SHORTNESS OF BREATH DURING DIALYSIS—A ROLE OF BICARBONATE IN DIALYSIS FLUID?

Occasionally dialysis patients show symptoms that indicate intolerance in the way dialysis is delivered. This paper describes two cases of transient shortness of breath during the initial treatments after starting online haemodiafiltration (HDF). Our actions to deal with these symptoms focused on reducing the bicarbonate gain during the first phase of the dialysis treatment. As the symptoms gradually disappeared we hypothesise that the bicarbonate concentration in the dialysis fluid may play an important role for the development of shortness of breath and hypoxemia during HDF treatments.     

3‐(2,4‐Dimethoxybenzylidene)‐anabaseine: A promising candidate drug for Alzheimer's disease?

3‐(2,4‐Dimethoxybenzylidene)‐anabaseine is an analog of the paralytic alkaloid, anabaseine, from the ribbon worms Amphiporus sp., that shows numerous properties, in particular an agonist activity on alpha7 nicotinic acetylcholine receptors. This article reviews these properties and explains to what extent they could be valuable to control symptomatology and/or neurodegeneration in Alzheimer's disease. Geriatr Gerontol Int 2012; 12: 365–371 .     

Internet use by patients ‐ A shift in power?

Traditionally, the patient has relied on health care professionals for advice and knowledge. The unprecedented access to information offered by the Internet may challenge this relationship. To investigate this, a questionnaire was sent to 640 transplant patients. 24 responded positively and were interviewed to see if the information they found on the net had been useful, in negotiating a change in treatment or as support. Internet use was associated with younger males who had access to the net at work. 22 had found useful information although only 1 patient had negotiated a change in treatment as a result. As the Internet becomes universally available, patients will be empowered to have a larger role in maintaining their health, and support groups will be better able to help patients. To prepare to deal with this avalanche of information we need to develop a system of accreditation of Internet sites, to create our own sites and to collaborate with patient support groups.     

Cough symptoms in children aged 5–14 years in Sydney,Australia: non‐specific cough or unrecognized pertussis?

OBJECTIVE: The aim of this study was to estimate the community prevalence of coughing symptoms, consistent with surveillance definitions for pertussis, and doctor-diagnosed pertussis in children aged 5-14 years. METHODOLOGY: A telephone survey of a cross-sectional community sample of parents regarding their child's cough symptoms in the previous 12 months was undertaken in a representative Australian urban region. RESULTS: In 2020 interviews, parents reported that 22% of children had a cough lasting 2 weeks or longer in the preceding 12 months, and 14% (283) had additional symptoms meeting the Centers for Disease Control (CDC) case definition for pertussis. A cough meeting the case definition was significantly more commonly reported by parents of children aged 5-9 years (17%; P < 0.001) but reported exposure to diagnosed pertussis in such cases was significantly more common in children aged 10-14 years (4.3%; odds ratio 12.8; P < 0.01). Parents of 90% of children meeting the CDC case definition sought medical advice. A diagnosis of pertussis was reported in only 1.2% of cases, which extrapolates to an annual incidence of doctor-diagnosed pertussis of 347/100,000 (95% confidence interval, 140-714 per 100,000). This contrasts with 29/100,000 notified cases in the same age group, time period and geographic area. CONCLUSION: Cough episodes meeting a clinical case definition for pertussis commonly used in surveillance are reported by a high proportion of carers of school-aged children in Australia. The majority of children who met the CDC and Australian case definitions for pertussis and sought medical attention were not identified as potentially having pertussis, suggesting underdiagnosis of pertussis. Even if less than half of this is true pertussis, the potential impact in terms of transmission of pertussis in the community is likely to be high. The reported incidence of doctor-diagnosed disease estimated from this survey was at least five and up to 20 times the official notification rate. More work needs to be done in raising awareness among medical practitioners of pertussis as a differential diagnosis in older children and adolescents with cough.     

Low‐grade systolic murmurs in healthy middle‐aged individuals: innocent or clinically significant? A 35‐year follow‐up study of 2014 Norwegian men

Abstract. Bodegard J, Skretteberg PT, Gjesdal K, Pyörälä K, Kjeldsen SE, Liestøl K, Erikssen G, Erikssen J (Oslo University Hospital, Oslo; University of Oslo, Oslo; University of Eastern Finland, Kuopio; University of Oslo, Oslo; Oslo University Hospital, Oslo). Low‐grade systolic murmurs in healthy middle‐aged individuals: innocent or clinically significant? A 35‐year follow‐up study of 2014 Norwegian men. J Intern Med 2012; 271 : 581–588. Objective. To determine whether a low‐grade systolic murmur, found at heart auscultation, in middle‐aged healthy men influences the long‐term risk of aortic valve replacement (AVR) and death from cardiovascular disease (CVD). Setting and subjects. During 1972–1975, 2014 apparently healthy men aged 40–59 years underwent an examination programme including case history, clinical examination, blood tests and a symptom‐limited exercise ECG test. Heart auscultation was performed under standardized conditions, and murmurs were graded on a scale from I to VI. No men were found to have grade V/VI murmurs. Participants were followed for up to 35 years. Results. A total of 1541 men had no systolic murmur; 441 had low‐grade murmurs (grade I/II) and 32 had moderate‐grade murmurs (grade III/IV). Men with low‐grade murmurs had a 4.7‐fold [95% confidence interval (CI) 2.1–11.1] increased age‐adjusted risk of AVR, but no increase in risk of CVD death. Men with moderate‐grade murmurs had an 89.3‐fold (95% CI 39.2–211.2) age‐adjusted risk of AVR and a 1.5‐fold (95% CI 0.8–2.5) age‐adjusted increased risk of CVD death. Conclusions. Low‐grade systolic murmur was detected at heart auscultation in 21.9% of apparently healthy middle‐aged men. Men with low‐grade murmur had an increased risk of AVR, but no increase in risk of CVD death. Only 1.6% of men had moderate‐grade murmur; these men had a very high risk of AVR and a 1.5‐fold albeit non‐significant increase in risk of CVD death.     

The HLA‐A1‐B8 haplotype hitchhiking with the hemochromatosis mutation: does it affect the phenotype?

BACKGROUND: Hemochromatosis is a recessively inherited disorder caused by a point mutation, C282Y of the HFE gene on chromosome 6p21.3 near the human leukocyte antigen (HLA) locus. It is unknown why some homozygotes develop a severe iron loading, while others do not. A recent study suggested that the A1-B8 haplotype may be associated with higher iron storage. METHODS: We studied HLA haplotypes of 85 probands, 31 females and 54 males, and their family members from a rural population where A1-B8 was common. We tested the hypothesis of a modifying effect of the A1-B8 haplotype. RESULTS: Most homozygotes had a mild phenotypic expression, and were often detected accidentally because of a laboratory routine including transferrin saturation. A disease-related morbidity [serum alanine aminotransferase (S-ALT) > 43 U] was present in 40%.Three had porphyria cutanea tarda. Two brothers with A1-B8 died of bronze diabetes, probably caused by co-inheritance of congenital spherocytosis. In females there were no significant differences in phenotypic expression between groups with regard to the presence or absence of A1-B8. Two females, <50 yr of age, with this haplotype had iron deficiency. Males with two copies of A1-B8 had significantly lower serum ferritin (P = 0.02) values than those without. Those with one A1-B8 haplotype were not different from those without. In men without A1-B8, those carrying HLA-A3 were not phenotypically different from those without this ancestral haplotype. CONCLUSION: The A1-B8 haplotype hitchhiking with the C282Y mutation was not associated with a more efficient iron absorption. On the contrary, males with double copies of this haplotype expressed a milder phenotype, possibly an effect of local (environmental and/or genetic) factors.     

The “Short‐Coupled” Variant of Right Ventricular Outflow Ventricular Tachycardia: A Not‐So‐Benign Form of Benign Ventricular Tachycardia?

Idiopathic ventricular tachycardia (VT) originating from the right ventricular outflow tract (RVOT-VT) and idiopathic RVOT-extrasystoles are generally considered benign arrhythmias. We described three cases who originally presented with typical "benign looking" RVOT-extrasystoles or RVOT-VT but developed malignant polymorphic VT during follow-up. The unusual aspect of their RVOT-extrasystoles was their coupling interval, which appears to be intermediate between the ultra-short coupling interval of idiopathic VF and the long coupling interval seen in the truly benign RVOT-VT.     

Does an undetectable rhTSH‐stimulated Tg level 12 months after initial treatment of thyroid cancer indicate remission?

Objectives Routine monitoring after the initial treatment of differentiated thyroid cancer (DTC) includes periodic cervical ultrasonography (US) and measurement of serum thyroglobulin (Tg) during thyrotrophin (TSH) suppression and after recombinant human TSH (rhTSH) stimulation. The aim of our study was to evaluate the utility of repeated rhTSH‐stimulated Tg measurements in patients with DTC who have had no evidence of disease at their initial rhTSH stimulation test performed 1 year after the treatment. Material and methods A retrospective chart review of 278 patients with DTC who had repeated rhTSH stimulation testing after an initial undetectable rhTSH‐stimulated serum Tg level. Results The number of rhTSH stimulation tests performed on individual patients during the follow‐up period (3–12 years, mean 6·3) varied from two to seven. Biochemical and/or cytological evidence of potential persistent/recurrent disease based on detectable second or third rhTSH‐stimulated Tg values and US findings was observed in 11 (4%) patients. Subsequent follow‐up data revealed that in five cases, the results of the second stimulation were false positive, in one case – false negative. Combined with the negative neck US, the negative predictive value for disease‐free survival was 98% after the first undetectable rhTSH‐stimulated Tg and 100% after the second one. Conclusions In patients with DTC, the intensity of follow‐up should be adjusted to new risk estimates evolving with time. The first rhTSH‐stimulated Tg is an excellent predictor for remission, independent of clinical stage at presentation. Second negative rhTSH‐Tg stimulation is additionally reassuring and can guide less aggressive follow‐up by the measurement of nonstimulated Tg and neck US every few years.