Association of use of Chinese herbal medicines and the risk of fracture in patients with osteoporosis: a population-based cohort study.

After utilizing a large population-based claims database and the application of propensity score match approach to reduce the confounding effects, we found that the use of Chinese herbal medicines (CHMs) was related to the lower risk of sequent osteoporotic fracture by 27% among the individuals with osteoporosis. The predominant effect was observed in those receiving CHMs for more than two years. INTRODUCTION: Osteoporosis (OS) is a highly disabling condition that can lead to fragility fracture, thus posing greater burdens of functional limitations for the affected individuals. It is unclear if the use of Chinese herbal medicines (CHMs) could reduce the risk of fracture due to OS. This study aimed to investigate the association of CHMs and the subsequent osteoporotic fracture risk among OS patients. METHODS: This longitudinal cohort study used the Taiwanese National Health Insurance Research Database to identify 250,699 newly diagnosed OS patients aged 20 years or older between 1998 and 2010. We recruited 103,325 CHM users following the onset of OS (CHM users) and randomly selected 103,325 subjects without CHM usage as controls (non-CHM users) by propensity score matching according to the demographic characteristics and comorbidities at enrollment. All enrollees were followed until the end of 2012 to record the incidence of osteoporotic fracture. We applied the Cox proportional hazard regression model to compute the hazard ratio (HR) of the risk of osteoporotic fracture. RESULTS: During the 15-year follow-up period, 7208 CHM users and 11,453 non-CHM users sustained osteoporotic fracture, with an incidence rate of 9.26 and 12.96, respectively, per 1000 person-years. We found that CHM users had a significantly reduced risk of osteoporotic fracture compared to non-CHM users (adjusted HR 0.73; 95% confidence interval [CI] = 0.70-0.75). Those treated with CHMs for longer than 730 days had a lower fracture risk by 54%. Some commonly used CHMs, such as Yan hu suo (Rhizoma Corydalis), Huang Qin (Scutellaria Baicale), Jie Geng (Platycodon grandifloras), Xiang Fu (Cyperus rotundus), Hai Piao Xiao (Cuttlebone Sepium), Jia-Wei-Xiao-Yao-San, Ge-Gen-Tang, Shao-Yao-Gan-Cao-Tang, and Du-Huo-Ji-Sheng-Tang, are related to the lower risk of fracture. CONCLUSIONS: The use of CHMs was associated with lower risk of osteoporotic fracture for OS patients, suggesting that it could be integrated into conventional therapy to prevent subsequent bone fracture.

Remediation of TCE-contaminated groundwater using acid/BOF slag enhanced chemical oxidation.

The objective of this study was to evaluate the potential of applying acid/H(2)O(2)/basic oxygen furnace slag (BOF slag) and acid/S(2)O(8)(2-)/BOF slag systems to enhance the chemical oxidation of trichloroethylene (TCE)-contaminated groundwater. Results from the bench-scale study indicate that TCE oxidation via the Fenton-like oxidation process can be enhanced with the addition of BOF slag at low pH (pH=2-5.2) and neutral (pH=7.1) conditions. Because the BOF slag has iron abundant properties (14% of FeO and 6% of Fe(2)O(3)), it can be sustainably reused for the supplement of iron minerals during the Fenton-like or persulfate oxidation processes. Results indicate that higher TCE removal efficiency (84%) was obtained with the addition of inorganic acid for the activation of Fenton-like reaction compared with the experiments with organic acids addition (with efficiency of 10-15% lower) (BOF slag=10gL(-1); initial pH=5.2). This could be due to the fact that organic acids would compete with TCE for available oxidants. Results also indicate that the pH value had a linear correlation with the observed first-order decay constant of TCE, and thus, lower pH caused a higher TCE oxidation rate.

Catechin stimulates osteogenesis by enhancing PP2A activity in human mesenchymal stem cells.

SUMMARY: Using human mesenchymal stem cells, we identified catechin from a panel of herbal ingredients and Chinese traditional compounds with the strongest osteogenic effects. Catechin increased alkaline phosphatase activity, calcium deposition, and mRNA expression of Runx2 and osteocalcin. We further clarified the signaling pathway that catechin mediated to stimulate osteogenesis. INTRODUCTION: Human mesenchymal stem cells (hMSCs), useful as a species specific cell culture system for studying cell lineage differentiation, were examined as a tool to identify novel herbal ingredients and Chinese traditional compounds for enhancing osteogenesis. METHODS: Immortalized and primary hMSCs were induced in osteogenic induction medium in the presence of a variety of herbal ingredients and Chinese traditional compounds and osteogenic differentiation was evaluated by histochemical assays and quantitative RT-PCR. RESULTS: Using immortalized hMSCs, we first identified catechin, 18ß-glycyrrhetinic acid, baishao, and danggui with osteogenic properties, which enhanced calcium deposition at the dose without significant cytotoxic effects. Primary hMSCs were then applied for confirming the osteogenic effects of catechin, which increased alkaline phosphatase activity, calcium deposition, and mRNA expression of Runx2 and osteocalcin. We further found the extracellular signal-regulated kinase (ERK) pathway was downregulated upon stimulation with catechin. Catechin increased the level and activity of protein phosphatases 2A (PP2A) that dephosphorylates ERK kinase (MEK) and ERK. Further, PP2A inhibitor, okadaic acid, abolished the effect of catechin-mediated inactivation of ERK and stimulation of osteogenesis. The blocking effect of okadaic acid on osteogenesis was further reversed by PD98059, a specific inhibitor of MEK. Co-immunoprecipitation revealed the association of PP2A to both MEK and ERK. CONCLUSIONS: These studies propose catechin enhanced osteogenesis by increasing the PP2A level that inhibits the MEK and ERK signaling in hMSCs. These results prove the concept of using hMSCs as a convenient tool for rapid and consistent screening of the osteogenic herbal ingredients and traditional Chinese compounds.

Adding moxifloxacin is associated with a shorter time to culture conversion in pulmonary tuberculosis.

OBJECTIVE: To investigate whether adding moxifloxacin (MXF) to the standard anti-tuberculosis regimen can shorten the time to sputum culture conversion in pulmonary tuberculosis (PTB). METHODS: Adults with culture-positive PTB were divided into two treatment groups by their choice: standard regimen alone (HERZ group) and standard regimen plus daily 400 mg MXF in the first 2 months (MXF group). Sputum samples were collected thrice weekly in the first 8 weeks. The propensity score was calculated to estimate the conditional probability of entering the MXF group. Factors influencing time to culture conversion were investigated using Cox proportional hazards regression analysis stratified by propensity score. RESULTS: Sixty-two patients were enrolled in the MXF group and 88 in the HERZ group; respectively 51 and 72 completed the study. The regimen was modified before culture conversion in respectively 6 (12%) and 12 (16%; P = 0.47) patients, due to adverse effects. The time to culture conversion was shorter in the MXF group (HR 2.1, 95%CI 1.4-3.2). The culture conversion rate after 6 weeks of treatment was respectively 82% and 61% (P = 0.011, <0.05/4, calculated using the modified Bonferroni method). CONCLUSIONS: Adding MXF to the standard anti-tuberculosis regimen in the first 2 months was associated with a shorter time to culture conversion, a higher 6-week culture conversion rate and reduced transmission of tuberculosis.

Treatment of petroleum-hydrocarbon contaminated soils using hydrogen peroxide oxidation catalyzed by waste basic oxygen furnace slag.

The contamination of subsurface soils with petroleum hydrocarbons is a widespread environmental problem. The objective of this study was to evaluate the potential of applying waste basic oxygen furnace slag (BOF slag) as the catalyst to enhance the Fenton-like oxidation to remediate fuel oil or diesel contaminated soils. The studied controlling factors that affect the removal efficiency of petroleum hydrocarbons included concentrations of H(2)O(2), BOF slag dosages, types of petroleum hydrocarbons (e.g., fuel oil and diesel), and types of iron mineral. Experimental results indicate that oxidation of petroleum hydrocarbon via the Fenton-like process can be enhanced with the addition of BOF slag. Results from the X-ray powder diffraction analysis reveal that the major iron type of BOF slag/sandy loam system was iron mineral (e.g., alpha-Fe(2)O(3) and alpha-FeOOH). Approximately 76% and 96% of fuel oil and diesel removal were observed (initial total petroleum hydrocarbon (TPH) concentration=10,000 mg kg(-1)), respectively, with the addition of 15% of H(2)O(2) and 100 g kg(-1) of BOF slag after 40 h of reaction. Because BOF slag contains extractable irons such as amorphous iron and soluble iron, it can act as an iron sink to supply iron continuously for Fenton-like oxidation. Results demonstrate that Fenton-like oxidation catalyzed by BOF slag is a potential method to be able to remediate petroleum-hydrocarbon contaminated soils efficiently and effectively.

Transpupillary thermotherapy for the treatment of choroidal neovascularization in age-related macular degeneration in Taiwan.

PURPOSE: To evaluate the therapeutic outcome and the recurrence of choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) after transpupillary thermotherapy (TTT) in light-brown retinas. METHODS: A retrospective, non-randomized study of 58 eyes in 55 patients with subfoveal CNV treated with TTT was conducted. Power settings were set about half the value for Caucasian eyes. The outcome was assessed with best-corrected visual acuity, fluorescein angiography, indocyanine green angiography, and fundoscopic examination. RESULTS: Forty-four membranes were occult, six classic, and eight mixed. Mean follow-up was 16.6+/-10.7 months (range: 6-48 months). Membranes closed in 46 eyes. Iatrogenic complications included three subretinal haemorrhage, two retinal pigment epithelium tears, and two macular area cystic changes. In eyes with occult CNV, visual acuity improved in six (13.6%), 14 (31.8%) remained unchanged, and 24 (54.6%) deteriorated. For various CNV, average logMAR changes from baseline at last follow-up were 0.30 in occult, -0.08 in classic, and 0.59 in mixed (P<0.01). Thirty eyes experienced recurrence within 9.2+/-6.2 months (range: 2-22 months). Cumulative recurrence rate was 45% at 12 months and 71% at 22 months, with no significant difference between occult and non-occult type CNV. CONCLUSIONS: Transpupillary thermotherapy does not cure CNV secondary to AMD. High recurrence was found independent of CNV type. Most improved vision was found mostly in classic CNV. Complications associated with high energy level should be considered in light-brown retinas.

The effects of the cyclosporin A, a P-glycoprotein inhibitor, on the pharmacokinetics of baicalein in the rat: a microdialysis study.

1. Baicalein is a bioactive flavonoid isolated from the root of Scutellaria baicalensis Georgi, a medicinal herb that has been used since ancient times to treat bacterial infections. As little is known concerning its pharmacokinetics, this study focussed on its pharmacokinetics as well as the possible roles of the multidrug transporter P-glycoprotein on its distribution and disposition. 2. Three microdialysis probes were simultaneously inserted into the jugular vein, the hippocampus and the bile duct of male Sprague-Dawley rats for sampling in biological fluids following the administration of baicalein (10, 30 and 60 mg kg(-1)) through the femoral vein. The P-glycoprotein inhibitor cyclosporin A was used to help delineate its roles. 3. The study design consisted of two groups of six rats in parallel: control rats which received baicalein alone and the cyclosporin A treated-group in which the rats were injected cyclosporin A, a P-glycoprotein inhibitor, 10 min prior to baicalein administration. 4. Cyclosporin A treatment resulted in a significant increase in elimination half-life, mean residence time and area under the concentration versus time curve (AUC) of unbound baicalein in the brain. However, AUC in the bile was decreased. 5. The decline of baicalein in the hippocampus, blood and bile suggested that there was rapid exchange and equilibration between the peripheral compartment and the central nervous system. In addition, the results indicated that baicalein was able to penetrate the blood-brain barrier as well as undergoing hepatobiliary excretion. 6. Although no direct transport studies were undertaken and multiple factors may affect BBB penetration and hepatobiliary excretion, strong association of the involvement of P-glycoprotein in these processes is indicated.

Sustained-release effect of codried excipients of microcrystalline cellulose and Ganoderma fiber.

The sustained-release effects of codried excipient of modified Ganoderma (treated with alkaline solution) and microcrystalline cellulose at different ratios were examined using acetaminophen (ACT) as a model drug. Results demonstrate that the crushing strength of most ACT tablets made with codried powder at all ratios increased as compaction force increased; but a rapid decline was observed when compression force exceeded 2 tons. Drug release from tablets compressed at 0.5 ton increased as modified Ganoderma fiber content increased. But when the compression force exceeded 1 ton, the release rate was not influenced by the compaction force or the increasing content of Ganoderma fiber. However, the dissolution of ACT from these tablets could be sustained for longer than 24 h. The extent of drug release was shown to increase with increasing amounts of modified Ganoderma in the codried excipient. The addition of disintegrants could further accelerate the drug release from the tablet. Drug release was also dependent upon the amount and kind of disintegrant used. The influence was in the following order: primojel>crospovidone>starch 1500.

Enhanced biodegradation of petrochemical wastewater using ozonation and BAC advanced treatment system.

The characteristics of degradation/conversion of bio-refractory and the growth of a biofilm are investigated in laboratory-scale pre-ozonation and lifted moving-bed biological activated carbon (BAC) advanced treatment processes treating phenol, benzoic acid, aminobenzoic acid and petrochemical industry wastewater which contains acrylonitrile butadiene styrene (ABS). The optimal reaction time and ozone dosage of pre-ozonation for bio-refractory conversion were determined to be 30 min and 100-200 mg O3/hr, respectively. After pre-ozonation of 30 min treatment, BOD5/COD ratio of influent and effluent increased apparently from 20 to 35%, approximately. However, the change of pH in pre-ozonation was inconspicuous. The optimal flow rate of influent and air were controlled at 1.6 l/h and 120-150 nl/min in lifted moving-bed BAC advanced treatment reactor. A COD removal efficiency of 85-95% and 70-90% may be maintained by using an organic loading of 3.2-6.3 kg COD/m3 day and 0.6-1.6 kg-COD/m3 day with an HRT of 6.0 h as secondary and advanced treatment system, respectively. The time required for the BAC bed is be regenerated by a thermal regeneration is prolonged 4-5 times more than that of GAC system. It can be estimated that the enhanced COD removal capability of the biofilm was not only due to the increase in the COD removal capability of acclimated bacteria, but also due to species succession of bacteria in bio-film ecosystem.

The clinical use of small-dose tetracaine spinal anesthesia for transurethral prostatectomy.

UNLABELLED: In a double-blinded study, we compared conventional dose tetracaine (8 mg), small-dose tetracaine (4 mg) with added fentanyl and epinephrine, and small-dose tetracaine (4 mg) with added fentanyl subarachnoid anesthesia. Forty-five patients scheduled for transurethral resection of prostate (TURP) under subarachnoid anesthesia were randomly assigned to Group 1 (8 mg hyperbaric tetracaine), Group 2 (4 mg hyperbaric tetracaine, 10 microg fen-tanyl, and 0.2 mg epinephrine), and Group 3 (4 mg hyperbaric tetracaine, 10 microg fentanyl, and 0.2 mL saline). Evaluations were performed after spinal anesthesia. Subarachnoid block was successful in all patients except one in Group 1, who required general anesthesia by mask. The median peak sensory levels 10 min after the induction of spinal anesthesia in Group 1 was T8, which was significantly higher than Group 2 and Group 3 (P < 0.05). The time of sensory and motor recovery in Group 3 was less than in Groups 1 and 2 (P < 0.05). Hypotension was observed in four patients in Group 1 and none in Groups 2 and 3. We conclude that small-dose 4-mg hyperbaric tetracaine plus 10 microg fentanyl might provide adequate anesthesia and fewer side effects for TURP when compared with the conventional (8 mg) dose. IMPLICATIONS: Small-dose hyperbaric tetracaine (4 mg with 10 microg fentanyl added) may provide adequate anesthesia and fewer side effects for transurethral resection of the prostate.

Analytical approaches for traditional chinese medicines exhibiting antineoplastic activity.

Traditional Chinese medicines have attracted great interest in recent researchers as alternative antineoplastic therapies. This review focuses on analytical approaches to various aspects of the antineoplastic ingredients of traditional Chinese medicines. Emphasis will be put on the processes of biological sample extraction, separation, clean-up steps and the detection. The problems of the extraction solvent selection and different types of column chromatography are also discussed. The instruments considered are gas chromatography, capillary electrophoresis (CE) and high-performance liquid chromatography (HPLC) connected with various detectors (ultraviolet, fluorescence, electrochemistry, mass, etc.). In addition, determinations of antineoplastic herbal ingredients, including camptothecin, taxol (paclitaxel), vinblastine. vincristine, podophyllotoxin, colchicine, and their related compounds, such as irinotecan, SN-38, topotecan, 9-aminocamptothecin, docetaxel (taxotere) and etoposide, are briefly summarized. These drugs are structurally based on the herbal ingredients, and some of them are in trials for clinical use. Evaluation of potential antineoplastic herbal ingredients, such as harringtonine, berberine, emodin, genistein, berbamine, daphnoretin, and irisquinone, are currently investigated in laboratories. Other folk medicines are excluded from this paper because their antineoplastic ingredients are unknown.

Recombinant adeno-associated virus vector expressing glial cell line-derived neurotrophic factor reduces ischemia-induced damage.

To explore the potential of using the recombinant adeno-associated viral (rAAV) vector, expressing glial cell line-derived neurotrophic factor (GDNF) as the gene therapy for stroke, we injected rAAV vectors expressing GDNF (rAAV-GDNF) into the cortex of rats which had been experiencing transient bilateral common carotid artery ligation and right middle cerebral artery ligation for 90 min. GDNF levels in cortical tissues of rAAV-GDNF-injected animals were significantly higher than in the control animals injected with rAAV-expressing lacZ (rAAV-lacZ), indicating that rAAV can deliver and express the GDNF gene in cortical tissues. Triphenyltetrazolium chloride tissue stain analysis revealed that the rAAV-delivered GDNF gene could rescue the brain tissues from ischemia-induced injury. Cortical tissues which received rAAV-GDNF injections had both significantly smaller total volumes of infarction and smaller areas of infarction on each brain slice than those which were injected with rAAV-lacZ. An in situ labeling analysis demonstrated significantly less apoptotic cells in cortical tissues rescued by rAAV-GDNF, indicating prevention of apoptosis as the mechanism of cortical cell protection. Moreover, immunohistochemistry staining of Neu-N indicated that the rescued brain tissues contained the same number of Neu-N-positive neuronal cells as contralateral undamaged brain tissues. This provides strong evidence that cortical neuronal cells can be rescued by GDNF gene therapy. Indeed, these findings show that the rAAV is a potential delivery vector of GDNF gene for the therapy of stroke.

Measurement and pharmacokinetic study of tetramethylpyrazine in rat blood and its regional brain tissue by high-performance liquid chromatography.

We used a rapid, sensitive and reliable high-performance liquid chromatographic method for the determination of tetramethylpyrazine in rat brain tissue and plasma. The lower limit of quantification in plasma and brain tissue was 0.1 microgram/ml and 0.1 microgram/g, respectively, and only a small amount of plasma (100 microliters) or brain tissue (100 micrograms) was required for analysis. The decline in the concentration of tetramethylpyrazine in plasma was generally two-exponential at a dose of 2, 5, or 10 mg/kg administered intravenously. Concentrations of tetramethylpyrazine in various regions of the brain (cerebral cortex, brainstem, striatum, hippocampus, cerebellum and midbrain) were not significantly different at 15 min following drug administration (10 mg/kg, i.v.). In additional analysis, mean concentration of the tetramethylpyrazine in rat plasma was approximately five-times greater than the drug in brain tissue.

Contact leukomelanosis induced by the leaves of Piper betle L. (Piperaceae): a clinical and histopathologic survey.

BACKGROUND: In April 1997, an unusual pigmentary disorder was noticed by dermatologists in Taiwan. All patients had a history of using facial dressings with steamed leaves of Piper betle L. (Piperaceae). OBJECTIVE: Our purpose was to clarify the evolution and the origin of this unique leukomelanosis. METHODS: Fifteen patients with an unusual pigmentary disorder, who visited our clinic in September and October 1997, were asked to complete a questionnaire designed to elicit the history related to the disorder. Eight of these 15 patients underwent skin biopsies: 6 on the mottled hyperpigmented area (group A) and 2 on the hypopigmented area (group B). All 8 specimens were prepared with hematoxylin-eosin, Masson-Fontana, and S-100 stains. RESULTS: The results of the questionnaire revealed that these patients had all experienced a temporary erythematous reaction in the first few days of the use of the facial dressing, and 9 of them also complained of an accompanying stinging sensation. A bleaching effect became noticeable approximately 1 week to 1 month later. Eight patients reported that the hyperpigmentation and confetti-like hypopigmentation occurred after overexposure to the sun. In both groups, histopathologic examination revealed some melanophages in the dermis. Masson-Fontana staining of specimens from group A showed local interspersed depigmentation and hyperpigmentation in the basal epidermis and pigmentary incontinence in the dermis. This picture was different from the homogeneous depigmentation within basal epidermis in specimens from group B. In both groups, S-100 staining was negative for melanocytes in the depigmented area. CONCLUSION: The clinical course and histopathologic findings suggest that the evolution of this pigmentary disorder can be divided into 3 stages. The first stage is the immediate bleaching stage, when an irritant reaction is usually conspicuous. The second stage consists of prominent hyperpigmentation visible both grossly and microscopically. The final stage is characterized by confetti-like depigmentation. It may be induced by chemicals in the betel leaves such as phenol, catechol, and benzene derivatives, perhaps through inhibition of melanin synthesis or melanocytotoxicity.

Solamargine purified from Solanum incanum Chinese herb triggers gene expression of human TNFR I which may lead to cell apoptosis.

Solamargine possessed a potent cytotoxicity to human hepatocyte (Hep3B) and normal skin fibroblast. The inhibition curves of solamargine to the both cells were essentially overlapped, suggesting a parallel effect for the cell death. To define mechanism of cytotoxicity of solamargine, the changes of morphology and DNA content in cells were studied. A sub-G1 cell stage was drastically increased after 3-h incubation with solamargine. The results evidence that solamargine arises cell death by apoptosis. In addition, the gene expression of TNFR I were up-regulated within 30 min of solamargine treatment. Since TNF Receptor I has been involved in apoptosis, the overexpression of TNF receptor I may be related with the mechanism of cytotoxicity of solamargine. This communication is the first report that a component of Chinese herbs triggers gene expression of human TNFR I which may lead to cell apoptosis.

Determination of wogonin in rat plasma by liquid chromatography and its pharmacokinetic application.

A high-performance liquid chromatographic method has been developed for the determination of wogonin in the rat plasma. After addition of an internal standard (clomipramine), plasma was deproteinized by acetonitrile and centrifuged for sample clean-up. The supernatant was separated by a reversed-phase column chromatography, identified by a photodiode-array detector, and quantified by ultraviolet detection at a wavelength of 275 nm. Acetonitrile-water-diethylamine (50:50:0.1, v/v/v, pH 3.0 adjusted by orthophosphoric acid) was used as the mobile phase. The method was applied to the pharmacokinetic study of wogonin in rats after a dose of mg/kg by intravenous administration. A biphasic phenomenon with a rapid distribution followed by a slower elimination phase was observed from the plasma concentration time profile.

Pharmacokinetics of osthole in rat plasma using high-performance liquid chromatography.

A simple high-performance liquid chromatographic method was developed to study the pharmacokinetics of osthole in rat plasma. After addition of an internal standard (paeonol), plasma was deproteinized by acetonitrile for sample clean-up. The drugs were separated on a reversed-phase column and detected by UV absorption at 323 nm. Acetonitrile-water-diethylamine (50:50:0.1, v/v/v) (pH 3.0, adjusted with orthophosphoric acid) was used as the mobile phase. It was applied to the pharmacokinetic study of osthole in rats after a dose of 10 mg kg-1 by intravenous administration. A biphasic phenomenon with a rapid distribution followed by a slower elimination phase was observed from the plasma concentration-time curve.

Breathing-coordinated exercise improves the quality of life in hemodialysis patients.

Breathing-coordinated exercise is a traditional Chinese exercise. These exercise maneuvers consist of slow diaphragmatic breathing, end-inspiratory pause, and Kegel's exercise. A total of 30 patients were enrolled in this study, with 12 patients as controls, to evaluate its effect on hemodialysis patients. Exercise was performed for 25 to 30 min twice a day for at least 3 months. Results from the exercise group showed a subjective improvement in appetite and physical strength, and an increase in the frequency of bowel movements, in addition to enhanced sexual activity and a significant increase in Karnofsky scores. Six patients in the exercise group underwent bicycle ergometry and demonstrated a stable maximal oxygen consumption, whereas the control group revealed a decline in maximal oxygen consumption. Photoelectric plethysmography and laser-Doppler flowmetry demonstrated a pulsatile enhancement of the peripheral microcirculation. Abdominal sonography revealed an oscillatory change in the diameter of the inferior vena cava. It was concluded that these gentle exercise maneuvers may improve the quality of life in hemodialysis patients, especially weak dialysis patients. The mechanism may be partly related to an improvement in microcirculation.