Relationship Between Adiposity and Cardiovascular Risk Factors in Prevalent Hemodialysis Patients

Increased body mass index (BMI) is associated with reduced all-cause and cardiovascular (CV) mortality in hemodialysis (HD) patients, whereas CV risk increases with BMI in the general population. In the general population, obesity is associated with inflammation, decreased high-density lipoprotein (HDL) cholesterol, increased low-density lipoprotein (LDL) cholesterol, and triglycerides (TGs), all risk factors for CV disease. Low-density lipoprotein cholesterol does not predict CV risk in HD, whereas increased C-reactive protein and interleukin-6 (IL-6), low HDL and apolipoprotein (apo) AI, and increased fasting TGs do predict risk. Renal failure is associated with dyslipidemia and inflammation in normal-weight patients. We hypothesized that the effects of obesity may be obscured by renal failure in HD.

Superselective microcoil embolization for endoscopically uncontrollable bleeding after endoscopic submucosal dissection

scopic submucosal dissection (ESD) for the treatment of early gastric cancer of the antrum (l" Fig. 1). There was no immediate bleeding after the procedure, and a proton pump inhibitor was given intravenously for the prevention of delayed bleeding after ESD. Twelve hours after ESD, the patient suddenly developed hematemesis and melena. His systolic blood pressure was 80 mm Hg and heart rate was 110 beats per minute. His hemoglobin level decreased from 14.5 g/dL to 9.2 g/dL. Emergency gastroscopy revealed profuse oozing of blood from the artificial ulcer with an overlying clot. Endoscopic hemostasis using hemoclips was attempted, however, cessation of bleeding was not achieved as the active oozing masked its source (l" Fig. 2). Owing to hemodynamic instability, the patient underwent emergency angiography. Extravasation of contrast medium was seen from a small side branch of the left gastric artery in the antrum (l" Fig. 3 a). The bleeding branch was successfully embolized by the placement of microcoils, both proximal and distal to the bleeding site, to prevent re-bleeding related to retrograde perfusion through the collateral vessels. No further extravasation of contrast medium was noted (l" Fig. 3 b). The patient was discharged after 5 days of close observation and conservative treatment. Endoscopy after 1 month revealed an ESD ulcer scar, without any evidence of ischemic complications (l" Fig. 4). Delayed bleeding, which is defined as hematemesis or melena at 0 –30 days after the procedure, may be the most seSuperselective microcoil embolization for endoscopically uncontrollable bleeding after endoscopic submucosal dissection

Aneurysms of the left gastric and splenic arteries presenting with massive upper gastrointestinal bleeding

with an incidence of 0.01 –0.20 % in routine autopsies [1]. They occur most commonly in the splenic artery (60%) [2]. Left gastric artery aneurysms are extremely rare [3]. Multiple aneurysms are present in approximately a third of patients [4]. Here we describe a case with aneurysms arising from the left gastric and splenic arteries, presenting with massive upper gastrointestinal bleeding. A 73-year-old man presented with an acute episode of hematemesis. He denied use of medications, including steroids, analgesics, and herbal or antiplatelet drugs. At admission, his heart rate was 130 beats/min and blood pressure was 97/ 61 mmHg. Laboratory data showed severe anemia (Hb 76 g/L). Emergency esophagogastroduodenoscopy revealed an elevated mass lesion over the lesser curvature of the cardiac area, measuring 35 mm, with a central ulcer with adherent blood clot, recognized as a bleeder (l" Fig. 1). Another elevated mass lesion with intact mucosa was found over the cardiac area, measuring 55 mm. Contrast-enhanced computed tomography (CT) of the abdomen revealed a 40 mm ” 40 mm left gastric artery aneurysm with thrombus abutting the lesser curvature of the stomach and a 55 mm ” 50 mm splenic artery aneurysm with thrombus at the splenic hilum and abutting the stomach (l" Fig. 2 a). CT angiography disclosed the aneurysms originating from the left gastric artery and splenic artery (l" Fig. 2 b). The patient underwent splenectomy and local excision of the stomach. Examination of the dissected specimens disclosed two aneurysms measuring 55 mm ” 50 mm ” 50 mm and 35 mm ” 35 mm ” 32 mm. Gross examination of the cut surface revealed fresh blood clots in the central space with several old laminated clots in the peripheral areas (l" Fig. 3). Microscopic findings showed aneurysms with thin walls and large numbers of layered organized and unorganized thrombi. Postoperatively, the patient recovered uneventfully and was discharged on day 21 after admission.

Synthesis of (+)-Quebrachamine

Cascade Reactions Directed by Polarity

Significance: A polarity-directed organocatalytic cascade reaction of two different aldehydes with nitromethane in biphasic systems is reported. Since the involved aliphatic aldehydes exhibit similar reactivities, the predominantly formed crossproducts of the reaction can be explained by slight differences in polarity. Most likely the proline (1)catalyzed condensation of the more polar aldehyde with nitromethane succeeds first in the aqueous phase, thus releasing a nitroalkene intermediate. This species enriches in the organic phase consisting of the neat aldehydes, where it undergoes conjugate addition preferred with the less polar aldehyde, accelerated by secondary amine catalyst 2, respectively. Comment: In modern organic synthesis reactions are mostly driven by reactivity profiles of substrates. The present example illustrates that even completely different properties, in this case polarity, can be used to achieve differentiation in chemoselective reactions efficiently. The desired cross-products were obtained in high selectivities, proving the active principle of the cascade process. Since the Fréchet group has already shown that proline-containing macromolecular assemblies exhibit highly interesting properties in aldol reactions (Y. Chi et al. J. Am. Chem. Soc. 2008, 130, 17287), the present examples underline the possibilities of this small organic catalyst and its derivatives. MeNO2

Traumatisierungen bei Psychosepatienten: Weitere Argumente gegen das „bio-bio-bio Modell”?

Von Steven Sharfstein, 2005±2006 Präsident der 1American Psychiatric Association“, stammen ei− nige pointierte Stellungnahmen. So müsse sich die Psychiatrie als Disziplin fragen, inwieweit sie zugelassen habe, dass 1aus dem bio−psycho−so− zialen Modell ein bio−bio−bio Modell“ geworden sei [1]. Ähnlich provokant erschien auf den ersten Blick Sharfsteins Aussage, Gewalt in der Kindheit habe 1denselben Stellenwert für die Psychiatrie wie Zigarettenrauchen für die restliche Medizin“ [2]. Vor dem Hintergrund von Studien aus den letzten zwei Jahrzehnten, die den Stellenwert früher Traumatisierungen als bedeutsamen Risi− kofaktor für spätere psychische Störungen bele− gen, handelt es sich dabei eher um eine nüchter− ne Feststellung. Sowohl prospektive populations− basierte Studien als auch Zwillingsstudien fan− den nach Kontrolle weiterer psychosozialer Risi− kofaktoren, dass alle darin untersuchten psy− chischen Störungen nach früher Gewalt häufiger auftraten, teilweise im Sinne einer Dosis−Wir− kungs−Beziehung. Unter anderem betraf dies Angststörungen, affektive Störungen, Essstörun− gen, Persönlichkeitsstörungen und Suchterkran− kungen [3±5]. Im Gegensatz dazu waren zum Zu− sammenhang zwischen frühen Traumatisierun− gen und psychotischen Erkrankungen lange kei− ne methodisch anspruchsvollen Studien verfüg− bar. In den letzten Jahren begann sich dies zu ändern. So wurden inzwischen zahlreiche populationsba− sierte Studien publiziert, die Zusammenhänge zwischen traumatischen Erfahrungen in frühen Lebensphasen, zumeist sexueller und körperli− cher Gewalt, und späteren psychotischen Syn− dromen nahe legen (Übersicht bei [6]). Exempla− risch sei die Untersuchung von Janssen et al. [7] genannt. Darin wurde eine repräsentative Bevöl− kerungsstichprobe von über 4000 Personen pro− spektiv im Hinblick auf das Auftreten psychoti− scher Symptome untersucht. Psychiatrisch un− auffällige Personen, die sexuellen Missbrauch oder körperliche Misshandlung in der Kindheit berichteten, entwickelten in dieser Studie im Verlauf von 2 Jahren 7−fach wahrscheinlicher be− handlungsbedürftige psychotische Symptome. Dies war auch nach Kontrolle möglicher weiterer Einflussvariablen, wie psychotischen Sympto− men in der Familie, Drogenkonsum, Alter und Bil− dungsstand der Fall. Mögliche Mechanismen, die zu einer Erhöhung des Psychoserisikos im Sinne einer 1erworbenen Vulnerabilität“ oder 1Sensitivierung“ [8] durch frühe Traumatisierungen führen, werden zum einen in den neurobiologischen Folgen traumati− scher Erfahrungen vermutet. Dies betrifft etwa Veränderungen verschiedener Neurotransmitter− systeme [9]. So ist gut belegt, dass frühe Trauma− tisierungen zu anhaltenden Veränderungen der neuroendokrinen Stressreaktivität führen, die auch für die Entstehung psychotischer Erkran− kungen von Bedeutung sind [10,11]. Auch direkte Auswirkungen auf das dopaminerge System wer− den aufgrund von tierexperimentellen Befunden und ersten Humanstudien diskutiert [12]. Zum anderen könnten die kognitiven und emotiona− len Langzeitfolgen früher Traumatisierungen zur späteren Entstehung psychotischer Erkrankun− gen beitragen [13]. So stehen negative emotiona− le Zustände, geringer Selbstwert und ungünstige kognitive Schemata, die häufig in der Folge frü− her Traumatisierungen auftreten, im Mittelpunkt neuerer psychologischer Modelle der Psychose− entstehung [14,15]. Während Zusammenhänge zwischen frühen Traumatisierungen und Psychosen in den letzten Jahren zunehmend empirische Unterstützung finden, ist die Häufigkeit und klinische Bedeu− tung traumatischer Erfahrungen bei Psychose− patienten bereits seit Langem gut belegt. In einer neueren Übersicht fassten Morgan und Fisher [16] 20 Studien zu früher sexueller und körperli− cher Gewalt bei dieser Patientengruppe zusam− men. Sexueller Missbrauch wurde im Mittel von

Hair Analysis Provides a Historical Record of Cortisol Levels in Cushing's Syndrome

The severity of Cushing's Syndrome (CS) depends on the duration and extent of the exposure to excess glucocorticoids. Current measurements of cortisol in serum, saliva and urine reflect systemic cortisol levels at the time of sample collection, but cannot assess past cortisol levels. Hair cortisol levels may be increased in patients with CS, and, as hair grows about 1 cm/month, measurement of hair cortisol may provide historical information on the development of hypercortisolism. We attempted to measure cortisol in hair in relation to clinical course in six female patients with CS and in 32 healthy volunteers in 1 cm hair sections. Hair cortisol content was measured using a commercially available salivary cortisol immune assay with a protocol modified for use with hair. Hair cortisol levels were higher in patients with CS than in controls, the medians (ranges) were 679 (279-2500) and 116 (26-204) ng/g respectively (P<0.001). Segmental hair analysis provided information for up to 18 months before time of sampling. Hair cortisol concentrations appeared to vary in accordance with the clinical course. Based on these data, we suggest that hair cortisol measurement is a novel method for assessing dynamic systemic cortisol exposure and provides unique historical information on variation in cortisol, and that more research is required to fully understand the utility and limits of this technique.

Optimizing Arteriovenous Fistula Maturation

Autogenous arteriovenous fistulas are the preferred vascular access in patients undergoing hemodialysis. Increasing fistula prevalence depends on increasing fistula placement, improving the maturation of fistula that fail to mature and enhancing the long-term patency of mature fistula. Percutaneous methods for optimizing arteriovenous fistula maturation will be reviewed.

Axillary Vein Rupture after Angioplasty

Venous rupture is an uncommon complication resulting from dialysis graft interventions. The authors describe a case of axillary vein rupture following angioplasty necessitating placement of a covered stent for the control of hemorrhage.

A Simple Single Serum Method to Measure Fractional Calcium Absorption using Dual Stable Isotopes

The dual stable isotope method with a timed 24-h urine collection is the gold standard approach to measure fractional calcium absorption. However, the need to collect urine for 24 h makes this technique time-consuming and laborious. Our study sought to determine whether a dual isotope method using a single serum sample obtained 4 h after administration of the initial isotope provides a useful approach to measure fractional calcium absorption. Following a metabolic diet with a fixed calcium intake of 30 mmol/day for 10 days, nineteen healthy subjects age 54-74 were given a test meal with an oral isotope ((44)Ca) followed 2 h later by an intravenous isotope ((42)Ca). Once the oral isotope was administered, urine was collected for 24 h, and a serum sample was obtained after 4 h. The ratio of the oral to intravenous isotopes was measured in the urine and serum by mass spectroscopy. Fractional calcium absorption was 16.2 ± 7.7% by the 4-h single serum method versus 18.5 ± 7.5% by the 24-h urine method. There was a small mean difference between the urine and serum methods of 2.33% with a confidence interval -3.97 to 8.60%. The two methods showed a strong linear association (r = 0.912, p<0.001). Use of dual stable isotopes with a 4-h single serum method gives fractional calcium absorption values that are 12.5% lower than with the 24-h urine method; however, it rank orders subjects accurately thus making it a useful alternative method in clinical research applications.