Restless legs syndrome is associated with cardio/cerebrovascular events and mortality in end-stage renal disease.

BACKGROUND AND PURPOSE: Earlier studies suggested an association between idiopathic restless legs syndrome (RLS) and cardiovascular diseases. However, the risk of cardiovascular events in patients with secondary RLS due to end-stage renal disease (ESRD) is unclear. Our aim was to examine whether ESRD patients with RLS had an increased risk of cardio/cerebrovascular events and mortality. METHODS: In all, 1093 ESRD patients were recruited between 2009 and 2010. The diagnosis and severity of RLS were assessed in a face-to-face interview. The occurrence of cardio/cerebrovascular events and death were confirmed by medical record review. The association between RLS and the outcomes of interest was examined using an adjusted multivariate Cox regression model. RESULTS: After a mean follow-up period of 3.7 ± 0.8 years, ESRD patients with RLS had a significantly higher risk of developing cardiovascular events and strokes [adjusted hazard ratio (aHR) 2.82, 95% confidence interval (CI) 2.02-4.11, and aHR 2.41, 95% CI 1.55-3.75, respectively] compared with patients without RLS. Increasing RLS severity was associated with an increasing likelihood of cardiovascular events [mild RLS severity, aHR 1.71 (95% CI 1.02-2.87); moderate, 2.79 (1.64-4.66); severe, 2.85 (1.99-4.46)] and strokes [mild, 1.89 (0.87-4.16); moderate, 2.42 (1.50-3.90); severe, 2.64 (1.49-4.91)] in a dose-dependent manner. RLS also increased the risk of total mortality in patients with ESRD [aHR 1.53 (95% CI 1.07-2.18), P = 0.02]; this association attenuated slightly after stratification by individual RLS severity category [mild RLS severity, aHR 1.44 (95% CI 0.78-2.67); moderate, 1.49 (0.98-2.55); severe, 2.03 (0.93-4.45)]. CONCLUSIONS: ESRD patients with RLS demonstrated an increased likelihood of cardio/cerebrovascular events and mortality.

Association of candidate genetic variants with restless legs syndrome in end stage renal disease: a multicenter case-control study in Taiwan.

BACKGROUND AND PURPOSE: Recent genome-wide association studies have shown associations between multiple genetic variants and primary restless legs syndrome (RLS). Their roles in end stage renal disease (ESRD) related secondary RLS are not clear and studies in Asian populations are scarce. The association between candidate genetic variants and uremic RLS was investigated in a large cohort of Taiwanese dialysis patients. METHODS: Sixteen RLS-related genetic variants at six loci, including MEIS1, BTBD9, MAP2K5/SKOR1, PTPRD, TOX3/BC034767 and the intergenic region of chromosome 2p14, in a total of 993 ESRD patients (259 subjects with and 734 subjects without RLS) were genotyped using TaqMan genotyping assays. Multivariate logistic regression analysis was used to test for associations between the genotypes and RLS in ESRD. Power calculations were completed using the CATs Genetic Power Calculator with settings of a multiplicative genetic model. RESULTS: A modest association between the PTPRD variant rs4626664 and uremic RLS (odds ratio 1.52, 95% CI 1.03-2.23, P = 0.03) and a trend that TOX3/BC034767 variant rs3104767 may associate with the occurrence of RLS were observed in our dialysis population (odds ratio 1.74, 95% CI 0.97-3.11, P = 0.06). No associations between other genetic variants and risk and severity of RLS were observed in our ESRD cohort. CONCLUSIONS: The genetic variants of primary RLS candidate genes did not play a major role in our uremic RLS populations. The ethnic difference and heterogeneous etiologies underlying renal failure may partly explain the minor genetic contribution to uremic RLS in our populations. Further studies for other ethnicities will be of worth.

Restless legs syndrome in end-stage renal disease: a multicenter study in Taiwan.

BACKGROUND AND PURPOSE: Restless legs syndrome (RLS) is an underestimated movement disorder in patients with end-stage renal disease (ESRD). Several clinical and laboratory factors were inconsistently reported to associate with RLS. We aim to perform a large-scale multicenter study to investigate the possible associated risk factors of RLS in patients with ESRD in Taiwan, a country with the highest incidence of uremia in the world. METHODS: From October 2009 to October 2011, we constitutively recruited 1130 patients with ESRD from 17 hemodialysis centers. Demographic, laboratory data, presence and severity of RLS were collected. Odds ratios (ORs) were estimated by logistic regression models. RESULTS: We found the prevalence of RLS to be 25.3% in patients with ESRD. Having type 2 diabetes [OR = 3.61 (2.27-5.77), P < 0.01], low serum transferrin saturation [OR = 1.42 (1.01-2.03), P < 0.05] and duration of dialysis [OR = 1.09 (1.03-1.14), P < 0.01] were associated with RLS. In contrast, high serum hemoglobin level was inversely associated with RLS [OR = 0.61 (0.40-0.89), P < 0.05]. RLS has a significant impact on sleep quality in dialysis patients. Among patients with RLS, history of type 2 diabetes [OR = 4.04 (1.65-10.79), P < 0.05], low serum hemoglobin level [OR = 5.41 (2.43-13.12), P < 0.01] and duration of dialysis [OR = 1.01 (1.01-1.02), P < 0.01] were associated with increased severity of RLS. CONCLUSIONS: Our findings demonstrated that RLS is common in Taiwanese dialysis patients. Clinicians should have a high suspicion for the presence of RLS symptoms in patients with ESRD, especially those with type 2 diabetes, anemia, low serum iron status and long duration of dialysis.

Bilateral aldosterone-producing adenomas: differentiation from bilateral adrenal hyperplasia.

BACKGROUND: Primary aldosteronism (PA) is a common curable disease of secondary hypertension. Most such patients have either idiopathic bilateral adrenal hyperplasia (BAH) or unilateral aldosterone-producing adenoma (APA). Bilateral APAs are reportedly extremely rare. AIM: To compare the distinctive characteristics, clinical course, and outcomes of bilateral APA vs. BAH. DESIGN: Retrospective record review. METHODS: From July 1994 to Jan 2007, 190 patients diagnosed with PA underwent surgical intervention at our hospital. Bilateral APA was diagnosed in 7/164 patients with histologically-proven APA. Twenty-one patients diagnosed as BAH, and 21 randomly selected of unilateral APA patients, matched by age and sex served as controls. RESULTS: Patients with bilateral APA had similar blood pressure, arterial blood gas analysis, spot urinary potassium to creatinine ratio and clinical symptoms to those with BAH, but lower serum potassium levels (p = 0.027), lower plasma renin activity (p = 0.037), and higher plasma aldosterone concentrations (p = 0.029). Aldosterone-renin ratio (ARR) after administration of 50 mg captopril was higher in bilateral APA than in BAH patients (p = 0.023), but not different between unilateral APA and BAH (p = 0.218). A cut-off of ARR >100 ng/dl per ng/ml/h and plasma aldosterone >20 ng/dl after captopril significantly differentiated bilateral APA from BAH. Bilateral subtotal adrenalectomy normalized blood pressure and biochemistry in all patients with bilateral APA. DISCUSSION: Bilateral APA, presenting simultaneously or sequentially, may not be a rare disease, accounting for 4.3% of APA in this sample. The clinical presentations of bilateral functional adenoma are not different from BAH, but patients with low serum potassium and ARR >100 after captopril should be carefully evaluated for bilateral adenoma.

A review of microbial injury and recovery methods in food.

The existence of injured microorganisms in food and their recovery during culturing procedures is critical. Microbial injury is characterized by the capability of a microorganism to return to normalcy during a resuscitation process in which the damaged essential components are repaired. Injury of microorganisms can be induced by sublethal heat, freezing, freeze-drying, drying, irradiation, high hydrostatic pressure, aerosolization, dyes, sodium azide, salts, heavy metals, antibiotics, essential oils, sanitizing compounds, and other chemicals or natural antimicrobial compounds. Injured microorganisms present a potential threat in food safety since they may repair themselves under suitable conditions. Detection of injured microorganisms can be important to practical interpretations of data in food microbiology. This review provides an overview of microbial injury in food and discusses the development of recovery methods for detecting injured foodborne microorganisms.

Pentoxifylline Decreases Dialysis Risk in Patients With Advanced Chronic Kidney Disease.

Few studies evaluated the effects of pentoxifylline on hard endpoints in patients with predialysis stage 5 chronic kidney disease (CKD). Thus, we tried to explore the effects of pentoxifylline and its interaction with renin-angiotensin-aldosterone system (RAAS) blockade on the development of endstage renal disease (ESRD) and mortality. This nationwide cohort study retrospectively included patients who had a serum creatinine level of >6 mg/dL and received erythropoiesis-stimulating agents (ESAs) between 2000 and 2010. We analyzed 7,366 pentoxifylline users and 7,366 propensity score-matched nonusers. Using Cox proportional hazard models, pentoxifylline reduced the risks of ESRD and the composite renal outcome but not that of mortality. In terms of the risks of developing ESRD, pentoxifylline alone exerted a comparable beneficial effect to combined therapy with an RAAS inhibitor and greater renoprotection than RAAS inhibitor monotherapy. This study suggests pentoxifylline is efficacious in slowing progression to ESRD in patients with predialysis stage 5 CKD.

Candida tropicalis-associated bilateral renal papillary necrosis and emphysematous pyelonephritis.

Although the kidney is often involved in disseminated and localized candidiasis, bilateral emphysematous pyelonephritis (EPN) is infrequently reported. Renal papillary necrosis (RPN) caused by fungi is also rare. We describe a patient with bilateral RPN and EPN caused by Candida tropicalis, who suffered from recurrent hematuria, flank pain, acute fulminant renal failure, and obstruction by a sloughed papilla. He was treated successfully with antifungal therapy and percutaneous nephrostomy (PCN). This is the first case report of C. tropicalis-associated EPN and RPN.

Evaluation of a 5'-nuclease (TaqMan) assay with the thin agar layer oxyrase method for the detection of Yersinia enterocolitica in ground pork samples.

A 5'-nuclease (TaqMan) assay was evaluated for its capability to recover and detect stressed Yersinia enterocolitica. Sensitivity studies of a 5'-nuclease assay for detecting Y. enterocolitica 0:8 in a pure culture system and spiked ground pork samples demonstrated that the assay has reliable sensitivity with a detection limit of 3 to 4 log CFU/ml or CFU/g. The PCR 5'-nuclease (TaqMan) assay was evaluated with the Thin Agar Layer Oxyrase method (TALO, overlaying 14 ml of Trypticase soy agar with a 1:30 dilution of "Oxyrase for Agar" onto a prepoured pathogen-specific, selective medium), and it was compared against the selective medium cefsulodin-irgasan-novobiocin (CIN) for recovering and detecting Y. enterocolitica from inoculated nonfrozen and frozen (-15 degrees C, 2 days) ground pork samples. The TALO method showed more sensitivity (detection limit, 2 log CFU/ml), and it has greater recovery capability (0.5 to 1 log CFU/ml) than CIN (P < 0.05). The 5'-nuclease assay provided rapid detection processing (5 versus 24 h after an 18-h enrichment). The sensitivity per PCR was calculated to as low as 0 to 1 log CFU per PCR reaction; however, in the method's current developmental stage, target pathogens should be enriched to 3 to 4 log CFU/ml or CFU/g to show consistent results. In a survey of 100 ground pork samples using TALO, CIN, and PCR methods, no Y. enterocolitica was recovered. A combined cultivation and an automated PCR TaqMan could be used as a presumptive screening test for detecting Y. enterocolitica in food samples.

Evaluation of thin agar layer method for recovery of acid-injured foodborne pathogens.

The thin agar layer (TAL) method of Kang and Fung was used to enumerate acid-injured foodborne pathogens. This method involves overlaying 14 ml of nonselective medium (tryptic soy agar [TSA]) onto a prepoured and solidified pathogen-specific, selective medium in a petri dish. After surface plating, injured cells resuscitated and grew on TSA during the first few hours of incubation; then, the selective agents from the selective medium diffused to the top layer, interacted with the recovered microorganisms, and started to produce typical reactions. Foodborne pathogens were exposed to 2% acetic acid for 1, 2, or 4 min, and the recovery rate with the TAL method was compared with the rate of TSA and pathogen-specific, selective media. No significant difference occurred between TSA and TAL (P > 0.05) for enumeration of acid-injured Escherichia coli O157:H7, Salmonella Typhimurium, Staphylococcus aureus, and Yersinia enterocolitica, and both recovered significantly higher numbers than the selective medium for each respective pathogen (P < 0.05). For recovery of acid-injured Listeria monocytogenes, no difference (P > 0.05) occurred among TSA, TAL, and selective media. However, fewer cells were recovered in the selective media. The TAL method is a one-step, convenient procedure for recovery of acid-injured cells.

Methimazole-induced pulmonary hemorrhage associated with antimyeloperoxidase-antineutrophil cytoplasmic antibody: a case report.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis has been recently recognized in Graves' disease patients treated with antithyroid drugs. We describe the case of an 18-year-old girl who developed antimyeloperoxidase ANCA (MPO-ANCA)-positive vasculitis manifesting as a skin lesion and hemoptysis with hypoxic respiratory failure after taking methimazole. An open lung biopsy was consistent with acute capillaritis. Both skin and sural nerve biopsy showed lymphocytic vasculitis. Administration of steroid and plasmapheresis produced a good clinical response.

A practical ultrasonic plethysmograph.

An ultrasonic plethysmograph, which gives improved performance over the standard Whitney Strain Gauge, is described. This instrument monitors dimension changes in human limbs by measuring the transit times of acoustic pulses across two chords of the limb. In the case of a small uniform expansion, the percentage change in limb volume is shown to be proportional to twice the percentage change in either of the measured chords. Measurement of two chords allows correction for possible non-uniform expansion. In addition, measurement of two chords allows an estimate of the absolute cross-sectional area of the limb. The developed instrument incorporates a microprocessor, which performs necessary calculation and control functions. Use of the microprocessor allows the instrument to be self-calibrating. In addition, the device can be easily reprogrammed to incorporate improvements in operating features or computational schemes.

Transducers for ultrasonic limb plethysmography.

Shifts in blood content of tissues cause dimension changes which can be measured with an ultrasonic dimension gauge. We have previously described the construction of a limb plethysmograph which uses this principle. Although other workers have described the construction of ultrasonic dimension gauge transducers intended for use inside animals, these transducers are not ideal for plethysmographic application. In this report we describe the design, construction, and performance characteristics of transducers suitable for limb plethysmography. Good signal quality is obtained with minimum care in transducer placement. These transducers incorporate a rugged external housing which provides for simple attachment to the calf by use of double-sided adhesive collars.

Leukoencephalopathy induced by levamisole alone for the treatment of recurrent aphthous ulcers.

We report imaging and clinical findings of leukoencephalopathy occurring after levamisole. The lesions were hypoattenuating on CT and appeared as multifocal oval or elliptical foci in the white matter or along the subependymal veins on MRI. Most lesions resolve after prompt withdrawal of levamisole. Detailed history taking is important for diagnosing levamisole-induced leukoencephalopathy because multiple sclerosis and acute disseminated encephalomyelitis cannot be differentiated by neuroimaging findings alone.

Does famotidine have similar efficacy to misoprostol in the treatment of non-steroidal anti-inflammatory drug-induced gastropathy?

The study aimed to evaluate the efficacy of famotidine, an H2 receptor blocker, and misoprostol, a prostaglandin E analogue, in the treatment of non-steroidal anti-inflammatory drug-induced (NSAID) gastropathy in arthritic patients. A total of 128 patients receiving piroxicam, sulindac, indomethacin, naproxen, tolmetin and aspirin were enrolled in the study. Gastroscopic examination was performed at the beginning and after eight weeks of randomised famotidine or misoprostol treatment. A standard scoring method for gastroscopic finding was applied. Forty-four patients with scores 1-3 were classified as group A; while the other 84 with score 4 (ulcer) were placed in group B. In group A, 26 received famotidine and 18 misoprostol. In group B, 36 received famotidine and 48 misoprostol. Biopsy specimens taken from the rim of the ulcer with adjacent normal mucosa were coded and tested for Helicobacter pylori. In group A, all but two patients taking famotidine recovered from NSAID gastropathy, and there was no statistical significance between the two drugs. In group B, all but four patients receiving famotidine improved and there was no statistical significance between the two subgroups for complete healing rate. The prevalence of H. pylori was 36.9%, lower than that in the general population. It was concluded that famotidine and misoprostol have similar efficacy in the treatment of NSAID gastropathy.

A mutant allele common to the type I adenine phosphoribosyltransferase deficiency in Japanese subjects.

Adenine phosphoribosyltransferase (APRT) deficiency is a genetic disorder which causes 2,8-dihydroxy-adenine urolithiasis. The estimated incidence of heterozygosity in Caucasian and Japanese populations is 1%. Mutant alleles responsible for the disease have been classified as APRT*Q0 (type I) and APRT* (type II). In our previous study, we demonstrated in APRT*J a single common base change which accounts for 70% of the Japanese mutants. The present report describes the analysis of an APRT*Q0 mutation in Japanese subjects. Two nucleotide substitutions common to all seven affected alleles from four unrelated subjects (three homozygotes and a heterozygote) were identified: G----A at nucleotide position 1453 and C----T at 1456. The G----A altered the amino acid Trp98 to a stop codon. The C----T did not alter Ala99. These point mutations were demonstrated by sequence analysis of polymerase chain reaction (PCR)-amplified genomic DNA and cDNA. The G----A change at 1453 results in the elimination of a PflMI site in the APRT gene. PflMI digests, which were used to confirm the G----A transition, can be useful in screening for this specific mutation.