Managing hyponatraemia secondary to primary polydipsia: beware too rapid correction of hyponatraemia

We describe three cases of severe hyponatraemia in the setting of primary polydipsia that were managed in our centre in 2016. Despite receiving different solute loads, large volume diuresis and rapid correction of serum sodium occurred in all cases. Given the potentially catastrophic consequence of osmotic demyelination, we highlight the judicious use of desmopressin and hypotonic fluid infusion to mitigate sodium overcorrection in this setting.     

Exercise performance-based outcomes of medically treated patients with coronary artery disease and profound ST segment depression

OBJECTIVES

We sought to determine the relationship between exercise duration and cardiovascular outcomes in patients with profound (≥2 mm) ST segment depression during exercise treadmill testing (ETT).

BACKGROUND

Patients with stable symptoms but profound ST segment depression during ETT are often referred for a coronary intervention on the basis that presumed severe coronary artery disease (CAD) will lead to unfavorable cardiovascular outcomes, irrespective of symptomatic and functional status. We hypothesized that good exercise tolerance in such patients treated medically is associated with favorable long-term outcomes.

METHODS

We prospectively followed 203 consecutive patients (181 men; mean age 73 years) with known stable CAD and ≥2 mm ST segment depression who are performing ETT according to the Bruce protocol for an average of 41 months. The primary end point was occurrence of myocardial infarction (MI) or death.

RESULTS

Eight (20%) of 40 patients with an initial ETT exercise duration ≤6 min developed MI or died, as compared with five (6%) of 84 patients who exercised between 6 and 9 min and three (3.8%) of 79 patients who exercised ≥9 min (p = 0.01). Compared with patients who exercised ≤6 min, increased ETT duration was significantly associated with a reduced risk of MI/death (6 to 9 min: relative risk [RR] = 0.25, 95% confidence interval [CI] 0.08 to 0.76; >9 min: RR = 0.14, 95% CI 0.04 to 0.53). This protective effect persisted after adjustment for potentially confounding variables. We observed a 23% reduction in MI/death for each additional minute of exercise the patient was able to complete during the index ETT.

CONCLUSIONS

Optimal medical management in stable patients with CAD with profound exercise-induced ST segment depression but good ETT duration is an appropriate alternative to coronary revascularization and is associated with low rates of MI and death.     

老年患者直接冠状动脉介入术后心肌组织灌注的特点及预后分析

目的观察老年急性心肌梗死(AMI)患者接受PCI后的心肌组织水平的灌注特点及预后情况。方法选择因AMI行PCI的患者388例,根据患者年龄分为老年组(≥60岁)187例及中青年组(<60岁)201例。通过观察TIMI心肌灌注(TMP)分级、心肌blush分级(MBG)及术后ST段回落比例,评价2组患者的术后心肌组织灌注及预后。结果中青年组较老年组病变血管数明显降低,梗死相关血管开通时间明显缩短,术后MBG 3级、术后TMP 3级及ST段回落比例及LVEF均明显升高(P<0.05)。结论老年AMI患者冠状动脉病变程度重,PCI术后虽病死率低于中青年,但组织水平灌注和心功能较差,应给予足够的重视。     

Short and long-term outcomes in patients with acute liver failure due to ischemic hepatitis

Aims  

The purpose of this study is to describe the incidence and presenting features of patients with acute liver failure (ALF) due to ischemic hepatitis and the prognostic factors associated with short (three-week) and long-term outcomes.     

Characteristics and outcomes of patients with coronary artery ectasia presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BackgroundThe clinical significance of coronary artery ectasia (CAE) is not yet fully understood. We aimed to examine differences in clinical and procedural characteristics, clinical management, and outcomes in patients with CAE undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI).MethodsThis was a retrospective analysis of consecutive patients presenting with STEMI with a culprit native coronary artery from July 2015 to June 2019. Patients were divided into CAE and Non-CAE groups as detected on coronary angiography during PPCI. Comparison between groups was made for baseline clinical and procedural characteristics, as well as complications, pharmacological treatment, and follow-up outcomes.Results36/1780 (2.0%) patients were found to have CAE. Patients with CAE had a median age of 57.1 ± 11.7 years and were more likely to be male 33/36 (91.7%). Diabetes was less commonly seen in the CAE group (11.1% vs 31.4%, p = 0.010), and there were no differences in the proportion of patients with hypertension and hyperlipidemia. Patients with CAE had more involvement of right coronary artery (RCA) culprit vessel (63.9% vs. 38.4%, p = 0.026), less coronary stenting (25.0% vs 87.2%, p < 0.001) and post-PPCI TIMI 3 flow (69.4% vs 95.5%, P < 0.001), and were more likely to be discharged with oral anticoagulants (36.1% vs 7.6%, p < 0.001). At 3-year follow-up, all-cause mortality rates were higher in the non-CAE group (0.0% vs 11.5%, p < 0.028), suggesting that CAE was not associated with unfavorable long-term outcome. On multivariate analysis, CAE was not an independent predictor of MACE.ConclusionDespite lower rates of post-PPCI TIMI 3 flow, CAE was not associated with unfavorable long-term outcome.     

Presence of circulating macromolecular IgA in patients with hematuria due to primary IgA nephropathy

The relation between renal histologic features and the presence of circulating immune complexes was studied in 50 patients with hematuria. Primary IgA nephropathy was found in 25 patients, and various other forms of glomerulopathy were seen in the remaining 25 patients. Circulating immune complexes were detected with the 125I-C1q-binding assay, the conglutinin-binding assay, and the anti-IgA inhibition binding assay, the latter detecting specifically IgA-containing immune complex-like material. The 125I-C1q-binding assay gave negative findings for all patients except one. With the conglutinin-binding assay, immune complexes were found in a similar frequency for patients with and without IgA nephropathy. However, the anti-IgA inhibition binding assay gave positive results only in patients with primary IgA nephropathy (68 percent) and in none of the other patients. Sucrose density ultracentrifugation, as well as experiments in which the anti-IgA inhibition binding assay was performed with and without pretreatment of serum with polyethylene glycol, showed the presumed IgA immune complexes to have intermediate sedimentation coefficients (11 to 21S). The presence and level of this macromolecular IgA in the circulation correlated significantly (p less than 0.001) with the presence of hematuria in patients who had this clinical manifestation intermittently. Furthermore, a significant correlation (r = 0.69, p less than 0.0001) was found between the degree of hematuria and the degree of positive findings of the anti-IgA inhibition binding assay. This study shows that in patients presenting with hematuria, a positive finding on the anti-IgA inhibition binding assay is restricted to patients with primary IgA nephropathy and therefore could be of diagnostic value.     

Characteristics and outcomes of patients with a history of cancer recruited to heart failure trials

Aims

Heart failure (HF) therapy trials usually exclude cancer patients. We examined the association between cancer history and outcomes in trial participants with HF and reduced (HFrEF) or preserved ejection fraction (HFpEF).

Methods and results

We combined PARADIGM-HF and ATMOSPHERE, which enrolled HFrEF patients (n = 15 415) and we pooled HFpEF patients (ejection fraction ≥45%) enrolled in PARAGON-HF and CHARM-Preserved (n = 7363). The associations between cancer history, cardiovascular (CV) death, HF hospitalization, non-CV and all-cause death in these trials were examined. Incident cancer diagnoses during these trials were also measured. There were 658 (4.3%) and 624 (8.5%) patients with a cancer history in the HFrEF and HFpEF trials, respectively. HFrEF patients with a cancer history had a higher risk of HF hospitalization (adjusted hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.07–1.52, p = 0.007) and non-CV death (adjusted HR 1.57; 95% CI 1.16–2.12, p = 0.003) than those without. The risks of other outcomes were similar. There were no differences in the risk of any outcome in HFpEF patients with and without a cancer history. Adjusting for age and sex, the incidence of new cancer in the HFrEF and HFpEF trials was 1.09 (95% CI 0.83–1.36) and 1.07 (95% CI 0.81–1.32) per 100 person-years, respectively.

Conclusions

Although participants in HFrEF trials with a cancer history had higher risks of HF hospitalization and non-CV death than those without, the risks of CV and all-cause death were similar. Outcomes in HFpEF patients with and without a cancer history were similar. Incident cancer diagnoses were similar in HFrEF and HFpEF trials.     

60例药物性肝损伤患者临床特征和转归分析

目的 分析总结药物性肝损伤(DILI)患者临床特征和转归情况。方法 2018年8月～2021年12月我院诊治的DILI患者60例,收集临床资料,包括应用药物、发病时间、临床病情和治疗时间,进行临床分型和病情分级。将临床症状体征完全消失或明显好转,肝功能指标恢复正常定义未痊愈,否则为未愈。结果 本组60例DILI患者主要应用药物包括化学药物16例(26.7%),中草药13例(21.7%),抗生素类药物8例(13.3%),抗甲状腺机能亢进症药物7例(11.7%),降血脂类药物5例(8.3%),应用抗结核药4例(6.7%),抗精神类药物3例(5.0%),降血压药2例(3.3%)和保健品2例(3.3%);用药至发病2～118 d,其中≤1周发病19例(31.7%), 1周～3月发病24例(40.0%),>3月发病17例(28.3%);临床表现包括纳差13例(21.7%)、恶心呕吐13例(21.7%)、乏力12例(20.0%)、皮肤巩膜黄染13例(21.7%)、腹痛腹泻8例(13.3%)、皮肤瘙痒2例(11.7%),无明显症状25例(41.7%);本组DILI患者严重程度分级分别为1级42...     

Access to primary dental care for patients with inherited bleeding disorders

Patients with inherited bleeding disorders (IBD) can face difficulty in accessing primary dental care either due to disease-specific or patient-related barriers. This can lead to poor oral health and increase the need for more invasive dental treatment. This study aimed to highlight actual and perceived barriers that IBD patients from the East London area were experiencing. It also gives an overview of the experience history of the General Dental Practitioners (GDPs) treating these patients. Information was gathered via pre-designed surveys as part of a service development audit. A total of 105 anonymous patient surveys and 50 GDP surveys were completed between December 2010 and July 2011. The patient survey highlighted more patients to be affected by patient-related than disease-specific barriers to access dental care. The GDP survey identified that just under half of GDPs questioned were not confident in the dental management of patients with bleeding disorders. Identifying misconceptions and barriers to access primary dental care will enable further development of our shared-care approach between General Dental Services, Hospital or Community Dental Services and Haemophilia Centre, optimizing regular preventative advice and follow ups to prevent dental disease and invasive dental treatment requiring haemostatic treatment.     

Clinicopathological features and outcomes of primary IgA nephropathy patients with chronic tonsillitis

正Objective To explore the clinicopathological features and renal outcomes of primary IgA nephropathy(IgAN)patients with chronic tonsillitis.Methods Patients with biopsy-proven primary IgAN admitted to The First Affiliated Hospital,Sun Yat-sen University from January 2006 to December 2011 were enrolled.The clinicopathological features and renal outcomes of     

Characteristics and outcomes of patients with sarcoidosis listed for lung transplantation

STUDY OBJECTIVES: To characterize the course of patients with advanced sarcoidosis who have been listed for lung transplantation and to identify prognostic factors for death while they are on the waiting list. DESIGN: Retrospective cohort study. SETTING: Tertiary-care university hospital. PATIENTS: Forty-three patients with sarcoidosis who have been listed for lung transplantation at the University of Pennsylvania Medical Center. METHODS: A multivariable explanatory analysis using a Cox proportional hazards model was performed to determine risk factors that are independently associated with mortality while patients await transplantation. RESULTS: Twenty-three of the 43 patients (53%) died while awaiting transplantation. The survival rate of listed patients (as determined by the Kaplan-Meier method) was 66% at 1 year, 40% at 2 years, and 31% at 3 years. In a univariate analysis, the following factors were significantly associated with death on the waiting list: PaO(2) < or = 60 mm Hg (relative risk [RR], 3.4; 95% confidence interval [CI], 1.2 to 9.3); mean pulmonary artery pressure > or = 35 mm Hg (RR, 3.2; 95% CI, 1.1 to 9.5); cardiac index < or = 2 L/min/m(2) (RR, 2.8; 95% CI, 1.2 to 6.6), and right atrial pressure (RAP) > or = 15 mm Hg (RR, 7.6; 95% CI, 3.0 to 19.3). Multivariable analysis revealed that RAP > or = 15 mm Hg was the only independent prognostic variable (RR, 5.2; 95% CI, 1.6 to 16.7; p = 0.006). Twelve patients underwent lung transplantation. Survival after transplantation determined by the Kaplan-Meier method was 62% at both 1 and 2 years, and 50% at 3 years. CONCLUSIONS: Patients with advanced sarcoidosis awaiting lung transplantation have a high mortality rate with a median survival of < 2 years. Mortality is most closely linked to elevated RAP. While earlier referral may diminish the mortality rate of patients on the waiting list for transplantation, further improvements in posttransplantation outcomes will be necessary to ensure that this procedure truly bestows a survival benefit.