Chronic Episodes Research Articles

Integrated Proteomic Analysis Reveals a Substantial Enrichment of Protein Trafficking Processes in Hippocampus Tissue after Hypoxic Stress

Acute and chronic hypoxic episodes of the brain have been generally recognized as a common denominator of several neuropathologies of which cerebral ischemic stroke represents one of the leading causes of mortality and morbidity. In an attempt to clarify the plethora of molecular events elicited by ischemic or hypoxic stress, several studies have reported before on large-scale expression analysis; however, only a minority have put focus on proteome based changes. To further enrich our knowledge, we investigated the differences in protein levels following prolonged exposure of mice to global hypoxic stress in the hippocampus, one of the most susceptible regions of the brain. This was accomplished using the conventional 2-DE approach and peptide-centered quantitative methionyl-COFRADIC. Together both methods resulted in the identification of 110 unique hypoxia regulated proteins, and 34 posthypoxic reoxygenation regulated proteins based on 2-DE analysis alone. The integration and comparison of the implicated biological functions with other large-scale analyses of similar hypoxia and ischemic stroke models gave an overall resemblance of implicated biological processes apart from model specific alterations in distribution. Nevertheless, further examination of the data clearly depicted a substantial enrichment of protein trafficking and targeting processes in our data which could be related to synaptic plasticity and remodeling events.

Functional disability as an explanation of the associations between chronic physical conditions and 12-month major depressive episode

Background The link between physical conditions and mental health is poorly understood. Functional disability could explain the association of physical conditions with major depressive episode (MDE) as an intermediary factor. Methods Data was analyzed from a subsample ( N = 8796) of the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross-sectional general population survey. MDE during the last 12 months was assessed using a revision of the Composite International Diagnostic Interview (CIDI 3.0). Lifetime chronic physical conditions were assessed by self-report. Functional disability was measured using a version of the World Health Organization Disability Assessment Schedule (WHODAS). The associations of physical conditions with MDE and explanation by functional disability were quantified using logistic regression. Results All physical conditions were significantly associated with MDE. The increases in risk of MDE ranged from 30% for allergy to amply 100% for arthritis and heart disease. When adjusted for physical comorbidity, associations decreased and were no longer statistically significant for allergy and diabetes. Functional disability explained between 17 and 64% of these associations, most substantially for stomach or duodenum ulcer, arthritis and heart disease. Limitations Due to the cross-sectional nature of the study the temporal relationship of the variables could not be assessed and the amount of explanation cannot simply be interpreted as the amount of mediation. Conclusions Our findings suggest that the association of chronic physical conditions with MDE is partly explained by functional disability. Such explanation is more pronounced for pain causing conditions and heart disease. Health professionals should be particularly aware of the increased risk of depressive disorder when patients experience disability from these conditions.

Documenting the health consequences of endemic warfare in three pastoralist communities of northern Kenya: A conceptual framework

Violent conflict represents the third most important source of mortality around the world, yet violence-related mortality remains profoundly undercounted (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). As a step toward documenting the consequences of even the "smallest wars" we offer a conceptual framework for a recently initiated project that comparatively examines the direct and indirect consequences of intercommunity violence among Pokot, Samburu, and Turkana herding communities of Northern Kenya. While a substantial body of work has accumulated on the social responses to this violence very little is known about the differential impacts on community health. Based on our cumulative ethnographic experience in the area, we offer a conceptual framework that merges a context-sensitive ethnographic approach with a comparative epidemiological one centered on documenting the lived experience of violence and inequality. In this paper, we provide evidence for the importance of a contextualized approach detailing how social environments that include chronic episodes of violence produce variations in health. We do so by presenting the results of previous work to highlight what is known and follow this by identifying what remains to be understood about how violence, inequality, and health interact in these communities. While much is known about the importance of access to livestock herds for health, nutrition, and child growth in this difficult physical environment, far less is known about how the social responses to violence interact with access to herds to create new patterns of nutrition and health. With respect to pastoralists, additional areas that remain only nominally understood include age-specific mortality patterns, reproductive health, and psychosocial/mental health, topics that we view as central to the current study. In sum, we suggest that health offers one of the most useful tools for examining the costs of violence by creating opportunities for advocacy.

Fanconi Syndrome and CKD in a Patient With Paroxysmal Nocturnal Hemoglobinuria and Hemosiderosis

Fanconi syndrome and chronic kidney disease associated with paroxysmal nocturnal hemoglobinuria is rarely reported. We describe a 51-year-old woman with glomerular filtration rate decrease and hypokalemia, glucosuria, and proteinuria during a 4-year period. Paroxysmal nocturnal hemoglobinuria was diagnosed 17 years earlier, and she has received multiple blood transfusions because of hemolytic episodes during the last 5 years. Deteriorating kidney function and persistent Fanconi syndrome were accompanied by a progressive increase in serum ferritin levels. Laboratory studies showed proximal renal tubular acidosis, hypophosphotemic hyperphosphaturia, normoglycemic glucosuria, and aminoaciduria. Serologic testing, tumor markers, Bence-Jones protein, and heavy-metal screening results were negative. Abdominal magnetic resonance imaging showed characteristic features of iron deposition in the bilateral renal cortices. Kidney biopsy showed chronic interstitial nephritis with prominent hemosiderin deposition in the proximal tubules. With potassium citrate, calcitriol, and deferoxamine therapy, Fanconi syndrome persisted, but kidney function was stable. Renal hemosiderosis secondary to both chronic repetitive hemolytic episodes and transfusion-related iron overload in patients with paroxysmal nocturnal hemoglobinuria can lead to Fanconi syndrome and chronic kidney disease.

Definition, epidemiology and classification of diabetes in children and adolescents

Diabetes mellitus is a group of metabolic diseases characterised by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The abnormalities in carbohydrate, fat, and protein metabolism that are found in diabetes are due to deficient action of insulin on target tissues. If ketones are present in blood or urine, treatment is urgent, because ketoacidosis can evolve rapidly.

Opioid Prescribing Practices in Chronic Pain Management: Guidelines Do Not Sufficiently Influence Clinical Practice

To examine the use of extended-release (ER) opioids relative to immediate-release (IR) opioids in chronic opioid prescription episodes, pharmacy claim data from a national health plan database were analyzed. Enrollees having at least 1 pharmacy claim for an opioid formulation between June 2003 and May 2006, and at least 1 year of continuous enrollment after their first observed pharmacy claim were included. Opioid prescription episodes were created by combining contiguous days of therapy, allowing for a maximum of 7 days between refills (>or=8 d = new episode). Outcomes are reported in the form of probabilities and odds ratios (ORs). A total of 3,993,011 opioid prescription episodes were derived from 1,967,898 enrollees. Overall, prescription episodes involving IR preparations (97.7%) were more prevalent than episodes using ER preparations (2.3%). The odds of an ER preparation being prescribed chronically (>or=60 d) were approximately 11 times that of an IR preparation (OR = 10.7); however, the majority of chronic prescription episodes used IR formulations (84.8%). When stratified by prescriber type (specialist vs nonspecialists), the probability of a specialist prescribing ER opioids in these chronic prescription episodes was 19.1% versus 13.7% for nonspecialists. Specialists were about 50% more likely to prescribe ER opioids relative to nonspecialists (OR = 1.49). This analysis suggests that the availability of pain-treatment guidelines, recommendations, and education alone may not be enough to influence opioid-prescribing practices in the treatment of chronic pain.

Dolor lumbar como manifestación inusual en una valvulopatía: ejemplo de dificultad en el diagnóstico etiológico de las lumbalgias crónicas

Low back pain is the most frequent complaint in chronic pain units. The differential diagnosis among the distinct causes is frequently difficult. The “red flags” of low back pain consist of a series of “signs and symptoms” that should warn clinicians of the possibility of the severity of the symptom and have been the subject of numerous publications. The present case report aims to highlight the need to take a detailed clinical history and to reevaluate patients with a prior diagnosis referred by other services in order to avoid diagnostic and treatment errors. We present the case of a 55-year-old man, who was referred to the chronic pain clinic by the internal medicine service, with a diagnosis of chronic low back pain unresponsive to analgesics. For the previous 2 years, the patient had reported moderate-severe pain in the lower dorsal and lumbar region. Seventeen years previously, a prosthetic mitral valve had been implanted. The patient's chronic pain episodes were exacerbated by crises of acute pain in the lower dorsal region radiating to the lumbar and inguinal areas. Although acute hemolytic anemia is described as an etiology of low back pain, this antecedent was not taken into account as a probable cause of the pain. Lumbar magnetic resonance imaging showed degenerative osteoarthritis. Replacement of the prosthetic valve resolved the lumbar pain and hemolysis. One year later, the patient remains asymptomatic.

Use of Mycophenolate Mofetil in Liver Transplantation: Andalusian Liver Registry

To evaluate the safety and efficacy of various immunosuppressant regimens using mycophenolate mofetil (MMF). This prospective, observational, multicenter study of 226 patients undergoing liver transplantation was carried out in 2005-2006, with 24-month follow-up. Studied variables were as follows: indicators of kidney, liver, and blood function; intercurrent infections; cardiovascular risk; acute and chronic episodes of rejection; recurrent hepatitis C virus infection; de novo tumors; and survival. Patients were classified into 4 groups according to treatment: no MMF (group 1, n = 91); MMF from induction (group 2, n = 83); late administration of MMF (group 3, n = 30); and MMF at induction, with early withdrawal (group 4, n = 22). Biodemographic characteristics were similar in all 4 groups. The MMF groups were at higher risk and had worse Model for End-Stage Liver Disease and Child-Pugh scores and worse pretransplantation blood and kidney function values. Significant differences were observed in creatinine concentration between groups 2 and 3: 0.45 mg/dL at 1 month (P < .01), 0.27 mg/dL at 3 months (P < .01), and 0.3 mg/dL at 6 months (P < .05). In contrast, differences of 0.34 mg/dL (P < .01) were observed between groups 1 and 3 at 1 month and 0.17 mg/dL (P < .05) between groups 1 and 2 at 3 months. No differences were noted in white blood cell counts, episodes of acute rejection (19%) and chronic rejection (5%), graft survival (80%), and rate of recurrent hepatitis C virus infection (75%) between the 4 groups. The infection rate at 3 months in groups 2 and 4 was 34.5%, and in groups 1 and 3 was 34.5% (P < .05). Use of MMF at induction and introduction of MMF in the first 3 months posttransplantation helps to preserve and restore creatinine levels in patients with worsened kidney function, and aids in keeping them stable, without increasing the risk of rejection while optimizing the anticalcineurin dosage.

Imagery rescripting as a brief stand-alone treatment for depressed patients with intrusive memories

Many depressed patients report intrusive and distressing memories of specific events in their lives. Where present, these memories are believed to act as a maintaining factor. A series of ten patients with major depressive disorder and intrusive memories, many of them reporting severe, chronic, or recurrent episodes of depression, were given an average of 8.1 sessions of imagery rescripting as a stand-alone treatment. Hierarchical linear modelling demonstrated large treatment effects that were well maintained at one year follow-up. Seven patients showed reliable improvement, and six patients clinically significant improvement. These gains were achieved entirely by working through patients' visual imagination and without verbal challenging of negative beliefs. Spontaneous changes in beliefs, rumination, and behaviour were nevertheless observed.

Endonasal laser–assisted microscopic dacryocystorhinostomy: surgical technique and follow-up results

Purpose Endonasal dacryocystorhinostomy is known as an increasingly attractive and effective approach for the surgical treatment of nasal duct obstruction with minimal complications and best cosmetic consequences. In a relatively large-scale case-series study over a 5-year period, we describe the surgical technique and 12-month follow-up results of microscopic laser dacryocystorhinostomy with particular regard to the effect of various pre-/postoperational factors (ie, patients' sex, age, symptoms chronicity, previous interventions, duration of silicone intubation) on the surgical outcome. Materials and methods A total of 162 cases in 151 patients with chronic epiphora, mucocele, or recurrent episodes of dacryocystitis were included in the study. Endonasal laser dacryocystorhinostomy was performed using a surgical microscope with transcanalicular lacrimal sac illumination. The laser types used were potassium-titanyl-phosphate and neodymium:yttrium-aluminum-garnet for ablation of nasal mucosa and application to bone, respectively. Patients were evaluated 6 months and 1 year later. Data were analyzed by χ 2 tests. Results There were no major complications during or after the operations. Complete cure occurred in 89.5% (after 6 months) and 74.2% (after 1 year) of the cases. Anatomical patency was shown by lacrimal system irrigation with fluorescein in 81.5% of the cases after the 12-month follow-up. It was found that patients younger than 55 years, with symptoms lasting less than 1 year, and without history of nasal problems, had significantly higher surgical success rates ( P < .05). Moreover, rates of failure were significantly lower in cases whose canaliculi were intubated for 5 to 6 months ( P < .05). Conclusions Endonasal microscopic laser dacryocystorhinostomy is a safe and minimally invasive procedure with reasonable results. It has many advantages over external or other conventional approaches. Successful results could be further enhanced by more wisely selecting the patients and by silicone extubation after 6 months.

Mature cerebellar teratoma in adulthood

Extragonadal teratomas in adulthood are exceptionally rare and usually not located within the cerebellum. We here report on a 66-year-old male patient clinically presenting with chronic occipital headache and episodes of severe vertigo. Neuroradiological investigations revealed a hemorrhagic tumor mass in the cerebellar vermis which was surgically removed and histologically diagnosed as mature teratoma. Hence, the presented case is extraordinary with regard to age, late clinical onset of symptoms and cerebellar location. Late clinical manifestation of the tumor in this case is probably due to an acute late-onset hemorrhage within the tumor.

Common mental disorder and obesity: insight from four repeat measures over 19 years: prospective Whitehall II cohort study

Objectives To examine potential reciprocal associations between common mental disorders and obesity, and to assess whether dose-response relations exist.Design Prospective cohort study with four measures of common mental disorders and...

Algaemia in a dairy cow byPrototheca blaschkeae

We describe the first known case of an algaemia by Prototheca blaschkeae in a dairy cow, which occurred after a chronic episode of mastitis caused by this pathogen. The organism was isolated from milk, joint fluid and blood samples, and microbiologic and molecular methods were performed to obtain a definitive identification of the algae. The affected cow was culled only after confirmation of a systemic infection by Prototheca.

Orthotopic liver transplantation and what to do during follow-up: recommendations for the practitioner

Improvements in surgical technique and the introduction of several new immunosuppressive medications mean that outcome after orthotopic liver transplantation (OLT) has improved continuously over the past 15 years. Given the increasing longevity of patients after OLT, the recognition and prevention of long-term complications after transplantation have become ever more important. With respect to graft function, physicians responsible for the everyday care of patients following transplantation should be particularly aware of the risk of late and chronic rejection episodes and of recurrence of the underlying liver disease. The major challenge of post-transplant care is, however, how best to prevent and manage the long-term adverse effects caused by the immunosuppressive medications prescribed. Screening investigations for early diagnosis of malignancy, strict control of cardiovascular risk factors, preservation of renal function, and prevention of infections are, therefore, fundamental. This Review suggests guidelines for the management of OLT recipients to improve long-term survival, overall outcome and health-related quality of life.

Efficacy and Safety of Mycophenolate Mofetil Monotherapy in Liver Transplant Patients With Renal Failure Induced by Calcineurin Inhibitors

Objective To assess the efficacy and safety of mycophenolate mofetil (MMF) monotherapy in liver transplant recipients with renal failure secondary to the use of calcineurin inhibitors (CNIs). Materials and methods Thirty-one patients on MMF monotherapy with creatinine levels >1.3 mg/dL, previously immunosuppressed with CNIs and MMF, were analyzed. Conversion was started in patients with no acute or chronic rejection episodes and stable liver chemistry. CNI doses were reduced by 25% every 2 to 3 months, or to 50% if the dose was lower than 1 mg/d of tacrolimus or 50 mg/d of cyclosporine. Different variables were recorded from the time that conversion to monotherapy was decided, on the discontinuation day of the calcineurin inhibitor, and during the follow-up. Results Mean times from transplant to conversion ranged from 14 to 186 months. The minimum follow-up time in monotherapy was 12 months. Renal function improved at 6 months in 70% of cases and at 12 months in 69.6%. Patients with no renal function improvement maintained stable creatinine values. There were no rejection episodes, graft losses, or deaths. No leukopenia occurred, and triglyceride and uric acid values improved. Conclusions MMF monotherapy is a safe alternative in patients with posttransplant renal failure secondary to the use of CNIs. Renal function improvement was achieved in almost 70% of patients at 12 months, and creatinine values were maintained in all other patients. The risk of rejection due to the slow tapering of CNIs is minimum.

Proposed physiopathological mechanisms and potential therapeutic targets for central serous chorioretinopathy

Central serous chorioretinopathy manifests as idiopathic serous detachment of the neurosensory retina, occasionally associated with small retinal pigment epithelium detachments in the macular area. The actual pathobiological mechanisms are not completely understood, but a strong association with endogenous or exogenous hypercortisolism is presumed. Although the clinical presentation may vary widely, visual symptoms are generally mild, unspecific and transitory. In rare circumstances the condition can evolve to significant and permanent visual impairment related to severe manifestations, relapsing or chronic episodes and secondary complications. Symptoms tend to resolve spontaneously in 3–6 months, but recurrences are expected to occur in up to 50% of the cases. Ancillary examinations may assist the diagnosis and identification of associated complications. While focal leaks at the level of the retinal pigment epithelium are highlighted on fluorescein angiography, indocyanine green angiography reveals widespread fundus involvement with multiple regions of choroidal hyperpermeability. Several therapeutic approaches have been proposed in unfavorable (persistent central serous chorioretinopathy) cases. In this article the proposed physiopathological mechanisms are discussed, leading to new insights into the clinical diagnosis and multidisciplinary management of this somewhat paradoxal disease.

The extrahepatic manifestations of hepatitis B virus.

Hepatitis B Virus (HBV) leads to a number of hepatic complications, from acute to chronic hepatitis, cirrhosis and hepatocellular carcinoma, is a well-established fact. Upcoming clinical research, over the years, associates numerous extrahepatic manifestations during the acute and chronic episodes of hepatitis B with significant morbidity and mortality. A causal relationship between HBV and serious autoimmune disorders has also been observed among certain susceptible vaccine recipients in a defined temporal period following immunization. The cause of these extrahepatic manifestations is generally believed to be immune mediated. The most commonly described include skin rash, arthritis, arthralgia, glomerulonephritis, polyarteritis nodosa, and papular acrodermatitis etc. The serum-sickness like "arthritis-dermatitis" prodrome has also been observed in approximately one-third of patients acquiring HBV infections. Skin manifestations of HBV infection typically present as palpable purpura reported to be caused by chronic HBV, although this association remains controversial. To consider the relationship between HBV and other clinically significant disorders as well as serious autoimmune disorders among certain vaccine recipients is the topic of this review. Variable factors that influence extrahepatic manifestation are discussed, including possible synergy between hepatitis B virus and the immune system.

Distribution of the MHC antigens after liver transplantation: relationship with biochemical and histological parameters

The aim of this study was to analyse the change in tissue distribution of HLA class I and class II molecules in patients during the course of liver transplantation. Sixty-one liver biopsies were analysed in 24 patients with or without rejection (acute or chronic) episode. In 93% of cases with chronic rejection and in 48% of cases with acute rejection episodes, HLA class I antigens are expressed in the membrane and/or the cytoplasm of hepatocytes. The expression of these molecules was significantly correlated with the ASP (aspartate amino transferase), AP (alkaline phosphatase), the bile duct damage and the centrolobular lesions. In contrast, the expression of HLA class II molecules is not correlated with either the type of rejection, the biological or histological findings. A strong expression of HLA class I antigen on hepatocytes after day 60 may be one of the best signs of chronic rejection.

Hematuria de origen papilar o medular: entidad de difícil diagnóstico

Renal haemangiomas of renal papillary or medullar origin are a difficult diagnosis entity, being one of the most frequent processes of chronic episodes of hematuria, secondary to benign disease, mainly in young patients. The objective of this paper is to show the difficulty of this diagnosis and the need to suspect it in cases with clinical history similar to the ones described in these cases. We report 4 cases of spontaneous hematuria of renal origin, with clinical presentation as renal colic, from the historical case series of the Fundacion Jimenez Díaz-Capio, the last two from the years 2005-6. We present the diagnostic and therapeutic methodology employed, including angio-CT and flexible ureterorenoscopy (URS) as well as various treatment options. Hematuria was identified as "essential" when any relation with tumor or lithiasic pathologies was ruled out, and of renal origin when the source was clearly pointed. We interpreted it was related to angiomas or microangiomas of papillary or medullar origin. In one case, the vascular malformation was interpreted as an arterial venous fistula (AVF) at that level. Hematuria stopped spontaneously in two cases after exploratory URS. The eldest historical case required surgical expiration of the caliceal structures. Years ago, following the professional development of Urology as speciality, conventional surgery was carried out in all these cases, of very difficult diagnosis, with a very small number of cases undergoing a conservative approach based on the examination of renal cavities trying to observe and find the bleeding point. Most cases underwent complete or partial nephrectomy. Currently, the possibility of exploration of all renal cavities with the flexible ureterorenoscope enables a better diagnosis of the lesions and a more conservative treatment. The ultimate diagnosis of renal papillary angioma is the pathologic diagnosis, without pathognomonic data in the imaging tests. This pathology is thought of at the end of the diagnostic workup, and when the papillary area is identified as the source of bleeding. The historical case series, with the pathologic findings from nephrectomy specimens, permits us to point out this entity as papillary angioma, in patients with similar clinical presentation.

Parental maltreatment and adulthood cohabiting partnerships: A life-course study of adult chronic depression — 4

Background This fourth paper of a series of five concerning depression in women considers: i. why parental maltreatment increases risk of highly aversive (‘very poor’) partnerships, and ii. how far these relationships explain the link of such maltreatment with adult chronic depression. Methods Data was collected retrospectively by semi-structured interviews and only women living at some point with a partner included. Results Parental maltreatment was indirectly linked to chronic depression via highly aversive partnerships. This was partly mediated by childhood conduct problems. However, a broader range of behaviour in late adolescence and early adulthood such as early risky sexual behaviour among those without conduct problems was also involved. In addition parental maltreatment was directly linked to chronic depression, judged by a substantial remaining association when other risk factors were controlled. Highly aversive partnerships were less common by the late 20s while this was matched by an increase of ‘very poor’ circumstances among those no longer living with a partner. This increase often involved lone motherhood, an established risk factor for chronic depression. Limitations These findings should be seen as tentative given the retrospective nature of many of the measures (But see the second paper in the present series [Brown, G.W., Craig, T.K.J., Harris, T.O., Handley, R.V., & Harvey, A.L. (2007b). Validity of retrospective measures of early maltreatment and depressive episodes using CECA (Childhood Experience of Care & Abuse) — A life-course study of adult chronic depression — 2. J. Affect. Disord., 103, 217–224]. Only women were studied. Conclusions Parental maltreatment relates indirectly to adult chronic episodes of depression with highly aversive partnerships playing an important mediating role. Parental maltreatment also has a direct link. While these results are broadly consistent with earlier research a more complete understanding of the mechanisms acting across the life-course requires an assessment of a wider range of factors around the time of an onset of depression. This is the task of our next and final paper.