Transient renal glycosuria in a patient with acute pyelonephritis.

Glycosuria was detected in a 37-year-old Chinese woman by a urinary examination in a local clinic with clinical evidence of acute pyelonephritis (APN). Transient glycosuria is an unusual complication of acute pyelonephritis in non-diabetic patients. As there is growing prevalence of type 2 diabetes in the population worldwide, it must be recognized that mistaken diagnosis of diabetes mellitus by glycosuria may predispose patients to an unfavorable hypoglycemic episode. Thus definite diagnosis of diabetes mellitus should be made only after recovery of APN by means of urinalysis or by simultaneous blood glucose concentration analysis.     

Risk Stratification in Acute Heart Failure

Acute heart failure is a leading reason for emergency department visits, hospital admissions, and readmissions. Despite the high rate of hospitalization for heart failure and the high resource burden attributable to acute heart failure, limitations of clinical decisions have been demonstrated. Risk stratification methods might provide guidance to clinicians who care for patients with acute heart failure syndromes, and might improve decision-making in emergent care when decisions must be made quickly and accurately. Although many acute heart failure risk models have been developed in hospitalized cohorts to predict in-hospital mortality, there are fewer methods to enable prognostication broadly among all patients in a community-based setting. As validated predictive risk algorithms become increasingly accessible, they may be applied to select optimal therapies, determine how patients will be cared for in the emergency department, and improve decisions pertaining to patient disposition and follow-up.     

Antibiotic dosing in critically ill patients with acute kidney injury

A common cause of acute kidney injury (AKI) is sepsis, which makes appropriate dosing of antibiotics in these patients essential. Drug dosing in critically ill patients with AKI, however, can be complicated. Critical illness and AKI can both substantially alter pharmacokinetic parameters as compared with healthy individuals or patients with end-stage renal disease. Furthermore, drug pharmacokinetic parameters are highly variable within the critically ill population. The volume of distribution of hydrophilic agents can increase as a result of fluid overload and decreased binding of the drug to serum proteins, and antibiotic loading doses must be adjusted upwards to account for these changes. Although renal elimination of drugs is decreased in patients with AKI, residual renal function in conjunction with renal replacement therapies (RRTs) result in enhanced drug clearance, and maintenance doses must reflect this situation. Antibiotic dosing decisions should be individualized to take into account patient-related, RRT-related, and drug-related factors. Efforts must also be made to optimize the attainment of antibiotic pharmacodynamic goals in this population.     

Diagnosis and treatment of ischemic stroke

Most patients who have a stroke are evaluated initially by a primary care physician. For patients to benefit from new stroke therapies that must be initiated within a few hours of stroke onset, primary care physicians must be prepared to diagnose stroke and initiate acute treatment. This article provides information on the rapid and accurate diagnosis and management of patients with acute ischemic stroke. This information is particularly relevant due to the relatively high risk:benefit ratio associated with some acute stroke therapies, such as tissue plasminogen activator. Information is also provided about medical and surgical therapies to prevent subsequent strokes.     

Acute renal failure in pregnancy

Acute renal failure is a most challenging clinical problem when it occurs in pregnancy. It requires an understanding of the normal physiology of the kidney in pregnancy and the natural history of different underlying renal diseases when pregnancy occurs. Because patients with chronic renal disease may present with worsening proteinuria, hypertension, and renal function, these disorders must be excluded from those conditions that cause acute deterioration of renal failure in otherwise normal women during pregnancy. As in all patients who develop acute renal failure, prerenal and obstructive causes must be excluded. Particularly important causes of prerenal azotemia in pregnancy include hyperemesis gravidarum and uterine hemorrhage, especially if it is unsuspected as in abruptio placentae. Infectious causes of acute renal failure in the pregnant woman include acute pyelonephritis and septic abortion. The clinical presentation of both these conditions should be apparent, and appropriate diagnosis and treatment can then be promptly instituted. Renal cortical necrosis is another cause of renal failure that occurs more frequently in pregnancy, and it must be differentiated from the many causes of acute tubular necrosis that may be associated with pregnancy. Those conditions that cause renal failure unique to pregnancy must always be considered when renal function deteriorates in the last trimester or the postpartum period. Severe preeclampsia, acute fatty liver of pregnancy, and idiopathic postpartum acute renal failure may all present similar complications, but the approach to each of these clinical disorders must be individualized. By understanding the causes of renal functional deterioration in pregnancy, a logical differential diagnosis can be established, allowing appropriate therapeutic decisions to preserve both maternal and fetal well-being.     

The clinical significance of bradycardic rhythms in acute myocardial infarction

The clinical significance of bradycardic rhythms as they pertain to patients developing acute myocardial infarctions is reviewed. Proper therapy of the arrhythmia frequently is predicated on an understanding of (1) the pathophysiologic mechanisms responsible for the production of the bradyarrhythmia, (2) the hemodynamic and electrophysiologic consequences of the slow ventricular rate, and (3) the exact electrocardiographic interpretation of the bradycardic rhythm. These three points are discussed in detail and illustrated by appropriate electrocardiographic examples. The factors responsible for the production of the bradycardic rhythm as well as the consequences of the slow heart rate may be unique in a patient with an acute myocardial infarction. The advent of artificial pacing has made it mandatory to be able to predict initially which bradyarrhythmia is likely to be progressive—in terms of further, more severe disturbance in impulse formation or conduction, or hemodynamic or electrophysiologic consequences—and may not respond to a medical approach. Artificial pacing must be instituted early in patients with these disturbances.     

Interventional treatment in evolving myocardial infarction

Residual myocardial function has been shown by many investigators to be a key factor in determining survival following acute myocardial infarction. In light of this, much effort has been undertaken to develop means of preserving myocardium in the setting of acute myocardial infarction. Acute revascularization has been approached as a logical method to reach this end. The development of more effective thrombolytic agents, better catheter dilatation systems, and improved surgical techniques have now made acute intervention possible, safe, and practical. Because of the marked clinical variability of patient presentation, as well as variability of available medical and surgical resources, a rational and logical system of approach must be developed, such that patients presenting with acute myocardial infarction can receive the most appropriate interventional therapy in any given setting.     

Melioidosis in systemic lupus erythematosus: the importance of early diagnosis and treatment in patients from endemic areas.

Serious infection is a common problem in immunosuppressed patients with systemic lupus erythematosus (SLE). Melioidosis is caused by the Gram-negative bacterium Burkholderia pseudomallei and may present as an acute fulminant pneumonia or septicaemia that is often fatal. The organism is endemic in much of South-east Asia but is being increasingly reported from other parts of the world, including India, Northern Australia and North and South America. In addition to occurring in people who come into contact with contaminated soil or water in endemic areas, the infection is more common in immunosuppressed patients and must be recognised early and treated with appropriate antibiotics. Importantly, it can activate many years after the initial exposure, causing diagnostic confusion. We present the cases of three patients with SLE who were admitted with fever and in whom Burkholderia pseudomallei was isolated from blood cultures. Following treatment with intravenous ceftazidime all patients made a good recovery. These cases demonstrate the importance of considering this infectious organism in patients from endemic areas with unexplained fever. They also illustrate how successful outcomes can be achieved in a frequently fatal disease if an early diagnosis is made and appropriate antibiotics are started promptly.     

The silent epidemic of thiazide-induced hyponatremia

Hyponatremia is a recognized complication of treatment with thiazide diuretics, particularly in patients older than 70 years. Severe and symptomatic hyponatremia requires urgent management, usually requiring infusion of normal or hypertonic saline. Milder, asymptomatic, thiazide-induced hyponatremia requires steps to manage the hyponatremia as well as to prevent its future recurrence. This is a particular problem in patients who despite a history of thiazide-induced hyponatremia might require a diuretic in the management of their hypertension. In this review, the acute management of symptomatic and asymptomatic thiazide-induced hyponatremia is reviewed. Emphasis is also placed on the chronic management of patients who have experienced mild hyponatremia, in whom decisions about treatment with diuretic and nondiuretic antihypertensive agents must be made to satisfy the twin goals of controlling hypertension and avoiding recurrent hyponatremia.     

Nichtinvasive Beatmung am Lebensende

The value of non-invasive ventilation (NIV) at the end of life is not sufficiently well known. This must be considered when NIV is used to palliate dyspnea. This explains the different statements made by scientific societies in different countries. However, as survey results have shown, NIV is used relatively often in clinical practice. NIV should be used if patients have made an advanced directive to forego endotracheal intubation but not mechanical ventilation. The indication is valid especially in situations with evidence-based effectiveness of NIV, such as acute exacerbation of chronic obstructive pulmonary disease or cardiogenic lung edema. The individual indications for NIV should be evaluated in a shared decision-making process after careful discussion of the determinants of success and failure, which are expressions of good medical care for the patient.     

Submucous lipoma of the ileocecal valve

Summary Lipoma of the ileocecal valve is a rare condition which must be distinguished from other neoplasms. It should be considered in the differential diagnosis of any acute or chronic abdominal pain of doubtful origin. In symptomatic cases when the diagnosis cannot be made with certainty, excision of the tumor is indicated.     

Paralytic ileus following myocardial infarction

Clinically severe adynamic ileus has been found to be a rare complication of acute myocardial infarction. Two such patients have been presented; each died suddenly after a prolonged hospital course. Complete autopsy study was made, and each was found to have died from a very recent myocardial infarction. In Case 1, clinical diagnosis was directed to mesenteric arterial occlusion with bowel infarction, and Case 2 clinically suggested intraor retroperitoneal hemorrhage. The post-mortem studies indicated that both patients had congestive failure secondary to arteriosclerotic heart disease and that the ileus was probably a manifestation of mesenteric vascular insufficiency. The prognosis of intestinal obstruction following myocardial infarction must rest upon the cause of the ileus and need not be ominous. In these cases, conservative management of the adynamic ileus was effective; however, they emphasize that the surgical implications of ileus must always be considered and directed to the pericardium as well as the abdomen.     

The treatment of acute non-lymphocytic leukemia

The treatment of acute nonlymphocytic leukemia involves a two stage approach. During the first stage, remission induction, cytotoxic drugs are administered to return hematopoiesis to normal. During the second stage, therapy is administered in an attempt to prolong the duration of remission. The clinical approaches and the problems incurred during these stages are not identical. At the time of diagnosis a decision must be made regarding whether or not the patient is likely to benefit from chemotherapy. If the answer is in the affirmative, then a decision must be made regarding the appropriate chemotherapeutic regimen. The optimal approach for the treatment of patients appears to vary depending on the age of the patient and whether or not there is a history of toxic exposure in the past. Overall remission rates vary from 40% to 85% depending upon the age of the patient and the patient's past history. Patients whose leukemia is induced into complete remission benefit from therapy administered after complete remission is attained. The optimal therapy, however, has not as yet been clearly defined. Conventional maintenance therapy appears to provide little benefit. On the other hand, the more intensive therapies are associated with substantial risk to the patient. The role of these modalities in the treatment of older patients is currently under investigation.     

Surgical presentation of abdominal tuberculosis: a protean disease

BACKGROUND/AIMS: The incidence of tuberculosis is rising again in the Western world, due to the emergence of new groups of patients at risk. This paper intends to describe the various patterns of surgical presentation of abdominal tuberculosis in an industrialized country. METHODOLOGY: A retrospective study was made of all patients admitted to our surgical institution, and in whom a diagnosis of abdominal tuberculosis was established. Eleven patients were identified. Ten of them were migrants from countries endemic for tuberculosis. RESULTS: Six patients presented with acute abdominal pain (3 in right lower quadrant) and had surgery in emergency. Two patients had elective surgery for diagnostic purposes. Two patients underwent other invasive diagnostic and/or therapeutic procedures. One patient was treated conservatively. Unusual presentations included 2 patients with periportal lymphadenitis and compressive features on the main bile duct and/or the portal vein, and 1 patient with acute duodenal tuberculous perforation. The main localization of disease was lymph nodes for 5 patients, intestinal for 4 and peritoneal for 2. CONCLUSIONS: Surgeons must be aware of the wide clinical spectrum of abdominal tuberculosis and have a high index of suspicion when confronted with patients from an endemic area and presenting with unclear abdominal symptoms.     

Akute Pankreatitis

Acute pancreatitis usually occurs as a result of alcohol abuse or bile duct obstruction. In most patients the clinical course is mild and without complication. But 15% develop necrotizing pancreatitis with subsequent, potentially life-threatening complications. Prompt diagnosis and identification of patients with a severe course is crucial. In severe pancreatitis, intensive care unit monitoring is mandatory and may minimize systemic sequelae. Early identification of risk factors for severe prognosis is a challenge. Scoring systems used in acute severe pancreatitis have some limitations. CRP and hematocrit are two tests which are simple to perform, but are very useful in distinguishing mild from severe acute pancreatitis. CT scans are very helpful in detecting necrosis and other local complications and to provide prognostic information. Treatment of acute pancreatitis is primarily non-surgical. Therapy of acute pancreatitis is supportive including pain control, intravenous fluids, and nutrition. The patients must be carefully monitored for organ dysfunction. Hypotension, hypoxemia, and renal failure must be treated adequately. Accumulating evidence suggests that enteral feeding is safe and reduces complications. Infection of necrosis is a leading cause of morbidity and mortality in acute necrotizing pancreatitis. The role of prophylactic systemic antibiotics in acute severe pancreatitis is still unsettled. Based on clinical practice it seems reasonable to give antibiotics to patients with proven necrosis. In case of biliary obstruction, it is beneficial to perform early ERCP. However, mortality does not seem to be influenced by urgent ERCP. Local complications should be first treated using minimally invasive approaches using CT, ultrasound, endoscopy and endoscopic ultrasound. If this fails, surgical debridement is the treatment of choice. Delayed surgical intervention is associated with better results.     

Cardiologic problems in the post acute ventilated patient

Chronically critically ill patients who develop acute respiratory failure commonly have complicating cardiac pathology that may or may not be evident at initial evaluation. The acute coronary syndromes should be excluded in all patients presenting with respiratory failure. Cardiac rhythm disturbances are common and should be actively investigated and treated in all critically ill patients. Heart failure is common in the chronically critically ill patient but usually responds to early diagnosis and prompt treatment. Finally, cardiogenic shock carries a poor prognosis in most patient subsets except when it is caused by cardiac tamponade. The intensivist must be vigilant for cardiac pathology complicating the recovery of patients with acute respiratory illness and initiate the search for correctable problems that may precipitate further episodes of respiratory insufficiency.     

Neurological and neuropsychiatric syndromes associated with liver disease

The clinical presentation of acute liver failure and hepatic encephalopathy (HE) in patients with cirrhosis differs significantly. The most serious neurological complication of acute liver failure is the development of devastating brain oedema. Therefore, intracranial pressure monitoring is urgently needed in these patients. Brain oedema is amplified by hypoglycemia, hypoxia and seizures, which are also frequent complications of acute liver failure. Therefore, these parameters must also be monitored. In contrast to acute liver failure in which cerebral dysfunction progresses rapidly, cognitive decline may be clinically undetectable for a long time in cirrhotic patients, until clinically overt symptoms such as psychomotor slowing, disorientation, confusion, extrapyramidal and cerebellar symptoms or a decrease in consciousness occur. Clinically, overt HE is preceded by minimal alterations of cerebral function that can only be detected by neuropsychological or neurophysiological measures, but which nevertheless interfere with the patient's daily living. Rapidly progressing spastic paraparesis (hepatic myelopathy) is a rare complication of cirrhosis. In contrast to HE, it does not respond to blood ammonia lowering therapies but must be considered as an indication for urgent liver transplantation. Cognitive dysfunction has recently been detected in hepatitis C virus (HCV)-infected patients with normal liver function. The patients presented with severe fatigue, cognitive dysfunction and mood disorders. Alterations in brain metabolites, as detected by magnetic resonance spectroscopy, indicated central nervous system alteration in these patients. In contrast to patients with HE, HCV-infected patients did not show motor symptoms or deficits in visual perception, but considerable deficits in attention and concentration ability.     

Therapiemanagement bei Malaria

Plasmodium falciparum and to some extent malaria caused by other species of Plasmodia can quickly lead to cerebral malaria, acute renal failure, or acute respiratory distress syndrome. The mortality rate for patients with severe malaria lies around 10%. Malaria must be given priority in the differential diagnosis of travelers returning febrile from endemic areas. Treatment requires prompt administration of safe and fast-acting antimalarials, which in severe malaria is treatment with quinine or artesunate. Hospitals must be prepared to diagnose and treat malaria patients-or have a standard operating procedure for transferring the patient to a specialized center.     

Endoscopic band ligation in the treatment of portal hypertension

The evidence that endoscopic band ligation (EBL) has greater efficacy and fewer side effects than endoscopic injection sclerotherapy has renewed interest in endoscopic treatments for portal hypertension. The introduction of multishot band devices, which allow the placement of 5-10 bands at a time, has made the technique much easier to perform, avoiding the use of overtubes and their related complications. EBL sessions are usually repeated at 2 week intervals until varices are obliterated, which is achieved in about 90% of patients after 2-4 sessions. Variceal recurrence is frequent, with 20-75% of patients requiring repeated EBL sessions. According to current evidence, nonselective beta-blockers are the preferred treatment option for prevention of a first variceal bleed, whereas EBL should be reserved for patients with contraindications or intolerance to beta-blockers. Nonselective beta-blockers, probably in association with the vasodilator isosorbide mononitrate, and EBL are good treatment options to prevent recurrent variceal rebleeding. The efficacy of EBL might be increased by combining it with beta-blocker therapy. Patients who are intolerant, have contraindications or bled while receiving primary prophylaxis with beta-blockers must be treated with EBL. In the latter situation, EBL should be added to rather than replace beta-blocker therapy. EBL, in combination with vasoactive drugs, is the recommended form of therapy for acute esophageal variceal bleeding; however, endoscopic injection sclerotherapy can be used in the acute setting if EBL is technically difficult.