Hiroki Nishiwaki

The role of digital rectal examination for diagnosis of acute appendicitis: A systematic review and meta-analysis

Background Digital rectal examination (DRE) has been traditionally recommended to evaluate acute appendicitis, although several reports indicate its lack of utility for this diagnosis. No meta-analysis has examined DRE for diagnosis of acute appendicitis. Objectives To assess the role of DRE for diagnosis of acute appendicitis. Data Sources Cochrane Library, PubMed, and SCOPUS from the earliest available date of indexing through November 23, 2014, with no language restrictions. Study Selection Clinical studies assessing DRE as an index test for diagnosis of acute appendicitis. Data Extraction and Synthesis Two independent reviewers extracted study data and assessed the quality, using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Bivariate random-effects models were used for the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio (DOR) as point estimates with 95% confidence intervals (CI). Main Outcomes and Measures The main outcome measure was the diagnostic performance of DRE for diagnosis of acute appendicitis. Results We identified 19 studies with a total of 7511 patients. The pooled sensitivity and specificity were 0.49 (95% CI 0.42–0.56) and 0.61 (95% CI 0.53–0.67), respectively. The positive and negative likelihood ratios were 1.24 (95% CI 0.97–1.58) and 0.85 (95% CI 0.70–1.02), respectively. The DOR was 1.46 (0.95–2.26). Conclusion and Relevance Acute appendicitis cannot be ruled in or out through the result of DRE. Reconsideration is needed for the traditional teaching that rectal examination should be performed routinely in all patients with suspected appendicitis.

Adrenal insufficiency in a haemodialysis patient

Sir, Abnormalities in the hypothalamic–pituitary–adrenocortical (HPA) axis do not usually lead to severe adrenal insufficiency in haemodialysis (HD) patients. However, drug administration may trigger a paradigm shift. A 67-year-old man receiving HD therapy for 4 years was admitted to our hospital due to a traumatic fracture of the right rib. Treatment with nonsteroidal anti-inflammatory drugs was started on the first hospital day. On the sixth hospital day, the patients body temperature rose to 38.0°C and he became disoriented. His condition worsened over time. A presumptive diagnosis of viral, fungal or tuberculous meningitis was made. Although the patient was given isoniazid, streptomycin sulfate and fluconazole, the fever and disorientation continued and he fell into a coma. On the 18th hospital day, the patient received mechanical ventilation due to Cheyne-Stokes breathing. Repeated blood cultures were found to be negative. Plasmapheresis was performed, but the patient remained in a coma. Four months from admission, adrenal insufficiency was suspected. Nine days later, the patients body temperature rose to 40.0°C. A blood culture yielded Serratia marcescens. Antibiotic (short-term) and steroid (long-term) therapies were given. The patient became afebrile and was completely free from the coma and disorientation. We evaluated the HPA axis. Corticotropin-releasing hormone (CRH) induced an ACTH response, but not a cortisol response (Figure ​(Figure1b,1b, c). The dexamethasone suppression test lowered the plasma ACTH level. Magnetic resonance imaging did not disclose any structural abnormalities (data not shown). Plasma levels of the pituitary hormones were within the normal range. Insulin reduced the blood glucose levels; however, the responsiveness of ACTH (Figure ​(Figure1f),1f), cortisol (Figure ​(Figure1f),1f), growth hormone (data not shown) and catecholamine (data not shown) was poor. Adrenal insufficiency with a disturbed hypothalamic regulation was strongly indicated. The HPA axis and hypothalamic abnormalities have been descried in HD patients. Reports on adrenal insufficiency in HD patients are rare and diverse (Table ​(Table1)1) and include cases of tuberculous Addisons disease [1], primary adrenal insufficiency and panhypopituitarism due to systemic AA-amyloidosis [2], isolated adrenocorticotropic hormone deficiency [3] and steroid withdrawal in rejected renal allografts [4]. Fig. 1 Time course of stimulation tests to evaluate the HPA axis. Blood levels of aldosterone (▴-▴), cortisol (•-•) and ACTH (-) shown, as well as described in the text, were measured at the Health Sciences Research Institute, ... Table 1 Cases of adrenal insufficiency in haemodialysis patients Our patient was exposed to multiple predisposing factors, such as trauma, infection and drug administration. In infection, a dysfunction of the HPA axis at the hypothalamus–pituitary level has been observed [5]. Fluconazole is an anti-fungal agent capable of interfering with steroid biosynthesis by inhibiting P450-dependent enzyme synthesis [5] and inducing adrenal insufficiency. Central nervous system symptoms may occur in adrenal failure. Importantly, soon after our patient received anti-fungal therapy, his disorientation worsened. This temporal association strongly indicated that fluconasol worsened the adrenal insufficiency. In conclusion, we have described an HD patient with adrenal insufficiency in whom abnormalities of the HPA axis, especially those at the hypothalamic level, emerged. We should bear in mind the possibility that drug administration may promptly induce severe adrenal dysfunction in HD patients with a background of multiple predisposing factors. Conflict of interest statement. None declared.

Association Between Staphylococcus aureus Bacteremia and Hospital Mortality in Hemodialysis Patients With Bloodstream Infection: A Multicenter Cohort From Japanese Tertiary Care Centers

Multiple studies have shown that Staphylococcus aureus bacteremia (SAB) has been a major cause of death in hemodialysis patients. We examined whether SAB is a risk for mortality among chronic hemodialysis patients in Japan where the standard vascular access is arteriovenous fistula (AVF). This was a multicenter, retrospective study of maintenance hemodialysis patients with bloodstream infection (BSI) from 2011 to 2013 at tertiary care centers in Japan. The endpoint was hospital mortality. Our cohort contained 32 SAB cases (14 MRSA and 18 MSSA) and 42 non‐SAB cases. Hospital mortality was higher among SAB cases than non‐SAB cases (46.9% vs. 23.8%, P = 0.038). In patients with BSI, SAB was significantly associated with hospital mortality after adjustment for potential confounders, including type of vascular access (OR 3.26). S. aureus was the leading cause of BSI and hospital mortality among this cohort. Therefore, initial empiric treatment should cover for S. aureus.

Development and Validation of a Clinical Prediction Rule for Bacteremia among Maintenance Hemodialysis Patients in Outpatient Settings

[This corrects the article DOI: 10.1371/journal.pone.0169975.].

Absence of mesangial C1q deposition is associated with resolution of proteinuria and hematuria after tonsillectomy plus steroid pulse therapy for immunoglobulin a nephropathy

Introduction and Aims: Deposition of C1q occurs in 0 to 45% of patients with IgAN. In order to identify whether mesangial C1q deposition in IgAN is a novel marker for the response to tonsillectomy plus steroid pulse therapy (TSP), we studied the association between mesangial C1q deposition in IgAN and the remission rate after TSP therapy for IgAN. Methods: We conducted a retrospective cohort study at a single Japanese center. We analyzed data on 110 patients diagnosed with IgA nephropathy who received TSP between January 2003 and December 2012. Positive C1q findings were defined as diffuse mesangial C1q deposition. The study outcome was the resolution of abnormal urinary findings and was defined as negative proteinuria and negative occult blood 1 year after steroid pulse therapy. Results: In all enrolled cases, 69 patients (62.7%) went into remission. Ten out of 24 (41.7%) C1q-positive patients experienced remission, and 59 out of 86 (68.6%) C1q-negative patients experienced remission. Multiple logistic regression model analysis showed that the absence of C1q deposition increased the odds ratio for remission (odds ratio 4.41; 95% confidence interval 1.33-15.75, p = 0.017). Conclusions: These results suggest that the absence of diffuse C1q deposition in the mesangial area of the glomerulus in patients with IgA nephropathy is a positive predictive sign for a response to TSP and is associated with the resolution of urinary abnormalities 1 year after TSP.

Dialysis‐related practice patterns among hemodialysis patients with cancer

With the achievement of longevity in hemodialysis patients, the risk of comorbid cancer has begun to draw attention. In the present study, we examined dialysis‐related practice patterns and compared those patterns by cancer status.

Chilaiditi syndrome in a peritoneal dialysis patient

A 55-year-old woman with end-stage renal disease from IgA nephropathy started continuous ambulatory peritoneal dialysis (CAPD). Three months later, she was admitted with sudden onset of right flank pain. She had undergone total hysterectomy 2 years ago and PD catheter placement 8 months ago. On admission she was afebrile and abdominal examination showed no sign of peritoneal irritation. Chest X-ray revealed air under the right diaphragm with haustrations suggestive of colonic air (Figure 1). CAPD fluid and blood test detected no sign of peritonitis. Abdominal computed tomographic (CT) scan revealed interposed colon between the liver and the diaphragm (Figure 2). Analgesics did not relieve her pain. Given a possibility of volvulus, laparoscopic enteropexy was planned. However, the pain was abruptly relieved after drainage of CAPD fluid and the subsequent chest X-ray showed that the interposed colon was no longer present. She has not experienced relapse since the last 6 months. Chilaiditi sign is asymptomatic appearance of interposed bowl between the liver and the diaphragm. It is found with an incidence of 0.025–0.28% in X-ray and of 1.2–2.4% in abdominal CT. With the presence of clinical symptoms, the condition is referred to as ‘Chilaiditi syndrome’. This condition is usually treated conservatively but rarely surgery is indicated in case of ileus, perforation, and ischemia. The predisposing factors include ascites, pregnancy, and any other conditions leading to an enlarged space under the right diaphragm or hypermobility of intestines.