The natural history of immunoglobulin a nephropathy among patients with hematuria and minimal proteinuria

PURPOSE: To determine the natural history of immunoglobulin (Ig) A nephropathy among patients who presented with hematuria and minimal proteinuria, and factors associated with the development of adverse clinical events, such as proteinuria. SUBJECTS AND METHODS: In Hong Kong, all patients who present with isolated hematuria are referred for renal biopsy after urologic diseases are ruled out. We reviewed the clinical course of 72 consecutive patients with histologically confirmed IgA nephropathy who presented with hematuria and minimal proteinuria (0.4 g/day or less). All patients were normotensive and had normal renal function at presentation. Adverse events were defined as proteinuria greater than 1 g per day, hypertension, or impaired renal function (serum creatinine level 120 micromol/L or estimated creatinine clearance < 70 mL per minute).RESULTS: The mean (+/- SD) age at presentation was 27 +/- 8 years; 56 (78%) were female. Nine patients (13%) had grade 2 histologic lesions. During a median follow-up of 7 years, 32 patients (44%) developed adverse events: 24 (33%) developed proteinuria of 1 g per day or more, 19 (26%) became hypertensive, and 5 (7%) developed impaired renal function. Another 30 patients (42%) had persistently abnormal urinalysis examinations. Only 10 patients (14%) had complete resolution of hematuria. The median time for progression from proteinuria (> l g/day) to renal impairment was 84 months (range 56 to 132). In a multivariate analysis, age at presentation (relative risk [RR] per 10 years of age = 2.0; 95% confidence interval [CI], 1.2 to 3.4) and histologic grade (grade 2 versus grade 1, RR = 4.5; 95% CI, 1.7 to 12) were independent predictors of developing an adverse event.CONCLUSIONS: IgA nephropathy that presents with hematuria and minimal proteinuria is usually a progressive disease. Life-long follow-up with regular monitoring of blood pressure and proteinuria is recommended.     

Heterotopic pancreas: a difficult diagnosis

Heterotopic pancreas is a rare disease. We evaluated 17 patients treated surgically at our hospital. Epigastric pain (77%), abdominal fullness (30%), and tarry stools (24%) were the three most frequent symptoms and signs. The lesions were diagnosed as gastroduodenal tumors by gastroduodenoscopy (67%) or upper gastrointestinal series (71%). Among these, only one gastric submucosal tumor was considered to be heterotopic pancreas preoperatively. Three patients were found to have gastric tumor by abdominal ultrasound. Computed tomography, small-intestinal series, barium enema, endoscopic retrograde cholangiopancreatography, angiography, and cholescintigraphy did not help in disclosing lesion. In about half of the patients, the lesions were located at the stomach. Tumor size varied from 1 to 3 cm. Surgical excision relieved symptoms. These findings indicated heterotopic pancreas is still a difficult disease for diagnosis, regardless of the improvements of diagnostic tools and techniques.     

Postobturation Pain Associated with Tricalcium Silicate and Resin-based Sealer Techniques: A Randomized Clinical Trial

IntroductionThe incidence of immediate postobturation pain associated with 2 sealer techniques was compared and potential prognostic factors identified.MethodsPatients referred for endodontic treatment were recruited with informed consent. Root canals were debrided and teeth rendered asymptomatic before random allocation to receive TotalFill BC (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) or AH Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland). Patients blinded to the sealer reported their postobturation pain experience 1, 3, and 7 days after treatment. Blinded and calibrated assessors independently reviewed treatment quality, sealer extrusion, and radiographic data under standardized conditions.ResultsOne hundred sixty eligible patients (163 teeth, 95.3%) returned their pain diary. No postobturation pain difference was found between the 2 sealers (P > .05), although the AH Plus sealer technique was significantly associated with extrusion beyond the apex (P < .05; odds ratio [OR] = 3.02; 95% confidence interval [CI], 1.39–6.57). Thirty-three (20.6%) patients reported pain on day 1 (median 1 = very mild pain), 16 (10.0%) on day 3 (median 1 = very mild pain), and 9 (5.6%) on day 7 (median 2 = mild pain). The prognostic factors were as follows:(1) moderate/severe preoperative pain (OR = 4.41; 95% CI, 1.42–13.76 on day 3 and OR = 5.16; 95% CI, 1.17–22.78 on day 7),(2) provoked preoperative pain (OR = 4.24; 95% CI, 1.40–12.78 on day 3 and OR = 5.35; 95% CI, 1.27–22.51 on day 7),(3) pulpless tooth (OR = 0.11; 95% CI, 0.02–0.57 on day 3), and(4) sonic activation during treatment (OR = 3.02; 95% CI, 1.39–6.57 on day 1 and OR = 3.01; 95% CI, 1.05–8.59 on day 3).ConclusionsThere was no significant difference in pain experience between teeth filled using AH Plus or TotalFill BC Sealer 1, 3, and 7 days after obturation. Patient- and treatment-related factors could influence postobturation pain.     

Rare complication of inflammatory bowel disease-like colitis from glycogen storage disease type 1b and its surgical management: A case report

BACKGROUNDGlycogen storage disease (GSD) is an autosomal recessive inborn metabolic disorder. Patients with GSD are prone to hypoglycaemia, hyperlactacidemia and bleeding. GSD type 1b (GSD-1b) patients specifically can develop neutropenia, recurrent bacterial infection and inflammatory bowel disease (IBD). Documentation of the long-term outcomes of surgical management of GSD-1b has been scarce, especially for Asian patients. We herein describe a case of GSD-1b complicated by IBD-like colitis and coloduodenal fistula. The patient was managed successfully with surgical intervention.CASE SUMMARYA 20-year-old Chinese lady confirmed by genetic testing to have GSD-1b was initially managed with uncooked cornstarch and granulocyte-colony stimulating factor. With recurrent abdominal symptoms, her condition was treated as clinical “Crohn’s disease” with mesalazine, prednisolone and azathioprine conservatively. Colonoscopy showed a tight stricture at the hepatic flexure. Subsequent computerized tomographic colonography revealed a phlegmon at the ileocaecal region with a suspected coloduodenal fistula. Eventually an exploratory laparotomy was performed and severe colitis at the ascending colon with coloduodenal fistula was confirmed. Right hemicolectomy with primary anastomosis and repair of the duodenum were performed. Surgical management of complications from GSD-1b associated IBD-like colitis has rarely been described. First-line treatment would usually be conservative. Surgical intervention like hemicolectomy is mainly reserved for refractory cases.CONCLUSIONSurgical management of coloduodenal fistula in GSD-1b patients is a feasible and safe option when failed conservative management.     

Analysis of Altered Baseline Brain Activity in Drug-Naive Adult Patients with Social Anxiety Disorder Using Resting-State Functional MRI

Objective

We hypothesize that the amplitude of low-frequency fluctuations (ALFF) is involved in the altered regional baseline brain function in social anxiety disorder (SAD). The aim of the study was to analyze the altered baseline brain activity in drug-naive adult patients with SAD.

Methods

We investigated spontaneous and baseline brain activities by obtaining the resting-state functional magnetic resonance imaging data of 20 drug-naïve adult SAD patients and 19 healthy controls. Voxels were used to analyze the ALFF values using one- and two-sample t-tests. A post-hoc correlation of clinical symptoms was also performed.

Results

Our findings show decreased ALFF in the bilateral insula, left medial superior frontal gyrus, left precuneus, left middle temporal gyrus, right middle temporal pole, and left fusiform gyrus of the SAD group. The SAD patients exhibited significantly increased ALFF in the right inferior temporal gyrus, right middle temporal gyrus, bilateral middle occipital gyrus, orbital superior frontal gyrus, right fusiform gyrus, right medial superior frontal gyrus, and left parahippocampal gyrus. Moreover, the Liebowitz Social Anxiety Scale results for the SAD patients were positively correlated with the mean Z values of the right middle occipital and right inferior occipital but showed a negative correlation with the mean Z values of the right superior temporal gyrus and right medial superior frontal gyrus.

Conclusion

These results of the altered regional baseline brain function in SAD suggest that the regions with abnormal spontaneous activities are involved in the underlying pathophysiology of SAD patients.     

Tumor necrosis factor-alpha polymorphism, bone strength phenotypes, and the risk of fracture in older women

TNFalpha is a proinflammatory cytokine that promotes osteoclastic bone resorption. We evaluated the association between a G-308A polymorphism (rs1800629) at the TNFA locus and osteoporosis phenotypes in 4306 older women participating in the Study of Osteoporotic Fractures. Femoral neck bone mineral density (BMD) and structural geometry were measured using dual-energy x-ray absorptiometry and hip structural analysis. Incident fractures were confirmed by physician adjudication of radiology reports. Despite similar femoral neck BMD, women with the A/A genotype had greater subperiosteal width (P = 0.01) and endocortical diameter (P = 0.03) than those with the G/G genotype. The net result of these structural differences was that there was a greater distribution of bone mass away from the neutral axis of the femoral neck in women with the A/A genotype, resulting in greater indices of bone bending strength (cross-sectional moment of inertia: P = 0.004; section modulus: P = 0.003). Among 376 incident hip fractures during 12.1 yr of follow-up, a 22% decrease in the risk of hip fracture was seen per copy of the A allele (relative risk 0.78; 95% confidence interval 0.63, 0.96), which was not influenced by adjustments for potential confounding factors, BMD, or bone strength indices. The G-308A polymorphism was not associated with a reduced risk of other fractures. These results suggest a potential role of genetic variation in TNFalpha in the etiology of osteoporosis.     

Factors for prolonged length of stay after elective hepatectomy for hepatocellular carcinoma. The surgeon's role in the managed care era

BACKGROUND/AIMS: Length of stay is an important marker of medical resource consumption. In the modern managed care era physicians are driven to deliver the highest quality of care while using fewest resources. Hepatectomy represents a technically challenging and resource-intensive procedure, particularly in the setting of hepatic malignancy and liver cirrhosis. For improving quality of surgical management in such cases, we aimed to identify the factors affecting length of stay after hepatectomy for patients with hepatocellular carcinoma. METHODOLOGY: A total of 375 consecutive surgical hepatocellular carcinoma patients at a tertiary referral center during a 7-year period were reviewed. Length of stay after hepatectomy longer than 14 days was defined as prolonged length of stay. Patients were divided into two groups according to their length of stay. Patients with length of stay less than or equal to 14 days were in Group A and those with length of stay longer than 14 days were in Group B. Data for comparative analysis between both groups were categorized according to preoperative patients' clinical demographic factors, operation-related factors, and pathological factors. The significant univariate factors were used for subsequent multivariate analysis. RESULTS: The significant independent factors were patients' preoperative prothrombin activity, intraoperative blood transfusion, surgical complication, and the time to abdominal drain removal. Among these independent factors, surgical complication (p < 0.001, relative risk 7.01, and 95% confidence interval 3.46 to 14.18) was the most powerful factor for prolonged length of stay after elective hepatectomy for hepatocellular carcinoma. CONCLUSIONS: Most of the independent factors for prolonged length of stay after elective hepatectomy for hepatocellular carcinoma patients are operation-related and surgeon-dependent. The surgeon plays a key role in determining length of stay. By minimizing blood transfusion, surgical complication, and the time to abdominal drain removal, length of stay can be significantly decreased in hepatocellular carcinoma patients undergoing hepatectomy.