Fluid therapy and acute kidney injury in cardiogenic shock after cardiac arrest

Aim of the study

It has recently been suggested that acute kidney injury (AKI) may strongly be influenced by post-resuscitation disease and cardiogenic shock (CS), and may not just be a consequence of cardiac arrest and time without spontaneous circulation. AKI also has been suggested as a strong independent predictor of in-hospital mortality. Therefore the present study aimed at investigating the effect of fluid management on the incidence of AKI in patients with cardiogenic shock after cardiac arrest treated by mild therapeutic hypothermia.

Methods

Fluid therapy and the incidence of acute kidney injury (AKI) was retrospectively reviewed in 51 patients with cardiogenic shock after cardiac arrest comparing patients with and without hemodynamic (PPV, SVV) and volumetric (ELWI, GEDI) monitoring.

Results

There was no significant difference in baseline or cardiac arrest characteristics between hemodynamic monitored patients and conventional monitored patients. 28 patients were monitored by standard monitoring, in 23 patients monitoring was complemented by a PICCO system. In the first 24 h of treatment the total amount of fluid was significantly higher in patients under PICCO monitoring compared to conventional monitoring (4375 ± 1285 ml vs. 5449 ± 1438 ml, p = 0.007). This was associated with a significant reduction in the incidence of AKI (RIFLE ‘I’/‘F’: PICCO-group: 1 (4.3%) vs. conventional group 8 (28.6%), p = 0.03).

Conclusion

The presented data suggest that volume therapy guided by volumetric (ELWI, GEDI) and arterial waveform derived variables (PPV, SVV) can reduce the incidence of AKI in patients with cardiogenic shock after cardiac arrest treated with mild therapeutic hypothermia.     

An assessment of resuscitation quality in the television drama Emergency Room: Guideline non-compliance and low-quality cardiopulmonary resuscitation lead to a favorable outcome?

Objective

Two earlier studies found that outcome after cardiopulmonary resuscitation (CPR) in the television medical drama Emergency Room (ER) is not realistic. No study has yet evaluated CPR quality in ER.

Design

Retrospective analysis of CPR quality in episodes of ER.

Setting

Three independent board-certified emergency physicians trained in CPR and the American Heart Association (AHA) guidelines reviewed ER episodes in two 5-year time-frames (2001–2005 and 2005–2009). Congruency with the corresponding 2000 and 2005 AHA guidelines was determined for each CPR scene.

Patients

None.

Interventions

None.

Main outcome measures

To evaluate whether CPR is in agreement with the specific algorithms of the AHA guidelines. Fisher's exact test and Mann–Whitney-U-test were used to evaluate statistical significance (P < 0.05).

Results

A total of 136 on-screen cardiac arrests occurred in 174 episodes. Trauma was the leading cause of cardiac arrest (56.6%), which was witnessed in 80.1%. Return of spontaneous circulation occurred in 38.2%. Altogether, 19.1% of patients survived until ICU admission, and 5.1% were discharged alive.

Conclusions

Only one CPR scene was in agreement with the published AHA guidelines. However, low-quality CPR and non-compliance with the guidelines resulted in favorable outcomes.     

Primary classic Kaposi''s sarcoma of the penis: report of a case and review

Kaposi's sarcoma is a vascular tumour of multifocal origin occurring primarily on the extremities. The case of a 45-year-old HIV negative and HHV-8 positive man with an asymptomatic reddish macular lesion on the inner layer of the prepuce is described. Although primary penile Kaposi's sarcoma is a relatively uncommon disorder in HIV negative men, dermatologists and venereologists should consider this possibility when treating non-specific penile lesions. A minimal penile lesion with non-distinctive clinical features may sometimes be the exclusive manifestation of Kaposi's sarcoma, making histologic evaluation necessary to establish the diagnosis.     

Microinvasive squamous cell carcinoma arising on lichen sclerosus of the penis

The case of a 70-year-old white man with a 10-year history of penile lichen sclerosus (LS) who developed microinvasive squamous cell carcinoma on LS is described. A high incidence of penile cancer arising on genital LS has recently been observed. The authors stress the importance of an adequate diagnosis and long-term follow-up in patients with penile LS because of the malignant potential of the disease.     

Cannabinoids, loratadine and allopurinol as novel additions to the antipsoriatic ammunition

As the current antipsoriatic medications are commonly associated with deleterious side-effects, a determined search for safer agents, which could be used alone or in combination with current antipsoriatic drugs, would be very imperative. Psoriasis is believed to be characterized by a type 1 cytokine pattern; interferon-gamma, interleukin (IL)-2 and tumour necrosis factor (TNF)-alpha are predominantly expressed in this disorder. Nitric oxide, reactive oxygen species, histamine, leukotriene B4, and decreased [corrected] keratinocyte cyclic adenosine monophosphate/cyclic guanosine monophosphate (cAMP/cGMP) ratio are supposed to play roles in the pathogenesis of this disorder. Based on the immunopathogenesis of psoriasis, this paper introduces three novel, potential treatments for this clinical conundrum: (i) cannabinoids, which exert inhibitory effects on antigen processing and macrophage/T-cell interaction and also on the release of IL-2, TNF-alpha and nitric oxide from immune cells; (ii) loratadine, which is an antihistamine capable of increasing [corrected] the cAMP/cGMP ratio and the production of leukotriene B4; and (iii) allopurinol, which scavenges free radicals, inhibits the production of TNF-alpha, and downregulates the expression of intercellular adhesion molecule-1 and P2X7 receptors on monocytes/macrophages, which are involved in antigen presentation and production of the inflammatory response, respectively. Importantly, allopurinol, especially in combination with cyclosporin, has been shown to be effective against experimental autoimmune uveitis, which, like psoriasis, is a cell-mediated autoimmune disorder.     

Innovation in clinical method: diabetes care and negotiating skills

The development of a method to facilitate clinical negotiationwith diabetic patients is described. The principles of the methodincorporate patient centredness, an assessment of readinessto change and some elements of motivational interviewing. Asimple low cost technology is part of the innovative method.Details of the method and its application are published beforethe results of a randomized controlled trial to ensure thatthe techniques are in the public domain before the outcome ofthe trial is known.     

Association of long-term adherence to evidence-based combination drug therapy after acute myocardial infarction with all-cause mortality. A prospective cohort study based on claims data

Purpose

To determine long-term adherence to evidence-based secondary preventive combination pharmacotherapy in survivors of acute myocardial infarction (AMI) and to investigate the association between adherence to recommended therapy and all-cause mortality in claims data.

Methods

Prospective cohort study based on claims data of an 18.75?% random sample of all persons insured with the local statutory health insurance fund AOK Hesse. Study population included patients with hospital discharge diagnoses of AMI between 2001 and 2005 excluding those who died within the first 30?days after AMI or who had been hospitalised with an AMI in the previous 2?years. A total of 3,008 patients were followed up until death, cancellation of insurance, or the end of the study period on 31 December 2007, whichever came first (median follow-up: 4.2?years).

Results

Drug adherence to single drug groups as determined by proportion of days covered ≥80?% was 21.8?% for antiplatelet drugs, 9.4?% for beta-blockers, 45.6?% for ACE inhibitors or angiotensin II receptor blockers and 45.1?% for lipid-lowering drugs. A total of 924 (39.7?%) patients met our definition of guideline adherence: Drugs available from three of four relevant drug groups on the same day for at least 50?% of the observation time. Of the patients adhering to the guidelines, 17.3?% died and of the non-adherents, 32.4?% died. All-cause mortality was 28?% lower for guideline-adherent patients than for the non-adherent group (adjusted HR 0.72, 95?% CI 0.60–0.86).

Conclusions

In everyday practice, post AMI patients benefit from guideline-oriented treatment, but the percentage of adherent patients should be improved.