Comparison of the efficacy of intravitreal triamcinolone acetonide for cystoid macular edema with versus without serous retinal detachment in branch retinal vein occlusion: influence on macular sensitivity and morphology

ABSTRACT: BACKGROUND: The influence of serous retinal detachment (SRD) on visual acuity, macular sensitivity, and macular thickness is unclear after intravitreal injection of triamcinolone acetonide (IVTA) for macular edema with branch retinal vein occlusion (BRVO). Methods: Twenty-one eyes of 21 BRVO patients with macular edema received IVTA. Patients were divided into two groups by optical coherence tomography findings: 11 patients who had cystoid macular edema (CME) with SRD (SRD (+) group) and 10 patients who had CME without SRD (SRD (-) group). Microperimetry was performed with a Micro Perimeter 1 before and at 3 and 6 months after IVTA. Macular thickness was measured by optical coherence tomography. We exchanged the superior and inferior regions to separate the regions into those with and without occlusion. As a result, the superior region was always the occluded region and the inferior region was non-occluded. Results: In both the SRD (-) group and the SRD (+) group, the mean macular thickness within the central 4degrees field and the 10degrees and 20degrees fields of the occluded region decreased significantly from baseline to 3 and 6 months after IVTA (all P<0.01). Visual acuity also improved significantly in both groups from baseline to 3 and 6 months after IVTA (both P<0.05). In both groups, the mean macular sensitivity (measured with by microperimetry) within the central 4degrees field and the 10degrees and 20degrees fields of the occluded region showed a significant increase from baseline to 3 and 6 months after IVTA (all P<0.05). The trend profiles of macular thickness within the 10degrees and 20degrees fields of the occluded region showed significant differences, but there were no significant differences with respect to the trend profiles of visual acuity and macular sensitivity within the central 4degrees field and the 10degrees and 20degrees fields of the occluded region. Conclusions: These results suggest that IVTA may achieve more marked improvement of macular morphology in BRVO patients with SRD than in those without SRD, while this therapy may have a similar effect on macular function in BRVO patients with or without SRD.     

Pleural dissemination of a mixed ground-glass opacity nodule treated as a nontuberculous mycobacterial infection for 6 years without growing remarkably

Pulmonary ground-glass opacity (GGO) nodules, which do not grow remarkably, are often observed without treatment. Lung tumors coexisting with inflammation and infection are difficult to diagnose. In this paper, we describe a very rare case of a pulmonary mixed GGO nodule with pleural dissemination. In 67-year-old female, chest computed tomography (CT) showed a mixed GGO nodule that had not grown remarkably in the right lung. For 6 years, the mixed GGO had been treated as nontuberculous mycobacterial infection. She was referred to our department for further investigation of the mixed GGO. We suspected lung cancer and performed lung segmentectomy. The tissue showed pleural dissemination. Coexisting nontuberculous mycobacteria (NTM) delayed the clinical diagnosis. Peripheral lung nodules should be resected or diagnosed as soon as possible, despite manifesting as a slow growth.     

Upper Gastrointestinal Symptoms Predictive of Candida Esophagitis and Erosive Esophagitis in HIV and Non-HIV Patients: An Endoscopy-Based Cross-Sectional Study of 6011 Patients

Upper gastrointestinal (GI) symptoms are common in both HIV and non-HIV-infected patients, but the difference of GI symptom severity between 2 groups remains unknown. Candida esophagitis and erosive esophagitis, 2 major types of esophagitis, are seen in both HIV and non-HIV-infected patients, but differences in GI symptoms that are predictive of esophagitis between 2 groups remain unknown. We aimed to determine whether GI symptoms differ between HIV-infected and non-HIV-infected patients, and identify specific symptoms of candida esophagitis and erosive esophagitis between 2 groups.We prospectively enrolled 6011 patients (HIV, 430; non-HIV, 5581) who underwent endoscopy and completed questionnaires. Nine upper GI symptoms (epigastric pain, heartburn, acid regurgitation, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia) were evaluated using a 7-point Likert scale. Associations between esophagitis and symptoms were analyzed by the multivariate logistic regression model adjusted for age, sex, and proton pump inhibitors.Endoscopy revealed GI-organic diseases in 33.4% (2010/6.011) of patients. The prevalence of candida esophagitis and erosive esophagitis was 11.2% and 12.1% in HIV-infected patients, respectively, whereas it was 2.9% and 10.7 % in non-HIV-infected patients, respectively. After excluding GI-organic diseases, HIV-infected patients had significantly (P < 0.05) higher symptom scores for heartburn, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia than non-HIV-infected patients. In HIV-infected patients, any symptom was not significantly associated with CD4 cell count. In multivariate analysis, none of the 9 GI symptoms were associated with candida esophagitis in HIV-infected patients, whereas dysphagia and odynophagia were independently (P < 0.05) associated with candida esophagitis in non-HIV-infected patients. However, heartburn and acid regurgitation were independently (P < 0.05) associated with erosive esophagitis in both patient groups. The internal consistency test using Cronbach''s α revealed that the 9 symptom scores were reliable in both HIV (α, 0.86) and non-HIV-infected patients (α, 0.85).This large-scale endoscopy-based study showed that HIV-infected patients have greater GI symptom scores compared with non-HIV-infected patients even after excluding GI-organic diseases. None of the upper GI symptoms predict candida esophagitis in HIV-infected patients, but dysphagia and odynophagia predict candida esophagitis in non-HIV-infected patients. Heartburn and acid regurgitation predict erosive esophagitis in both patient groups.     

Esophagogastric varices as a prognostic factor for the determination of clinical stage in patients with primary biliary cirrhosis

Background Primary biliary cirrhosis (PBC) is usually classified as either asymptomatic PBC (a-PBC) or symptomatic PBC (s-PBC). Although the proportion of a-PBC versus s-PBC patients has been consistently increasing, it is not clear whether the present criteria for the staging of PBC are optimal or not. We investigated the clinical stage of PBC patients from the standpoint of esophagogastric varices (EGV).Methods One hundred and nine PBC patients were enrolled in this retrospective study. We investigated the clinical features of PBC based on laboratory data, histological stage, symptoms, and existence of EGV. In addition, the clinical course and prognosis in patients who were periodically followed up were also studied.Results (1) EGV was detected in a-PBC patients, and there was no difference in the grade of EGV between a-PBC and s-PBC patients. (2) a-PBC patients with EGV had more liver damage than those without EGV, and a-PBC patients with EGV had a poorer prognosis than those without EGV. (3) Three of 11 patients who progressed from a-PBC to s-PBC within 3 years had EGV. (4) One of 3 a-PBC patients with EGV had progressed to s-PBC at 3-year follow-up.Conclusions These results indicate that EGV is one of the most important factors for evaluating PBC. Therefore, we would like to propose that a-PBC patients with EGV should either be included in the presently defined s-PBC class, or that new prognostic classes of PBC be created that include EGV as a prognostic factor.     

Severe pulmonary hypertension in a patient with systemic lupus erythematosus and minimal lupus activity

Pulmonary hypertension (PH) sometimes occurs in patients with systemic lupus erythematosus (SLE). We report a case of 51-year-old-woman with PH associated with SLE. She had been diagnosed as SLE on the basis of pericardial effusion, hematological disorder, positive antinuclear antibody, and hypocomplementemia. Despite minimal lupus activity, she had marked elevation of pulmonary arterial pressure (101/53 mmHg) and decreased cardiac index (1.5 l/min/m2). Symptoms related to PH were progressive under treatment with oral corticosteroids, oxygen, calcium antagonists, and warfarin. After 17 months of epoprostenol treatment, she died of pulmonary infarction. SLE-associated PH is often severe and progressive even in association with minimal activity.     

Differential effect of sulfonylureas on production of reactive oxygen species and apoptosis in cultured pancreatic beta-cell line, MIN6

Sulfonylureas are considered to cause β-cell apoptosis. However, it is unclear how this occurs and whether there is a difference in such effects among various sulfonylureas. Here, we examined the effects of various sulfonylureas and a short-acting insulin secretagogue, nateglinide, on oxidative stress and apoptosis using the β-cell line MIN6. After cultured MIN6 cells were exposed to various concentrations of sulfonylureas (glibenclamide, glimepiride, and gliclazide) or nateglinide, intracellular production of reactive oxygen species (ROS) was evaluated by staining with 2′,7′-dichlorofluorescein diacetate. The effect of these agents on apoptosis was also evaluated by the terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate–biotin nick-end labeling technique. Exposure of β-cells to glibenclamide, glimepiride, and nateglinide significantly increased intracellular ROS production in a concentration-dependent manner (0.1-10 μmol/L). These effects were completely blocked by nicotinamide adenine dinucleotide phosphate [NAD(P)H] oxidase inhibitors (diphenylene iodonium or apocynin) or a protein kinase C inhibitor (calphostin C). After exposure to these agents for 48 hours, the numbers of apoptotic cells were also significantly increased. These effects were significantly blocked by apocynin and antioxidant N-acetyl-l-cysteine. In contrast, exposure to any concentrations of gliclazide did not affect either intracellular ROS production or the numbers of apoptotic cells. Sulfonylureas (glibenclamide and glimepiride, but not gliclazide) and nateglinide stimulated ROS production via protein kinase C–dependent activation of NAD(P)H oxidase and consequently caused β-cell apoptosis in vitro. Because of the lack of such adverse effects, gliclazide may have a benefit in the preservation of functional β-cell mass.     

Hepatic Encephalopathy Associated with Extensive Portal Hepatic Venous Shunts: A Case Report

Extensive intrahepatic portal-hepatic venous anastomosis is very rare. This report describes a 47-year-old man with cirrhosis who presented with mental confusion and flapping tremor, and in whom percutaneous transhepatic portography and superior mesenteric angiography demonstrated shunting between the portal vein branches and the right hepatic vein. Measurements of pressure, ammonia, and immunoreactive insulin in blood of the portal and right hepatic veins clearly indicated that a large amount of portal vein blood was being shunted into the right hepatic vein. These findings suggest that hepatic encephalopathy in this patient is accounted for at least in part by an intrahepatic portal-hepatic venous shunting.