Hydroelectrolytic Disturbances Research Articles

Sinus arrest associated with diabetic ketoacidosis regressing to sinus rhythm after compensation of diabetic process: a case report and review of literature

Abstract Background Diabetic ketoacidosis (DKA) is a serious, life-threatening condition known for its profound hydro electrolytic disturbances and multiple complications, including cerebral edema and circulatory collapse. While this complication is traditionally associated with patients suffering from type 1 diabetes, numerous studies have documented its non-negligible incidence in type 2 diabetics. However, conductive disorders that manifest during its course, such as sinus arrest, are poorly reported and can be life-threatening on their own when not promptly recognized and treated. The primary objective of this report is to increase awareness regarding the uncommon conduction complications associated with diabetic ketoacidosis, even in the absence of overt hyperkalemia, and to underscore the critical significance of early diagnosis and prompt intervention in managing these complications. Case presentation We present the case of a middle-aged man with past history of type 2 diabetes whose symptoms included asthenia and consciousness disorder concomitant with ketoacidosis decompensation. Electrocardiogram (ECG) revealed the presence of sinus arrest with ventricular escaping rhythm. Rapid management of the diabetic decompensation led to spontaneous restoration of normal sinus rhythm, thus obviating the necessity for permanent pacing in the patient. Conclusions Atypical complications arising during ketoacidosis decompensation, including conditions like sinus arrest, are frequently overlooked and tend to carry a guarded prognosis. Proper recognition and prompt treatment are imperative to achieve the optimal clinical outcome.

Features of respiratory syncytial virus infection in children in the post-COVID 19 era

Respiratory syncytial virus (RSV) infection in children is a major public health problem, especially in the 0-1 year age group where clinical forms of the disease can evolve severely with life-threatening complications. In the period 2020 – 2022, as a result of epidemiological measures specific to the COVI-19 pandemic (protective mask, online teaching activity, social distancing) we have witnessed a considerable decrease in the number of cases of RSV infection in children. With the lifting of prophylactic measures and the onset of the cold season, we have seen an increase in the number of admissions with a diagnosis of respiratory virus in pediatric wards. In this article, we aim to analyze the clinical, evolutionary and epidemiological features of respiratory syncytial virus infection in children in the 2022 - 2023 season. We conducted a retrospective clinical study of RSV infection cases admitted to the Pediatric Infectious Diseases Clinical Departments of the National Institute of Infectious Diseases “Prof. Dr. Matei Bals” in the period October 2022 - March 2023. During this period, we registered 195 cases of RSV infection in children, which represents 6.47% of the total number of hospitalized virologic illnesses in children (195/3012). All pediatric RSV infection cases admitted to our wards have progressed favorably; we have not recorded any deaths. From an epidemiological point of view, the peak incidence of RSV infection in children occurred in December (98 cases). The most frequent clinical form of the disease was the medium form, but severe forms represented 31.8%. Among the complications, the most common were respiratory (acute respiratory failure, pneumonia/bronchopneumonia), hematological (intrainfectious and deficiency anemia, leukopenia, thrombocytopenia), digestive (diarrheal disease, hepatic cytolysis syndrome) and acute dehydration syndrome associated with hydro electrolytic and acid-base disturbances. Severe complications were more frequent than in previous seasons, being associated with a risk of an unfavorable outcome: acute respiratory failure and neurological complications (convulsions, encephalitis). We also observed that acute RSV infection in the 2022 - 2023 season is characterized by the association of co-infections (viral, bacterial and fungal) more frequent than in previous years (22.5%). The most frequent co-infections were bacterial (superinfections - pneumonia/bronchopneumonia) probably due to the immunosuppression of the hosts as a result of repeated recent episodes of viral infections. Of note, RSV infection associated with other coinfections evolved more severely, with prolonged hospitalization and more complications. In conclusion we can say that RSV infection in the 2022 - 2023 season evolved more severely in children compared to previous seasons because in the last 3 years during the COVID-19 pandemic there were very few cases of respiratory viroids, thus the population was not naturally immunized, especially the age group 0 - 4 years. In addition, the abandonment of specific protective measures for respiratory diseases has “exploded” the number of respiratory illnesses in the pediatric population, especially in children.

Pseudo Bartter Syndrome in anorexia nervosa.

Anorexia nervosa is a psychiatric disorder with various non-psychiatric manifestations that arise from the self-imposed malnourishment and possible purging behaviors. These medical manifestations or complications may mimic non psychiatric disorders and difficult the diagnosis of an eating disorder. We report the case of a patient with a binge-eating/purging subtype of anorexia nervosa, whose purges consisted in diuretic abuse. She kept her purges secret and during more than 1year she was admitted several times in the emergency room for, sometimes life-threatening, hypokalemia. Furthermore, she consulted practitioners from different specialties and was hospitalized in a nephrology service to investigate chronic hypokalemia and other metabolic and hydroelectrolytic disturbances. A Bartter Syndrome was suspected, and she underwent genetic testing. Eventually she started psychiatric follow up and was admitted as an inpatient under the care of a specialized eating disorders unit. This patient presented a series of metabolic disturbances secondary to the diuretic abuse, that mimicked the manifestations of hereditary tubulopathies like Bartter Syndrome. Coincidentally it was found that the patient had a mutation in a gene linked to Bartter Syndrome, that wasn't enough to justify this diagnosis. So, a Pseudo Bartter Syndrome secondary to the diuretic abuse was evident. The focus on medical manifestations delayed the recognition of the anorexia nervosa and the associated diuretic abuse as the main cause of the electrolyte and metabolic disturbances. This case emphasizes the importance of being familiarized with the non-psychiatric manifestations of eating disorders, so they may be rapidly recognized and managed. Level V, Case Report.

The urine as a diagnostic key for a homozygous EGFR mutation

Primary inherited epidermal growth factor receptor defects have recently been described in severe inflammatory skin disease and diarrhoea case reports. We describe two case reports of female preterm newborns of Roma consanguineous parents who presented both with alopecia and erythroderma/ichthyosis, in addition to nephromegaly at birth in case 1. Later, they both developed hypomagnesaemia and other severe hydroelectrolyte disturbances, recurrent life-threatening sepsis and failure to thrive. Exome sequencing identified a homozygous mutation in the epidermal growth factor receptor, rarely described. Despite optimization of medical supportive care, the prognosis was poor and both patients died before the first year of life. There are few similar cases of epidermal growth factor receptor homozygous mutation reported so far. Our manuscript describes the genetics, clinical presentation, and complex treatment of our two patients, aiming to contribute to new advances in the management of this condition.

Ectopic ACTH-Producing Pheochromocytoma as a Rare Cause for Rapid Progressing Cushing Syndrome: A Case Report

Background: Cushing syndrome due to ectopic CRH or ACTH secretion can be rarely caused by pheochromocytoma, commonly as part of genetic conditions. Case: A 21 year-old male, previously healthy, with no usual medication, went to the physician assistant for hematuria. The kidney US revealed, besides lithiasis, a highly vascularized mass in the right adrenal gland with 10 cm. In his first evaluation the patient had no complaints or pheochromocitoma/hypercortisolism stigmata, other than hand tremor and slight rounding of the face. Blood pressure was 149/88 mmHg, and heart rate 86 bpm. There was no family history of endocrine disease. He rapidly developed increased appetite, insomnia, and severe myalgias, with filling of supraclavicular fossae, facial plethora, and cervical and truncal acne. Laboratory analysis showed abnormal overnight dexamethasone suppression test (57.4 µg/dL, N < 1.8), elevated ACTH 378 pg/mL (N 9.0–52.0), 24h-urinary free cortisol (UFC) (5334.0 µg/24h, N 4.3–176.0), and late-night salivar cortisol (1.44 µg/dL, N < 0.32), hypokalemia (2.8 mEq/L, N 3.8–5.0), and leukocytosis (22.4*109/L, N 4.0–11.0); DHEA-S 962 µg/dL (N 80–560), 4-androstenedione 380 ng/dL (N 70–360), 17-OH progesterone 4.5 ng/mL (N 0.59–3.44), cromogranine A 6063 ng/mL (N 0–100), and markedly elevated urinary amines (adrenaline 173 nmol/24h, N 0–109; noradrenaline 5033 nmol/24h, N 89–473; normetanephrine 334605 nmol/24h, N 480–2424; metanephrine 15998 nmol/24h, N 264–1729; dopamine 4808 nmol/24h, N 424–2612). Hypercalcemia with hypophosphatemia and supressed PTH level was also detected. 68Ga-DOTANOC PET revealed a mass of the right adrenal gland with overexpression of somatostatin receptors (likely pheochromocytoma), without evidence of other tumor lesions of neuroendocrine origin. Pituitary MRI showed normal pituitary gland. Potassium supplementation, alpha-blockade with phenoxybenzamine, and metyrapone were initiated. Due to severe back pain, a CT scan of the spine was performed detecting compressive osteoporotic fractures in the mid dorsal and low dorsal segments. The patient was submitted to right adrenalectomy. Histology revealed pheochromocytoma with 11.2*9mm, with capsular and vascular invasion, extra-adrenal extension, necrosis, and atypical mitosis, with Ki67 of 9.5% and PASS score of 16. Postoperative analysis showed ACTH 45.6 pg/mL (N 7.2-63,3), late-night salivar cortisol < 0,0544 µg/dL (N < 0,32) and free urinary cortisol 41.4 µg/24h (N 4.3–176.0). Discussion: Ectopic cushing syndrome caused by pheochromocytoma is a rarely described entity. In this young patient, it caused rapid clinical progression of hypercortisolism with important hydroelectrolytic disturbances and compressive vertebral fractures, requiring prompt surgical intervention for clinical remission and improvement.

POS-097 BARTTER'S SYNDROM AND DEAFNESS: A CASE REPORT

Bartter's syndrome exhibits genetic heterogeneity. The neonatal form with deafness is due to mutations in the BSND gene encoding a subunit of the chlorine channels ClC-Ka and ClC-Kb (Bartter type IV). We report the case of a patient with Bartter syndrome associated with bilateral deafness 18-year-old patient with a family history of a niece with bartter syndrome, 2 sisters who died in the neonatal period and 4 late abortions in the mother’s medical history. Personal history of inbreeding. Resulting from a complicated hydramnios pregnancy with low birth weight. Followed since the age of 10 months for failure to thrive and facial dysmorphism with an episode of meningoencephalitis at the age of 1 year. The diagnosis of bartter syndrome was made at the age of 3 years due to hypokalaemia with high kaliuresis, metabolic alkalosis with polyuropolydipsia treated with potassium supplementation and NSAIDs. In view of hydramnios, dysmorphia and deafness, type IV bartter was suspected, confirmed by a genetic study showing the mutation of the BSND gene. After 15 years of follow-up after the positive diagnosis, polyuria was moderate at 3l / d with hypokalaemia at 2.2 mmol / l and moderate renal failure. This observation is distinguished by the association of bartter syndrome with deafness and a facial dysmorphism, as well as a progressive evolution despite the severity of the initial presentation. Bartter's syndrome is a rare condition whose prognosis is dominated by the severity of the hydroelectrolyte disturbances and the risk of chronic kidney disease. Type IV is a rare neonatal form associated with neurogenic deafness that progresses early to chronic renal failure. The immediate severity of this disease requires careful monitoring of pregnancy and birth

Resección de adenoma velloso gigante causante del síndrome de Mckittrick-Wheelock

Large colorectal villous adenomas are unusual. They can cause a rectal bleeding, a chronic diarrhea and less frequently a rectal obstruction and a prolapse. In addition, they can secrete a mucinous material rich in electrolytes, causing hydroelectrolyte disturbances, dehydration and acute kidney injury. In most cases, the management of these adenomas due to their size has been surgical, but endoscopic treatment has been reported with promising results, reducing the morbidity. We report and discuss the case of a 73-year-old man, who presented with syncope, with chronic diarrhea and a hydroelectrolytic alteration. Colonoscopy revealed a granular lateral spreading tumor of the rectum, and pathology confirmed a villous adenoma with a low-grade dysplasia. An initial symptomatic management of diarrhea and electrolyte disorders was performed with a subsequent surgical treatment using pull through technique with coloanal anastomosis.

Intoxication of the immature fruit of the ackee (Blighia sapida Koenig): Summary and development

Deaths linked to the consumption of plants are sometimes overlooked by health personnel in tropical environments. Parts of several plants are recognized as potentially toxic, including the fruit of the ackee. This review paper aimed to synthesize data on the toxicity of the fruit of the ackee (Blighia sapida) and a brief overview on the measures of management of its acute intoxication. This was a documentary and analytical study. We made an analysis/synthesis of the articles relating to the poisoning with the immature fruit of the ackee. The PubMed, AJOL and Google scholar databases were used. The ackee is a plant native to West-Africa. Known by several names, lissètin in Fon in Benin, atsia in Evé in Togo, Finzan in Bambara in Mali, its aril contains lipids, proteins, carbohydrates, vitamins and trace elements. Hypoglycin is present in two forms A (2-methylene-cyclopropane-alanine) and B found in immature fruit, a very toxic compound which disrupts β-oxidation of fatty acids. Acute immature fruit poisoning, manifests as an acute hypoglycemic encephalopathy, gastrointestinal signs, hydro-electrolyte disturbances, metabolic acidosis and liver damage. The detection of urinary dicarboxylic acids is pathognomonic. Its treatment is symptomatic. A crude gastrointestinal and hepatic symptomatology characterizes chronic intoxication. The ackee is a tree whose unripe fruit is of acute lethal toxicity. Treatment of acute intoxication is symptomatic.

Evaluation of Metabolic and Hydroelectrolytic Disturbances in Patients Diagnosed with Diabetic Ketoacidosis

Ketoacidosis is a life-threatening complication of diabetes mellitus, especially type 1 diabetic patients being predisposed to this condition. Ketoacidosis might occur also in other types of diabetes triggered by circumstances leading to shortage of insulin. The aim of the study was the assessment of metabolic, hydroelectrolytic disturbances and the relationship between different parameters in patients hospitalized with diabetic ketoacidosis. We evaluated the clinical state, parameters of blood-gas analyzer, biochemistry and hematology laboratory results of 32 patients admitted with diabetic ketoacidosis between January-November 2018 at the Department of Diabetology, Nutrition and Metabolic Diseases of the Emergency County Hospital in T�rgu Mureș. Demographic data, associated diseases, body mass index were also evaluated. The considered threshold of significance was 0.05. The distribution of type 1 and 2 diabetes was 40.6 and 46.9% in the studied group, 53.1% being male patients. Positive correlation could be observed between pH and base excess and between pH and bicarbonate values, while negative correlation could be found between triglyceridemia and body mass index (BMI). Severe hyperglycemia, very low pH values, glucosuria, ketonuria and electrolytic imbalances were very common in the studied patients. Pancreatitis, respiratory tract and urinary infections could be found in the background of ketoacidotic manifestations in the majority of the patients, dehydration occured in each of the cases. Many severe metabolic and hydroelectrolytic disturbances could be observed in the studied patients presenting diabetic ketoacidosis. Infectious diseases are the most common triggers of metabolic imbalance in diabetic patients.

Hydroelectrolytic Disorders in Cerebroleted Patients in the Intensive Care Unit of Gabriel Tour&amp;#233; Teaching Hospital

A cerebrole is a patient with a neurological deficit of central origin; these patients very often present disorders of the ion concentration, hence the need for hospitalization in intensive care. The aim of our study was to study hydro-electrolyte disorders in brain-damaged patients, to describe the clinical aspects, to identify the contributing factors and to determine the prognosis of these patients in the intensive care unit of gabriel toure teaching hospital. Material and Methods: It was a prospective cross-sectional study, descriptive of a period of 11 months going from June 2015 to April 2016 in the intensive care unit of CHU Gabriel TOURE we included all the cerebral patients admitted in intensive care in which hydro-ionic disorders have detected on arrival or during hospitalization. Data were collected through transfer sheets, a survey sheet and medical records. Data entry and analysis were done respectively on SPSS software (version 19) and Microsoft Word Starter 2010 software. Results: During our study, out of 450 hospitalization patients, we identified 110 brain-damaged patients and 75 patients were retained in our study, i.e. a prevalence of 16.6%. Male was predominant with 72% with a sex ratio of 2.5 the age group 20 - 50 years was majority with 45.3%, the average age was 38.49 years. The majority of patients (58.7%) were admitted from the emergency department. The most common reason for admission was impairment of consciousness in 94.7% (Table 1) of cases and the Glasgow admission score was less than or equal to 8 in 58.7% (Table 1) of patients. Hydro-electrolyte disturbances were present in 93.3% of patients on admission. Hyponatremia was the most common disorder with 56% (42 cases). Followed by hyperkalaemia 10.7% (8 cases), hypernatremia 9.3% (7 cases), at hypocalcemia 9.3% (7 cases), associated disorders 8% (6 cases). Brain CT was performed in 52% of the patients. In our study, malaria was the most common etiology of ionic disorders with 36%. Of the patients who died, 80% had developed hyponatremia after 5 days in hospital, and the overall lethality was 73.3%. Conclusion: Hydro-electrolyte disorders are frequent in the intensive care setting and their management must be rapid in order to reduce morbidity and mortality.

Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019.

ESGE recommends a low fiber diet on the day preceding colonoscopy.Strong recommendation, moderate quality evidence.ESGE recommends the use of enhanced instructions for bowel preparation.Strong recommendation, moderate quality evidence.ESGE suggests adding oral simethicone to bowel preparation.Weak recommendation, moderate quality evidence.ESGE recommends split-dose bowel preparation for elective colonoscopy.Strong recommendation, high quality evidence.ESGE recommends, for patients undergoing afternoon colonoscopy, a same-day bowel preparation as an acceptable alternative to split dosing.Strong recommendation, high quality evidence.ESGE recommends to start the last dose of bowel preparation within 5 hours of colonoscopy, and to complete it at least 2 hours before the beginning of the procedure.Strong recommendation, moderate quality evidence.ESGE recommends the use of high volume or low volume PEG-based regimens as well as that of non-PEG-based agents that have been clinically validated for routine bowel preparation. In patients at risk for hydroelectrolyte disturbances, the choice of laxative should be individualized.Strong recommendation, moderate quality evidence.

Biochemical testing in a laboratory tent and semi-intensive care of Ebola patients on-site in a remote part of Guinea: a paradigm shift based on a bleach-sensitive point-of-care device

During the West Africa Ebola virus disease (EVD) outbreak, a Belgian laboratory was deployed for supporting the Ebola treatment unit (ETU) of N'Zerekore, Guinea. Besides diagnosis of EVD and malaria, biochemical parameters were tested and used to guide supportive treatment of EVD. To preserve analytes stability, lithium-heparin blood samples were analyzed using the i-STAT® point-of-care testing (POCT) handheld device without the viral inactivation step. To mitigate the risk of Ebola virus transmission, assays were performed inside a portable glovebox with strict biosafety procedures. Providing the medical staff with real-time biochemical data modified their therapeutic attitude, shifting from empiric to a semi-intensive laboratory-guided treatment of hydro-electrolytic disturbances, metabolic acidosis and/or impaired kidney function. As illustrated with representative EVD cases (n=8), optimized supportive treatment with intravenous fluid therapy and electrolyte replacement often helped correct these abnormalities. However, the harsh operating conditions, especially the use of bleach decontamination inside the glovebox, caused several technical failures and the final breakdown of the POCT device. POCT availability resulted in a paradigm shift in laboratory practice and care delivery at the N'Zerekore ETU. We conclude that there is urgent need for novel well-designed and validated POCT devices usable by non-expert operators in high ambient temperature and limited space. These devices should withstand regular and thorough decontamination by the personnel working on-site with life-threatening pathogens and be compatible with high biosafety level procedures. Such specific users' requirements need a European validation and standardization process of proposed solutions led by the EU Standardization Committee (CEN).

Central pontine myelinolysis after liver transplantation: case report

Central Pontine Myelinolysis (CPM) is a demyelinating disease with central pontine localization which presents in patients with chronic hepatic disease and hydroelectrolytic disturbances. In spite of pathophysiology still unknown, the patient liver transplanted has several risk factors to CPM. Its clinical manifestations are mainly motor and awareness alterations. Diagnosis requires brain images like magnetic resonance and it has a poor prognosis in critical care patients and it is very important to know about the possibility of presentation and to be aware about this pathology. The main objective to present this case report is sensitizing the medical community regarding the CPM in patients with liver transplant. The case report of a 40-year-old female patient who had previous history of biliary cirrhosis secondary to autoimmune hepatitis and liver transplantation was performed; subsequently developed alteration of awareness, hydroelectrolytic disturbances and abnormal findings in brain imaging. CPM is a neurological demyelinating disease with multifactorial origin, its treatment is supportive and prevention is the main goal in patients with risk factors like patient after liver transplantation.

Mixed Acid-Base Disorders, Hydroelectrolyte Imbalance and Lactate Production in Hypercapnic Respiratory Failure: The Role of Noninvasive Ventilation

BackgroundHypercapnic Chronic Obstructive Pulmonary Disease (COPD) exacerbation in patients with comorbidities and multidrug therapy is complicated by mixed acid-base, hydro-electrolyte and lactate disorders. Aim of this study was to determine the relationships of these disorders with the requirement for and duration of noninvasive ventilation (NIV) when treating hypercapnic respiratory failure.MethodsSixty-seven consecutive patients who were hospitalized for hypercapnic COPD exacerbation had their clinical condition, respiratory function, blood chemistry, arterial blood gases, blood lactate and volemic state assessed. Heart and respiratory rates, pH, PaO2 and PaCO2 and blood lactate were checked at the 1st, 2nd, 6th and 24th hours after starting NIV.ResultsNine patients were transferred to the intensive care unit. NIV was performed in 11/17 (64.7%) mixed respiratory acidosis–metabolic alkalosis, 10/36 (27.8%) respiratory acidosis and 3/5 (60%) mixed respiratory-metabolic acidosis patients (p = 0.026), with durations of 45.1±9.8, 36.2±8.9 and 53.3±4.1 hours, respectively (p = 0.016). The duration of ventilation was associated with higher blood lactate (p<0.001), lower pH (p = 0.016), lower serum sodium (p = 0.014) and lower chloride (p = 0.038). Hyponatremia without hypervolemic hypochloremia occurred in 11 respiratory acidosis patients. Hypovolemic hyponatremia with hypochloremia and hypokalemia occurred in 10 mixed respiratory acidosis–metabolic alkalosis patients, and euvolemic hypochloremia occurred in the other 7 patients with this mixed acid-base disorder.ConclusionsMixed acid-base and lactate disorders during hypercapnic COPD exacerbations predict the need for and longer duration of NIV. The combination of mixed acid-base disorders and hydro-electrolyte disturbances should be further investigated.

Evolution of critically ill patients with gastroschisis from three tertiary centers

OBJECTIVES AND INTRODUCTION:Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20–30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers.METHODS:From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables.RESULTS:163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1%). The mean serum sodium level was 127.4±6.7 mEq/L, and the mean serum albumin level was 2.35±0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9%.CONCLUSION:In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome.

Osmoregulation of vasopressin secretion is altered in the postacute phase of septic shock*

To determine whether septic shock patients have an abnormal reponse to increasing osmolarity. Prospective interventional study. Intensive care unit at Raymond Poincaré and Etampes Hospitals. Normonatremic patients at > 72 hrs from septic shock onset. Osmotic challenge consisting of infusing 500 mL of hypertonic saline solution (with cumulative amount of sodium not exceeding 24 g) over 120 mins. Plasma arginine vasopressin levels were measured 15 mins before the test and then four times every 30 mins. A slope of the relation between arginine vasopressin and plasma sodium levels of < 0.5 pg/mEq defined nonresponders. Among the 33 included patients, 17 (52%) were nonresponders. During osmotic challenge, variations throughout the test in plasma sodium levels, blood pressure, and central venous pressure were comparable between the two groups. Arginine vasopressin increased from 4.8 pg/mL [3.3-6.4 pg/mL] to 14.4 pg/mL [11.2-23.3 pg/mL] in responders but only from 2.8 pg/mL [2.3-4.0 pg/mL] to 4.0 pg/mL [3.1-5.3 pg/mL] in nonresponders (p < .0001). Responders had a higher plasma arginine vasopressin levels at baseline and a more severe hematosis alteration. Nonresponders had more frequently bacteremia and liver dysfunction, been referred from the ward and undergone surgery. Critical illness severity, hemodynamic alteration, hydroelectrolytic disturbances, treatment, and outcome did not differ between the two groups. Osmoregulation is dramatically altered in half of patients with prolonged septic shock.

Transient blindness and seizures in severe lupus nephritis.

A 19-year-old woman with severe lupus nephritis was brought to the emergency department for blindness and generalized seizures. Class IV lupus nephritis had been diagnosed 1 year earlier and treated with corticosteroids and mycophenolate mofetil. Three months before admission, serum creatinine was 1.0 mg/dL. Poor compliance to prescribed therapy 2 months before admission led to worsening nephrotic syndrome (proteinuria 22 g/day) and renal failure (creatinine 5.1 mg/dL), with a systemic lupus erythematosus (SLE) disease activity index of 39. A second kidney biopsy confirmed severe class IV lupus nephritis with crescents in ∼50% of the glomeruli and a histological activity index of 18/42. Despite aggressive immunosuppressive therapy including corticosteroids, cyclophosphamide and rituximab, haemodialysis had to be initiated 2 weeks before the current admission. On the morning of admission, she complained of acute onset blindness and headache, and developed generalized tonic–clonic seizures. Physical examination revealed hypertension (155/100 mmHg), obtundation and visual loss. There were no hydroelectrolytic disturbances, and cerebrospinal fluid examination was normal. Fundoscopic examination showed a grade 2 hypertensive retinopathy. Magnetic resonance imaging showed bilateral parietooccipital hyperintensities on fluid-attenuated inversion recovery (FLAIR) sequences (Figure 1A), consistent with cerebral oedema.

Treating seizures in renal and hepatic failure

INTRODUCTION: Renal and hepatic diseases cause seizures and patients with epilepsy may suffer from such diseases which change antiepileptic drugs (AEDs) metabolism. OBJECTIVES: To revise how seizures may be caused by metabolic disturbances due to renal or hepatic diseases, by their treatment or by comorbidities and how AEDs choice might be influenced by these conditions. RESULTS: Seizures arise in renal failure due to toxins accumulation and to complications like sepsis, hemorrhage, malignant hypertension, pH and hydroelectrolytic disturbances. Hemodialysis leads to acute dysequilibrium syndrome and to dementia. Peritoneal dialysis may cause hyperosmolar non-ketotic coma. Post-renal transplant immunosupression is neurotoxic and cause posterior leukoencephalopathy, cerebral lymphoma and infections. Some antibiotics decrease convulsive thresholds, risking status epilepticus. Most commonly used AEDs in uremia are benzodiazepines, ethosuximide, phenytoin and phenobarbital. When treating epilepsy in renal failure, the choice of AED remains linked to seizure type, but doses should be adjusted especially in the case of hydrosoluble, low-molecular-weight, low-protein-bound, low apparent distribution volume AEDs. Hepatic failure leads to encephalopathy and seizures treated by ammonium levels and intestinal bacterial activity reductions, reversal of cerebral edema and intracranial hypertension. Phenytoin and benzodiazepines are usually ineffective. Seizures caused by post-hepatic immunosupression can be treated by phenytoin or levetiracetam. Seizures in Wilson's disease may result from D-penicillamine dependent piridoxine deficiency. Porphyria seizures may be treated with gabapentin, oxcarbazepine and levetiracetam. Hepatic disease changes AEDs pharmacokinetics and needs doses readjustments. Little liver-metabolized AEDs as gabapentin, oxcarbazepine and levetiracetam are theoretically more adequate. CONCLUSIONS: Efficient seizures treatment in renal and hepatic diseases requires adequate diagnosis of these disturbances and their comorbidities besides good knowledge on AEDs metabolism, their pharmacokinetic changes in such diseases, careful use of concomitant medications and AEDs serum levels monitoring.

Adverse drug reactions in patients older than 70 years during the heat wave occurred in France in summer 2003: a study from the French PharmacoVigilance Database

To evaluate adverse drug reactions (ADRs) in patients older than 70 years reported during the 2003 summer heat wave in France to the French Network of Pharmacovigilance Centres and to discuss the interest of such a pharmacovigilance database in the surveillance of such sanitary alerts. All 'serious' ADRs occurred in patients older than 70 years between 1st July and 31st August 2003, reported to the French network of Pharmacovigilance Centres and recorded in the French PharmacoVigilance Database, were analysed with respect to age, gender, type of ADR, drug(s) involved as well as imputability of heat wave. The total number of 'serious' ADRs registered in the French PharmacoVigilance Database in patients older than 70 years was similar in 2003 (a year with heat wave) and in 2002 (a year without heat wave). Sixty-eight ADRs [27 'possible' (I1), 27 'plausible' (I2) and 14 'likely' (I3)] related to heat occurred in 2003, with a maximal peak between the 28th July and the 17th August. The most frequently ADRs were metabolic (dehydratation, hydroelectrolytic disturbances) and neuropsychiatric (confusion, falls, coma). Drugs more frequently involved were diuretics, angiotensin converting enzyme inhibitors, antidepressants (mainly serotonin reuptake inhibitors), proton pump inhibitors, digoxin, benzodiazepines, oral hypoglycemics and sartans. This study underlines the role of heat wave in the occurrence of 'serious' ADRs in elderly. However, the French PharmacoVigilance Database was not enough sensitive to be used as an efficient surveillance system during such an acute episode, like a heat wave (at least while underreporting remains so important).

Double‐barrelled wet colostomy with simultaneous urinary and faecal diversion: results in 9 patients and review of the literature

Double-barrelled wet colostomy is a urinary diversion technique indicated when a concurrent faecal diversion is needed. It is a simple procedure, technically easy to accomplish and well received by patients. The purpose of this study is to report the results of double-barrelled wet colostomy, with emphasis on operating technique, morbidity, functional results and a review of the literature on the subject. The medical records of 9 consecutive patients, between January 2001 and May 2005, who underwent surgical extended resections with double-barrelled wet colostomy for a malignant central pelvic mass, were reviewed retrospectively. The patients were asked to respond to a questionnaire assessing quality of life. The questionnaire used was the QLQ-C30 version 3, proposed by the European Organization for Research and Treatment of Cancer (EORTC). This study presents results obtained from 9 patients, emphasizing morbidity and quality of life. One patient presented with pyelonephritis. We did not identify complications such as hydroelectrolytic disturbances, peristomal dermatitis or hydronephrosis. The patients who submitted to the procedure exhibited high levels of quality of life and found caring for the stomas straight forward. We conclude that double-barrelled wet colostomy is an excellent choice for patients who require concurrent urinary and faecal diversion, one that does not present technical difficulties and does not require a prolonged operating time. It avoids the complications frequently present in standard wet colostomy and does not rule out making a continent urinary reservoir later, in patients that meet healing criteria.