[Homecare Support for Patients with Foot Ulcers Rejecting Lower Limb Amputations: Effects of Visiting Nursing].

The patient, a 60-year-old male with a combination of diabetes mellitus and hypertension, was hospitalized for peripheral arterial disease and recommended as a candidate for lower limb amputation after vascular IVR. The patient rejected this recommendation and left the hospital. The toes of both feet turned black and became mummified, which resulted in the patient being unable to walk at home and being prescribed narcotics for the pain. The patient requested home nursing where he was provided with lower limb wound care and rehabilitation to improve lower limb muscle strength together by visiting nurses and his wife. A daily regime was devised to prevent accompanying pain in the wounds, which improved gradually. The time spent together through repeated daily care helped build a relationship in which everyone involved was pleased with the improvements to the wounds. The necrotic site was auto-amputated and healed after 15 months. During this time, the feelings of the patient who did not want to amputate were considered and he was able to be cured without additional complications.

Association of hyperhomocysteinemia with plasma sulfate and urine sulfate excretion in patients with progressive renal disease.

BACKGROUND: Plasma total homocysteine (tHcy) level is increased in patients with renal disease, parallel to serum creatinine concentration. In renal failure, the final product of sulfated amino acid metabolism, sulfate, also accumulates as renal function declines. We hypothesized that the elevation in sulfate level could cause hyperhomocysteinemia and tested the relation between tHcy level and both urinary excretion and plasma levels of sulfate. METHODS: Forty patients with renal disease were divided into three groups: patients without renal failure (nRF; creatinine clearance [CCr] > or = 80 mL/min/1.73 m2 [> or =1.33 mL/s/1.73 m2]), patients with mild renal failure (mRF; 80 > CCr > or = 25 mL/min/1.73 m2 [1.33 > CCr >/ or 0.42 mL/s/1.73 m2]), and patients with severe renal failure (sRF; CCr < 25 mL/min/1.73 m2 [<0.42 mL/s/1.73 m2]). Daily urinary excretion and plasma levels of tHcy, total cysteine (tCys), and sulfate were measured. A healthy control (HC) group also was tested. Serum methionine, taurine, vitamin B12, and folate levels also were determined in patients with renal disease. RESULTS: Plasma tHcy and sulfate concentrations in the groups with mRF and sRF were greater than in the HC group. Plasma tCys concentrations in the mRF and sRF groups were greater than in the nRF group. Daily urinary Hcy and Cys excretion did not differ among the four groups. Daily urine sulfate and urea nitrogen excretion in the sRF group were significantly less than in the HC and nRF groups. Multiple regression analyses showed that plasma creatinine (beta = 0.40) and sulfate (beta = 0.43) levels were independently associated with plasma Hcy level; among urine parameters, only daily urine sulfate excretion (beta = -0.52) was independently associated with plasma Hcy level. CONCLUSION: The elevated plasma sulfate level, in accordance with renal function, is associated with plasma tHcy level. Decreased sulfate excretion, which might parallel the intake of sulfated amino acid or protein, may increase tHcy levels.

Sequential changes in the plasma concentration of risperidone following intentional overdose.

Risperidone (RIS) is a novel antipsychotic agent whose pharmacokinetics have yet to be fully determined. In particular, little is known about RIS following an overdose. We report the pharmacokinetics following ingestion of a high dose of RIS by serially measuring the plasma concentration in two patients. These patients were admitted in a comatose state following an intentional overdose of RIS; all patients survived. In the first patient, 14 mg of RIS had been ingested 2 hr before the first blood sample was obtained. The second patient ingested an estimated 90 mg of RIS. Seven time-points were determined. The maximum concentration of unaltered RIS was 325 ng/mL and that of the principal metabolite (9-hydroxy-risperidone: 9-OH RIS) was 139 ng/mL. By plotting the time-concentration curve for the active fraction (RIS plus 9-OH-RIS) in the first and second patients, the half-life of RIS following overdose was determined and was approximately 12.7 hr and 17.8 hr, respectively. These values are similar to the half-life of RIS in healthy individuals ingesting a therapeutic dose. Two patients did not developed parkinsonism nor dystonia, and were discharged without sequelae.

[Reversible white matter lesions and antithyroid antibodies in the cerebrospinal fluid in Hashimoto's encephalopathy: a case report].

A 71-year-old woman with Hashimoto's disease was admitted to our hospital because of involuntary movement, gait disturbance, and mental decline. Her consciousness was alert but her orientation about time and place was disturbed. She was mentally ill (HDS-R; 12/30, MMSE; 14/30), and could not walk because of truncal ataxia. Myoclonus was present in the upper extremities. Laboratory examinations showed hypothyroidism and very high titers of antithyroid antibodies (ATA) in serum. Head MRI showed no abnormal lesions. On electroencephalogram (EEG), the basic rhythm was slow and bursts of irregular slow waves (4-6 Hz) were present. Her conditions gradually ameliorated so that she was discharged. However, she was hospitalized again because of sudden worsening of the illness: her consciousness got disturbed and the myoclonus became marked. As the result, she got bed-ridden. At the time, thyroid function was almost normal, suggesting that the deterioration could not be attributed to hypothyroidism. The EEG findings were quite different from the former: complex of multiple spikes and slow waves was continuously present. Examination of the cerebrospinal fluid (CSF) revealed an elevated level of protein and IgG (cell 1/m3, protein 101 mg/dl, sugar 60 mg/dl ,Cl 124 mEq/l, IgG 20.4 mg/dl). IgG index was 0.57 and Q albumin (CSF-albumin/serum-albumin ratio) was 15.2 (9.0>) . After the second admission, she recovered from the bed-ridden state but was still unable to walk or communicate. She continued to need complete support for all daily lives. The diagnosis was made as Hashimoto's encephalopathy (HE), from the following points: 1) encephalopathy not due to hypothyroidism, 2) very high titers of ATA, 3) elevated CSF protein. The effectiveness of steroid therapy was so amazing that the neurological problems faded away very soon. Finally she completely recovered. As well as the clinical manifestations, the EEG findings were improved. At the stage in which excellent clinical improvement had achieved, head MRI revealed that T2/FLAIR high lesions without Gd-enhancement temporarily appeared diffusely and extensively in the cerebral white matter. They thereafter almost disappeared on follow-up MRI. Judging from the lesions being non-enhanced and reversible, they supposedly reflected brain edema. It is important to keep it in mind that MRI findings may change abruptly and drastically in HE. ATA was detected not only in serum but also in CSF. Either titer thereafter decreased along with the healing of the illness. Concerning the reason why ATA is present in CSF, we supposed leakage from blood through the disrupted blood-brain barrier, for the following reasons: 1) IgG index was normal, 2) Q albumin was elevated, 3) the change of CSF-ATA titer was almost parallel to that of serum-ATA titer, and 4) the white matter lesions, which presumably reflected brain edema, were observed.

[A case of sarcoidosis overlapping with rheumatoid arthritis].

We report the case of a 54-year-old woman who presented on May 28, 2001 with sarcoidosis overlapping with rheumatoid arthritis. She had experienced morning stiffness 2 years previously and was diagnosed as having rheumatoid arthritis. She had been treated with bucillamine and loxoprofen for 3 months. In October 2000, she developed proteinurea. The patient discontinued treatment with bucillamine and loxoprofen. Proteinurea persisted, and the patient's renal function declined. On admission, subcutaneous nodules were palpable in the patient's legs. The patient's serum creatinine and calcium levels were 2.49 mg/dl and 11.6 mg/dl, respectively. Intact-PTH was suppressed, and PTHrP was not elevated. Despite the presence of hypercalcemia, the patient's serum 1 alpha 25(OH)2D3 was not suppressed. Serum ACE and lysozyme levels were elevated beyond the normal ranges. A renal biopsy was performed, and non-caseous epithelioid granuloma was found in the renal interstitium. Based on the histological findings, the patient was diagnosed as having sarcoidosis. Following treatment with prednisolone, the patient's serum calcium levels returned to normal and her renal function improved.

Polysomnographic features of idiopathic central sleep apnea.

Two patients with idiopathic central sleep apnea (ICSA), which is an uncommon condition, were recently encountered. This study examines the polysomnographic features of ICSA. The characteristic findings of ICSA are summarized as follows: (i) central apneas and hypopneas are progressively less frequent as sleep state deepens from stage 1 to stage 2 to stage 3 + 4 to stage REM (rapid eye movement); (ii) desaturation related to apneas and hypopneas is mild; and (iii) periodic breathing is commonly observed. However, the two patients demonstrated apparently different findings. It is suggested that the mechanisms underlying apnea and hypopnea in ICSA are heterogeneous.

Autopsy case of the cerebellar form of progressive multifocal leukoencephalopathy without immunodeficiency.

A case of the cerebellar form of progressive multifocal leukoencephalopathy (PML) without remarkable immune depression or immune deficiency is reported here. The patient was a 74-year-old-woman who had complications of chronic renal failure and renal anemia for several years. Seven months before her death she had symptoms of general fatigue, gait disturbance and articulation disorder. During her hospitalization period her neurological disorder gradually progressed irreversibly with failure of consciousness and she died of respiratory failure. She did not have remarkable clinical signs of immunodeficiency nor did she receive immunosuppressive therapy. Clinically she had not been diagnosed with PML. At the post-mortem examination different degrees of demyelination were observed in the brain white matter: diffuse and severe in the cerebellum, moderate and coalescent in the brainstem, and light and patchy in the cerebrum. JC virus antigen-positive cells were frequently observed in the demyelinated lesions in the cerebrum and sometimes observed in the brainstem, but were rarely found in the cerebellum. These findings suggest that PML lesions may be present with different degrees of demyelination that are inversely correlated with the number of JC virus-infected cells. This fact should be considered when evaluating the brain biopsies of PML patients.

Free cysteine is increased in plasma from hemodialysis patients.

BACKGROUND: Although only the total thiol concentration, which includes bound and free forms, has been determined in most previous clinical studies, the free form may be a better predictor of cardiovascular risk. METHODS: We measured the apparent concentration of free homocysteine (Hcy) and cysteine (Cys) in filtered and acid-soluble fractions of plasma in healthy control subjects and in patients with chronic renal failure just before and after a hemodialysis session. RESULTS: In control, filtered Hcy and acid-soluble Hcy were similar, while filtered Cys was much smaller than in acid-soluble Cys. In prehemodialysis samples, filtered Cys was more than 60 times as abundant (259.2 +/- 26.2 micromol/L) as in control samples (4.1 +/- 0.7 micromol/L ). Free-to-total ratios for filtered Cys were 1.6 +/- 0.3% in controls, but 40.9 +/- 2.7% in prehemodialysis patients. CONCLUSIONS: The filtered fraction of thiols can be used to estimate solute transport across the dialysis membrane. In addition, the possible involvement of cysteine in the pathogenesis of atherosclerosis in hemodialysis patients should be reexamined.