Leptospirosis in an urban setting: case report and review of an emerging infectious disease

Leptospiosis is a common zoonosis affecting most mammals. Leptospirosis has protean manifestations ranging from a flu-like illness to fulminant hepatic and renal failure culminating in death. Although the diagnosis is often not considered upon presentation, the literature suggests that leptospirosis is a reemerging infectious disease in urban centers throughout the industrialized world. It will be incumbent upon Emergency Physicians to include this spirochetal disease in the differential diagnosis of febrile patients with appropriate risk factors and symptomatology. We present the case of a 36 year-old woman who presented to the Emergency Department with fever and hypotension. We review the literature on leptospirosis with specific focus on risk factors and pathogenesis, clinical manifestations, diagnosis, treatment, and outcome.     

短期激素降阶梯应用对慢性阻塞性肺疾病急性加重期治疗的影响

目的 观察短期糖皮质激素降阶梯全身应用对急性加重期慢性阻塞性肺疾病(AECOPD)患者治疗的影响,探讨其对AECOPD的疗效及不良反应,进一步规范AECOPD全身糖皮质激素治疗.方法 将96例AECOPDⅡ级的患者随机分为4组:A组24例给予常规的静脉滴注抗生素、氨茶碱(0.25 g/d)、盐酸氨溴索、雾化吸入沙丁胺醇(每日4次)及口服法莫替丁(20 mg/次,每日2次),出院带药为茶碱控释片(0.1 g/次,每日2次,1个月);B组24例,在A组的基础上加用地塞米松(第1～3天,每天10 mg;第4～6天,每天5 mg,共用6天);C组24例,在A组的基础上加用甲泼尼龙(第1～3天,每天80 mg;第4～6天,每天40 mg,共用6天),D组24例,在A组的基础上加用地塞米松(第1～10天,每天5 mg,共用10天),所有患者疗程均为15天;所有患者在治疗前和治疗15天及出院后1个月时均进行以下检查:肺功能、血气分析、痰量观察、呼吸困难评分、空腹血糖(FPG)、空腹胰岛素、餐后2小时血糖(2 hPG)、餐后2小时胰岛素(2 h instllin)、促肾上腺皮质激素(ACTH)及血浆皮质醇(Cor).结果 B组、C组及D组在治疗15天时第1秒用力呼气流量(FEV1)(0.27±0.10)L、(0.26±0.10)L、(0.23±0.10)L,血气分析、痰量及呼吸困难评分比较均比A组改善(P＜0.05),出院1个月时虽A组、B组、C组及D组在FEV1及血气分析方面比较差异无统计学意义(P＞0.05),但B组、C组及D组在痰量及呼吸困难评分比较均比A组改善(P＜0.05);治疗15天时,FPG D组比A组升高(6.5±2.07)mmol/L vs(4.8±1.8)mmol/L(P＜0.05),A组、B组与C组3组间比较差异无统计学意义(P＞0.05),治疗15天时,2 h PG D组(10.9±2.3)mmol/L比A组、B组及C组升高(8.7±2.2)mmol/Lvs(9.1±2.1)mmol/L、(9.5±2.2)mmol/L(P＜0.05),A组、B组及C组3组间比较差异无统计学意义(P＞0.05).空腹胰岛素及2 h insulin在治疗15天及出院1个月时A组、B组、C组及D组4组问比较差异均无统计学意义(P＞0.05).在治疗15天时,ACTH D组比A组、B组及C组降低(P＜0.01),而出院1个月时A组、B组、C组及D组4组间ACTH比较差异均无统计学意义(P＞0.05).结论 短期全身糖皮质激素可在短期内改善AECOPD患者的FEV1、血气分析、痰量及呼吸困难评分,AECOPD患者空腹血糖升高、糖耐量降低及ACTH降低与全身糖皮质激素治疗时间有关,短期全身搪皮质激素降阶梯治疗AECOPD患者对空腹血糖、糖耐量及ACTH影响不明显.     

Continuous renal replacement therapy outcomes in acute kidney injury and end-stage renal disease: a cohort study

Introduction

Continuous renal replacement therapy (CRRT) is a widely used but resource-intensive treatment. Despite its broad adoption in intensive care units (ICUs), it remains challenging to identify patients who would be most likely to achieve positive outcomes with this therapy and to provide realistic prognostic information to patients and families.

Methods

We analyzed a prospective cohort of all 863 ICU patients initiated on CRRT at an academic medical center from 2008 to 2011 with either new-onset acute kidney injury (AKI) or pre-admission end-stage renal disease (ESRD). We examined in-hospital and post-discharge mortality (for all patients), as well as renal recovery (for AKI patients). We identified prognostic factors for both in-hospital and post-discharge mortality separately in patients with AKI or ESRD.

Results

In-hospital mortality was 61% for AKI and 54% for ESRD. In patients with AKI (n = 725), independent risk factors for mortality included age over 60 (OR 1.9, 95% CI 1.3, 2.7), serum lactate over 4 mmol/L (OR 2.2, 95% CI 1.5, 3.1), serum creatinine over 3 mg/dL at time of CRRT initiation (OR 0.63, 95% CI 0.43, 0.92) and comorbid liver disease (OR 1.75, 95% CI 1.1, 2.9). Among patients with ESRD (n = 138), liver disease was associated with increased mortality (OR 3.4, 95% CI 1.1, 11.1) as was admission to a medical (vs surgical) ICU (OR 2.2, 95% CI 1.1, 4.7). Following discharge, advanced age became a predictor of mortality in both groups (AKI: HR 1.9, 95% CI 1.2, 3.0; ESRD: HR 4.1, 95% CI 1.5, 10.9). At the end of the study period, only 25% (n = 183) of patients with AKI achieved dialysis-free survival.

Conclusions

Among patients initiating CRRT, risk factors for mortality differ between patients with underlying ESRD or newly acquired AKI. Long-term dialysis-free survival in AKI is low. Providers should consider these factors when assessing prognosis or appropriateness of CRRT.     

Madelung’s disease with alcoholic liver disease and acute kidney injury: A case report

BACKGROUNDMadelung’s disease (MD) is a rare disorder of lipid metabolism, characterized by the growth of unencapsulated masses of adipose tissue symmetrically deposited around the neck, shoulders, or other sites around the body. Its pathological mechanism is not yet known. One of the most common comorbidities in MD patients is liver disease, especially chronic alcoholic liver disease (CALD); however, no reports exist of acute kidney injury (AKI) with MD.CASE SUMMARYWe report a 60-year-old man who presented with complaint of edema in the lower limbs that had persisted for 3 d. Physical examination showed subcutaneous masses around the neck, and history-taking revealed the masses to have been present for 2 years and long-term heavy drinking. Considering the clinical symptoms, along with various laboratory test results and imaging characteristics, a diagnosis was made of MD with acute exacerbation of CALD and AKI. The patient was treated with liver function protection and traditional Chinese medicine, without surgical intervention. He was advised to quit drinking. After 10 d, the edema had subsided, renal function indicators returned to normal, liver function significantly improved, and size of subcutaneous masses remained stable.CONCLUSIONIn MD, concomitant liver or kidney complications are possible and monitoring of liver and kidney functions can be beneficial.     

急性肾损伤后慢性肾脏病发病机制及其诊治进展

急性肾损伤后常出现肾小管间质纤维化等慢性肾脏病表现,甚至进展至终末期肾病,发病机制包括小管上皮细胞适应不良性修复、免疫炎症过度反应、毛细血管稀疏、氧化应激等。随着人们对急性肾损伤后慢性化转归机制的深入认识,近年来相关的干预新靶点和新策略相继问世,展示了人类攻克急性肾损伤预后不良的良好前景。     

Peritoneal dialysis in childhood acute kidney injury: experience in southwest Nigeria

♦ Background: The choices for renal replacement therapy (RRT) in childhood acute kidney injury (AKI) are limited in low-resource settings. Peritoneal dialysis (PD) appears to be the most practical modality for RRT in young children with AKI in such settings. Data from sub-Saharan Africa on the use of PD in childhood AKI are few.♦ Methods: We performed a retrospective study of children who underwent PD for AKI at a tertiary-care hospital in southwest Nigeria from February 2004 to March 2011 (85 months).♦ Results: The study included 27 children (55.6% female). Mean age was 3.1 ± 2.6 years, with the youngest being 7 days, and the oldest, 9 years. The causes of AKI were intravascular hemolysis (n = 11), septicemia (n = 8), acute glomerulonephritis (n = 3), gastroenteritis (n = 3), and hemolytic uremic syndrome (n = 2). Peritoneal dialysis was performed manually using percutaneous or adapted catheters. Duration of PD ranged from 6 hours to 12 days (mean: 5.0 ± 3.3 days). The main complications were peritonitis (n = 10), pericatheter leakage (n = 9), and catheter outflow obstruction (n = 5). Of the 27 patients, 19 (70%) survived till discharge.♦ Conclusions: In low-resource settings, PD can be successfully performed for the management of childhood AKI. In our hospital, the use of adapted catheters may have contributed to the high complication rates. Peritoneal dialysis should be promoted for the management of childhood AKI in low-resource settings, and access to percutaneous or Tenckhoff catheters, dialysis fluid, and automated PD should be increased.     

Urine output is associated with prognosis in patients with acute kidney injury requiring continuous renal replacement therapy

Purpose

Although some studies have found that early initiation of continuous renal replacement therapy (CRRT) is associated with better prognosis, no consensus exists on the best timing to start CRRT. We investigated whether the timing of CRRT initiation was relevant to overall mortality and explored which factors at the time of CRRT initiation were associated with better outcomes in critically ill patients with acute kidney injury (AKI).

Materials and Methods

A total of 361 patients who received CRRT for AKI between 2009 and 2011 were collected and divided into 2 groups based on the median blood urea nitrogen (BUN) levels or 6-hour urine output immediately before CRRT was started. The impact of the timing of CRRT initiation stratified by BUN concentration or urine output on 28-day all-cause mortality was compared between groups.

Results

When the timing of CRRT initiation was stratified by 6-hour urine output, 28-day all-cause mortality rates were significantly lower in the nonoliguric group compared with the oliguric group (P = .02). In contrast, clinical outcomes were not different between the low-BUN and the high-BUN groups (P = .30). Cox regression analysis revealed that 28-day all-cause mortality risk was significantly lower in the nonoliguric group stratified by 6-hour urine output, even after adjusting for age, sex, mean arterial pressure, Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and serum biomarkers (hazard ratio, 0.85; 95% confidence interval, 0.65-0.99; P = .04).

Conclusions

Urine output but not BUN concentration was significantly associated with a better prognosis in critically ill patients with AKI requiring CRRT.     

Increased distance or time from a major trauma centre in South Australia is not associated with worse outcomes after moderate to severe traumatic brain injury

Objective

Considerations in traumatic brain injury (TBI) management include time to critical interventions and neurosurgical care, which can be influenced by the geographical location of injury. In Australia, these distances can be vast with varying degrees of first-responder experience. The present study aimed to evaluate the association that distance and/or time to a major trauma centre (MTC) had on patient outcomes with moderate to severe TBI.

Methods

A retrospective cohort study was conducted using data from the Royal Adelaide Hospital's (RAH) Trauma Registry over a 3-year period (1 January 2018 to 31 December 2020). All patients with a moderate to severe TBI (Glasgow Coma Scale [GCS] ≤13 and abbreviated injury score head of ≥2) were included. The association of distance and time to the RAH and patient outcomes were compared by calculating the odds ratio utilising a logistic regression model.

Results

A total of 378 patients were identified; of these, 226 met inclusion criteria and comprised our study cohort. Most patients were male (79%), injured in a major city (55%), with median age of 38 years old and median injury severity score (ISS) of 25. After controlling for age, ISS, ED GCS on arrival and pre-MTC intubation, increasing distance or time from injury site to the RAH was not shown to be associated with mortality or discharge destination in any of the models investigated.

Conclusion

Our analysis revealed that increasing distance or time from injury site to a MTC for patients with moderate to severe TBI was not significantly associated with adverse patient outcomes.     

Changes in transfusion practice in multiple injury between 1993 and 2006: a retrospective analysis on 5389 patients from the German Trauma Registry

To evaluate transfusion practices in multiple injured patients and to demonstrate changes in the pattern of packed red blood cell (pRBC) transfusions over the last one-and-half decade (1993–2006). A retrospective analysis using the German Trauma Registry database (DGU-Traumaregister) including 29 353 multiple injured patients was conducted. The study population included primary admissions presenting to the emergency room (ER) with clinical and laboratory signs of active haemorrhage [haemoglobin < 9 g × dL⁻¹, platelets < 90000 ×μL⁻¹ and prothrombin time (Quick-value) < 60%]. The pattern of pRBC transfusions was followed from ER to intensive care unit (ICU) admission. A total of 5389 patients with complete data sets were divided into the following three groups according to the year of treatment and analysed: (a) group 1: 1993–1998 ( n = 870), (b) group 2: 1999–2002 ( n = 2044) and (c) group 3: 2003–2006 ( n = 2475). Patients had a mean age of 40.5 (±20) years and were predominantly male (67.2%). All patients were substantially injured (mean injury severity score = 32 ± 15.5) and in 93% the mechanism of injury was blunt. The percentage of patients who received pRBC transfusions between ER and ICU dropped from 72% in 1993–1998 to 54% in 2003–2006 ( P < 0.005). Similarly, the percentage of patients receiving mass transfusions (> 10 pRBC units) dropped from 51.3 to 17.1%. This decline was accompanied by lower incidence rates for septic complications, ventilator days, ICU length-of-stay and mortality. pRBC transfusion practices in acute trauma care have changed substantially over the last one-and-half decade and were associated with better outcome.     

Proenkephalin for the early detection of acute kidney injury in hospitalized patients with chronic kidney disease

Background

The early detection of acute kidney injury (AKI) in patients with chronic kidney disease (CKD) is an unmet clinical need. Proenkephalin (PENK) might improve the early detection of AKI.

Methods

One hundred and eleven hospitalized CKD patients undergoing radiographic contrast procedures were enrolled. PENK was measured in a blinded fashion at baseline (before contrast media administration) and on day 1 (after contrast media administration). The potential of PENK levels to predict contrast‐induced AKI was the primary endpoint.

Results

Baseline creatinine and baseline PENK were similar in AKI and no‐AKI patients. In AKI patients, day 1 PENK (198 pmol/L vs 121 pmol/L, P < 0.01) was significantly higher compared to no‐AKI patients. The area under the curve (AUC) for the prediction of AKI by day 1 PENK was 0.79, 95% CI: 0.70‐0.87, similar to serum creatinine: 0.78, 95% CI: 0.61‐0.95. Delta PENK was significantly higher in AKI compared to no‐AKI patients (53 pmol/L vs 1 pmol/L, P < 0.01). The AUC for the prediction of AKI by delta PENK was high (0.92, 95%CI 0.82‐1.00) and remained high for creatinine‐blind AKI (0.94, 95% CI: 0.87‐0.97).

Conclusion

Delta PENK levels improve the early detection of contrast‐induced AKI in CKD patients over serial creatinine sampling. Delta PENK accelerates the detection of creatinine‐blind AKI by 24 hours.     

中医骨科综合治疗骨伤后期肢体肿胀的效果

目的探讨中医骨科综合治疗骨伤后期肢体肿胀的效果。方法将我院2018年6月至2019年1月收治的90例骨伤后期肢体肿胀患者作为研究对象,按治疗方式将其分为观察组和对照组,各45例。观察组接受中医骨科综合治疗,对照组接受常规治疗。比较两组治疗效果。结果观察组肢体肿胀消散、住院时间均明显短于对照组(P<0.05)。观察组治疗总有效率高于对照组,差异具有统计学意义(P<0.05)。治疗后,观察组中医证候积分低于对照组,差异具有统计学意义(P<0.05)。观察组不良反应总发生率低于对照组,差异具有统计学意义(P<0.05)。结论对骨伤后期肢体肿胀患者应用中医骨科综合治疗,能够有效改善肢体肿胀症状,提高治疗效果,值得推广。     

Castleman's disease of the kidney: Sonographic findings

We report a case of rare Castleman's disease of the kidney that mimicked a renal neoplasm with emphasis on the imaging and histologic findings. A 47‐year‐old man presented with dyspeptic symptoms. Ultrasound revealed a vascular, heterogeneous mass in the left kidney. Multiphasic CT scan confirmed an enhancing lesion with enlarged left para‐aortic lymph nodes suspicious for nodal metastases. The provisional diagnosis was renal cell carcinoma. Percutaneous biopsy yielded a diagnosis of Castleman's disease of the hyaline‐vascular type. Despite advancement in imaging modalities, differentiation of hyaline‐vascular variant of Castleman's disease from hypervascular renal neoplasm remains difficult and the final diagnosis requires histopathological confirmation. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43 :438–442, 2015     

Athlete’s heart syndrome: A diagnostic dilemma in the emergency department

Athletic training can cause morphological cardiac changes as part of physiological adaptation. When these changes result in abnormalities of physical examination, the electrocardiogram, chest radiography or echocardiographic findings the individual is said to have athlete’s heart syndrome. Many of these changes mimic significant cardiovascular disease, including myocardial ischaemia, hypertrophic cardiomyopathy (the most common cause of sudden cardiac death), dilated cardiomyopathy and pericarditis. Recognizing and distinguishing physiological changes from significant cardiovascular disease is extremely important in an emergency medicine setting. Inappropriate or withheld treatment can affect morbidity and mortality significantly; detection of genuine cardiovascular disease usually requires exclusion from athletic competition to reduce the risk of sudden death. A number of criteria and methods have been proposed to assist in the task of differentiating physiological from pathological changes. Three case reports of ultra-endurance athletes, which highlight these dilemmas, are presented. These patients had significant electrocardiogram changes, including marked ST segment elevation, T wave inversion and evidence of left ventricular hypertrophy. This paper discusses the morphological and clinical changes associated with athlete’s heart syndrome and the current criteria and methods available to help differentiate this from cardiovascular disease. In many emergency department situations, a clinical history and examination may be all that is required. More complex cases are best resolved by use of echocardiography. Emergency physicians need to be aware of this syndrome and the diagnostic difficulties they may face when managing such patients.     

量化感染与抗菌策略对慢性阻塞性肺病急性发作患者预后的影响

目的　试图找出针对慢性阻塞性肺病 (COPD)急性发作患者合适的抗菌治疗策略。方法　根据SepsisScore(SS)评分 ,对 4 7例接受过NIPPV治疗的COPD急性发作患者进行肺部感染严重度的评分 ,并依据治疗效果和支气管—肺泡灌洗液细菌学检测结果评价抗菌治疗是否充分 ,以及对临床转归的影响。结果　监测COPD急性发作期患者的SS ,发现当SS≤10时 ,充分的经验性抗菌治疗可明显降低死亡率 ;但是 ,当SS积分 >10时 ,抗菌治疗策略并不能明显改善患者的预后。结论　根据COPD急性发作患者感染严重度 ,早期采取相应抗菌治疗策略 ,可降低死亡率并防止滥用抗菌药物