Generalized edema and heart failure caused from hypothyroidism and ferrous agent for hypochromic anemia

The patient was an 85-year-old female who has been treated for hypertension and atrial fibrillation (Af). She has visited outpatient clinic and has received regularly general blood tests for every six months. Hemoglobin (Hb) level was stable as 11.2-12.3 g/dL and MCV 88fL from 2017, but it decreased suddenly to 5.2 g/dL and 64 fL in Sept 2020. She did not feel any symptoms or signs. Further evaluations revealed that occult blood in stool and upper and endoscopic exams were negative. About 40 days after starting sodium ferrous citrate, she developed edema anasarca, bilateral pleural effusion and heart failure. Laboratory test showed hypothyroidism, and then the administration of thyroid hormone and diuretics brought her early improvement. As to this impressive case report, general clinical progress and some discussion of the relationship among anemia, edema anasarca, heart failure and hypothyroidism would be described

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

Background and purposeThe Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] https://doi.org/10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine.MethodsMembers of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members.ResultsA total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs.ConclusionsBased on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals

Post-intensive care syndrome: its pathophysiology, prevention, and future directions

Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS

Airway obstruction caused by achalasia: A case report

We report a rare case of airway obstruction caused by megaesophagus associated with achalasia. A 78-year-old man was admitted with post meal dyspnea, decreased consciousness, expiratory and inspiratory wheezing, and respiratory distress. Arterial blood gas analysis showed findings of marked acute respiratory acidosis (pH 7.18, PaCO2 75 mmHg, PaO2 225 mm Hg, HCO3− 22 mmol/L). An emergency laryngoscopy was performed because of a suspected airway obstruction, but no abnormalities were observed from the airway to the glottis. Noninvasive positive pressure ventilation (NPPV) was immediately introduced, and the respiratory rate and breathing pattern was normalized. A chest X-ray showed an enlarged upper mediastinal outline and an ill-defined border of the trachea. A computed tomography (CT) scan showed an enlarged esophagus with a maximum diameter of 9.90 cm, compressing the trachea to the back of the sternal notch. Following removal of the esophageal contents using a nasogastric tube, NPPV was discontinued with no respiratory episodes. After he was stabilized, he was transferred to another hospital for endoscopic myotomy. In a review of the literature, we identified 66 cases of airway obstruction due to achalasia, mainly in older women. None of the patients received NPPV. As a differential diagnosis for acute airway obstruction, achalasia-related airway obstruction should be considered, particularly in older women. Furthermore, since this condition is suspected to involve tracheomalacia, NPPV may be a useful respiratory support therapy

TRIM24 mediates ligand-dependent activation of androgen receptor and is repressed by a bromodomain-containing protein, BRD7, in prostate cancer cells

The androgen receptor (AR) is a ligand-dependent transcription factor that belongs to the family of nuclear receptors, and its activity is regulated by numerous AR coregulators. AR plays an important role in prostate development and cancer. In this study, we found that TRIM24/transcriptional intermediary factor 1α (TIF1α), which is known as a ligand-dependent nuclear receptor co-regulator, interacts with AR and enhances transcriptional activity of AR by dihydrotestosterone in prostate cancer cells. We showed that TRIM24 functionally interacts with TIP60, which acts as a coactivator of AR and synergizes with TIP60 in the transactivation of AR. We also showed that TRIM24 binds to bromodomain containing 7 (BRD7), which can negatively regulate cell proliferation and growth. A luciferase assay indicated that BRD7 represses the AR transactivation activity upregulated by TRIM24. These findings indicate that TRIM24 regulates AR-mediated transcription in collaboration with TIP60 and BRD7

Data from: Early rehabilitation to prevent post-intensive care syndrome in critically ill patients: a systematic review and meta-analysis

Introduction: We examined the effectiveness of early rehabilitation for the prevention of post-intensive care syndrome (PICS), characterised by an impaired physical, cognitive, or mental health status, among survivors of critical illness. Methods: We performed a systematic literature search of several databases (Medline, Embase, and Cochrane Central Register of Controlled Trials) and a manual search to identify randomised controlled trials (RCTs) comparing the effectiveness of early rehabilitation versus no early rehabilitation or standard care for the prevention of PICS. The primary outcomes were short-term physical-, cognitive-, and mental health-related outcomes assessed during hospitalisation. The secondary outcomes were the standardised, long-term health-related quality of life scores (EuroQol 5 Dimension [EQ5D] and the Medical Outcomes Study 36-Item Short Form Health Survey Physical Function scale [SF-36 PF]). We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the quality of evidence (QoE). Results: Six RCTs selected from 5,105 screened abstracts were included. Early rehabilitation significantly improved short-term physical-related outcomes, as indicated by an increased Medical Research Council scale score (MRC score) [standardised mean difference (SMD): 0.38, 95% confidence interval (CI): 0.10–0.66, p = 0.009] (QoE: low) and a decreased incidence of ICU-acquired weakness (ICU-AW) [odds ratio (OR) 0.42, 95% CI 0.22 to 0.82, p = 0.01] (QoE: low), compared to standard care or no early rehabilitation. However, the two groups did not differ in terms of cognitive-related delirium-free days (SMD: -0.02, 95% CI: -0.23–0.20) (QoE: low) and the mental health-related Hospital Anxiety and Depression Scale score (odds ratio: 0.79, 95% CI: 0.29–2.12) (QoE: low). Early rehabilitation did not improve the long-term outcomes of PICS as characterised by EQ5D and SF-36PF. Conclusions: Early rehabilitation improved only short-term physical-related outcomes in critically ill patients. Additional large RCTs are needed