

Tertiary referral center.

PATIENTS

Forty-five patients with symptomatic secondary hyperparathyroidism who underwent total parathyroidectomy and autotransplantation were included. They were divided into an osteoporotic group (n = 20) and a nonosteoporotic group (n = 25) according to preoperative T scores less than -2.5 at either the lumbar spine (L1-L4) or the femoral neck (FN).

INTERVENTIONS

Serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were checked before surgery and 1 day, 1 week, and 3 months after surgery. The BMDs of the FN and L1-L4 were measured using dual-energy x-ray absorptiometry before surgery and 6 months after surgery.

RESULTS

Patients with osteoporosis were older (mean +/- SD, 50.2 +/- 14.0 years) than those without osteoporosis (42.7 +/- 9.1 years) (P =.04). Except for bone fractures found in 2 women in the osteoporotic group, there were no significant differences between the 2 groups in sex, clinical manifestations, duration of dialysis, weight of removed parathyroid tissue, and types of dialysis. Also, serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were similar in both groups. Both 1 day and 1 week after total parathyroidectomy and autotransplantation, serum levels of calcium and intact parathyroid hormone decreased rapidly and then gradually increased 3 months later; however, serum levels of alkaline phosphatase increased rapidly and then gradually decreased 3 months later. Six months after parathyroidectomy, BMD, T score, and Z score at L1-L4 and the FN increased significantly (P<.001). The increment was much better in the osteoporotic group than in the nonosteoporotic group (P<.001). Also, osteopenia or osteoporosis improved significantly after parathyroidectomy at both L1-L4 and the FN (P<.001 for both).

CONCLUSION

Parathyroidectomy and autotransplantation can improve BMD of symptomatic secondary hyperparathyroidism at L1-L4 and the FN.

Minimal change nephrotic syndrome associated with malignant thymoma: case report and literature review

We report on a patient with nephrotic syndrome with myasthenia gravis and malignant thymoma status post thymectomy and radiotherapy. This 44-year-old woman underwent a thymectomy and localized radiotherapy for invasive thymoma in 1991. She also took azathioprine and pyridostigmine regularly for the control of her symptoms of myasthenia gravis following thymectomy. Neither evidence of recurrence of myasthenia gravis, nor enlargement of residual thymoma was noted following treatment in 1991. Unfortunately, this patient developed a pronounced nephrotic syndrome in 1999, a renal biopsy revealing a minimal-change glomerulonephritis as being present. The patient entered remission subsequent to steroid and cyclosporin therapy, whereas many previously-reported cases of a similar nature either died or remained with a persistent proteinuria. Herein, we review the literature pertaining to examples of nephrotic syndrome for those patients diagnosed with malignant thymoma, and discuss the possible mechanisms for this association, and emphasize the need for the aggressive treatment of the condition, recommending the early use of steroids and cyclosporins.

[Studies on chemical constituents of Fragaria ananassa Duch]

OBJECTIVE

To study the chemical constituents from the fruit of Fragaria ananassa.

METHOD

Using chromatographic methods to isolate compounds and chemical and spectral methods to elucidate their structures.

RESULT

Three compounds, 9, 19-cyclolanost-24-en-3-ol(1), 14-methyl-stigmasta-7, 24(28)-dien-3-ol(2) and beta-sitosterol(3) were isolated from the freeze-dried powder.

CONCLUSION

All of the compounds were obtained from this plant for the first time.

Lymphovascular clearance in laparoscopic surgery of cancer in low rectum

BACKGROUND

The success of laparoscopic biliary surgery has encouraged application of laparoscopic surgery in colorectal disease. There are some questions regarding laparoscopic colorectal surgery, especially for colorectal cancer. Most important is whether adequate resection of colorectal malignancy can be achieved. A retrospective study was performed to evaluate the pathology of resected specimens following laparoscopic surgery and that following open surgery in cancer of the low rectum. Comparing the number of lymph nodes in specimens, we could then prove whether laparoscopic surgery can provide adequate clearance as well as open surgery and if laparoscopic surgery has no difference in comparison with open surgery.

METHODS

The retrospective study was performed to evaluate the pathology of resected specimens following laparoscopic surgery and that following open surgery in cancer of the low rectum. Data regarding patient details and tumor pathology were obtained by case-note review and from Taichung Veterans General Hospital from July, 1998 to April, 1999. There were nine patients with rectal carcinoma in the low rectum who received laparoscopic surgery, 7 male and 2 female. The control group had 8 patients, 7 male and 1 female, with similar tumor location who received similar operation with open method by the same surgical team in the same period. The average age was 67.7 years in the laparoscopic group and 67.4 years in the control group. The characteristics of tumor and the location of tumor were well matched between these two groups.

RESULTS

All of the resected specimens in the two groups were free of tumor in margin of clearance. The average number of lymph nodes harvested was 13 in the laparoscopic group and 9.4 in the open group.

CONCLUSIONS

Although the case number was not adequate, the clinical implication is obvious. Laparoscopic surgery in cancer of the low rectum allows lymphovascular clearance even better than that is afforded by open surgery.

Surgical treatment for rectal prolapse

BACKGROUND

The problem of full-thickness rectal prolapse is formidable, with no clear predominant treatment of choice. Several operations have been proposed to correct rectal prolapse which can be divided into transabdominal and perineal procedures.

METHODS

From September 1982 to October 1999, 32 patients with rectal prolapse were treated with surgical procedures. There were 16 males and 16 females with a mean age of 58.3 years (Range 17-89). Forteen patients received rectopexy procedure, 6 patients received sigmoidectomy, 6 patients received perineal rectosigmoidectomy, 1 patient received Delorme procedure, 1 patient received Thiersch procedure and 4 patients received laparoscopic-assisted sigmoidectomy. The median follow up times were 7.5 years.

RESULTS

In the rectopexy group, complication occurred in one patient (7.1%) and one patient recurred (7.1%). In the sigmoidectomy group, there were no complication but one patient recurred (10%). In the perineal rectosigmoidectomy group, there were no complication, but one patient recurred (16.7%). The total complication rate were 3.1% and total recurrence rate were 9.3%.

CONCLUSIONS

Although, the best operation for rectal prolapse remains a controversial subject, we believe that laparoscopic-assisted sigmoidectomy offers a promising new option for the treatment of rectal prolapse.

Kimura's disease in a chronic hemodialysis patient

Eosinophilia is not an uncommon finding in chronic dialysis patients. It is usually benign in nature although definite pathogenesis is unknown. We have encountered a young uremic Chinese adult who developed Kimura's disease after being on maintenance hemodialysis for about 3 years. Asymptomatic eosinophilia had been noted for 1 year and 8 months prior to the development of progressively enlarged neck masses, which leads to the diagnosis of Kimura's disease. In contrast to most cases, eosinophilia was first noticed before the neck masses appeared. There is often a close correlation between Kimura's disease and glomerular disease, where renal involvement is considered as a systemic manifestation. However, we do not have strong evidence to support this relationship between terminal renal failure and Kimura's disease in this patient. To our knowledge, our patient is the first reported case of Kimura's disease occurring in chronic hemodialysis patients. Eosinophilia persisted for nearly 2 years before the neck mass developed and recurred after the excision. Besides, our patient also demonstrated a chronic and recurrent course typical of Kimura's disease.

Robotic synthesis of 6-[18F]fluoro-L-dopa

The aim of this study was to develop a method of semi-automated 6-[18F]fluoro-L-dopa (6-[18F]FDOPA) synthesis using a robotic system (Scanditronix Anatech RB III, Uppsala, Sweden). [18F]Fluorine was produced via 20Ne(d,alpha)18F using a Scanditronix MC17F cyclotron (Uppsala). The radiosynthesis was performed by the Scanditronix Anatech RB III robotic system. On average, a typical run produced 16-19 mCi of 6-[18F]FDOPA at end of synthesis (EOS) after 2 h irradiation of the F2/neon gas target. The total synthesis time was 110 min. The retention time of 6-[18F]FDOPA (the radio peak) was 8.2 min, which was consistent with the 6-[19F]FDOPA ultraviolet peak. The radiochemical purity was greater than 97%. A robotic, semi-automated method for 6-[18F]FDOPA radiosynthesis is therefore feasible. The radiation burden for the operator can be reduced as much as possible. Sufficient activity of 6-[18F]FDOPA could be obtained for positron emission tomography studies of dopaminergic function.

Hyponatremia in the emergency department

Hyponatremia is a clinical manifestation of a wide variety of diseases, some of which have high mortality rates. To assess the prevalence, cause, and prognosis of hyponatremia encountered in the emergency department, we conducted a prospective study at a major hospital in southern Taiwan. We included all adult internal medicine patients treated in the emergency department during a 2-month period. Hyponatremia was defined as a serum sodium level below 134 mEq/L, and cases patients were followed till being discharged. Among the 3,784 patients included, 166 case patients were identified. Most (65%) case patients were hypovolemic, and the overall mortality rate was 17.9%. The mortality rate increased as the sodium level decreased, but was not related to gender, age, cause, or serum potassium level. When 21 hyperglycemic patients whose serum sodium levels went beyond 134 mEq/L after the adjustment for blood sugar levels were excluded, the prevalence of true hyponatremia was 3.83%. The most common underlying diseases were those of the gastrointestinal system. It is concluded that hyponatremia is a common condition encountered in the emergency department. The mortality is correlated with the serum sodium level, and adjustment of the level is required in hyperglycemic patients to make a correct diagnosis. Unlike the cases in some other clinical settings, almost all cases of hyponatremia encountered in the emergency department were not iatrogenic and had recognizable underlying diseases. Therefore, more effort is generally required to identify the cause of hyponatremia cases in the emergency department.

Idiopathic myelofibrosis associated with renal extramedullary hematopoiesis and nephrotic syndrome: case report

Idiopathic myelofibrosis is characterized by bone marrow fibrosis, anemia, leukoerythroblastosis, and extramedullary hematopoiesis in many organs. Renal abnormalities in idiopathic myelofibrosis have been rarely described in the literature and include extramedullary hematopoiesis in the pararenal or retroperitoneal areas resulting in obstructive uropathy and hemtopoietic cell infiltration in tubulointerstitial area and urolithiasis. These lead to azotemia or acute renal failure, which may respond well to radiotherapy and adjuvant chemotherapy. To our knowledge, there has been only one case report of nephrotic syndrome associated with glomerulonephritis in a myelofibrosis patient; however, no effective treatment was described. Herein, we report the case of a patient with idiopathic myelofibrosis who initially presented with hepatomegaly, anemia, and leukoerythroblastosis. A nephrotic syndrome developed 7 years after initial diagnosis. Renal biopsy disclosed the unique pathological finding of simultaneous mesangial proliferative glomerulonephritis, renal extramedullary hematopoiesis, and gouty nephropathy. Despite treatment with busulfan, proteinuria persisted that implied irreversible glomerular injury and a terminal prognosis. We focus on the unusual pathological finding and the association between nephrotic syndrome and idiopathic myelofibrosis.

Experience in the treatment of myasthenia gravis with double filtration plasmapheresis

BACKGROUND

Myasthenia gravis (MG) is an autoimmune disease characterized by production of autoantibodies directly against acetylcholine receptors on postjunctional membranes. The treatment modalities of myasthenia gravis include cholinesterase inhibitors, surgical thymectomy, immunosuppressive treatment, and short-term immunotherapies, including plasmapheresis and intravenous immune globulin. Double filtration plasmapheresis (DFP) is a new technique of plasmapheresis. The aim of our study is to evaluate the effectiveness and complications of DFP in the treatment of MG.

METHODS

From December, 1993 to August, 1998, a total of 33 patients with MG received 68 courses (total of 299 sessions) of DFP in our hospital. Plasmapheresis volume, drainage volume, treatment duration, heparin dose, and complications were recorded. In addition, clinical responses after DFP were also evaluated.

RESULTS

Only 4 courses (5.88%) of treatment were ineffective. Sixty-four courses (94.12%) of treatment lessened disease activity. The complications of DFP included 15 episodes of hypotension (5.01%), 2 of bradycardia (0.67%), 3 of chest pain (1.00%), 7 of dizziness (2.34%), 58 of high transmembranous pressure of plasma separator (19.40%), 3 of high secondary pressure of plasma fractionator (1.00%), 12 of hemolysis (4.01%), 2 of plasma separator clot (0.67%), 2 of plasma fractionator clot (0.67%), 3 of blood leakage (1.00%), and 1 of air embolism (0.33%). There was no mortality associated with the DFP procedure.

CONCLUSION

DFP is a safe, convenient, and time-saving therapy with rare severe complications in the treatment of MG. Our experience confirms its effectiveness when used in combination with drug therapy and thymectomy.

Low dose desferrioxamine can improve erythropoiesis in iron-overload hemodialysis patients without side effects

OBJECTIVE

Multiple blood transfusions were often required to treat anemia in uremia patients before the era of recombinant human erythropoietin (r-HuEPO). Iron overload thus frequently occurred in chronic hemodialysis patients. Desferrioxamine (DFO) is an effective chelating agent, which can remove excessive iron and can enhance erythropoiesis. Large dose DFO treatment is a therapy associated with the development of severe complications. In this study, a low dose DFO regime was used to treat iron overloaded hemodialysis patients. The efficacy and side effects of this regiment were evaluated.

MATERIALS AND METHODS

Eight iron overloaded chronic hemodialysis patients were enrolled in this study. All patients received DFO 500 mg intravenously twice-a-week for eight months. Serum aluminum, transferrin saturation (TFS) and r-HuEPO requirement were recorded before and after DFO treatment. Serum ferritin and hematocrit (Hct) were measured before, during, and after the DFO withdrawal period. All patients were evaluated and followed closely during treatment.

RESULTS

Changes in aluminum, TFS and r-HuEPO dosage were unremarkable (p > 0.05). Hct increased significantly after eight months of DFO treatment (from 25.3% to 27.0%, p < 0.05). Ferritin level was reduced by 43.2% at the end of treatment and an evident decline of ferritin was achieved after four months of treatment (2102 ng/mL to 1166 ng/mL, p < 0.05). All patients tolerated the treatment well and no complications were found.

CONCLUSION

Low dose DFO can chelate iron effectively in chronic hemodialysis patients. This treatment can enhance erythropoiesis without adverse effects.

General weakness as an indication for parathyroid surgery in patients with secondary hyperparathyroidism

HYPOTHESES

There are factors that affect patients with general weakness owing to secondary hyperparathyroidism and as reported by results noted after parathyroidectomy and autotransplantation.

DESIGN

Case series and consecutive samples.

SETTING

Tertiary care center.

PATIENTS

From July 1996 to June 1998, 56 patients with secondary hyperparathyroidism underwent total parathyroidectomy and autotransplantation. Their ages were 45 +/- 13 years (mean +/- SD) and preoperative duration of dialysis was 75 +/- 37 months. Prior to surgery the patients were divided into 2 groups: group A comprised 2 men and 19 women who had some general weakness; and group B, 15 men and 20 women who reported no general weakness. The etiologies of renal failure, such as diabetic nephropathy (n = 3) or hypertensive nephropathy (n = 3), were found only in group A patients.

INTERVENTIONS

Serum levels of calcium, phosphorus, alkaline phosphatase, and parathyroid hormone (intact) were checked preoperatively and 1 day, 1 week, and 3 months after surgery. Extension force of the quadriceps femoris muscle was measured at 60 degrees of right knee flexion preoperatively and 3 months after surgery. The extension force was expressed as newtons (N) in 2 different quantities: peak force and average force. The degree of general weakness was classified into 4 groups: 0, no weakness; 1, some subjective weakness and/or walking with assistance; 2, the patient was wheelchair bound; and 3, the patient was bedridden.

MAIN OUTCOME MEASURES

The t test was used for paired and unpaired data; Wilcoxon signed rank and Fisher exact tests were incorporated for nonparametric data. Any values of P<.05 were considered significant.

RESULTS

Prior to surgery, 2 patients in group A reported degree 3 weakness; 5, degree 2 weakness; and 14, degree 1 weakness. Three months after surgery, the peak force was noticed to have increased from 185 +/- 56 N to 249 +/- 82 N (mean +/- SD) (n = 11, P = .003), and the average force showed an increase from 136 +/- 45 N to 202 +/- 69 N (n = 11, P = .003). Postoperatively, only 5 patients had degree 1 weakness, 1 had degree 2 weakness, and none had degree 3 weakness. The patient with degree 2 weakness after surgery had diabetes mellitus and a femoral neck fracture prior to parathyroidectomy. Improvement in condition of general weakness was found (P<.001) between preoperative and postoperative periods. Serum levels of calcium were higher in group A (2.82 +/- 0.23 mmol/L [11.3 +/- 0.9 mg/dL]) than in group B (2.64 +/- 0.27 mmol/L [10.6 +/- 1.1 mg/dL]) (P = .013), and serum levels of parathyroid hormone (intact) were lower in group A (108.9 +/- 39.2 pmol/L) than in group B (139.8 +/- 39.6 pmol/L) (P = .006). Except for sex, other data such as phosphorus and alkaline phosphatase levels, age, and duration of dialysis were not significantly different between the 2 groups.

CONCLUSIONS

General weakness that is commonly observed in patients with secondary hyperparathyroidism is found more frequently in women and only in patients with diabetic nephropathy or hypertensive nephropathy. Patients with general weakness had relatively higher levels of calcium and lower levels of parathyroid hormone (intact). We found that improvement of muscle power and general weakness can be achieved by parathyroidectomy and autotransplantation. In addition to itchy skin, bone pain, and soft tissue calcification, general weakness that may cause disability is also an indication for surgery in secondary hyperparathyrodism.

Hyperglycemic hyperosmolar non-ketotic syndrome in hemodialysis patients

BACKGROUND

Hyperglycemic hyperosmolar non-ketotic syndrome (HHNK) is an emergency complication of diabetes mellitus. The conventional treatment modality often includes massive fluid supplementation. In maintenance hemodialysis patients, dehydration via the renal route may not occur, and fluid management is rather complicated. In this study, we investigated the precipitating factors, treatment modalities, clinical course and prognosis of HHNK patients who received maintenance hemodialysis.

METHODS

From January 1988 through August 1998, 16 diabetic patients who had developed HHNK were enrolled. Eight of them were end stage renal disease (ESRD) patients on maintenance hemodialysis, and another group included 8 acute renal failure (ARF) diabetes mellitus patients who received their first hemodialysis during the HHNK episode. We retrospectively reviewed their medical charts and recorded each patient's age, treatment modalities, especially fluid supplementation, predisposing factors, and biochemical data during the HHNK episode. Complications and the final outcome were also recorded.

RESULTS

There were no significant differences in biochemical data and patients' ages between the two groups (p > 0.05). The major predisposing factor for the ARF patients was infection, but irregular use of or discontinuing oral hypoglycemic agents (OHA) or insulin was the major predisposing factor for the ESRD patients. Less fluid supplementation was given in the ESRD group as compared to the ARF group and no deaths occurred in the ESRD group of patients. However, 6 patients expired in the ARF group of patients.

CONCLUSION

Regular medical care, early diagnosis and recognition, and easier management of fluid administration explain the rather smooth course and better prognosis in the ESRD group of patients.

Acute fish liver intoxication: report of three cases

The livers of some larger fish such as shark, tuna and seabass have been reported to be responsible for a peculiar poisoning causing headaches and desquamation. This type of poisoning can also be induced by ingestion of the livers of the sea whale, the polar bear and the seal. Since these animals contain an extremely large quantity of vitamin A in their livers and the symptoms of poisoning in the patients resembled those of patients with acute hypervitaminosis A, the poisoning was believed to have been caused by excessive vitamin A intake. We observed an episode of acute fish liver intoxication in which 3 man experienced dizziness, headache, blurred vision, nausea, vomiting, fever, and desquamation after ingesting the liver of the grouper fish Cephalopholis boenak (C. boenak). One of the patients had full-blown symptoms and presented with a high fever, headache, dizziness, generalized aching pain, and superficial vesicles and bullae of the skin. The treatment was mainly supportive. In the follow-up period, he subsequently developed hair loss and diffuse peeling of the skin on his palms and soles. Acute fish liver intoxication is rare, especially in subtropical regions. Symptomatologically, the clinical pictures of these patients were comparable to acute hypervitaminosis A or retinoid intoxication. The average vitamin A content in the grouper (C. boenak) is high enough to cause acute vitamin A intoxication. Moreover, ethanol may play a potentiating role in this type of event.