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Maternal pregravid obesity is a significant risk factor for adverse outcomes during pregnancy. In early pregnancy there is an increased risk of spontaneous abortion and congenital anomalies. In later gestation maternal metabolic manifestations of the metabolic syndrome, such as gestational hypertensive disorders and diabetes, become clinically recognized because of the increased insulin resistance in obese compared with nonobese women. In women with pregestational glucose intolerance, hypertension, central obesity, and lipid disorders, the physiologic changes in pregnancy increase the risk of problems previously not routinely encountered during pregnancy. These include chronic cardiac dysfunction, proteinuria, sleep apnea, and nonalcoholic fatty liver disease. At parturition the obese patient is at an increased risk of cesarean delivery and associated complications of anesthesia, wound disruption, infection, and deep venous thrombophlebitis. For the fetus there are short-term risks of fetal macrosomia, more specifically obesity, and long-term risks of adolescent components of the metabolic syndrome. Although preliminary results of bariatric surgery are encouraging, the procedure is expensive and not for all obese women, and we recognize that long-term follow-up data on offspring of obese women who have undergone bariatric surgery before pregnancy are lacking. In the interim, we need to encourage obese women to lose weight before conception, using lifestyle changes if possible. During pregnancy, weight gain should be limited to Institute of Medicine guidelines (currently under review) and encouragement given for physical activity.
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PMID:Management of obesity in pregnancy. 1726 45

We report a rare case of IgA nephropathy (IgAN), that was considered as showing tonsillar focal infection, involving pulmoplantar pustulosis (PPP), and sternocostoclavicular hyperosteosis (SCCH). A 53-year-old man with a 3-year history of PPP had hematuria and proteinuria, and he sometimes had anterior chest pain. He was also diagnosed with IgAN and SCCH. We performed tonsillectomy as a treatment. The tonsillectomy was done with the patient under general anesthesia, and this treatment was followed by steroid therapy. Interestingly, all the symptoms of IgAN, PPP, and SCCH were alleviated 6 months after the tonsillectomy. Thus, tonsillectomy and steroid therapy may be effective and could be considered as treatment for these diseases.
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PMID:Tonsillar focal infectious disease involving IgA nephropathy, pustulosis, and ossification. 1738 6

Diabetes and increased blood pressure (BP) are believed to interact synergistically in the pathogenesis and progression of diabetic nephropathy. The present studies were performed to examine if there were differences in BP load and/or protective renal autoregulatory capacity between the obese diabetic Zucker fatty /spontaneously hypertensive heart failure F1 hybrid (ZSF1) (fa/fa cp) rats and their lean controls. By approximately 26 wk of age, ZSF1 (n = 13) but not their lean controls (n = 16) had developed substantial proteinuria (180 +/- 19 vs. 16 +/- 1.4 mg/24 h) and glomerulosclerosis (19 +/- 2.4 vs. 0.6 +/- 0.2%; P < 0.001). However, average ambient systolic BP by radiotelemetry (12-26 wk of age) was modestly lower in ZSF1 than in lean controls (130 +/- 1.4 vs. 137 +/- 1.7 mmHg, P < 0.002), although the 24-h BP power spectra showed a mild increase at frequencies <0.1 Hz in the ZSF1. Autoregulatory capacity under anesthesia in response to step changes in perfusion pressure between 100 and 140 mmHg was similarly well preserved in both ZSF1 and lean controls at 16-18 wk of age [autoregulatory indexes (AI) <0.1]. Similarly, differences were not observed for dynamic autoregulation in conscious rats [transfer functions between BP (input) and renal blood flow (output) using chronic Transonic flow probes]. Collectively, these data indicate that the pathogenesis of nephropathy in the ZSF1 model of type 2 diabetic nephropathy is largely independent of differences in systemic BP and/or its potential renal transmission. However, these data do not exclude the possibility that the diabetic milieu may alter the glomerular capillaries in the ZSF1, such that there is an enhanced local susceptibility to injury with even normal glomerular pressures.
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PMID:Dynamic blood pressure load and nephropathy in the ZSF1 (fa/fa cp) model of type 2 diabetes. 1772 79

Two women with Eisenmenger syndrome, aged 63 and 45 years, presented with different symptoms: the first patient had peripheral oedema, proteinuria, progressive fatigue and cyanosis and the other had increasing dyspnoea and blue lips. The first patient was successfully treated with diuretics but experienced a collum fracture that occurred after hypovolemic collapse caused by diuretic use. She was given sildenafil and underwent hip surgery with spinal anaesthesia 10 days later. In the following weeks, the patient was haemodynamically stable but then died suddenly; no autopsy was performed. The second patient was given oxygen therapy at home and bosentan. After 6 months the symptoms of dyspnoea resolved and her 6-minute walking distance increased from 453 to 512 m. The life expectancy of patients with congenital heart disorders such as Eisenmenger syndrome has improved dramatically, due in part to the efficacy of novel agents that inhibit endothelial-cell proliferation. With these advances, treatment of these patients is no longer restricted to tertiary-care centres. Therefore, community cardiologists, pulmonologists and internists should be aware of these congenital heart disorders and the available treatment options.
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PMID:[Two patients with Eisenmenger syndrome treated with novel agents that target vasodilation of the pulmonary capillary bed]. 1823 58

The number of newly diagnosed cases of multiple myeloma in the Czech Republic is about 3-4 per 100 000 persons per year. In the higher age groups, the incidence increases. Multiple myeloma is an illness that reacts well to treatment which can result in periods of remission lasting for years. Some of the patients are even able to return to work. A pre-requisite for successful treatment is early diagnosis and this is usually in the hands of first line physicians. This is the reason why the Czech Myeloma Group, in conjunction with neurologists, orthopedicians and radio diagnosticians has issued the following recommendations for first line physicians containing a more detailed description of the symptoms and the diagnostic pitfalls of the disease. This disease reminds a chameleon for the variety of its symptoms. For the sake of clarification, we shall divide multiple myeloma symptoms into five points, each of which is reason enough to warrant an examination to confirm or rule out a malignant cause of health problems (a negative result does not automatically mean exclusion). If any of the recommended examinations results positive, the diagnostic process must be continued, in which case a general practitioner refers the patient to a specialist health centre. Observing these recommendations should minimize the number of cases of late diagnosis. 1. Bone destruction symptoms. - Unexplained backache for more than one month in any part of spine even without nerve root irritability or without pain in other part of skeleton (ribs, hips, or long bones). - Pain at the beginning of myeloma disease is very similar to benigne common discopathy, however the intensity of backache is decreasing within one months in benigne disease. In the case of malignant process the intensity of bone pain is steadily increasing. - Immediate imaging and laboratory investigation are indicated by resting and night pain in spinal column or in any part of skeleton. - Backache with the sign of spinal cord or nerve compression should be sent for immediate X Ray, and focussed CT/MRI followed by acute surgery if needed. - Osteoporosis especially in men and premenopausal women. 2. Features of changed immunity or bone marrow function. Persistent and recurrent infection, typical is normochromic anaemia, with leucopenia and trombocytopenia. 3. Raised erythrocyte sedimentation rate even increase concentration of total plasma protein. 4. Impaired renal function. Increased level of creatinin or proteinuria, nephrotic syndrome with bilateral legs oedema. 5. Hypercalcemia with typical clinical symptoms (polyuria with dehydratation, constipation, nausea, low level conscience, coma). Every one from these points has to be reason for general medical doctor to start battery of tests: -X-ray of bones focused to painful area (mandatory before physiotherapy, local anaesthesia or other empiric therapy). If plain X-ray does not elucidate pain and symptoms are lasting more than one month, please consider all circumstances and results from laboratory investigation. This patient needs referral to the centre with MRI/CT facilities (CT or MRI is necessary investigation in case of nerve root or spine compression). -Investigation of erythrocyte sedimantion rate (high level of sedimentation of erythrocyte can indicate multiple myeloma). -Full blood count. -Basic biochemical investigation serum and urine: serum urea, creatinin, ionts including calcium, total protein, and albumin CRP (high concentration of total protein indicates myeloma, low level of albumin indicates general pathological process, similary increased concentration of fibrinogen, impaired renal function indicates myeloma kidney, however hypercalcemia is typical for highly aggressive myeloma). -Quantitative screening for IgG, IgM and IgA in serum (isolated raised level one of immunoglobulin with decreased level of the others indicates myeloma). -Common electrophoresis of serum is able to detect monoclonal immunoglobulin level at few gramm concentration. If all the laboratory investigation are in normal level the possibility that the current problems are multiple myeloma origine is smaller, but it does not exclude one of rare variant--non secretory myeloma (undifferentiated plasmocyt lost characteristic feature to produce monoclonal immunoglobulin). If any of tests indicate the possibility of myeloma, patient require urgent specialist referral to department with possibility to make diagnosis of malignant myeloma.
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PMID:[Recommendations for early identification of damage to the skeleton by malignant processes, and for early diagnosis of multiple myeloma]. 1817 27

Preeclampsia is a pregnancy-associated illness affecting multiple organ systems. Symptoms typically occur after the 20th week of gestation and consist of hypertension (>140/90 mmHg) and proteinuria (>300 mg/day). It is one of the leading causes of premature birth worldwide and early diagnosis and treatment are essential for both fetal and maternal health. Therapy is aimed at lowering blood pressure sufficiently to prevent the most severe complications such as intracranial hemorrhages. At the same time attention must be paid to the possible untoward effects of blood pressure medications on uteroplacental perfusion and fetal well being. Magnesium is the cornerstone for both prevention and control of eclamptic cerebrovascular events. In cases of severe preeclampsia and eclampsia prompt delivery is indicated, often carried out by Cesarean section (>34 weeks of gestation). Compared to general anesthesia, regional anesthesia techniques offer certain advantages to both mother and fetus and in the absence of contraindications are the methods of choice.
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PMID:[Anesthetic management of parturients with pre-eclampsia and eclampsia]. 1853 23

We present a rare case of postpartum eclampsia with overt acute heart and renal failure, in the absence of any precursive signs of preeclampsia. A 41-year-old parturient underwent elective cesarean section for the delivery of twins under spinal anesthesia. Prior to the procedure, preoperative laboratory examination revealed only traceable proteinuria but she had hypertension perioperatively. Approximately 8 hours after the cesarean section, she developed seizures, followed by evident acute heart and renal failure. The diagnosis of postpartum eclampsia with HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome was established and she was admitted to the surgical intensive care unit for close care. Fortunately, the patient recovered fully and was discharged 26 days later. From this illustrative example, unexplainable and sustained hypertension following cesarean section should serve as a signal to warn the health care staff concerned about the possibility of impending life-threatening postpartum eclampsia.
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PMID:Eclampsia following cesarean section with HELLP syndrome and multiple organ failure. 1839 Apr 2

We report hypoxemia during cesarean section in a 33-year-old woman with preeclampsia. She developed generalized body weight increase, severe proteinuria and decrease of platelets at week 33 of gestation. Cesarean section was scheduled under general anesthesia. The patient did not complain of dyspnea preoperatively. After induction of general anesthesia, arterial oxygen saturation decreased from 99 to 88%. Massive left pleural effusion was detected and chest drainage was performed, and oxygenation was improved. Accumulation of pleural effusion tends to be over-looked because many parturients with pleural effusion do not complain of dyspnea. Physicians should pay attention to pleural effusion in parturients, especially those with risk factors such as preeclampsia, generalized body weight increase and administration of beta stimulant.
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PMID:[Hypoxemia during cesarean section due to massive pleural effusion in a patient with preeclampsia]. 1841 98

This case report describes postoperative, reversible renal dysfunction and hypertension in a 5-year-old healthy boy after administration of relevant doses of ketorolac during anaesthesia. Two days postoperatively, the boy presented with polyuria, polydipsia, proteinuria, microscopic haematuria, and hypertension. He was treated with nifedipine. After six months the blood pressure and azotaemia parameters had normalised and antihypertensive treatment was discontinued.
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PMID:[Ketorolac as a possible cause of reversible renal dysfunction in a 5-year-old child]. 1941 44

Diabetic nephropathy (DN) is a severe and life-threatening complication of long-standing diabetes. As one of the main causes of end-stage renal disease, the prevention and treatment of DN in early stage, and the slowing down of DN progression are of utmost importance and are topics of several ongoing research studies. Nutraceuticals endowed with antioxidant-anti-inflammatory properties may offer an opportunity of integrative treatment for this condition. Male Wistar rats were randomly assigned to two groups. One group of rats (diabetic group) received a single tail-vein injection of STZ compound (50 mg/kg) under light anaesthesia. A protective dose of 0.5 ml of 5 percent dextrose was given intraperitoneally 30 min before the administration of STZ. One diabetic group was fed a normal pellet diet (group A) while group B was fed the diet added with DTS (panax pseudoginseng, eucommia ulmoides), (Kyotsu Jigyo, Tokyo, Japan) in the proportion of 50/25 (percent weight/weight), at the dose of 50 mg/kg/day throughout the experimental period. At the end of 8 weeks, 24-hour urine was collected for the measurement of the albumin concentration: blood samples were collected for serum biochemistry and the rats were sacrificed for kidney measurement of oxidative stress and histomorphological features. Nephrin and Macrophage Chemoattractant Protein-1 (MCP-1) gene expression were also assessed by fluorescence real-time quantitative PCR after RNA extraction and cDNA synthesis. STZ-treated animals showed significantly increased in lipid peroxidation in the kidney and in proteinuria. DTS supplementation did not affect plasma glucose but significantly decreased malonyldialdehyde (MDA) plasma level and the overall redox parameters together with a partial mitigation of proteinuria. Histological analysis showed also that DTS significantly reduced the glomerular volume together with glomerulosclerosis and interstitial fibrosis score (p less than 0.05), the latter two being correlated to proteinuria (p less than 0.05). DTS supplementation also enabled a reduction of diabetes-induced decrease of nephrin mRNA expression and a 67 percent reduction of MCP-1 mRNA up-regulation (p less than 0.01). Taken altogether, these data show that, besides the mandatory control of glycemia, intervention with a nutraceutical with antioxidant and anti-inflammatory properties may have beneficial effects when integrated in the mainstream of the therapeutic regimen.
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PMID:Protective effect of a poly-phytocompound on early stage nephropathy secondary to experimentally-induced diabetes. 2038 70


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