Successful treatment by doxycycline of endocarditis caused by ornithosis.

The case of a 59 year old man with ornithosis endocarditis and a history of contact with pheasants is reported. Treatment with oxytetracycline was not tolerated and so doxycycline was substituted. Over the two year follow up the patient's clinical condition and serial echocardiographic appearances improved and Chlamydia psittaci complement fixation titres returned to normal. Valve replacement was not required.     

Hereditary pheochromocytoma--a family affected by von Hippel-Lindau disease

The authors present a case of a 37 year old male (proband) with a 13 year history of progressive sight impairment leading to blindness and a 4 year history of a mild hypertension. He was incidentally found to have large adrenal tumors after an ultrasound kidney examination. The tumors were confirmed with CT scan and magnetic resonance imaging. A bilateral pheochromocytoma was biochemically demonstrated and successfully removed. The eye diagnosis of angiomatosis retinae von Hippel-Lindau was ascertained after a search of the patient files in other medical departments, which led to a family screening. Proband's brother, having hypertension and a history of a cerebellar astrocytoma operation, was also diagnosed with CT scan to have a bilateral pheochromocytoma. Unfortunately, at the same time he was found to have a large irremovable neuroendocrine pancreatic carcinoma, which caused complications and his eventual death. Both proband and his brother were affected by the same CGG(Arg167)->CAG(Gln) mutation in the exon 3 of the VHL gene. Other living and examined family members were not affected, which was confirmed by negative genetic testing. One year after the pheochromocytoma operation, proband was diagnosed to have a retroperitoneal tumor left to the aorta, clinically silent, with slightly and non-constantly elevated urine norepinephrine and normetanephrine. Metaiodobenzylguanidine scintigraphy showed that it was a paraganglioma. The old CT and magnetic resonance picture review demonstrated that the tumor had already been present at the time of the operation. It was surgically removed and histologically verified. It is a pity that proband had not been sent by his ophthalmologist for an endocrine examination when the eye diagnosis was determined. Affection of the family would have been discovered earlier, and proband's brother might have possibly been saved.     

Use of mental health care by community-dwelling older adults

OBJECTIVES: To examine relationships between perceived need for care, illness characteristics, attitudes toward care, and probability that older adults will use mental health care (MHC). DESIGN: Secondary data analysis. SETTING: The Collaborative Psychiatric Epidemiology Surveys (2001–2003). PARTICIPANTS: One thousand six hundred eighty‐one community‐dwelling adults aged 65 and older. MEASUREMENTS: Self‐reported MHC use and perceived need for care in the previous 12 months, previous year and history of mental illness, history of physical illness, attitudes toward care, and sociodemographic characteristics. RESULTS: Of the entire sample, 6.5% had received some type of MHC in the previous year, although 65.9% of those with major depressive disorder (MDD) and 72.5% with anxiety did not receive MHC. In respondents with previous‐year depression or anxiety, use was less likely for those with low World Health Organization Disability Assessment Scale (WHO‐DAS) self‐care ability. Use was more likely for those with more chronic physical conditions and worse WHO‐DAS cognitive capacity. Seventeen percent of those with perceived need for MHC did not receive it. In respondents with perceived need, subthreshold generalized anxiety disorder was associated with lower likelihood of use. Use was more likely for older respondents and those with more household members, at least a high school education, and better self‐care ability. Forty‐one percent of those who perceived a need for care but did not use it met previous‐year diagnostic criteria for anxiety, and 17% met criteria for MDD. CONCLUSION: Understanding the perceptions that underlie individuals' health care–seeking behavior is an important step toward reducing underuse of MHC by older adults.     

Tachyarrhythmias triggered by swallowing and belching

Three cases with supraventricular tachyarrhythmias related to oesophageal transit are reported. A 61 year old man had episodes of atrial tachycardia on each swallow of food but not liquid; this has been reported only rarely. A 55 year old man had atrial fibrillation initiated by drinking ice cold beverages; this has not been described previously although atrial tachycardia triggered by drinking ice cold beverages has been described once. A 68 year old man had supraventricular tachycardia initiated by belching; this has not been described previously. These cases illustrate the diversity of atrial tachyarrhythmias that can be precipitated by oesophageal stimulation and suggest that what is regarded as a very rare phenomenon may be found more commonly when sought.     

Long-term outcome of patients treated by home mechanical ventilation]

To investigate the long-term survival of 95 patients treated by home mechanical ventilation, we prospectively analyzed the outcomes of their cases (treatments: 34, tracheostomy; 61, non-invasive methods) using the database of the local registration system in Aichi Prefecture. The annual actuarial probability of continuing home mechanical ventilation for the tracheostomized patients was 97.0% in the first year, 79.0% in the second year, 79.0% in the third year, and 69.2% in the fourth year, and those for the patients treated by non-invasive ventilation were 85.6%, 67.9%, 56.8%, and 46.4%, respectively. In comparison with patients with neuromuscular disease, patients with respiratory disease (both tracheostomized and non-tracheostomized) tended to show a lower continuation ratio, but the difference was not statistically significant. These data were comparable to those of previous reports, suggesting that home respiratory care in Aichi Prefecture satisfied the normal standards of quality.     

Effective maintenance of inflammatory bowel disease remission by azathioprine does not require concurrent 5-aminosalicylate therapy.

OBJECTIVES: To assess the effect of 5-aminosalicylate treatment in conjunction with azathioprine on remission maintenance in inflammatory bowel disease patients. METHOD: This retrospective study was based on a total of 186 inflammatory bowel disease patients (104 with Crohn's disease; 82 with ulcerative colitis), who were stable on azathioprine for a minimum of 6 months. The median duration of follow-up was 4.3 years (range 0.6-15.5 years). Relapse rates per year of follow-up were compared in an azathioprine + 5-aminosalicylate group (n = 103) and an azathioprine alone group (n = 83); survival curves for cumulative remission rates were compared by log-rank test. Discontinuation of azathioprine in both groups was also recorded, as was the incidence of malignancy. RESULTS: In ulcerative colitis patients (n = 82), mean relapse rates for the azathioprine + 5-aminosalicylate group were 0.21/year compared with 0.19/year for the azathioprine alone group (P = not significant). In Crohn's disease patients (n = 104), mean relapse rates for the azathioprine + 5-aminosalicylate group were 0.27/year compared with 0.3/year for the azathioprine alone group (P = not significant). The cumulative remission percentage (determined from time to first relapse) was used in Kaplan-Meier survival analysis and showed no difference between the azathioprine + 5-aminosalicylate group and the azathioprine alone group by log-rank analysis, for ulcerative colitis and Crohn's disease as well as for all inflammatory bowel disease patients. Concurrent use of 5-aminosalicylates was no more frequent in patients who discontinued azathioprine due to adverse events. The only malignancy recorded was Waldenstr?m's macroglobulinaemia after 7 years of azathioprine therapy. CONCLUSION: Concurrent use of 5-aminosalicylate drugs did not reduce the relapse rates of inflammatory bowel disease patients who were established on azathioprine therapy. The use of 5-aminosalicylate drugs did not lead to any increase in discontinuation of azathioprine due to adverse events.     

Syncope caused by cardiac asystole during dobutamine stress echocardiography.

Syncope caused by cardiac asystole during dobutamine stress echocardiography occurred in a 60 year old woman presenting with chest pain and a non-diagnostic exercise test. Cardiac asystole was not associated with myocardial ischemia and was attributed to a powerful cardioinhibitory vagal reflex elicited by the stimulation by the drug of cardiac and aortic mechanoreceptors. Cardiac asystole was promptly reversed by the administration of atropine with no significant sequelae.     

Changes of shear-wave velocity by interferon-based therapy in chronic hepatitis C

AIM: To evaluate the changes of shear-wave velocity(Vs) by acoustic radiation force impulse after treatment in chronic hepatitis C.METHODS: Eighty-seven patients with chronic hepatitis C were consecutively treated with combinations of interferon(IFN) plus ribavirin(RBV). Vs value(m/s) was measured with acoustic radiation force impulse before treatment, at end of treatment(EOT), 1 year after EOT, and 2 years after EOT.RESULTS: In patients with a sustained virological response(SVR)(n = 41), Vs significantly decreased at EOT [1.19(1.07-1.37), P = 0.0004], 1 year after EOT [1.10(1.00-1.22), P = 0.0001], and 2 years after EOT [1.05(0.95-1.16), P 0.0001] compared with baseline [1.27(1.11-1.49)]. In patients with a relapse(n = 26), Vs did not significantly decrease at EOT [1.23(1.12-1.55)], 1 year after EOT [1.20(1.12-1.80)], and 2 years after EOT [1.41(1.08-2.01)] compared with baseline [1.39(1.15-1.57)]. In patients with a nonvirological response(n = 20), Vs did not significantly decrease at EOT [1.64(1.43-2.06)], 1 year after EOT [1.66(1.30-1.95)], and 2 years after EOT [1.61(1.36-2.37)] compared with baseline [1.80(1.54-2.01)]. Among genotype 1 patients, baseline Vs was significantly lower in SVR patients [1.28(1.04-1.40)] than in non-SVR patients [1.56(1.20-1.83)](P = 0.0142).CONCLUSION: Reduction of Vs values was shown in SVR patients after IFN-plus-RBV therapy by acoustic radiation force impulse.     

Prospective evaluation of ileoanal pouch characteristics measured by barostat

PURPOSE: The aim of this study was to evaluate pouch sensory and motor characteristics prospectively during the first postoperative year and to compare those with rectal characteristics. METHODS: Twelve patients with an ileoanal J-pouch were studied at 3 and 12 months postoperatively. The results were compared with those obtained in 12 healthy controls. Visceral compliance was assessed using an electronic barostat by a pressure distention procedure, during which sensitivity was also scored by visual analog scales. The response to a meal was assessed during set pressure. RESULTS: During the first postoperative year, pouch compliance increased significantly from 7.2 ± 0.6 to 10.7 ± 0.9 ml/mmHg (rectal compliance 10.6 ± 1.1 ml/mmHg). The increase in pouch compliance significantly influences the 24-hour stool frequency (r2 = 0.42). Visceroperception scores remained unchanged. Postprandial decrease in intrabag volume was more pronounced in patients (45 ± 13 percent at 3 months, 32 ± 15 percent at 12 months) than in controls (9 ± 6 percent, P < 0.05), and residual postprandial bag volumes were significantly lower in patients at 3 months compared with patients at 12 months. CONCLUSIONS: Ileoanal pouch compliance increases significantly during the first postoperative year to values in the range of rectal compliance. The increase in pouch compliance is related to a decrease in 24-hour stool frequency. Postprandial bag volumes increase during the first postoperative year but remain significantly smaller than in the rectum. Pouch sensitivity does not change.     

Refractory angina treated by spinal cord stimulation. The results of a long-term follow-up

INTRODUCTION AND OBJECTIVES: The quality of life in patients with refractory angina has been shown to improve dramatically with spinal cord stimulation because of its beneficial results. The aim of this study was to assess the long-term morbimortality of this technique of spinal cord stimulation in the long term. PATIENTS AND METHODS: 41 patients with refractory angina and treated with spinal cord stimulation were included. Median follow-up was 31.0 [12.0-42.5] months, and total follow-up was 1,236 months. RESULTS: Annual number of admissions per patient year were dramatically reduced after spinal cord stimulation (2.31 vs. 0.28). Patients that died during follow-up had a 3-fold increase rate of admissions than patients that survived (0.37 vs. 0.19). However, patients that died during follow-up also had a lower admission rate after spinal cord stimulation (2.03 vs. 0.37). Overall mortality was 9.7%/year; cardiac mortality was 7.7%/year. Both figures are not different from those of other groups of patients with similar anatomical characteristics of coronary artery disease severity without spinal cord stimulation. Complications of this treatment were minimal (we only observed an early post implantation infection and a battery extrusion, without any complications with electrodes). The outcome was similar in patients with subacute unstable refractory angina or stable angina. CONCLUSIONS: Spinal cord stimulation can be considered a safe and effective alternative treatment of refractory angina. Long-term morbidity is low, and mortality is not higher than the expected in this group of patients.     

Improving inpatient glycemic control by diabetes education program in internal medicine residents

AimsThe purpose of this study was to investigate the effectiveness of an inpatient diabetes care education during the first year of internal medicine residency training on inpatient glycemic control.MethodsThe program was comprised of 1-hr small group teaching per 4-week rotation and twice-a-week morning insulin round by an endocrinologist. Inpatient insulin management guideline leaflet was provided to all internal medicine residents. We retrospectively collected the point-of-care testing for glucose (POCT-glu) data in patients admitted to the general medicine wards and compared the mean of blood glucose (BG) before and after the education program. A total of 134438 POCT-glu values from 7055 patients were analyzed.ResultsAfter the initiation of the education program, mean BG levels significantly decreased during the first year and were lowest during the second year after education (Mean BG at baseline was 161.38 ± 64.10 mg/dL; 1st year, 159.48 ± 62.53 mg/dL and 2nd year, 155.60 ± 64.94 mg/dL, p-value < 0.0001). The reduction of BG levels was more pronounced in the patients with previously undiagnosed diabetes mellitus than patients with underlying diabetes mellitus. The rates of severe hypoglycemia (defined by BG < 40 mg/dL or 2.2 mmol/L) were not significantly different before and after education (baseline 0.12%, 1st year 0.14%, and 2nd year 0.14%, p-value = 0.632).ConclusionsLack of confidence and inadequate knowledge of insulin treatment in physicians were important barriers to glycemic management. Consistent education in internal medicine residents led to a significant improvement in inpatient glycemic control.     

Torsade de pointes induced by N-acetylprocainamide

N-Acetylprocainamide (NAPA), a class III antiarrhythmic drug, caused torsade de pointes in a 72 year old woman who had this arrhythmia on two previous occasions while being treated with quinidine and disopyramide. Initial evaluation with an intravenous infusion of NAPA indicated a favorable antiarrhythmic response. The QTC interval was prolonged, but the 2.4 ms/microgram per ml incremental QTC interval lengthening caused by NAPA was not greater than usual. During subsequent oral therapy with NAPA, torsade de pointes developed at plasma levels of this drug that appeared to be well tolerated during the initial evaluation.     

Sustainability of 8% weight loss, reduction of insulin resistance, and amelioration of atherogenic-metabolic risk factors over 4 years by metformin-diet in women with polycystic ovary syndrome

In 74 women with polycystic ovary syndrome, treated for 4 years with metformin (MET) and diet, we prospectively assessed whether, and to what degree, weight loss, reduction of insulin resistance, and amelioration of coronary heart disease risk factors could be sustained. We hypothesized that response to MET-diet would not differ by pretreatment body mass index (BMI) classes <25 (normal), > or =25 to <30 (overweight), > or =30 to <40 (obese), and > or =40 (extremely obese). [table: see text] Metformin-diet was successful in producing stable approximately 8% weight reduction for all 4 years (trend P < .0001). Percentage of reductions in weight on MET-diet was significant (P < .05) and did not differ among the 3 highest BMI categories (> or =40, > or =30 to <40, > or =25 to <30), but were not significant in the normal-weight category (BMI, <25). On MET-diet, median homeostasis model assessment of insulin resistance (HOMA-IR) was 33% lower than entry at 1 year, 50% at 2 years, 51% at 3 years, and 50% at 4 years (trend, P < .0001). On MET-diet, median low-density lipoprotein cholesterol (LDL-C) was 6% lower than entry at year 1, 6% at year 2, 7% at year 3, and 11% at year 4 (trend P < .0001). On MET-diet, median high-density lipoprotein cholesterol (HDL-C) was 3% higher than entry at year 2, 8% higher at year 3, and 11% higher at year 4 (trend P < .0001). Percentage of reductions in HOMA-IR, LDL-C, triglyceride, and systolic blood pressure, and increments in HDL-C did not differ (P > .1) in the 4 BMI categories. By stepwise regression, weight loss was a significant (P < or = .01) positive explanatory variable for reduction in HOMA-IR for all 4 follow-up years. Metformin-diet in women with polycystic ovary syndrome effectively and safely reduces weight and LDL-C while raising HDL-C, and maintains these outcomes stable over 4 years.     

Differential mortality by sex. Causes and behavior of respiratory and gastroenteric infections in Mexico

The differential in mortality by sex has not been broadly studied in Mexico. In this work mortality by sex in under one year old children and infants by federal entity for the main infectious diseases during 1980-1982 was analyzed. The results showed that the rate of mortality by sex (RMS) for under one year old children was higher than one, which means that there is a male over-mortality for that group of age. In the one to four year old children group, there were three entities that showed over-mortality among women. The analysis of the proportional mortality revealed that 40 to 50 percent of deaths in under one year old children were due to gastroenteral and respiratory infections. The probable causes of the male over-mortality observed and the need to determine the regional patterns of mortality are also discussed.     

Cutaneous infection by Phomopsis longicolla in a renal transplant recipient from Guinea: first report of human infection by this fungus

A. Garcia‐Reyne, F. López‐Medrano, J.M. Morales, C. García Esteban, I. Martín, I. Eraña, Y. Meije, A. Lalueza, A. Alastruey‐Izquierdo, J.L. Rodríguez‐Tudela, J.M. Aguado. Cutaneous infection by Phomopsis longicolla in a renal transplant recipient from Guinea: first report of human infection by this fungus.
Transpl Infect Dis 2011: 13: 204–207. All rights reserved Abstract: We report the case of a 72‐year‐old female renal transplant recipient with a nodular lesion in the distal phalange of the third left finger produced by a dematiaceous fungus that was identified as Phomopsis longicolla. She was treated with itraconazole and terbinafine and later with voriconazole, without response. The patient underwent a surgical resection with lesion‐free edge and continued on voriconazole. One year later she was asymptomatic and had not developed new lesions.     

Intragastric balloon for treatment-resistant obesity: safety, tolerance, and efficacy of 1-year balloon treatment followed by a 1-year balloon-free follow-up

BACKGROUND: Prior efforts to treat obesity with intragastric balloons were thwarted by high complication rates. Therefore, fundamental requirements for optimal balloon designs were defined. The aim of the present study was to investigate the effectiveness, the safety, and the tolerance of a new intragastric balloon. METHODS: Adults with treatment-resistant obesity and no GI contraindications to balloon placement were invited to participate in a randomized, double-blind trial of balloon or sham treatment of 3 months' duration. Patients (sham- and balloon-treated groups) in whom a preset weight-loss goal was achieved were given an additional 9 months of balloon treatment. After removal of the balloon at year 1, patients were followed for a second year without the balloon. RESULTS: Forty-three treatment-resistant patients (mean body mass index 43.3 kg/m 2) were enrolled. Five patients did not meet the preset weight-loss goal (nonresponse 11.6%). Three patients did not tolerate the balloon (7.0%), with endoscopy demonstrating severe esophagitis. Three other patients developed esophagitis that was related to use of nonsteroidal anti-inflammatory drugs, albeit prohibited (2 patients), or substantial weight loss with balloon treatment (1). In intention-to-treat analysis, sham- and balloon-treated groups had a similar mean weight loss of 11.2 kg (9.0%) and 12.9 kg (10.4%), respectively, during the first 3 months. During months 3 to 6, patients who had sham therapy in months 0 to 3 lost 8.8 kg (7.9%) during the first 3 months of balloon treatment. In contrast, patients in the balloon-treatment group lost 3.9 kg (3.5%) during months 3 to 6 (their second balloon treatment period). The overall weight loss was 20 kg (16.1%) and 16.7 kg (13.4%) after 6 months in the sham/balloon and in the balloon/balloon treated groups (not significant), respectively. After 1-year of balloon treatment, a mean weight loss of 21.3 kg (17.1%) was achieved in all patients, of which 12.6 kg (9.9%) was maintained at the end of the second balloon-free year; 47% of patients sustained a greater than 10% weight loss, with considerably reduced comorbidity. In 33 patients who completed the study per protocol, weight loss was 25.6 kg (20.5%) after 1 year and 14.6 kg (11.4%) after 2 years; 55% maintained a weight loss of greater than 10%. Interventional complications occurred in 1.6% (2/128) and balloon deflations in 2.3% (3/128). CONCLUSIONS: For patients with treatment-resistant obesity, the intragastric balloon appeared to be safe but was not a treatment option in a fifth of patients. Although an independent benefit of balloon treatment beyond diet, exercise, and behavioral therapy could not be demonstrated in the first 3 months, balloon treatment for 1 year resulted in substantial weight loss, the greater part of which was maintained during the balloon-free second year.     

A dietary and exercise intervention slows menopause-associated progression of subclinical atherosclerosis as measured by intima-media thickness of the carotid arteries

OBJECTIVES: The object of this study was to assess the effects of menopause and a diet/exercise intervention on subclinical atherosclerosis progression. BACKGROUND: Subclinical atherosclerosis has been linked to higher coronary heart disease and stroke rates and is greater among postmenopausal women according to cross-sectional analyses. Whether menopause is associated with an accelerated progression of subclinical disease is unknown, as is the extent to which lifestyle intervention can alter the course of progression. METHODS: Intima-media thickness (IMT) measures of the common carotid artery (CCA), internal carotid artery (ICA), and bulb segments of the carotid arteries were measured twice during the course of 4 years in 353 women from the Women's Healthy Lifestyle Project, a dietary and exercise clinical trial designed to prevent adverse risk factor changes through the menopause. A third measure was obtained 2.5 years later for 113 women. RESULTS: The progression of IMT was observed for the average of all segments (AVG), the CCA, and the bulb (0.007 mm/year, 0.008 mm/year, and 0.012 mm/year; p < 0.01 for all), but not for the ICA. Among controls, menopause was associated with accelerated IMT progression (0.003 mm/year for premenopausal women vs. 0.008 mm/year for perimenopausal/postmenopausal women for AVG IMT; p = 0.049). Additionally, among the 160 perimenopausal/postmenopausal women, the intervention slowed IMT progression (0.008 mm/year for the control group vs. 0.004 mm/year for the intervention group for AVG IMT; p = 0.02). Similar results were found for the CCA and bulb segments. CONCLUSIONS: These data demonstrate that the menopause transition is associated with accelerated subclinical atherosclerosis progression and that a diet/exercise intervention slows menopause-related atherosclerosis progression.     

The symptomatic status of patients one year following revascularization by either coronary surgery or angioplasty

This study consisted of a one year clinical follow-up of 81 patients who had coronary revascularization. In 32 patients, this was accomplished by bypass surgery and in 49, by percutaneous angioplasty. Prior to the procedure the two groups of patients were similar with regard to age, sex, antianginal medication and angina severity with 75% of the surgical patients and 65% of the angioplasty patients in CCS Angina Class III or IV. Although most of the surgical patients had multivessel disease and most of the angioplasty patients had single vessel disease, all had complete revascularization. At one year, 78% of the surgical patients and 84% of the angioplasty patients did not have angina and few patients in either group were taking medication. However, in the intervening year 39% of the angioplasty patients had had a second revascularization procedure, whereas, only 3% of the surgical patients required a second procedure. Extracardiac sequelae were more frequent in the surgical cohort. Therefore, at one year following complete revascularization, bypass surgery and angioplasty result in comparable symptomatic and functional improvement.     

Induction of ventricular tachycardia by esophageal stimulation. Apropos of 2 cases]

The utility of transesophageal atrial pacing in sustained left ventricular tachycardia is reported in two cases. A 46 year old man without any apparent cardiac disease presented with invalidating but undocumented palpitations. Transesophageal atrial pacing with isoproterenol infusion induced wide complex tachycardia with a right bundle branch block morphology and left axis deviation. Atrio-ventricular dissociation was observed and it was possible to reduce the ventricular complex width by rapid transesophageal atrial pacing: the tachycardia was terminated by an injection of verapamil. It was not possible to reinduce the tachycardia after treatment with atenolol 100 mg/day, introduced because of the catecholinergic nature of the arrhythmia. The patient is symptom free after 2 years of treatment with this drug. Regular wide complex tachycardia with right bundle branch block and left axis deviation without any detectable atrial activity was recorded in a 50 year old man without known cardiac disease. Transesophageal atrial pacing with isoproterenol infusion induced an identical tachycardia. The tachycardia started after a normally conducted atrial extrastimulus followed by ventriculo-atrial dissociation and it was possible to overdrive with atrial pacing. The tachycardia could not be reinduced after treatment with atenolol and the patient is asymptomatic 12 months later. These reports show that it is possible to study certain ventricular tachycardias by transesophageal atrial pacing. The efficacy of antiarrhythmic therapy can be controlled simply by this non-invasive technique.