Severe Failure Research Articles

Influence of Right and Left Bundle Branch Block in Patients With Cardiogenic Shock and Cardiac Arrest.

The study investigates the prognostic impact of right bundle branch block (RBBB) and left bundle branch block (LBBB) in patients with cardiogenic shock (CS) compared with no bundle branch block (BBB). In patients with heart failure, existence of RBBB and LBBB has influence on prognosis. Prospective registry-study. ICU of a tertiary academic hospital in Germany. Adult patients with CS. None. Consecutive patients with CS were included. The prognostic impact of RBBB and LBBB on 30-day all-cause mortality was tested within the entire cohort and in the subgroup of CS patients with cardiac arrest at admission. The final study cohort comprised 248 patients. Patients with RBBB showed the highest 30-day all-cause mortality followed by LBBB and no BBB (72.5% vs. 52.9% vs. 50.0%; log-rank p = 0.015). These findings were consistent even after solely including CS patients with cardiac arrest (90.0% vs. 73.3% vs. 62.2%; log-rank p = 0.008). After adjustment for lactate, norepinephrine, troponin I, Acute Physiology Score, Society of Cardiovascular Angiography & Interventions shock stage, and heart rate in a multivariable Cox regression analysis, RBBB still revealed a negative impact on 30-day all-cause mortality (hazard ratio [HR], 1.807; 95% CI, 1.107-2.947; p = 0.018), whereas LBBB was not associated with 30-day all-cause mortality. In this multivariable Cox regression model lactate (HR, 1.065; 95% CI, 1.018-1.115; p = 0.006), troponin I (HR, 1.003; 95% CI, 1.001-1.005; p = 0.001), and Acute Physiology Score (HR, 1.033; 95% CI, 1.001-1.066; p = 0.041) were as well associated with 30-day all-cause mortality. Finally, no association of RBBB was found with the incidence of liver or severe renal failure. Besides the Acute Physiology Score, lactate, and troponin levels, RBBB was associated with an increased 30-day all-cause mortality in consecutive CS patients with and without cardiac arrest, whereas LBBB showed no prognostic impact.

Sex differences in in-hospital management and outcomes of patients with acute pulmonary embolism

Abstract Background Acute pulmonary embolism (PE) is a life-threatening disease with specific risk factors among women. Systematic evaluation of contemporary quality of care and outcomes in women hospitalized with acute PE is needed. Methods The COPE Registry (COntemporary management of acute Pulmonary Embolism) is a nationwide registry that was run in Internal Medicine, Cardiology and Emergency Departments in Italy. Using data from the COPE Registry, we evaluated sex differences in acute management, medical therapies, in-hospital and 30-day mortality and major bleeding in 5,213 patients admitted for acute PE at 182 hospitals in Italy from 2018 to 2020. Results Women (n=2,728) were older than men (71.2 versus 66.6 years, P<0.001) and had different distribution of comorbidities, with dementia and severe renal failure being more prevalent (13.6 vs 6.4% and 6.1 vs 3.0%, respectively) and cancer, COPD and recent bed-rest less prevalent (15.2 vs 18.5% and 11.1 vs 14.5% and 23.5 vs 20.2%) in women than men. At presentation, PE was more severe in women than men in terms of hemodynamic instability (4.1 vs 2.7%), prevalence of right ventricle overload at echocardiography (64.5 vs 57%) and prevalence of sPESI=0 (29.4 vs 38.5%). Concerning the likelihood to receive evidence-based acute treatments for PE, women were more likely than men to receive reperfusion in the case of hemodynamic compromise at presentation after adjusting for age and dementia (63.1 vs 50.0%; OR 1.934, 95% CI 1.01-3.71), and to receive direct oral anticoagulants during hospitalization after adjusting for age, dementia and severe renal failure (50.9 vs 48.6%; OR 1.14, 95% CI 1.01-1.28); similar proportions of low-risk women and men were managed as outpatients or by short hospital stay (1.4% vs 1.4% and 8.6 vs 6.0%, respectively). In-hospital and 30-day mortality rates were not different in women and in men (3.7% versus 3.1% and 5.5 vs 4.8%), but PE-related mortality was higher in women than in men (2.1 vs 1.3%). The sex difference in PE-related mortality was no longer observed in after adjusting for age, hemodynamic instability and dementia (adjusted HR 1.20; 95% CI 0.77-1.88; P=0.415). Similar rates of early and delayed major bleedings occurred in women and in men, both at univariate analysis and after adjusting for age, creatinine clearance and use of thrombolysis. None of 22 pregnant women and 1 out of 204 women with estro-progestin associated PE died or experienced major bleeding. Conclusions Women hospitalized for acute PE in Italy received evidence-based acute treatments more commonly than men. The observed sex differences in PE-related mortality were mainly attributable to worse clinical profiles and older age. Women with sex-related risk factor for PE had favorable prognosis.

Feasibility of ultra-low volume contrast pulmonary arterial injection protocol for CTA in TAVI candidates with severe renal failure

Abstract Introduction Computer tomography angiography (CTA) has an important role in patient screening before TAVI. The high volumes of iodinated contrast media (CM) injected during the examination represents the main limitation of CTA with a dose-dependent association with contrast-induced nephropathy. Purpose Show the feasibility of an ultra-low-dose CM pulmonary arterial injection protocol for CTA in TAVI candidates in high risk patients with severe renal failure. Methods In our retrospective study seventy-seven (77) patients with CKD on stage 3b or worse (eGFR ≤ 45/min/1.73 m2) underwent pre-procedural CTA for TAVI-planning with a pulmonary arterial administration of CM. All CTA examinations were performed using a Dual Source 256-slice CT system. All enhanced CT acquisitions were performed using our dedicated biphasic injection protocol composed of two connected phases of contrast medium injection using different amount of CM (8, 10, 15 and 20 ml) according to BMI (<22 kg/m2; 22-24 kg/m2; 24-28 kg/m2; >28 kg/m2). The CM was administered directly into the pulmonary artery in all patients. For each examination was measured Intraluminal attenuation at thoraco-abdominal aorta and along the ilio-femoral vessels using the ROI (mean SD in HU) as objective image parameters (Picture 1). Serum creatinine and the eGFR were recorded pre-TAVI CT scan and after the procedures as reference of CM to renal function. Results CTA was successfully performed in all patients. Mean creatinine was 2.25 ± 0,76 mg/dL and mean GFR was 26.5± 8.1 mL/min/m2. Mean vessel attenuation was 352±164 HU at the aortic annulus, 238.1 ± 141,3 HU in the aortic arch and 266±168 in the iliac arteries (Picture 2). The mean image noise was 28.2 ± 7 HU in the aortic annulus, 24.4 ± 10,9 in the right external iliac artery, and 25. ± 12,8 HU in the left external iliac artery. After CTA examination, a total of 74 patients (96%) underwent TAVI. Mean CM dose administered during TAVI procedure was 150,6 ± 85,8. Three patients (3.9%) were abolished for TAVI. Postprocedural settings complications were recorded. A total of 31 patients (41%) had grade 1 paravalvular regurgitation, 10 patients (14%) grade 2. No cases of valve embolization or anulus rupture occured. No major vascular complications occured. No significant differences between creatine and eGFR pre and post procedures (p<0,001). Conclusions The use of an ultra-low-dose CM pulmonary arterial injection protocol for CTA in TAVI candidates does not affect the renal function and procedural success rate is high and the clinical outcomes after TAVI is satisfactory according to the litterature.

Cardio-renal syndromes in patients admitted with ST-elevation myocardial infarctions: Incidence and impact on renal and overall outcome

Abstract Background The importance of cardiorenal syndromes (CRS) in patients with heart failure has been shown in many studies. However, there is little data on the impact of a combination of heart failure and renal disease in patients with acute myocardial infarctions. Aim of the present study was to investigate, how often a combination of heart failure (HF) and kidney disease (KD) could be detected in patients with ST-elevation myocardial infarctions and to estimate its impact on outcome. Methods All patients from a German heart center, admitted with STEMI between 2006 and 2022 were analysed. CRS was defined as a combination of heart failure (HF: left ventricular ejection fraction (LV-EF<40%), HF) and kidney disease (KD: GFR at admission <60 ml/min). Patients were assigned in a 2x2 model: HF-/KD-, HF-/KD+, HF+/KD-, HF+/KD+. Outcome analysis was adjusted by confounders in a multivariate Cox-regression-model. Acute kidney injury (AKI) was calculated by AKIN-criteria (KDIGO) Results Of a total of 8276 STEMI-patients included in the study 5696(69%) had a preserved LV-EF and no KD (HF-/KD-), 1354 (16%) a preserved LV-EF and KD (HF-/KD+), 743 (9%) a reduced LV-EF and no KD (HF+/KD-) and 483 (6%) both a reduced LV-EF and KD (HF+/KD+, CRS-Group). In the CRS-group patients were on average older (74.2±12 yrs. vs. 60.8±13 yrs., p<0.01), more likely to be female (36.9% vs. 23.1% in the control group, p<0.01) and more likely to be diabetics (31.0% vs. 16.8% in the control group, p<0.01). CRS was associated with higher rates of cardiogenic shock (41.5% vs. 8.7% in the control group) and higher rates of subsequent AKI with a 18x higher risk to develop AKIN-3 with or without the need for renal replacement therapy (RRT), (table, upper part). In patients with CRS in 11% of patients a temporal RRT was necessary vs. 0.5% in controls. Furthermore, in CRS-patients in-hospital and 1 year-mortality-rates were markedly higher (table, lower part). When adjusting outcomes for confounders (age, gender, CS, diabetes, anterior STEMI, 3 VD) the detrimental effect of CRS on outcome remained: AKIN-3/RRT: OR 16.5, 95% CI 7.5-30.0, p<0.01, In-hospital-mortality: OR 14.2, 95% CI 7.8-21, p<0.01, 1-year-mortality: HR 10.5, 95% CI 7.5-14.1, p<0.01. Conclusions In this analysis of registry data, cardiorenal disease could be detected in 6% of STEMI-patients, with higher rates in women and in diabetics. Patients with cardiorenal disease showed a more than 18-fold higher risk of suffering severe renal failure during the index event and a 24-fold higher risk of in-hospital death. Patients with either heart failure or renal disease were situated between the CRS and control group with regard to outcome. These results underline the additive effects of cardiac and renal disease.Table:Event rates by HF and KD group

The true incidence and risk factors of hemolysis in patients with Impella CP placement

Abstract Background The Impella, a micro axial-flow pump, is effective in treating cardiogenic shock. However, compared to other mechanical circulatory support devices, its high pump speeds can result in complications like hemolysis and subsequent renal failure. Previous reports have defined hemolysis based on the elevation of LDH levels or the presence of hemoglobinuria, but this approach may underestimate its occurrence. Hemolysis is commonly assessed using the hemolysis index, which is calculated through biochemical auto-analysis based on the absorbance measure of the red color change. However, since the hemolysis index is not highly sensitive, it is recommended to measure plasma free hemoglobin (PFHb) for accurate diagnosis of hemolysis. Purpose The aim of this single-center retrospective cohort study is to investigate the frequency of hemolysis in Impella CP using PFHb measurements and its association with the Impella support level. Methods Between December 2019 and June 2023, we included 116 patients who had the Impella CP device implanted at our hospital. For these patients, PFHb was measured twice daily during the Impella placement period (up to 13 days). A PFHb value of 0.06 or higher was considered indicative of hemolysis, at which point a haptoglobin preparation of 4000 units was administered. Separately, the hemolysis index was defined as hemolysis at a level of 41 mg/dL. We investigated the relationship between daily Impella settings, PFHb, and hemolysis index for each patient. Results The average age was 70 ± 13 years. 59% underwent ECPELLA, and 15% were introduced to renal replacement therapy (RTT) due to severe renal failure. During Impella placement, hemolysis was diagnosed in 33% of patients based on PFHb, while only 18% were diagnosed with hemolysis according to the hemolysis index. Upon separate analysis for Impella and ECPELLA during the initial three days, the support levels of Impella were significantly higher in the Impella group on Days 1 and 2, with no significant difference noted on Day 3. Moreover, PFHb levels were significantly higher in the Impella group on Day 1, while on Day 3, the levels were higher in the ECPELLA group. Patients on RRT had significantly higher max PFHb levels than those not on RRT (0.19 vs. 0.06 g/dL; p < 0.001). Next, we investigated the relationship between PFHb levels and Impella support levels in patients with either Impella or ECPELLA over 711 data points. Dividing Impella support into low (P1-3), middle (P4-6), and high (P7-9) categories, PFHb values were significantly higher at high P levels compared to low and middle P levels. Similar results were observed for both Impella and ECPELLA. Conclusion There is a possibility of underestimating hemolysis associated with Impella if PFHb measurement is not performed. Hemolysis showed a significant correlation with higher P levels (P7 and above) for both Impella and ECPELLA.

Successful treatment of severe renal failure caused by malignant hypertension using a combination of renin-angiotensin-aldosterone system inhibitors: a case report.

Marked activation of the renin-angiotensin-aldosterone system (RAAS) plays an important role in malignant hypertension (MHT) by worsening hypertension and renal function. The rates of readmission for severe hypertension and cardiovascular disease in such emergencies are high, suggesting that suppression of the RAAS may be inadequate during the acute phase in some cases. This report presents a case of MHT complicated with renal insufficiency (creatinine 3.93mg/dL) and massive proteinuria, in which antihypertensive therapy, including an angiotensin receptor blocker, aliskiren, and spironolactone, normalized blood pressure (BP) and preserved renal function. Plasma renin activity was extremely high (131.9ng/mL/h) on admission but normalized within almost 2weeks. Although aliskiren and spironolactone were discontinued before discharge, BP was well controlled and renal function was further improved (creatinine 1.14mg/dL) at follow-up 24months later. This case of renal failure induced by MHT was successfully treated with a combination of RAAS inhibitors during the acute phase. The controlled BP and improved renal function in this patient suggest that adequate suppression of the RAAS cascade during the acute phase is potentially effective in terms of breaking the vicious cycle of MHT with hyperreninemia.

Sterile water and regional citrate anticoagulation: A simple CRRT strategy for safe correction of severe hyponatraemia.

Hyponatraemia is a prevalent electrolyte disturbance observed in critically ill patients. The rapid correction of low plasma sodium levels by continuous renal replacement therapy (CRRT) carries the risk of developing osmotic demyelination syndrome (ODS), which can be prevented by implementing an individualized CRRT method. This study aims to introduce a CRRT protocol for the safe and gradual correction of severe hyponatraemia. This retrospective case series study was conducted in an intensive care unit (ICU). All four patients with severe hyponatraemia (<125 mmol/L) and renal failure between October 1, 2022, and September 30, 2023, were treated by CRRT with sterile water and regional citrate anticoagulation (RCA). Data on patient demographics, laboratory biochemical parameters, urine outputs and CRRT-related adverse events were collected. Laboratory parameters and urine outputs were compared by paired t-tests before and after CRRT. After CRRT, sodium levels were significantly increased (112.7 ± 6.7 vs. 141.9 ± 2.8 mmol/L, p = .005). Abnormal urine outputs, potassium, creatinine and bicarbonate were corrected (p for all <.05). Safe and gradual correction of hyponatraemia and internal environmental dysregulation was achieved in all patients without any complications related to CRRT, particularly ODS. It is a novel and simple strategy to correct severe hyponatraemia effectively while ensuring the safety of patients that can be easily implemented by experienced nurse staff. The sterile water-based protocol for postfilter dilution is safe to correct severe hyponatraemia with RCA and can be easily performed by experienced critical care nurses according to the precalculated formula. CRRT-trained, experienced ICU nurses are competent to initiate and adjust sterile water infusion discretely to prevent overcorrection of hyponatraemia.

Legionella Pneumophila Presenting as a Rare Cause of Acute Thrombocytopenia: A Case Report and Review of Literature.

Legionella pneumophila can cause a wide spectrum of clinical manifestations, ranging from a mild flu-like illness to fulminant multi-organ involvement, characterised by severe pneumonia, diarrhoea, encephalopathy, shock, hepatic dysfunction and renal failure. Very rarely, it can be associated with haematologic conditions such as thrombotic thrombocytopenic purpura (TTP), haemolytic uraemic syndrome (HUS) and immune thrombocytopenic purpura (ITP). We report a rare case of L. pneumophila causing ITP and review previously published cases of thrombocytopenia associated with Legionellosis in the literature. A 53-year-old male presented with fevers, chills, a productive cough and severe haemoptysis. Blood work was remarkable for leukocytosis, severe thrombocytopenia and hyponatraemia. Computed tomography (CT) imaging showed left lower lobe lung consolidation, and a peripheral blood smear showed giant platelets consistent with ITP. Legionella urine antigen testing returned positive. He was treated with intravenous immunoglobin, steroid taper and a ten-day course of azithromycin, which led to normalisation of his platelet count and resolution of the pneumonia. L. pneumophila can lead to complement-mediated destruction of platelets resulting in ITP. Antibodies against L. pneumophila can also cross-react with the enzyme ADAMTS13, inhibiting its function and resulting in TTP and HUS. Additionally, L. pneumophila can infect vascular endothelial cells causing their death and stimulating release of von Willebrand factor (vWF) multimers into the bloodstream, promoting thrombosis and platelet consumption. It is important for internists to consider L. pneumophila in the differential for any patient presenting with pneumonia and severe thrombocytopenia. Earlier detection and intervention can lead to prevention of critical bleeding and better outcomes. Legionella pneumophila is rarely associated with different haematologic disorders resulting in severe bleeding diathesis as well as thrombosis.It is important for internists to consider Legionella pneumophila in the differential diagnosis for any patient presenting with pneumonia and severe thrombocytopenia.Earlier detection and intervention can lead to prevention of critical bleeding and better outcomes.

Approach to Pulmonary-Renal Syndrome – A Narrative Review

The term “Pulmonary-renal syndrome” is a clinical syndrome, which encompasses a group of disorders with distinctive clinical and radiological features suggestive of diffuse alveolar hemorrhage and glomerulonephritis. The most common etiologies implicated are antineutrophil cytoplasmic antibody ANCA ANCA-associated vasculitis and Goodpasture syndrome. Early diagnosis and prompt treatment are critical for the management as patients can land up in severe respiratory distress and renal failure. A multi-disciplinary team is required for its management. The mainstay of treatment includes steroids, immunosuppressants, and plasmaphereses, depending on the etiology. Despite optimal management, mortality and morbidity remain high.

Cardiopulmonary Bypass Blood Flow Rates and Major Adverse Kidney Events in Cardiac Surgery: A Propensity Score-adjusted Before–After Study

ObjectiveCardiac surgery associated-acute kidney injury (CSA-AKI) is a common and serious postoperative complication of cardiac surgery, which is associated with increased postoperative morbidity and mortality. This study aimed to explore the association between CPB blood flow rate (CPB-BFR) and major adverse kidney events at day 30 (MAKE30). DesignRetrospective single-center before-after observational study. Patients were divided in two groups according to CPB flow rates: a first group with an institutional protocol targeting a CPB-BFR >2.2 L/min/m² (low CPB-BFR group), and a second group with a modified institutional protocol targeting a CPB-BFR >2.4 L/min/m² (high CPB-BFR group). The primary outcome was MAKE 30, defined as the composite of death, renal replacement therapy or persistent renal dysfunction. SettingThe data were collected from clinical routines in university hospital. ParticipantsAdult patients who underwent elective and urgent cardiac surgery without severe chronic renal failure, for whom CPB duration was ≥90 minutes. Interventions533 patients were included (low CPB-BFR group n=270, high CPB-BFR group n=263). Measurements and Main ResultsA significant decrease in MAKE 30 was observed in the high CPB-BFR group (3% vs. 8%; OR 0.779, 95% CI [0.661;0.919]; P<0.001) mainly mediated by a lower 30-day mortality in the high CPB-BFR group (1% vs. 5%; OR 0.697, 95% CI [0.595;0.817]; P= 0.001), as was renal replacement therapy (1% vs. 4%; OR 0.739, 95% CI [0.604;0.904]; P=0.016). ConclusionsIn patients undergoing cardiac surgery, increased CPB-BFR was associated with a reduction in MAKE 30 including mortality and renal replacement therapy.

A Series of Eight Cases of Pigment Nephropathy: An Obscured Aspect of Acute Kidney Injury.

Pigment-induced acute kidney injury (AKI) is an important and preventable complication of rhabdomyolysis or hemolysis. It is characterized by the release of free heme pigment (myoglobin or hemoglobin) in the circulation, leading to direct injury of the proximal tubuleand distal tubule obstruction by pigment cast. We are reporting eight cases of pigment-induced AKI, including six cases of myoglobin cast nephropathy and two cases of hemoglobin cast nephropathy.The causes of rhabdomyolysis were strenuous exercise, infection/febrile illness, and drug-induced neuroleptic malignant syndrome. Paroxysmal nocturnal hemoglobinuria and anti-tuberculosis treatment (rifampicin and isoniazid) had led to hemoglobin cast nephropathy each in one case. Seven cases had severe renal failure requiring dialysis.Short-term renal outcome was favorable. However, long-term follow-up is necessary to determine whether pigment-induced AKI has delayed sequelae. Therefore, clinicians should consider rhabdomyolysis or hemolysis as potential hidden causes of AKI in diverse clinical conditions, especially those of non-traumatic origin, to achieve an accurate diagnosis.

Causes and factors of death in the Pulmonology Department in Abidjan

Introduction Respiratory diseases constitute a major cause of morbidity and mortality worldwide. The objective of our study was to identify the causes and factors associated with the death of patients in the Pulmonology Department of the Treichville University Hospital. Patients and methods This was a retrospective cross-sectional study analyzing patients who died while hospitalized in the Pneumology Department of Treichville University Hospital between April 2019 and April 2020. Results The study covered 514 files, including 177 deaths, representing an overall mortality of 34.4%. There were 109 men and 68 women with an average age of 45.20 years. The main antecedents were HIV infection (42.18%) and tuberculosis (38.1%). The main causes of death were pulmonary tuberculosis (49.69%), pneumocystosis (20.75%), and bacterial pneumonia (18.87%). Severe anemia (53.68%) and severe renal failure (19.85%) were the biological abnormalities associated with pulmonary pathologies. In univariate analysis, the factors associated with deaths were age less than 25 years, HIV seropositivity, nonmedical access to the service, self-medication, the presence of signs of initial clinical and radiological severity, a diagnosis of tuberculosis and neoplastic pathology, also the existence of difficulties during hospitalization. Multivariate analysis revealed HIV infection [odds ratio (OR)=1.46, confidence interval (CI)=0.27–0.77, P=0.003], diagnosed pulmonary tuberculosis (OR=1.51, CI=0.30–0.87, P=0.01), the presence of signs of clinical severity (OR=1.20, CI=0.09–0.42, P=0.00) and initial radiological severity (OR=1.27, CI=0.11–0.64, P=0.003) and the presence of difficulties during hospitalization (OR=1.16, CI=0.05–0.54, P=0.003). Conclusion Mortality remains high in pulmonology hospitalizations. Currently, tuberculosis and HIV infection are the main causes of death. Efforts to combat these two conditions must be strengthened by taking into account these factors associated with deaths.

One problem, multiple potential targets: Where are we now in the development of small molecule inhibitors against Shiga toxin?

Shiga toxin-producing Escherichia coli (STEC) are a group of enteric pathogens which carry phage-encoded Shiga toxins (Stx). STEC infections begin with severe abdominal pain and non-bloody diarrhoea, which can progress to bloody diarrhoea after approximately 4-days post-infection. In high-risk groups such as children and the elderly, patients may develop haemolytic uremic syndrome (HUS). HUS is characterised by microangiopathic haemolytic anaemia, thrombocytopenia, and in severe disease acute renal failure. Traditional antibiotics have been linked with increased toxin production due to the activation of recA-mediated bacterial stress response, resulting in poorer patient outcomes. Therefore, treatment relies on supportive therapies. Antivirulence strategies have been explored as an alternative treatment for bacterial infections and blockers of virulence factors such as the Type III Secretion System. Recent improvements in the mechanistic understanding of the Stx pathway have led to the design of inhibitors to disrupt the pathway, leading to toxin-mediated ribosome damage. However, compounds have yet to progress beyond Phase III clinical trials successfully. This review explores the progress in developing small molecule inhibitors by collating lead compounds derived from in-silico and experimental approaches.

Sine-wave pattern in a case of severe hyperkalemia and end-stage renal failure from a hospital in a rural area: A case report and narrative review

Background: A sine-wave pattern in electrocardiography (ECG) is one of the manifestations of severe hyperkalemia and requires rapid medical intervention and urgent hemodialysis. This manifestation has high specificity for detecting hyperkalemia, and rapid medical intervention is required upon first medical contact. Case Description: A 60-year-old woman presents to the emergency room with generalized weakness that started around two days ago, and became increasingly more severe and noticeable to the point that the patient went to the emergency department. The patient initially was stable and experienced no other complaints including chest pain or dyspnea. A 12-lead ECG was obtained which showed the sine-wave morphology. Minutes later, the patient rapidly deteriorated and underwent cardiac arrest while waiting for lab results to confirm the hyperkalemia. The patient was resuscitated successfully and lab results confirmed potassium levels of 9.7mmol/L and a creatinine level of 9.55mg/dL (estimated GFR using CKD-EPI formula of 4 ml/min/1.73m2. The patient underwent potassium correction therapy with fast-acting insulin agents, dextrose and calcium gluconate infusions. A secondary ECG post ROSC and potassium correction therapy was taken, showing a reversal of the sine-wave pattern into an accelerated junctional rhythm with tall T waves. Chest X-ray was performed and showed cardiomegaly, and the patient was admitted into the ICU to undergo urgent hemodialysis. Conclusion: This case further emphasizes the importance of recognizing ECG manifestations of hyperkalemia and rapid management after recognition of said ECG patterns to prevent the clinical deterioration of the patient and potentially fatal outcomes should be undertaken as soon as possible.

Exploration and Validation of Lead Molecules against Yellow Fever through High Throughput Virtual Screening and Molecular Dynamics Simulation

Background: Yellow fever (YF) is a mosquito-borne flaviviral hemorrhagic fever (VHF) that causes severe hepatitis, renal failure, bleeding, and quick terminal events such as shock and multi-organ failure. There are currently no particular anti-viral medications for the management of the YF virus (YFV). Despite the availability of a commercial YFV vaccination, there are roughly 30,000 fatalities globally each year, with instances rising over the previous 20 years. After being translocated into the endoplasmic reticulum lumen, glycosylated NS1 resides as a membrane-associated dimer, where it is required for viral genome replication. The secreted hexamer NS1 has a role in immune evasion and pathogenesis and has been discovered as a possible diagnostic marker for the early identification of viral infections. Objective: The main aim of this study is to analyze the small molecule as a potent drug candidate against the target NS1 protein. Methods: In this study, Computational approaches, including high throughput virtual screening, molecular docking, and dynamics simulation, were carried out against the target NS1 protein using three different chemical libraries Enamine, Asinex, and NCI. The selected lead compounds were validated through HOMO-LUMO analysis, ADME prediction, and Toxicity parameters to analyze the biological and pharmacological properties of the lead small molecules. Results: From the result, it was concluded that the leads possessed the highest docking scores, interacting with the binding residues, and were stable in the simulation period. Conclusion: Overall findings revealed that the lead three small molecules could act as the potential drug candidate for the target NS1 protein to inhibit the diseasing efficacy of Yellow fever.

Mortality prediction and influencing factors for intensive care unit patients with acute tubular necrosis: random survival forest and cox regression analysis

Background: Patients with acute tubular necrosis (ATN) not only have severe renal failure, but also have many comorbidities, which can be life-threatening and require timely treatment. Identifying the influencing factors of ATN and taking appropriate interventions can effectively shorten the duration of the disease to reduce mortality and improve patient prognosis.Methods: Mortality prediction models were constructed by using the random survival forest (RSF) algorithm and the Cox regression. Next, the performance of both models was assessed by the out-of-bag (OOB) error rate, the integrated brier score, the prediction error curve, and area under the curve (AUC) at 30, 60 and 90 days. Finally, the optimal prediction model was selected and the decision curve analysis and nomogram were established.Results: RSF model was constructed under the optimal combination of parameters (mtry = 10, nodesize = 88). Vasopressors, international normalized ratio (INR)_min, chloride_max, base excess_min, bicarbonate_max, anion gap_min, and metastatic solid tumor were identified as risk factors that had strong influence on mortality in ATN patients. Uni-variate and multivariate regression analyses were used to establish the Cox regression model. Nor-epinephrine, vasopressors, INR_min, severe liver disease, and metastatic solid tumor were identified as important risk factors. The discrimination and calibration ability of both predictive models were demonstrated by the OOB error rate and the integrated brier score. However, the prediction error curve of Cox regression model was consistently lower than that of RSF model, indicating that Cox regression model was more stable and reliable. Then, Cox regression model was also more accurate in predicting mortality of ATN patients based on the AUC at different time points (30, 60 and 90 days). The analysis of decision curve analysis shows that the net benefit range of Cox regression model at different time points is large, indicating that the model has good clinical effectiveness. Finally, a nomogram predicting the risk of death was created based on Cox model.Conclusion: The Cox regression model is superior to the RSF algorithm model in predicting mortality of patients with ATN. Moreover, the model has certain clinical utility, which can provide clinicians with some reference basis in the treatment of ATN and contribute to improve patient prognosis.

Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review.

Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2-8.7] vs. 5.6], p = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, p < 0.001), more vasopressor use (51% vs. 34%, p = 0.006), and more positive pressure ventilation (38% vs. 24%, p = 0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p = 0.47), new oxygen requirement (68% vs. 59%, p = 0.16), ED death (3% vs. 4%, p = 0.15), or hospital death (31% vs. 27%, p = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.

A case of Gloriosa superba poisoning

ABSTRACT Gloriosa superba (GSb), or Glory Lily, is not an uncommon plant found in Sri Lanka. Every part of the plant is poisonous, especially the rhizome. It contains mainly colchicine and gloriocine which are toxic alkaloids. Fatalities following ingestion are rarely reported with current medical management. A 37-year-old male, with history of cannabis dependence and heroin abuse, ingested one and half of GSb rhizomes following a family dispute, witnessed by his family. He was hospitalized nearly eighteen hours later and he developed severe gastro-enteritis associated with nausea and vomiting. The patient’s presenting condition necessitated intensive care management for severe liver and renal failure. On the second day following admission he underwent haemodialysis and one cycle of plasma paresis but he ultimately succumbed due to unresponsive cardiac failure with arrhythmia. Subsequent autopsy examination revealed inflamed stomach and small intestinal mucosa with erosions, severe diffuse pulmonary haemorrhages with oedema, necrosis of liver and myocardium, and acute tubular necrosis. Multi-organ failure due to ingestion of GSb attributed to his death and manner of death was concluded as suicide following an inquest. This case report highlights the severity of effects of GSb poisoning including the effects on myocardium which is rarely encountered in clinical practice.

Acute severe renal failure in a patient receiving apixaban: a case report

Because there is little clinical experience with apixaban in patients with severe renal impairment and non-valvular atrial fibrillation, the European Medicines Agency does not advise using it to prevent strokes in these patients. However, only a small number of pharmacokinetic and pharmacodynamic investigations showed how crucially different elimination pathways contribute to the clearance of apixaban. A 74-year-old male patient who was receiving apixaban treatment for stroke prevention in atrial fibrillation was referred to our hospital because of acute severe renal failure brought on by dehydration and abnormally elevated apixaban plasma levels. The patient was treated only with intravenous fluid therapy; serum creatinine recovered slowly over the course of six days, but plasma apixaban levels recovered quickly. No bleeding events have been recorded. Our experience demonstrates the safety profile of apixaban in cases of severe renal failure, but it also emphasizes the need for more research to confirm this evidence.

Lupic Glomerulonephritis in a Patient Presenting with Hyperimmunoglobulin E Syndrome: A Case Report

Hyper-IgE syndrome (also known as Job or Buckley syndrome) is a hereditary immune deficiency of autosomal dominant inheritance. It is clinically characterized by the occurrence of recurrent staphylococcal, skin abscesses, bacterial and fungal pneumopathies, and a significant increase in immunoglobulin E. Its association with systemic lupus erythematosus has been described, the mechanism of which involves the deposition of immune complexes. We report the case of an 11-year-old girl with hyper IgE syndrome who was admitted to our clinic with severe renal failure, diagnosed as lupus glomerulonephritis on kidney biopsy.