Showing papers in "Internal Medicine in 2015"
TL;DR: Compared with the placebo, Lactobacillus treatment was found to be associated with a significantly higher rate of treatment responders in the overall population with IBS, without any side effects.
Abstract: OBJECTIVE: As the lack of reliable treatment for irritable bowel syndrome (IBS) prompts interest in the development of new therapies, we aimed to systematically evaluate the effect of Lactobacillus in treating this disease. METHODS: We searched MEDLIINE, PubMed, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials for the period from 1966 to August 2013 for double-blind, placebo-controlled trials investigating the efficacy of Lactobacillus treatment in the management of IBS. The studies were screened for inclusion based on randomization, controls and reported measurable outcomes. We used the Jadad score to assess the quality of the articles. The STATA 11.0 and Revman 5.0 software packages were used for the meta-analysis. The STATA 11.0 software program was also used to assess indicators of publication bias according to Begg's and Egger's tests. RESULTS: Six randomized, placebo-controlled clinical trials met the criteria and were included in the meta-analysis. The Jadad score of the articles was >3, and three articles were of high quality. We analyzed the heterogeneity of the studies and found no heterogeneity in the meta-analysis. In the forest plot, the diamond was on the right side of the vertical line and did not intersect with the line. The pooled relative risk for clinical improvement with Lactobacillus treatment was 7.69 (95% confidence interval: 2.33-25.43, p=0.0008). For adults, the pooled relative risk for clinical improvement with Lactobacillus treatment was 17.62 (95% confidence interval: 5.12-60.65, p<0.00001). For children, the pooled relative risk for clinical improvement with Lactobacillus treatment was 3.71 (95% confidence interval:1.05-13.11, p=0.04). Using the STATA 10.0 and Revman 5.0 software programs, we confirmed that Lactobacillus exhibited significant efficacy in treating IBS. CONCLUSION: Compared with the placebo, Lactobacillus treatment was found to be associated with a significantly higher rate of treatment responders in the overall population with IBS, without any side effects. As to limitations of the analysis, additional research is needed.
70 citations
TL;DR: Preceding ESD with additional therapy is very effective for the local control of cancer, and useful for histologically confirming the high-risk factors of relapse, such as ≥submucosal layer 2 (SM2) invasion and lymphovascular involvements.
Abstract: OBJECTIVE The standard treatment for submucosal esophageal cancer is esophagectomy or chemoradiotherapy (CRT). However, these treatment modalities could deteriorate the general condition and quality of life of the patients who are intolerant to invasive therapy. It is therefore important and beneficial to develop less invasive treatment protocols for these patients. METHODS The study included 43 patients who were clinically suspected of mucosa or submucosal esophageal cancer but underwent endoscopic submucosal dissection (ESD) as a primary treatment, due to the patients' poor performance statuses and/or preferences for less invasive therapy. According to the pathological findings and patient's general condition, whether the patient underwent additional treatments or remained hospitalized without additional treatments was thereafter decided for each patient. We retrospectively analyzed the outcomes of these patients. RESULTS Fifteen patients underwent additional surgery, 11 patients underwent CRT/radiation therapy (RT) and 17 patients were followed without additional treatments. During the 3-year follow-up period, the relapse-free survival rates in the patients who received or did not receive additional treatments were 88% and 64%, respectively (95% confidence interval, 0.45-0.76, p=0.04). The relapse-free and overall survival rates in the patients with additional treatments were equivalent or superior to those described in previous reports of the standard treatments. Preceding ESD contributed to reduce the local relapse significantly to approximately 3.5% and additional CRT-related toxicities. CONCLUSION Preceding ESD is very effective for the local control of cancer, and useful for histologically confirming the high-risk factors of relapse, such as ≥submucosal layer 2 (SM2) invasion and lymphovascular involvements. ESD with additional therapy may be a promising strategy for optimizing the selection of therapy depending on the patient's general condition.
67 citations
TL;DR: The first case of Takotsubo cardiomyopathy triggered by influenza A virus is reported, with the aim of describing a new cardiovascular complication of influenza virus infection.
Abstract: We herein report the first case of Takotsubo cardiomyopathy triggered by influenza A virus. Myocardial involvement in influenza virus infection has been described in 10% of cases. The literature has principally reported cases of acute myocarditis ranging from asymptomatic to fulminant heart failure and cardiac tamponade. Takotsubo cardiomyopathy frequently occurs in the setting of significant emotional or physical stress or acute medical illness, with a predominance in postmenopausal women. We report the diagnosis, management and outcomes presented in this case, with the aim of describing a new cardiovascular complication of influenza virus infection.
49 citations
TL;DR: The pooled evidence suggests that sequential therapy, concomitant therapy and hybrid therapy are similar with respect to the treatment of H. pylori infection.
Abstract: Objective To compare the efficacy of sequential therapy, concomitant therapy and hybrid therapy for the treatment of Helicobacter pylori (H. pylori) infection. Methods PubMed, Web of Science, Medline, Embase, the Cochrane Central Register of Controlled Trials and CNKI were searched up to the end of May 10, 2014 in order to identify all randomized controlled trials (RCTs) reporting the effects of sequential therapy, concomitant therapy and hybrid therapy on H. pylori eradication. The relative risk (RR) of eradicating H. pylori infection after sequential therapy compared with concomitant therapy or hybrid therapy was pooled. The eradication rates were considered both on an intention-to-treat (ITT) and per-protocol (PP) basis. Results A total of 10 RCTs involving 3,501 patients were included. The pooled data suggested that the differences between the three groups were not statistically significant (ITT analysis: sequential therapy vs. concomitant therapy: RR=1.01, 95%confidence interval (CI): 0.97-1.04, sequential therapy vs. hybrid therapy: RR=1.02, 95%CI: 0.85-1.22, concomitant therapy vs. hybrid therapy: RR=1.03, 95%CI: 0.97-1.08; PP analysis: sequential therapy vs. concomitant therapy: RR=1.00, 95%CI: 0.96-1.03, sequential therapy vs. hybrid therapy: RR=0.97, 95%CI: 0.86-1.09, concomitant therapy vs. hybrid therapy: RR=1.01, 95%CI: 0.93-1.10). In the ITT and PP analyses, the overall eradication rates were 84.3% (95%CI: 79.1-89.4) and 86.4% (95%CI: 81.7-91.0) for the sequential therapy group, 86.7% (95%CI: 81.0-92.3) and 89.8% (95%CI: 85.1-94.5) for the concomitant therapy group and 86.6% (95%CI: 82.3-91.0) and 92.7% (95%CI: 90.5-94.9) for the hybrid therapy group, respectively. There were no significant differences among these therapies in terms of the rate of side effects. Conclusion The pooled evidence suggests that sequential therapy, concomitant therapy and hybrid therapy are similar with respect to the treatment of H. pylori infection.
43 citations
TL;DR: Introducing lifestyle interventions had a significant effect on both reflux and dyspeptic symptoms in GERD patients with dyspepsia who receive a proton pump inhibitor.
Abstract: Objective Although gastroesophageal reflux disease (GERD), a very common disorder worldwide, is considered to be a lifestyle disease, the pathogenic role of lifestyle factors and consequently the efficacy of lifestyle interventions, remains controversial Lifestyle factors associated with GERD and the beneficial effect of specific recommended lifestyle interventions in the primary care setting were evaluated as a post-hoc analysis of the LEGEND study which investigated the effect of lansoprazole in patients with GERD who reported dyspeptic symptoms Methods GERD patients with dyspepsia were treated with lansoprazole 15 mg or 30 mg daily for four weeks Reflux and dyspeptic symptoms were evaluated using patient-reported questionnaires before and four weeks after the administration of lansoprazole Results Among 12,653 patients, "feelings of continued stress" was the most common lifestyle factor (456% of patients), and >30% of the patients reported "eating sweet foods at least once every two to three days," "eating greasy foods at least once every two to three days" and "drinking coffee almost daily" Introducing lifestyle interventions had a significant effect on both reflux and dyspeptic symptoms Conclusion Lifestyle interventions are thus considered to be important in GERD patients with dyspepsia who receive a proton pump inhibitor
41 citations
TL;DR: The finding of extravasation on CECT is the most important factor for identifying and treating bleeding diverticula by colonoscopy in cases of diverticular bleeding, and in such cases, urgent Colonoscopy is recommended.
Abstract: OBJECTIVE Diverticular bleeding is the most common cause of acute lower gastrointestinal bleeding, and its incidence has recently increased. However, the treatment strategy of diverticular bleeding has not yet been established. The aim of the study was to investigate the efficacy of contrast-enhanced computed tomography (CECT) to determine the indication for urgent colonoscopy to achieve hemostasis. METHODS A total of 124 patients diagnosed with diverticular bleeding between 2012 and 2013 in our hospital were analyzed. The clinical behavior, factors related to detecting bleeding diverticula, and risk factors for early rebleeding of diverticular bleeding were evaluated. RESULTS Clinical behavior: Bleeding diverticula were identified in 23 of 124 (19%) patients and most of them (16/23; 70%) were located in the ascending colon. Hemostasis was achieved in all 23 cases, however, six (26%) developed early rebleeding. Factors for detecting bleeding diverticula: In patients in whom extravasation was detected using CECT, the endoscopic detection rate of bleeding diverticula was 60% (12/20), while bleeding diverticula were detected in only 31% (11/35) of patients in whom extravasation was not detected using CECT (p<0.05). The interval between the first hematochezia and colonoscopy in which the bleeding point was detected by colonoscopy (median 23.5 hours) was shorter than that in which bleeding diverticula were not detected (median 43.6 hours) (p<0.01). Risk factors for short term rebleeding: Using a univariate analysis, atherosclerotic comorbidity, anti-inflammatory drugs including low-dose aspirin, antithrombotic agents, vital signs on admission, hemoglobin level on hospitalization, and extravasation on CECT were not found to be significant risk factors. CONCLUSION The finding of extravasation on CECT is the most important factor for identifying and treating bleeding diverticula by colonoscopy. In such cases, urgent colonoscopy is recommended.
37 citations
TL;DR: The hypothesis that oxidative stress and neuroinflammatory reactions play a role in the pathogenesis of AD is supported by the results of this study.
Abstract: Objective Haptoglobin (Hpg) is known to have several functional properties, including antioxidant and anti-inflammatory activities. In addition, it has been shown that the pathogenesis of neurodegenerative disorders, such as Alzheimer's disease (AD), involves inflammation as well as oxidative stress. However, evidence suggesting an association between the serum Hpg level and AD is lacking. Therefore, we conducted this study in order to investigate whether serum Hpg is associated with AD. Methods We compared the serum Hpg levels of 121 patients with newly diagnosed AD, 58 patients with Parkinson's disease (PD) and 43 healthy controls. We also evaluated the relationship between the severity of cognitive impairment in patients with AD and the serum Hpg level. Results The mean serum Hpg level of the patients with AD was significantly higher than that of the healthy controls (p=0.042), although it was not significant different from that observed in the PD group (p=0.613). We also found a significant positive association between the serum Hpg level and the severity of cognitive impairment, as measured using several neuropsychological tests, in the patients with AD. The odds ratio (95% confidence interval) of the patients with AD grouped according to the Hpg level was 2.417 (95% confidence interval=1.134-5.149). Conclusion We observed a significantly higher mean serum Hpg level among the patients with AD compared to the healthy controls. These results support the hypothesis that oxidative stress and neuroinflammatory reactions play a role in the pathogenesis of AD.
33 citations
TL;DR: Few patients had a site of progression capable of being accessed using relatively noninvasive biopsy procedures, and further investigations are warranted to develop more optimal treatment strategies after PD in patients with oligoprogressive disease or CNS failure.
Abstract: OBJECTIVE Analyses of tumor biopsy samples from non-small cell lung cancer patients with acquired epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) resistance are expected to reveal the molecular mechanisms of resistance. However, due to limited tissue availability, performing such analyses can be challenging. We herein investigated the feasibility of tumor rebiopsy in this patient population. METHODS From April 2004 to March 2013, 53 consecutive patients were treated with EGFR-TKIs at our department. A retrospective medical chart review was conducted among patients with progressive disease (PD) according to the Response Evaluation Criteria in Solid Tumors criteria, as assessed radiographically. Sites of progression were evaluated at the time of PD. RESULTS Forty patients experienced PD at the following sites: isolated central nervous system (CNS) in 10 patients; isolated bone in five patients; isolated lymph nodes in two patients; the primary lesion in 10 patients; and systemic disease in 11 patients. Concerning the site of progression, 20 of the 40 patients had a lesion that could be accessed using endobronchial, transbronchial or percutaneous biopsy procedures. Among the 19 patients with oligoprogressive disease or CNS failure, the median overall survival was 24.1 months in eight patients who had received continuing treatment with EGFR-TKIs following radiotherapy and 16.8 months in 11 patients who received other therapies after PD. CONCLUSION In this study, few patients had a site of progression capable of being accessed using relatively noninvasive biopsy procedures. Further investigations are warranted to develop more optimal treatment strategies after PD in patients with oligoprogressive disease or CNS failure.
33 citations
TL;DR: Cerebral toxoplasmosis should be included in the differential diagnosis of patients under immunosuppressive medication who present with neurological manifestations, and is reported in a 76-year-old Caucasian woman on methotrexate and infliximab for rheumatoid arthritis.
Abstract: Cerebral toxoplasmosis is a rare disease predominantly found in immunocompromised hosts. However, cerebral toxoplasmosis has not been frequently described in association with the use of immunosuppressive medications. We herein report a case of cerebral toxoplasmosis in a 76-year-old Caucasian woman on methotrexate and infliximab for rheumatoid arthritis. The patient presented with right facial droop, slurred speech and difficulty walking. In addition to receiving methotrexate and infliximab and owning a cat, she had no other obvious risk factors. Imaging studies were not conclusive; however, brain biopsy confirmed the diagnosis. Serology was positive for anti-toxoplasma immunoglobulin G. Cerebral toxoplasmosis should be included in the differential diagnosis of patients under immunosuppressive medication who present with neurological manifestations.
32 citations
TL;DR: In the present study, all four touch-panel screening tests could be employed to discriminate AD patients from normal controls, whereas only the flipping cards game was effective for distinguishing MCI subjects fromnormal controls.
Abstract: OBJECTIVE The increasing population of elderly people in Japan has accelerated the demand for a simple screening test to detect cognitive and affective declines in mild cognitive impairment (MCI) and the early stage of dementia. Methods We compared the cognitive and affective functions, activities of daily living (ADLs) and the results of four computerized touch-panel screening tests in 41 MCI subjects, 124 patients with Alzheimer's disease (AD) and 75 age- and gender-matched normal controls. RESULTS All computerized touch-panel games were successfully used to discriminate the AD patients from the normal controls (** p<0.01). Although there were no differences in the findings of the conventional cognitive assessments, the results of the flipping cards game were significantly different (** p<0.01) between the normal controls (19.3 ± 9.5 sec) and MCI subjects (30.9 ± 18.4 sec). Three conventional affective assessments, the ADL score, Abe's behavioral and psychological symptoms of dementia (ABS) (** p<0.01) and the apathy scale (AS) (* p<0.05), could be used to discriminate the MCI subjects (ABS, 0.9 ± 1.5; AS, 12.8 ± 5.9) from the normal controls (ABS, 0.1 ± 0.4; AS, 8.9 ± 5.3). CONCLUSION In the present study, all four touch-panel screening tests could be employed to discriminate AD patients from normal controls, whereas only the flipping cards game was effective for distinguishing MCI subjects from normal controls. Therefore, this novel touch-panel screening test may be a more sensitive tool for detecting MCI subjects among elderly patients.
32 citations
TL;DR: It was unable to confirm, based on the data of published studies, the favorable impact of corticosteroid therapy on mortality in overall ARDS cases, and previous meta-analyses may be affected by this publication bias.
Abstract: OBJECTIVE The impact of corticosteroids on acute respiratory distress syndrome (ARDS) mortality remains controversial following the publication of numerous trials, observational studies and meta-analyses. An updated meta-analysis is warranted, as a few original studies on this topic have been published since the last meta-analysis. METHODS We searched for eligible articles using four databases. In particular, we included full-length original articles providing sufficient data for evaluating the impact of corticosteroid treatment on adult ARDS mortality in the form of odds ratios. A fixed model with the confidence interval method was used. An assessment of publication bias and sensitivity analyses were also conducted. RESULTS We included 11 of 185 articles. The pooled odds ratio for corticosteroids with respect to all-cause mortality involving 949 patients was 0.77 [95% confidence interval (CI): 0.58-1.03, p=0.079] with strong heterogeneity(I2=70%, p<0.001). The results of the sensitivity analysis, Begg-Kendall test (τ=0.53, p=0.024)and funnel plot consistently suggested the existence of strong publication bias. After six potentially unpublished cohorts were filled using Duval's trim and fill method, the pooled odds ratio shifted to 1.11 (95% CI0.86-1.44, p=0.427). In addition, the sensitivity analyses suggested that corticosteroid treatment has a different impact on mortality depending on the comorbidities and trigger events. CONCLUSION We were unable to confirm, based on the data of published studies, the favorable impact of corticosteroid therapy on mortality in overall ARDS cases. Published articles exhibit strong publication bias,and previous meta-analyses may be affected by this publication bias. Further research focusing on pathophysiology- or trigger event-specific ARDS is anticipated.
TL;DR: The case of a 48-year-old woman who presented with nonconvulsive status epilepticus refractory to antiepileptic drugs caused by anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis without any tumors markedly improved following second-line immunotherapy with rituximab and cyclophosphamide.
Abstract: We herein describe the case of a 48-year-old woman who presented with nonconvulsive status epilepticus refractory to antiepileptic drugs caused by anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis without any tumors. She developed nausea and psychiatric symptoms, followed by fever and an acute progressive disturbance of consciousness. On admission to our hospital, she presented with involuntary orofacial movements and central hypoventilation, and an electroencephalogram showed a generalized slow activity consistent with nonconvulsive status epilepticus. The patient's drug-resistant status epilepticus markedly improved following second-line immunotherapy with rituximab and cyclophosphamide. Physicians should consider the early initiation of second-line therapy in certain cases of anti-NMDAR encephalitis.
TL;DR: Won therapy, a form of thermal therapy using a far-infrared dry sauna, suggests that Waon therapy may be a useful and safe treatment for CFS.
Abstract: OBJECTIVE: Chronic fatigue syndrome (CFS) is a disabling condition of unknown etiology, and no definitive therapy has been identified to date. We developed Waon therapy, a form of thermal therapy using a far-infrared dry sauna, and in this study herein examined its feasibility and safety in patients with CFS. METHODS: Ten consecutive inpatients with CFS stayed in a 60°C sauna for 15 minutes and then rested on a bed under a blanket for an additional 30 minutes outside the sauna room. The treatments were performed once a day, five days a week for four weeks. Perceived fatigue, the primary outcome measure, was evaluated using a numerical rating scale before, during (two weeks after the commencement of therapy) and after therapy. The pain level, evaluated using a numerical rating scale, mood, assessed using the Profile of Mood States questionnaire, and performance status, assessed using a scale developed for CFS patients were also examined before and after therapy. RESULTS: Perceived fatigue significantly decreased after therapy, although no significant reductions were observed during therapy. In addition, a negative mood, including anxiety, depression and fatigue, and the performance status significantly improved after therapy. However, the levels of pain and vigor did not change significantly. No patients reported any adverse effects during the therapy. CONCLUSION: These findings suggest that Waon therapy may be a useful and safe treatment for CFS.
TL;DR: VBN improves the diagnostic yield when combined with R-EBUS to assess lesions exhibiting involved bronchi on CT images, and is identified as a useful method for diagnosing peripheral pulmonary lesions.
Abstract: Objective Bronchoscopy using radial-endobronchial ultrasound (R-EBUS) and virtual bronchoscopic navigation (VBN) is a promising method for diagnosing peripheral pulmonary lesions. We previously performed a randomized comparative trial (RCT) (i.e., VBN combined with EBUS RCT) involving patients with 30-mm or smaller peripheral pulmonary lesions and found that the addition of VBN to R-EBUS improved the diagnostic yield. In the present study, we performed a retrospective subanalysis in order to identify patients for whom VBN is useful. Methods The per-protocol population (194 cases) of the VBN combined with EBUS RCT was divided into subgroups based on the lesion size, lung lobe containing the lesion, lesion location, presence or absence of involved bronchi (bronchus sign) on thin-section CT and whether the lesion was detected on posterior-anterior (P-A) radiographs. The difference in the diagnostic yield between the VBN-assisted (VBNA) and non-VBN-assisted (NVBNA) groups was investigated. Results Within the bronchus sign-positive subgroup, the diagnostic yield in the VBNA and NVBNA groups was 94.4% (68/72) and 77.8% (56/72), respectively, showing a significantly higher yield in the VBNA group (p=0.004; odds ratio: 4.9). The yield was particularly high for lesions smaller than 20 mm (94.6% vs. 70.7%; p=0.006), lesions located in the peripheral third of the lung field (95.1% vs. 71.4%; p=0.005) and lesions invisible on P-A radiographs (90.0% vs. 41.7%; p=0.026). Conclusion VBN improves the diagnostic yield when combined with R-EBUS to assess lesions exhibiting involved bronchi on CT images.
TL;DR: HFNC therapy showed a good compliance and the improvement of the physiologic parameters in an adult population, and the failure to improve oxygenation within 24 hours was a useful predictor of intubation.
Abstract: Objective High-flow nasal cannula (HFNC) therapy is an oxygen delivery system. However, evidence regarding the clinical applications of HFNC is still emerging. We herein evaluated the clinical predictors of HFNC therapy success for adult patients with acute hypoxemic respiratory failure. Methods We retrospectively reviewed the medical records of the subjects with acute hypoxemic respiratory failure supported by HFNC therapy in the medical intensive care unit between July 2011 and March 2013. Therapy success was defined as the avoidance of intubation. The patients' baseline characteristics and the serial changes in the respiratory parameters after HFNC therapy at 1 and 24 hours were measured. Results Of the 75 eligible patients, 62.7% successfully avoided intubation. Overall, HFNC therapy significantly improved the physiologic parameters, such as partial pressure of arterial oxygen (PaO2), saturation of arterial oxygen (SaO2), respiratory rate (RR), and heart rate (HR), throughout the first 24 hours. After the adjustment for the other clinical variables, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), cardiogenic pulmonary edema, and PaO2 improvement at 1 and 24 hours were associated with therapy success. The overall intensive care unit (ICU) mortality was 25.3%. However, out of 37.3% of the patients who required intubation, the ICU mortality in this proportion of patients was 67.9%. The ICU mortality in the therapy failure group was associated with the use of a vasopressor and a limited PaO2 improvement at 1 hour. Conclusion HFNC therapy showed a good compliance and the improvement of the physiologic parameters in an adult population. The failure to improve oxygenation within 24 hours was a useful predictor of intubation. Among the failure group, the vasopressor use and failed oxygenation improvement were associated with ICU mortality.
TL;DR: Although CT and MRI are considered to be gold standard modalities for diagnosing psoas abscess, both methods can fail to notice this condition in its early stage.
Abstract: Objective Patients diagnosed with psoas abscess have a high mortality rate. The major cause of its poor prognosis is delayed treatment. Therefore, making a correct diagnosis rapidly is important. Both computed tomography (CT) and magnetic resonance imaging (MRI) are considered to be the gold standards as imaging modalities that have a high sensitivity for detecting psoas abscess. There have been few reports regarding the limitations of these methods, but psoas abscess in its early stage may go undetected by CT and MRI. Methods Detection of psoas abscess by CT and MRI was investigated in the present study through a retrospective review of 15 patients in whom psoas abscess was diagnosed during a course of ten years at our hospital. Results In all patients, psoas abscess was diagnosed by at least a plain CT, enhanced CT, and/or plain MRI. The interval between the onset of symptoms and diagnosis was 20.9±17.9 days (mean ± standard deviation). In three patients, repeat imaging identified a psoas abscess, whereas initial imaging failed to detect it. The overall sensitivity of plain CT, enhanced CT, and plain MRI for psoas abscess was 78%, 86%, and 88%, respectively. From six days after the onset of symptoms, the sensitivity of each modality was 100%, while the sensitivity from day one to five days was only 33%, 50%, and 50%, respectively. Conclusion Although CT and MRI are considered to be gold standard modalities for diagnosing psoas abscess, both methods can fail to notice this condition in its early stage.
TL;DR: Additional revision of the current diagnostic criteria, including severity grading, will be needed in the future for Japanese patients with AIH.
Abstract: Autoimmune hepatitis (AIH) is thought to be associated with various genetic and immunological abnormalities. Concerning the pathogenesis of AIH, increasing attention has been paid to genome-wide association studies, toll-like receptors and Treg/Th17 balance. For Japanese patients with AIH, novel diagnostic guidelines have been proposed in view of the differential clinical features between Japanese and Caucasian patients. However, the diagnosis of some patients in acute hepatitis phase is not easy. Histologically, centrilobular necrosis without portal inflammation is particularly characteristic in the acute hepatitis phase. Some patients become resistant to steroid therapy and have a very poor prognosis once they progress to acute hepatic failure. Therefore, additional revision of the current diagnostic criteria, including severity grading, will be needed in the future.
TL;DR: The overall outcomes of critically ill patients with rheumatic diseases are impaired compared to that observed in other patient groups, however, there were no significant differences in outcomes between the different rhematic disease groups or based on the use of immunosuppressive therapy in this study.
Abstract: Objective To assess the outcomes in a large cohort of patients suffering from rheumatic diseases admitted to the ICU of a tertiary university medical center. Methods A retrospective chart analysis was performed in 108 patients suffering from various rheumatic diseases and the outcomes, including morbidity and mortality, were assessed in relation to the underlying diseases, treatments and complications. Results Overall, 48 patients with rheumatoid arthritis, five patients with spondyloarthritis, 14 patients with vasculitis, 30 patients with connective tissue diseases and 11 patients suffering from other rheumatologic conditions were admitted to the intensive care unit (ICU). The reasons for ICU admission included infection (30%), cardiovascular complications (22%), gastrointestinal problems (18%), endocrinological disorders (7%), neurological complications (2%) and others (3%). A total of 4% of the admitted patients required close monitoring and 14% suffered from acute exacerbation of the underlying rheumatic disease. The ICU mortality rate was 16%, whereas the overall hospital mortality rate was 20%. Fatal outcomes were related to exacerbation of the rheumatic disease in 14% of the patients, infectious complications in 46% of the patients and other reasons in 41% of the patients. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality. Conclusion The overall outcomes of critically ill patients with rheumatic diseases are impaired compared to that observed in other patient groups. However, there were no significant differences in outcomes between the different rheumatic disease groups or based on the use of immunosuppressive therapy in this study. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.
TL;DR: Uninterrupted dabigatran therapy in CA for AF thus may be a safe and effective anticoagulant therapy, and appears to be closely similar to continuous warfarin; however, it is essential to pay close attention to the APTT values when using dabig atran during CA.
Abstract: Objective Uninterrupted oral warfarin strategy has become the standard protocol to prevent complications during catheter ablation (CA) for the treatment of atrial fibrillation (AF). However, little is known about the safety and efficacy of uninterrupted dabigatran therapy in patients undergoing CA for AF. Therefore, this study investigated the safety and efficacy of uninterrupted dabigatran therapy and compared the findings with those for uninterrupted warfarin therapy. Methods Bleeding and thromboembolic events during the periprocedural period were evaluated in 363 consecutive patients who underwent CA for AF at Nagoya University Hospital, and received uninterrupted dabigatran (n=173) or uninterrupted warfarin (n=190) for periprocedural anticoagulation. Results A total of 27 (7%) patients experienced either bleeding or thromboembolic complications. Major bleeding complications occurred in 2 (1%) patients in the dabigatran group (DG) and 2 (1%) patients in the warfarin group (WG). Eight (5%) patients in the DG and 9 (5%) patients in the WG experienced groin hematoma, a type of minor bleeding complication. Meanwhile, no patient in the DG and 1 (1%) in the WG developed cerebral ischemic stroke. Overall, there was no significant difference between the groups for any category. The activated partial thromboplastin time (APTT) independently predicted periprocedural complications in the DG. Conclusion Uninterrupted dabigatran therapy in CA for AF thus may be a safe and effective anticoagulant therapy, and appears to be closely similar to continuous warfarin; however, it is essential to pay close attention to the APTT values when using dabigatran during CA.
TL;DR: The Candida species and antifungal resistance profiles in patients with ICUAC were similar to non-ICUAC patients, but led to worse outcomes, and the protective and risk factors for death may be relevant for the clinical management of patients with candidemia in ICU and non- ICU settings.
Abstract: OBJECTIVE The burden of candidemia is shifting from intensive care units (ICU) to non-ICU settings. This study aimed to define the differences in epidemiology and predictors of death between ICU-acquired candidemia (ICUAC) and non-ICUAC. METHODS We conducted a retrospective study of 80 patients with ICUAC and 147 patients with non-IUCAC at five hospitals. RESULTS The distribution of Candida species and resistance to antifungal agents did not differ between the ICUAC and non-ICUAC groups. ICUAC patients received more echinocandins and less triazoles, as well as more adequate antifungal therapy than non-ICUAC patients (all p<0.05). ICUAC patients had a significantly higher average acute physiology and chronic health evaluation (APACHE) II score (21.0±7.9 vs. 17.8±8.6; p<0.01), Sequential Organ Failure Assessment score (9.2±5.5 vs. 7.4±3.9; p<0.05) and day-90 mortality rate (52.5% vs. 36.7%; p<0.05) when compared to non-ICUAC patients. Using a multivariate logistic analysis, adequate antifungal therapy was found to be the only protective factor for death in both groups. Respiratory failure supported with invasive mechanical ventilation, renal failure supported with replacement therapy and an APACHE II score ≥20 were independent predictors of death in ICUAC patients, while age ≥60 years, concurrent bacteremia and APACHE II score ≥20 were independent predictors of death in non-ICUAC patients. CONCLUSION The Candida species and antifungal resistance profiles in patients with ICUAC were similar to non-ICUAC patients, but led to worse outcomes. The protective and risk factors for death may therefore be relevant for the clinical management of patients with candidemia in ICU and non-ICU settings.
TL;DR: There was a significant overall correlation between prehospital delay and the National Institute of Health Stroke Scale scores and public education is therefore necessary to encourage early hospital visitation even with the appearance of mild symptoms.
Abstract: OBJECTIVE Prehospital delay is the major cause of treatment delay in stroke. This study was conducted to clarify the contribution of specific stroke-related symptoms to prehospital delay. METHODS A consecutive series of 469 patients hospitalized within 2 weeks of stroke onset was collected. In this study, prehospital delay was defined as the time interval from recognition of stroke-related symptoms to hospital arrival. The prevalence of each symptom or sign and prehospital delay were analyzed. RESULTS Weakness of the lower limb (43.5%) was the most common symptom followed by weakness of the upper limb (37.1%) and dysarthria (31.6%). Conversely, the most common sign was weakness of the upper limb (54.1%) followed by dysarthria (53.3%), weakness of the lower limb (53.1%), and sensory disturbance (39.0%). The presence of confusion/decreased level of consciousness (p<0.001), aphasia (p<0.001), headache (p=0.017), and nausea/vomiting (p=0.035) were associated with earlier hospital visitation compared with the absence of these symptoms in univariate analyses. Conversely, the presence of sensory disturbance (p=0.0017) and vertigo/dizziness (p=0.044) were associated with a significant delay in hospital visitation compared with the absence of these symptoms. There was a discrepancy in the prevalence between symptoms recognized by the patients or bystanders and signs diagnosed by the physicians. CONCLUSION There was a significant overall correlation between prehospital delay and the National Institute of Health Stroke Scale scores. Public education is therefore necessary to encourage early hospital visitation even with the appearance of mild symptoms.
TL;DR: To differentiate between true CoCC (cholangiole origin) and pseudo-CoCC (interlobular duct origin), assessing the size of the cancer duct, positivity for c-Kit and coexistence of an ordinary ICC component is useful.
Abstract: Cholangiolocellular carcinoma (CoCC) is categorized as a different entity from ordinary intrahepatic cholangiocarcinoma (ICC) due to its unique clinical, radiological and histological features. The lesion is supposed to originate from cholangioles, where hepatic stem/progenitor cells exist. However, the interlobular duct is also speculated to be the origin of CoCC. According to the findings of morphometric and immunohistochemical studies, CoCC closely resembles the interlobular duct. The unique clinical and pathological features of this disease can also be explained by the interlobular duct origin theory. The malignant counterparts of cholangioles and interlobular ducts have been categorized as CoCC to date. In order to differentiate between true CoCC (cholangiole origin) and pseudo-CoCC (interlobular duct origin), assessing the size of the cancer duct, positivity for c-Kit and coexistence of an ordinary ICC component is useful.
TL;DR: A leukemia patient who developed hepatitis E seven months after undergoing a transfusion with contaminated blood products was unable to eliminate the virus due to immunosuppression following chemotherapy and the administration of steroids.
Abstract: We herein report the case of a leukemia patient who developed hepatitis E seven months after undergoing a transfusion with contaminated blood products. The latency period in this case was significantly longer than that of typical hepatitis E. Recently, chronic infection with hepatitis E virus (HEV) genotype 3 has been reported in immunocompromised patients. There is a possibility that our patient was unable to eliminate the virus due to immunosuppression following chemotherapy and the administration of steroids. The prevalence of HEV in healthy Japanese individuals is relatively high and constitutes a critical source of infection via transfusion. Hepatitis E is an important post-transfusion infection, and immunocompromised patients may exhibit a long latency period before developing the disease.
TL;DR: The evidence for the role of thyroid dysfunction and TSH abnormality in CVD pathogenesis is summarized and the possible underlying molecular mechanisms of TSH-mediated cardiovascular pathology are explored in hopes of providing better therapeutic strategies for the patients with deregulated TSH.
Abstract: Thyroid hormone plays an important role in regulating the lipid and glucose metabolism. Previously, much attention has been drawn to define the pathophysiological relationship between thyroid dysfunction and the incidence of cardiovascular diseases (CVDs). While the conditions of overt hypothyroidism and subclinical hypothyroidism were both emphasized, the association between CVD risks and the deregulated circulating thyroid-stimulating hormone (TSH) level remains to be elucidated. Nevertheless, multiple TSH-mediated physiological adaptations, including alteration of the serum lipids, body mass index, blood pressure and insulin sensitivity, have led to the difficulty of clearly examining the association between the TSH level and CVD prevalence. The current review aims to 1) summarize the evidence for the role of thyroid dysfunction and TSH abnormality in CVD pathogenesis and 2) explore the possible underlying molecular mechanisms of TSH-mediated cardiovascular pathology in hopes of providing better therapeutic strategies for the patients with deregulated TSH.
TL;DR: The clinical features of three patients with anti-muscle-specific tyrosine kinase (MuSK) antibody-positive myasthenia gravis, which was initially difficult to distinguish from amyotrophic lateral sclerosis (ALS), appeared to be more rapid than that of ALS.
Abstract: We herein investigated the clinical features of three patients with anti-muscle-specific tyrosine kinase (MuSK) antibody-positive myasthenia gravis (MG), which was initially difficult to distinguish from amyotrophic lateral sclerosis (ALS). The patients exhibited dropped head syndrome or dysphagia as initial symptoms. Although their clinical findings were compatible with the revised El Escorial Criteria for ALS, their progression appeared to be more rapid than that of ALS. Both the edrophonium and repetitive nerve stimulation tests yielded negative results, and diurnal fluctuation was not confirmed. The patients were ultimately diagnosed with anti-MuSK antibody-positive MG. We therefore recommend the measurement of anti-MuSK antibodies when encountering such cases.
TL;DR: This case indicates that continuing anti-TNF therapy may be necessary to prevent IRIS in patients who develop TB, particularly disseminated TB, during the course of anti- TNF therapy.
Abstract: A 64-year-old neurologically asymptomatic woman with rheumatoid arthritis who was treated with the tumor necrosis factor (TNF)-α antagonist adalimumab developed disseminated tuberculosis (TB) After receiving anti-TB therapy and discontinuing adalimumab, she exhibited paradoxical worsening due to immune reconstitution inflammatory syndrome (IRIS) with the appearance of meningitis and brain tuberculomas This case indicates that continuing anti-TNF therapy may be necessary to prevent IRIS in patients who develop TB, particularly disseminated TB, during the course of anti-TNF therapy In addition, careful screening for central nervous system (CNS) TB should be performed prior to the initiation of therapy, as even neurologically asymptomatic patients can develop CNS manifestations of IRIS
TL;DR: The incidence of HCC can be reduced by phlebotomy treatment, which should be performed in patients with chronic hepatitis C not receiving or not responding to antiviral therapy, thus suggesting protection against the development of H CC.
Abstract: OBJECTIVE To determine the impact of phlebotomy on the laboratory values and the incidence of hepatocellular carcinoma (HCC) in patients with hepatitis C. METHODS Study patients with chronic hepatitis C were treated with glycyrrhizin injection and oral ursodeoxycholic acid and either with (n=52) or without (n=50) phlebotomy during the period of 2005-2012. Six phlebotomized patients had previously received interferon therapy and were subsequently excluded from the data analysis. The serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase, lactate dehydrogenase, ferritin, iron and albumin, as well as the hemoglobin concentration, platelet count and prothrombin time, were determined. We compared the long-term outcomes based on the incidence of HCC and laboratory values, including the baseline serum ferritin levels, in patients treated with versus without phlebotomy. RESULTS In the phlebotomy group, the mean AST and ALT levels decreased significantly at each one-year interval over five years (p<0.01), whereas the platelet counts did not. The incidence of HCC in the phlebotomized patients was significantly lower than that observed in the patients treated without phlebotomy: 10.3% vs. 43.7%, respectively, during the 8-year observation period (p=0.04). The incidence of HCC was also lower in the phlebotomized patients with a normal baseline ferritin level: 0.0% vs. 36.0% in the matched subgroup treated without phlebotomy at year 8. Phlebotomy offered a risk ratio of 0.13, thus suggesting protection against the development of HCC. CONCLUSION The incidence of HCC can be reduced by phlebotomy treatment, which should be performed in patients with chronic hepatitis C not receiving or not responding to antiviral therapy.
TL;DR: The case of a 78-year-old man with AMI who had a history of paroxysmal atrial fibrillation and transthoracic echocardiography revealed a moderately sized LVT in the apex, which subsequently disappeared after 18 days of treatment with dabigatran demonstrates that dabig atran may represent an alternative to warfarin as a therapeutic option in patients with LVT after AMI.
Abstract: Left ventricular thrombus (LVT) after acute myocardial infarction (AMI) is a risk factor for embolic complications. Although warfarin has traditionally been used to treat LVT, it has relevant disadvantages that limit its use. We herein describe the case of a 78-year-old man with AMI who had a history of paroxysmal atrial fibrillation. Following 10 days of urgent coronary reperfusion therapy, transthoracic echocardiography revealed a moderately sized LVT in the apex, which subsequently disappeared after 18 days of treatment with dabigatran. This case demonstrates that dabigatran may represent an alternative to warfarin as a therapeutic option in patients with LVT after AMI.
TL;DR: Reducing the consumption of miso soup and Japanese pickles may be an effective approach for decreasing the level of dietary salt intake in the general Japanese population, although not in octogenarians or nonagenarians.
Abstract: OBJECTIVE: In Japan, reducing the consumption of miso soup and Japanese pickles, both traditional Japanese dishes, is recommended in order to decrease dietary salt intake. With the Westernization of dietary habits, however, these dishes are now consumed less frequently, and thus a reduction in their effect on sodium intake is suspected. This study examined cross-sectional associations between the frequency of intake of miso soup and Japanese pickles and the estimated 24-hour urine sodium excretion using data obtained from health examination surveys conducted in 2013 in Sado City, Japan. METHODS: The level of daily salt intake was estimated based on spot urine sodium and creatinine measurements. The frequency of intake of miso soup and Japanese pickles was determined using a self-reported questionnaire. Multiple linear regression models were used to assess associations. RESULTS: Among a total of 8,821 participants (3,956 men; age range, 19-97 years), the mean daily salt intake was 9.4 g/day. The frequency of intake of miso soup and Japanese pickles increased with age and was associated with the level of daily salt intake (p for trend <0.0001). A linear regression model analysis adjusted for age, sex, body mass index, hypertension, diabetes, hypercholesterolemia and chronic kidney disease revealed that daily salt intake was associated with the frequency of intake of miso soup (p<0.0001) and Japanese pickles (p<0.0001) in all age groups, except those ≥ 80 years of age. CONCLUSION: These findings suggest that reducing the consumption of miso soup and Japanese pickles may be an effective approach for decreasing the level of dietary salt intake in the general Japanese population, although not in octogenarians or nonagenarians.
TL;DR: This review summarizes the current methods for the functional assessment of vascular damage (e.g., assessment of endothelial function, measurement of pulse wave velocity, and pressure wave analysis) and describes the association between vascular dysfunction and chronic cardio-renal syndrome.
Abstract: This review summarizes the current methods for the functional assessment of vascular damage (e.g., assessment of endothelial function, measurement of pulse wave velocity, and pressure wave analysis) and describes the association between vascular dysfunction and chronic cardio-renal syndrome. Vascular dysfunction may contribute to the development and progression of heart failure. Additionally, vascular dysfunction, especially increased arterial stiffness and abnormal pressure wave reflection and central hemodynamics, has been reported to accelerate renal function decline. Furthermore, renal dysfunction worsens vascular pathophysiological abnormalities. Therefore, the functional assessment of vascular damage may be useful in the management of cardio-renal syndrome.