Paradoxical response in HIV-negative patients with pleural tuberculosis: a retrospective multicentre study

OBJECTIVE

To evaluate the incidence, clinical characteristics and predicting factors for the development of paradoxical response in human immunodeficiency virus negative patients with isolated pleural tuberculosis (TB).

DESIGN

A multicentre, retrospective cohort study including 458 patients who were diagnosed and treated with isolated pleural TB between March 2005 and February 2010.

RESULTS

Paradoxical response developed in 72 patients (16%) with isolated pleural TB. The mean time to development of paradoxical response was 8.8 ± 6.4 weeks after initiation of anti-tuberculosis treatment. The main presentation of paradoxical response was aggravation of pre-existing pleural effusion in 58 patients (81%). However, the majority of the patients who developed paradoxical response had no associated symptoms (n = 49, 68%). In multiple logistic regression analysis, development of paradoxical response was independently associated with the proportion of eosinophils (adjusted OR 1.293, 95%CI 1.077-1.553) and protein concentrations (adjusted OR 0.590, 95%CI 0.397-0.878) in the pleural fluid at the time of diagnosis.

CONCLUSION

Paradoxical response developed in 16% of the patients approximately 2 months after initiation of anti-tuberculosis treatment, presenting with aggravation of pre-existing pleural effusion. Development of paradoxical response was associated with the proportion of eosinophils and protein concentrations in the pleural fluid at the time of diagnosis.

Pulmonary artery pressure in chronic obstructive pulmonary disease without resting hypoxaemia

BACKGROUND

Chronic obstructive pulmonary disease (COPD) can lead to pulmonary hypertension and cor pulmonale, which are predictors of mortality.

OBJECTIVE

To identify predictors of increased pulmonary artery pressure (PAP) in COPD patients without resting hypoxaemia, and to characterise COPD patients with increased PAP.

DESIGN

A study of 117 COPD patients from the Korean Obstructive Lung Disease (KOLD) cohort who had measurable tricuspid regurgitant flow under transthoracic Doppler echocardiography and no resting hypoxaemia.

RESULTS

The mean patient age was 67 years. Mean forced expiratory volume in 1 second (FEV(1)) was 47% predicted, mean haemoglobin (Hb) concentration was 145 g/l and mean systolic PAP (sPAP) was 33 mmHg. Multiple linear regression analysis showed that Hb was the only factor independently associated with sPAP (beta = -1.752, P = 0.005). Cluster analysis using FEV(1)% predicted, sPAP and Hb concentration as variables indicated three patient clusters: Cluster 1 (n = 36; mean FEV(1) 44% predicted, mean sPAP 39 mmHg, mean Hb 132 g/l), Cluster 2 (n = 45; FEV(1) 35% predicted, sPAP 31 mmHg, Hb 154 g/l), and Cluster 3 (n = 36; FEV(1) 65% predicted, sPAP 29 mmHg, Hb 148 g/l).

CONCLUSION

Elevated PAP was linked to low haemoglobin levels in COPD without resting hypoxaemia.

Morphological study of the proximal boundary of the flexor retinaculum and of its constituent parts

The proximal boundary of the flexor retinaculum is not readily demarcated, and previous reports of three distinct regions of the flexor retinaculum were not consistent with the authors' experience. This study was undertaken to clarify the proximal boundary and the constituent parts of the flexor retinaculum. A total of 56 cadaveric wrists were used in the study. The proximal boundary of the flexor retinaculum was identified by a change in thickness and colour of the longitudinally sectioned surface of the continuous membranous sheet of the flexor retinaculum and antebrachial fascia. Steel wires were placed on the proximal and distal boundaries, and anteroposterior radiographic images were taken. MRI was carried out before dissection or serial section. The locations of the proximal and distal boundaries of the flexor retinaculum varied. The flexor retinaculum was comprised of two parts, which were distinguishable by thickness and transparency. These two parts were also identified on MR images and by light microscopy.

Different therapeutic responses in chronic obstructive pulmonary disease subgroups

SETTING

Eleven referring hospitals in South Korea.

OBJECTIVE

To compare therapeutic responses in chronic obstructive pulmonary disease (COPD) subgroups, classified by diffusing capacity of the lung for carbon monoxide (DL(CO)) and lung volume.

DESIGN

A total of 130 stable male COPD patients were classified into four subgroups according to baseline DL(CO) and residual volume/total lung capacity (RV/TLC) ratio. We compared therapeutic responses to short acting β(2)-agonist (SABA) and 3-month combined inhalation of long-acting β(2)-agonist (LABA) and corticosteroid among patients with these subgroups.

RESULTS

Among the 130 COPD patients, 41 (31.5%) had normal DL(CO) and RV/TLC, 28 (21.5%) low DL(CO) and normal RV/TLC, 31 (23.8%) normal DL(CO) and high RV/TLC, and 30 (23.1%) low DL(CO) and high RV/TLC. The normal DL(CO)/high RV/TLC subgroup showed a significantly larger flow response (changes in forced expiratory volume in 1 s) to salbutamol than the normal DL(CO)/RV/TLC subgroups, and a larger volume response (changes in forced vital capacity) than the two normal RV/TLC subgroups. The normal DL(CO)/high RV/TLC subgroup also showed significantly larger flow and volume response to 3-month combined inhalation of LABA and corticosteroid than the two normal RV/TLC subgroups.

CONCLUSION

COPD subgroups classified by DL(CO) and RV/TLC may have different pulmonary function responses to pharmacological treatment.

Perforator-based Pacman flap in the plantar region

Numerous techniques have been used to reconstruct the plantar area to preserve the function of both recipient and donor sites and to produce satisfying results. We describe a method of plantar soft tissue reconstruction using a perforator-based Pacman flap to cover the circular defects after wide excision in cases of plantar malignancy. Eight patients who underwent plantar reconstruction between September 2008 and February 2011 were reviewed in the present study. Of the 8 patients, 6 had malignant melanoma, 1 had basosquamous basal cell carcinoma, and 1 had squamous cell carcinoma. Medial (5 patients) and lateral (3 patients) plantar artery perforator-based Pacman flaps were used. All flaps provided satisfactory coverage of the soft tissue defects in the plantar region, and all patients achieved a good functional outcome after a mean follow-up of 13 (range 2 to 22) months. The median patient age was 54 (range 26 to 67) years. The median maximum diameter of the circular defects was 40 (range 20 to 70) mm, and the mean operative time was 65 (range 50 to 120) minutes from flap elevation to wound closure. We believe that good functional outcomes and minimal complications can be achieved when the perforator-based Pacman flap is used for plantar reconstruction. Furthermore, the full extent and utility of this method of plantar reconstruction remains to be determined.

Haematic cyst formation after orthognathic surgery

A 34-year-old man suffered from discomfort originating from a mass located in his right zygomatic area. He developed orbital symptoms, such as diplopia, which lasted for 5 months. He also suffered from Crouzon's syndrome and had undergone a Lefort III osteotomy 9 years prior for correction of midfacial hypoplasia. The size of the mass slowly increased and his orbital symptoms developed further, eventually leading to surgical exploration. During the operation, a mass was found near titanium plates which had been used to fix bone segments during a previous surgery. The total mass, including the capsule, was excised. The pathologic report was a chronic haematic cyst with a non-neoplastic collection of blood or blood products that exerted a mass effect in the orbit and adjacent tissues. The causes of haematic cysts are diverse, with trauma being the most common. Although haematic cysts resulting from trauma have been widely reported, there have been few reports on haematic cysts associated with orthognathic surgeries, such as Lefort III osteotomies. This case demonstrates that haematic cysts may be delayed complications of major bone surgery and that surgeons and patients should be aware of this possibility.

Difficult tracheostomy tube placement in an obese patient with a short neck -A case report-

We report a difficult case of tracheostomy in a 34-year-old obese woman with a short neck. The tracheostomy tube placement repeatedly failed because of anatomical changes due to obesity and a short neck, tracheal mucosal swelling due to prolonged intubation, and unexpected false passage; however, it was successfully performed using an endotracheal tube exchanger as a guidewire.

Topographic relationship between the medial intermuscular septum and the ulnar nerve in the upper arm

OBJECT

The authors have observed that the ulnar nerve (UN) passes through the medial intermuscular septum (MIMS) into the posterior compartment of the upper arm in more complicated patterns than those described in anatomy textbooks. Given that these unreported patterns might be related to the idiopathic UN entrapment at the midarm, this study focused on the relationship between the MIMS and the UN.

METHODS

One hundred upper arms were dissected. The site at which the UN pierced the MIMS was analyzed and measured from the medial epicondyle.

RESULTS

The relationship between the MIMS and the UN could be classified into 3 types according to whether the nerve pierced the MIMS and whether it ran through a fibrous tunnel within the septum. The UN pierced the MIMS in the middle third of the upper arm.

CONCLUSIONS

The results of this study are expected to further understanding of the relationship between the MIMS and the UN. They could also be helpful for surgeons aiming to relieve UN entrapment at the midarm, especially in nerve lesions of idiopathic origin.

Acute, fatal postoperative myocardial infarction after laparoscopic cholecystectomy in a cardiac patient -A case report-

This report presents the case of a 63-year-old man who had a myocardial infarction leading to coronary artery bypass graft 2 years earlier who subsequently underwent elective laparoscopic cholecystectomy. After an uneventful operation, the patient developed an acute postoperative myocardial infarction in the recovery room and died 19 days postoperatively. Anesthesiologists should be aware of the rare possibility of acute, fatal postoperative myocardial infarction and consider this complication when they perform the preoperative risk evaluation, anesthesia, and postoperative care for cardiac patients undergoing noncardiac surgery.

Rami Communicans Nerve Block for the Treatment of Symptomatic Schmorl's Nodes -A Case Report-

Histologically, Schmorl's nodes are defined as the loss of nuclear material through the cartilage plate, growth plate, and end plate into the vertebral body. Most Schmorl's nodes are asymptomatic, although there are some reports of symptomatic Schmorl's nodes, which should be treated similarly to vertebral compression fractures, with conservative treatment as the first choice. We report the case that we reduced the pain by blocking the ramus communicans nerve in a patient with Schmorl's node.

Remifentanil-propofol sedation as an ambulatory anesthesia for carpal tunnel release

OBJECTIVE

This prospective study evaluated the use of continuous sedation using propofol and remifentanil when carpal tunnel release (CTR) was performed under local anesthesia.

METHODS

We sedated 60 patients undergoing CTR using local anesthesia with remifentanil at loading and continuous doses of 0.5 µg kg(-1) and 0.05 µg kg(-1)min(-1), respectively, and propofol, using a target controlled infusion (TCI) pump set to a target of 2 µg mL(-1) (group A), or with the same drug doses except that the continuous remifentanil dose was 0.07 µg kg(-1)min(-1) (group B) or 0.1 µg kg(-1)min(-1) (group C).

RESULTS

In group B, the levels of pain when local anesthetics were administered (p = 0.001), intraoperative pain (p < 0.001) and anxiety (p = 0.001) were significantly lower than those of group A. Furthermore, the incidence of adverse events, including desaturation (p < 0.001) and vomiting (p = 0.043), was significantly lower in group B than in group C.

CONCLUSION

Continuous sedation using an appropriate dose of remifentanil and propofol can be used as safe, efficacious ambulatory anesthesia in cases of CTR under local anesthesia, performed using only 2 mL of local anesthetic, with a high degree of patient satisfaction.

Three phenotypes of obstructive lung disease in the elderly

SETTING

Eleven referring hospitals in South Korea.

OBJECTIVE

To classify the phenotypes in elderly subjects with obstructive lung disease (OLD).

METHODS

We analysed 191 subjects aged ≥ 60 years with chronic respiratory symptoms and either obstructive spirometry or bronchial hyperresponsiveness. Factor analysis was performed using commonly measured variables and revealed four significant variables: 1) the ratio of inspiratory capacity to total lung capacity, 2) the total score on the St George's Respiratory Questionnaire, 3) the volume fraction of the lung less than 950 Hounsfield Unit at full inspiration on volumetric computed tomography and 4) post-bronchodilator forced expiratory volume in 1 second (FEV(1)) changes. We performed a cluster analysis on these four variables.

RESULTS

The mean age was 68.5 (± 5.2 SD) years and the mean post-bronchodilator FEV(1) was 52.4% (± 16.5) predicted. Three clusters with the following phenotypes were identified: Cluster 1 included subjects with moderate to severe airflow obstruction and bronchodilator reversibility; Cluster 2 subjects had moderate airflow obstruction without bronchodilator reversibility, and Cluster 3 subjects had severe airflow obstruction without bronchodilator reversibility.

CONCLUSIONS

We identified three phenotypes in elderly subjects with OLD. Follow-up studies are needed to explore the clinical significance of each phenotype.

Association of coronary artery calcification with obstructive sleep apnea and obesity in middle-aged men

BACKGROUND AND AIMS

Obstructive sleep apnea (OSA) and obesity are closely associated, and both have been reported to increase the risk of coronary heart disease. Although obesity is known to be associated with coronary artery calcification (CAC), there is limited information on whether OSA is associated with CAC independent of obesity.

METHODS AND RESULTS

A cross-sectional study examined the association between OSA and CAC among 258 healthy men, ages 40-49 years old, randomly selected from a population-based cohort. All individuals underwent overnight polysomnography and electron-beam computed tomography to measure their apnea-hypopnea index (AHI) and degree of CAC. A logistic regression model including potential cardiovascular risk factors excluding body mass index (BMI) showed that the presence of CAC was significantly greater in the fourth quartile versus the first quartile of AHI severity (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.01-4.86). A multivariate linear regression model excluding BMI also showed that AHI was significantly associated with CAC (P = 0.004). However, this association was no longer significant after adjusting for BMI.

CONCLUSIONS

In our cross-sectional study, even though both OSA and obesity were positively associated with the presence and extent of CAC, only obesity remained a significant independent contributor after an adjustment for potential cardiovascular risk factors, irrespective of OSA.

Continuous infusion of two doses of remifentanil immediately after laparoscopic-assisted vaginal hysterectomy

Background

We evaluated the effect and safety of the immediate postoperative continuous infusion of remifentanil at two doses in patients undergoing laparoscopic-assisted vaginal hysterectomy (LAVH) with alfentanil-based patient-controlled analgesia (PCA).

Methods

The study enrolled 50 ASA physical status 1 or 2 patients scheduled to undergo LAVH. Anesthesia was maintained with sevoflurane-remifentanil-air. At the last skin suture, the sevoflurane was discontinued, and patients were randomized to receive remifentanil 0.05 µg/kg/min (group I) or 0.1 µg/kg/min (group II). PCA was started at the time of eye opening and response to a verbal command. In the recovery room, we monitored the mean arterial blood pressure (MAP), heart rate (HR), respiratory rate (RR), SpO₂, and bispectral index (BIS) at 5-minute intervals. Thirty minutes after starting PCA, the remifentanil was discontinued. Pain was assessed using a visual analog scale (0 = no pain; 100 = the worst possible pain) at 0, 5, 10, and 30 minutes after stopping the remifentanil infusion.

Results

The eye opening time, BIS, MAP, and HR did not differ significantly between the two groups, and pain scores were similar between the two groups. Respiratory depression (SpO₂ < 90% or RR < 8/min) did not occur in group I but did occur in three patients in group II.

Conclusions

Continuous remifentanil infusion (0.05 µg/kg/min) immediately postoperatively with alfentanil-based PCA had a similar effect as a 0.1 µg/kg/min infusion with respect to pain control without side effects. However, special attention must be given to respiratory depression.

A complication of subclavian venous catheterization: extravascular kinking, knotting, and entrapment of the guidewire -A case report-

Various complications of central venous catheterization have been reported, some of which are well-known, while others are described as a sporadic events. We experienced a case of left subclavian venous catheterization complicated by extravascular knotting, kinking, and entrapment of the guidewire and the guidewire was removed surgically. Although minimal resistance was encountered during guidewire insertion, the guidewire was advanced approximately 30 cm. Physicians should be aware of these rare potential complications when a guidewire is advanced if any resistance is encountered.

Current and future disease-modifying therapies in multiple sclerosis

The development of disease-modifying therapies (DMT) in multiple sclerosis (MS) has rapidly evolved over the last few years and continues to do so. Prior to the United States Food and Drug Administration approval of the immunomodulatory agent, interferon-beta1b in 1993, no other drug had been shown to alter the course of the disease in a controlled study of MS. At present, there are five licenced disease-modifying agents in MS - interferon-beta1b, interferon-beta1a, glatiramer acetate, natalizumab and mitoxantrone. All have shown significant therapeutic efficacy in large controlled trials. However, current therapies are only partially effective and are not free from adverse effects. Moreover, available DMTs are overwhelmingly biased in favour of those with relapsing-remitting disease. Effective treatment for progressive MS is severely limited, with only interferon-beta1b and mitoxantrone having licenced use in secondary progressive, but not primary progressive disease. Monoclonal antibodies, such as natalizumab selectively target immune pathways involved in the pathogenic process of MS. Alemtuzumab, daclizumab and rituximab are other notable monoclonal antibodies currently undergoing phase II and III trials in MS. Alemtuzumab has so far shown promising therapeutic benefit in relapsing disease, although immunological adverse effects have been a problem. Oral therapies have the benefit of improved tolerability and patient compliance compared with current parenteral treatments. Cladribine and fingolimod (FTY720) have shown encouraging results in their phase III clinical trials. It is also worth noting the evidence for starting DMT in patients with clinically isolated syndrome, whereby early treatment has shown to delay the onset of clinically definite MS in separate phase III studies.

Inhibition of eNOS/sGC/PKG Pathway Decreases Akt Phosphorylation Induced by Kainic Acid in Mouse Hippocampus

The serine/threonine kinase Akt has been shown to play a role of multiple cellular signaling pathways and act as a transducer of many functions initiated by growth factor receptors that activate phosphatidylinositol 3-kinase (PI3K). It has been reported that phosphorylated Akt activates eNOS resulting in the production of NO and that NO stimulates soluble guanylate cyclase (sGC), which results in accumulation of cGMP and subsequent activation of the protein kinase G (PKG). It has been also reported that PKG activates PI3K/Akt signaling. Therefore, it is possible that PI3K, Akt, eNOS, sGC, and PKG form a loop to exert enhanced and sustained activation of Akt. However, the existence of this loop in eNOS-expressing cells, such as endothelial cells or astrocytes, has not been reported. Thus, we examined a possibility that Akt phosphorylation might be enhanced via eNOS/sGC/PKG/PI3K pathway in astrocytes in vivo and in vitro. Phosphorylation of Akt was detected in astrocytes after KA treatment and was maintained up to 72 h in mouse hippocampus. 2 weeks after KA treatment, astrocytic Akt phosphorylation was normalized to control. The inhibition of eNOS, sGC, and PKG significantly decreased Akt and eNOS phosphorylation induced by KA in astrocytes. In contrast, the decreased phosphorylation of Akt and eNOS by eNOS inhibition was significantly reversed with PKG activation. The above findings in mouse hippocampus were also observed in primary astrocytes. These data suggest that Akt/eNOS/sGC/PKG/PI3K pathway may constitute a loop, resulting in enhanced and sustained Akt activation in astrocytes.

The Mantle Cell Lymphoma International Prognostic Index: Does it work in routine practice?

The Mantle Cell Lymphoma International Prognostic Index (MIPI) combines four factors to differentiate low-, intermediate- and high-risk prognostic groups in advanced mantle cell lymphoma using data from patients treated in clinical trials. To evaluate its use in routine practice, we applied the simplified index retrospectively to 50 consecutive new patients attending our lymphoma service. In the log-rank and multiple comparison statistical tests there was favorable differentiation between survival curves, and particularly between the high- and low-risk groups. We concluded that the MIPI is of value in routine lymphoma practice.