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Journal of Investigative Medicine High... 2024Balkan endemic nephropathy (BEN) is a rare progressive chronic renal disease found in residents living along the Balkan peninsula. We present a 92-year-old female who... (Review)
Review
Balkan endemic nephropathy (BEN) is a rare progressive chronic renal disease found in residents living along the Balkan peninsula. We present a 92-year-old female who complained initially of cardio-respiratory symptoms and was found to have an acute hypoxemic respiratory failure with hypervolemia. The patient underwent computed tomography imaging and was found to have bilateral pleural effusions and moderate left-sided renal atrophy with left-sided hydronephrosis. The patient underwent diuresis for fluid overload and was treated with broad-spectrum antibiotics for hospital-acquired pneumonia. Further urological work-up revealed masses in the posterior bladder wall and left ureteropelvic junction. A biopsy of the posterior bladder wall mass confirmed high-grade papillary urothelial carcinoma. A review of the epidemiological history revealed the patient lived in Kosovo/former Yugoslavia for several decades following birth. A review of old records revealed the patient had chronic kidney disease (CKD) that was not fully explained by other causes, such as hypertension or diabetes. Given the epidemiological history, accelerated CKD, and unusual locations of urothelial carcinoma, the patient was diagnosed with BEN. Despite medical management and hemodialysis, the patient's renal function and mental status continued to deteriorate, and the decision was made to proceed with palliative care measures.
Topics: Female; Humans; Aged, 80 and over; Balkan Nephropathy; Carcinoma, Transitional Cell; Urinary Bladder Neoplasms; Kidney Failure, Chronic; Uremia
PubMed: 38494779
DOI: 10.1177/23247096241238529 -
Journal of Clinical Medicine Oct 2023Heart failure (HF) is associated with high mortality, morbidity, and frequent hospitalizations due to acute HF (AHF) and requires immediate diagnosis and individualized...
BACKGROUND
Heart failure (HF) is associated with high mortality, morbidity, and frequent hospitalizations due to acute HF (AHF) and requires immediate diagnosis and individualized therapy. Some differences between acutely decompensated chronic heart failure (ADCHF) and de novo HF (dnHF) patients in terms of clinical profile, comorbidities, and outcomes have been previously identified, but the hemodynamics related to both of these clinical states are still not well recognized.
PURPOSE
To compare patients hospitalized with ADCHF to those with dnHF, with a special emphasis on hemodynamic profiles at admission and changes due to hospital treatment.
METHODS
This study enrolled patients who were at least 18 years old, hospitalized due to AHF (both ADCHF and dnHF), and who underwent detailed assessments at admission and at discharge. The patients' hemodynamic profiles were assessed by impedance cardiography (ICG) and characterized in terms of heart rate (HR), blood pressure (BP), systemic vascular resistance index (SVRI), cardiac index (CI), stroke index (SI), and thoracic fluid content (TFC).
RESULTS
The study population consisted of 102 patients, most of whom were men (76.5%), with a mean left ventricle ejection fraction (LVEF) of 37.3 ± 14.1%. The dnHF patients were younger than the ADCHF group and more frequently presented with palpitations ( = 0.041) and peripheral hypoperfusion ( = 0.011). In terms of hemodynamics, dnHF was distinguished by higher HR ( = 0.029), diastolic BP ( = 0.029), SVRI ( = 0.013), and TFC (only numeric, = 0.194) but lower SI ( = 0.043). The effect of hospital treatment on TFC was more pronounced in dnHF than in ADCHF, and this was also true of N-terminal pro-brain natriuretic peptide (NT-proBNP) and body mass. Some intergroup differences in the hemodynamic profile observed at admission persisted until discharge: higher HR ( = 0.002) and SVRI (trend, = 0.087) but lower SI ( < 0.001) and CI ( = 0.023) in the dnHF group.
CONCLUSIONS
In comparison to ADCHF, dnHF is associated with greater tachycardia, vasoconstriction, depressed cardiac performance, and congestion. Despite more effective diuretic therapy, other unfavorable hemodynamic features may still be present in dnHF patients at discharge.
PubMed: 37959233
DOI: 10.3390/jcm12216768 -
Diagnostics (Basel, Switzerland) Dec 2023Data comparing lung ultrasound (LUS) and chest X-rays (CXRs) have increased over the past years. However, there still is a lack of knowledge as to how these modalities...
PURPOSE
Data comparing lung ultrasound (LUS) and chest X-rays (CXRs) have increased over the past years. However, there still is a lack of knowledge as to how these modalities compare with one another in the critical care setting, and several factors, including artificial study conditions, limit the generalizability of most published studies. Our study aimed to analyze the performance of LUS in comparison with CXRs in real-world critical care practice.
MATERIALS AND METHODS
This study presents new data from the prospective FASP-ICU trial. A total of 209 corresponding datasets of LUS and CXR results from 111 consecutive surgical ICU patients were subanalyzed, and categorial findings were compared. Statistical analysis was performed on the rates of agreement between the different imaging modalities.
RESULTS
A total of 1162 lung abnormalities were detected by LUS in ICU patients compared with 1228 detected by CXR, a non-significant difference ( = 0.276; 95% CI -0.886 to 0.254). However, the agreement rates varied between the observed abnormalities: the rate of agreement for the presence of interstitial syndrome ranged from 0 to 15%, consolidation from 0 to 56%, basal atelectasis from 33.9 to 49.34%, pleural effusion from 40.65 to 50%, and compression atelectasis from 14.29 to 19.3%. The rate of agreement was 0% for pneumothorax and 20.95% for hypervolemia.
CONCLUSIONS
LUS does not detect more lung abnormalities in real-world critical care practice than CXRs, although a higher sensitivity of LUS has been reported in previous studies. Overall, low agreement rates between LUS and CXRs suggest that these diagnostic techniques are not equivalent but instead are complementary and should be used alongside each other.
PubMed: 38201391
DOI: 10.3390/diagnostics14010082 -
Journal of Diabetes Investigation Dec 2023To evaluate the efficacy of sensor-augmented pump (SAP) for improving obstetric and neonatal outcomes among pregnant women with type 1 diabetes mellitus by comparing...
AIMS/INTRODUCTION
To evaluate the efficacy of sensor-augmented pump (SAP) for improving obstetric and neonatal outcomes among pregnant women with type 1 diabetes mellitus by comparing it with continuous subcutaneous insulin infusion plus self-monitoring of blood glucose (continuous subcutaneous insulin infusion [CSII]/SMBG).
MATERIALS AND METHODS
This retrospective cohort study included 40 cases of pregnancy complicated by type 1 diabetes mellitus treated with SAP (SAP group), and 29 cases of pregnancy complicated by type 1 diabetes mellitus treated with CSII/SMBG (CSII/SMBG group). The obstetric and neonatal outcomes were compared between the two groups.
RESULTS
The median of the glycoalbumin levels in the first (18.8% vs 20.9%; P < 0.05) and second (15.4% vs 18.0%; P < 0.05) trimesters, the hemoglobin A1c levels in the peripartum period (6.1% vs 6.5%; P < 0.05) and the standard deviation score of birthweights (0.36 vs 1.52; P < 0.05) were significantly lower in the SAP group than in the CSII/SMBG group. The incidence rate of large for gestational age newborns was significantly lower in the SAP group than in the CSII/SMBG group (27.5% vs 65.5%; P < 0.05). No significant differences in the incidence rates of hypertensive disorders of pregnancy, small for gestational age, respiratory distress syndrome, neonatal hypoglycemia, hypervolemia and hyperbilirubinemia were observed between the groups.
CONCLUSION
The present study showed that SAP therapy is more effective in preventing large for gestational age newborns in pregnant women with type 1 diabetes mellitus than CSII/SMBG.
Topics: Infant, Newborn; Humans; Female; Pregnancy; Diabetes Mellitus, Type 1; Hypoglycemic Agents; Pregnant Women; Retrospective Studies; Blood Glucose Self-Monitoring; Insulin; Blood Glucose; Hyperinsulinism
PubMed: 37706627
DOI: 10.1111/jdi.14075 -
International Journal of Molecular... Dec 2023Hypervolemia is associated with inflammation in hemodialysis (HD) patients. How hypervolemia triggers inflammation is not entirely known. We initiated a cross-sectional...
Hypervolemia is associated with inflammation in hemodialysis (HD) patients. How hypervolemia triggers inflammation is not entirely known. We initiated a cross-sectional study enrolling 40 hemodialysis patients who were categorized into normovolemic (N; 23) and hypervolemic (H; 17) groups by bioimpedance measurement. A caspase activity assay in combination with a specific caspase-4 inhibitor was used to detect caspase-4 activity in isolated peripheral blood mononuclear cells (PBMCs). Transcription factors RelA (pS529) and RelB (pS552) were analyzed by phospho-flow cytometry. Serum endotoxins were detected by an amebocyte lysate-based assay, and (interleukin-6) and (Tumor necrosis factor-α) gene expression were detected using the ELISA technique. Hypervolemic patients were older, more frequently had diabetes and showed increased CRP and IL-6 levels. Caspase-4 activity, which is linked to intracellular endotoxin detection, was significantly elevated in H patients. While the frequency of RelA-expressing immune cells and the expression density in these cells did not differ, the monocytic frequency of cells positively stained for RelB (pS552) was significantly decreased in H patients. Increased caspase-4 activity in H patients may indicate a cause of inflammation in H patients. The post-translational modification of RelB (pS552) is linked to downregulation of NF-kB activity and may indicate the resolution of inflammation, which is more distinct in N patients compared to H patients. Therefore, both higher inflammatory loads and lower inflammatory resolution capacities are characteristics of H patients.
Topics: Humans; Caspases; Cross-Sectional Studies; Endotoxins; Inflammation; Interleukin-6; Leukocytes, Mononuclear; Renal Dialysis; Transcription Factor RelB; Tumor Necrosis Factor-alpha
PubMed: 38139378
DOI: 10.3390/ijms242417550 -
Journal of Translational Internal... Dec 2023Haemodilution leads to complications in clinical practice. It is exactly unknown whether this damage is caused by the fluid or by the stretching of the vascular bed. We...
BACKGROUND AND OBJECTIVES
Haemodilution leads to complications in clinical practice. It is exactly unknown whether this damage is caused by the fluid or by the stretching of the vascular bed. We aimed to compare two different haemodilution techniques at the same anaemic level.
METHODS
Normovolemic or hypervolemic haemodilution was performed on twelve adult male Wistar rats. In the normovolemic procedure, blood was withdrawn and instantaneously administered with similar amounts of 6% hydroxyethyl starch (HES 130/0.4). Fluid was administered without withdrawing blood in the hypervolemic procedure. In both models, a 25% haematocrit level was targeted and kept at this level for 90 min to deepen the anaemia effect. Besides haemodynamics measurement, renal function (creatinine, blood urea nitrogen) and injury (tissue norepinephrine, malondialdehyde) were evaluated. Also, systemic hypoxia (lactate), oxidative stress (malondialdehyde, ischaemia-modified albumin), inflammation (tumour necrosis factor-alpha [TNF-α]), osmotic stress, adrenal stress (norepinephrine, epinephrine), and vascular stretching (atrial natriuretic peptide [ANP]) were assessed.
RESULTS
Arterial pressure in the normovolemic group was lower than in the hypervolemic group. Serum creatinine, blood urea nitrogen, and lactate levels were higher in the normovolemic group. Tissue norepinephrine and malondialdehyde levels were higher in the normovolemic group. Serum ANP, malondialdehyde, ischaemia-modified albumin, free haemoglobin, syndecan-1, and TNF-α were higher in both groups compared to respective baseline.
CONCLUSIONS
Normovolemic haemodilution may lead to hypoxic kidney injury. The hypervolemic state may be advantageous if fluid is to be administered. Thus, the effect of the fluid itself can be relatively masked.
PubMed: 38130643
DOI: 10.2478/jtim-2022-0045 -
International Journal of Clinical... 2024Volume overload is a fatal complication for people undergoing hemodialysis. Therefore, regulating a patient's "dry weight" based on their fluid status is imperative....
BACKGROUND
Volume overload is a fatal complication for people undergoing hemodialysis. Therefore, regulating a patient's "dry weight" based on their fluid status is imperative. Clinical experiences are too subjective to accurately judge a patient's fluid status, but techniques have emerged for improved fluid control in the two decades. Specifically, lung ultrasonography (LUS) uses a unique aspect of ultrasound images, the B-lines, to evaluate extravascular lung water, which has increasingly attracted attention. However, the role of B-line quantification in predicting short-mid-term death and/or cardiovascular complications is unclear.
METHODS
Patients undergoing MHD at the hemodialysis center of Zhejiang Provincial People's Hospital from October 1, 2020, to February 28, 2021, were examined using LUS and a bioelectrical impedance analysis before and after dialysis, and related clinical data were collected. All patients were followed up for one year after the examination, and deaths and first cardiovascular events (e.g., stroke, myocardial infarction, and heart failure) during this period were recorded.
RESULTS
98 patients were enrolled and divided into three groups in relation to their mild (<16 B-lines), moderate (16-30 B-lines), or severe (>30 B-lines) hypervolemia, defined by the number of B-lines. The long-term survival rate was significantly lower in the severe group than in the mild and moderate groups. LUS and bioelectrical impedance-related parameters (e.g., extracellular water-to-water ratio) were closely related to cardiac ultrasound parameters (left ventricular ejection fraction) ( < 0.001). The optimal B-line cutoff value on LUS for predicting fluid overload (defined clinically) in patients on hemodialysis was 11.5 lines (AUC = 0.840, 95% confidence interval 0.735-0.945, < 0.001), and the diagnostic sensitivity and specificity were both 76.5%. During the one-year follow-up period, ten deaths and six cardiovascular events occurred. The survival rate was significantly lower in the severe group than in the mild group (log-rank test = 10.050, =0.002) but did not differ between the severe and moderate groups ( = 2.629, =0.105).
CONCLUSION
LUS is a cheap, noninvasive, simple, and repeatable volume-monitoring method that can assist with individualized fluid volume management in patients undergoing MHD. LUS results may also help to predict the short-mid-term survival rate of patients to a certain extent.
Topics: Humans; Stroke Volume; Electric Impedance; Ventricular Function, Left; Lung; Ultrasonography; Renal Dialysis; Heart Failure
PubMed: 38229934
DOI: 10.1155/2024/1232211 -
Rhode Island Medical Journal (2013) Aug 2023There have been anecdotal observations of rhinorrhea as an isolated symptom indicating volume overload and impending congestive heart failure (CHF). We present a case of...
There have been anecdotal observations of rhinorrhea as an isolated symptom indicating volume overload and impending congestive heart failure (CHF). We present a case of apparent cardiogenic rhinorrhea presaging acute systolic CHF, with hemodynamics supported by thoracic impedance data (Medtronic OptiVol 2.0).
Topics: Humans; Heart Failure; Heart Diseases
PubMed: 37494619
DOI: No ID Found -
Global Cardiology Science & Practice Sep 2023Lung transplants (LTx) are being offered to increasingly older patients, and as a result, more concomitant coronary artery disease is being encountered in LTx...
BACKGROUND
Lung transplants (LTx) are being offered to increasingly older patients, and as a result, more concomitant coronary artery disease is being encountered in LTx candidates. While concurrent coronary artery bypass grafting (CABG) and LTx have become more common, the long-term considerations of reoperative CABG in patients following CABG with concomitant LTx are not fully understood.
CASE PRESENTATION
A 75-year-old man with a history of bilateral LTx and concomitant CABG X 2 15 years prior presented to the emergency room with tachycardia and chest discomfort radiating to the left upper extremity. Emergent coronary angiography revealed severe three-vessel coronary artery disease with two occluded saphenous vein grafts, severe distal obtuse marginal (OM) and left circumflex disease, a collateralized chronic total occlusion of the mid LAD, and tortuosity of the proximal right innominate artery. The patient underwent a complex redo sternotomy and CABG X 2 due to dense adhesions in the mediastinum and pleura bilaterally. The postoperative course was complicated by left leg SVG harvest site cellulitis treated with IV antibiotics and hypervolemia treated with diuresis. The patient was discharged postoperatively on day 13.
DISCUSSION
To our knowledge, this is the first reported successful reoperative CABG in a patient with a history of concomitant LTx and CABG. This case demonstrates feasibility, though additional caution is required due to the technical complexity and risk of immunosuppression in such complex patients.
PubMed: 38404627
DOI: 10.21542/gcsp.2023.25 -
Emergency Medicine International 2024Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when...
BACKGROUND
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.
METHODS
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 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.
RESULTS
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], = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, < 0.001), more vasopressor use (51% vs. 34%, = 0.006), and more positive pressure ventilation (38% vs. 24%, = 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, = 0.47), new oxygen requirement (68% vs. 59%, = 0.16), ED death (3% vs. 4%, = 0.15), or hospital death (31% vs. 27%, = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure.
CONCLUSIONS
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.
PubMed: 38742136
DOI: 10.1155/2024/5675066