AIM: To test the hypothesis that fluid resuscitation with Ringer's solution enriched with pyruvate(PR), a physiological antioxidant and energy substrate, affords protection of myocardial metabolism and electrophys...AIM: To test the hypothesis that fluid resuscitation with Ringer's solution enriched with pyruvate(PR), a physiological antioxidant and energy substrate, affords protection of myocardial metabolism and electrophysiological performance superior to lactated Ringer's(LR) during hypovolemia and hindlimb ischemia-reperfusion.METHODS: Male domestic goats(25-30 kg) were exsanguinated to a mean arterial pressure of 48 ± 1 mm Hg. Right hindlimb ischemia was imposed for 90 min by applying a tourniquet and femoral crossclamp. LR or PR, infused iv, delivered 0.05 mmol/kg per minute L-lactate or pyruvate, respectively, from 30 min hindlimb ischemia until 30 min post-ischemia. Time controls(TC) underwent neither hemorrhage, hindlimb ischemia nor resuscitation. Goats were sacrificed and left ventricular myocardium biopsied at 90 min fluid resuscitation(n = 6 per group) or 3.5 h later(n = 9 LR, 10 PR, 8 TC).RESULTS: Myocardial 8-isoprostane content, phosphocreatine phosphorylation potential, creatine kinase activity, and heart rate-adjusted QT interval(QTc) vari- ability were evaluated at 90 min resuscitation and 3.5 h post-resuscitation. PR sharply lowered pro-arrhythmic QTc variability vs LR(P < 0.05); this effect persisted 3.5 h post-resuscitation. PR lowered myocardial 8-isoprostane content, a product of oxidative stress, by 39 and 37% during and 3.5 h after resuscitation, respectively, vs LR. Creatine kinase activity fell 42% post-LR vs TC(P < 0.05), but was stable post-PR(P < 0.02 vs post-LR). PR doubled phosphocreatine phosphorylation potential, a measure of ATP free energy state, vs TC and LR(P < 0.05); this energetic enhancement persisted 3.5 h post-resuscitation.CONCLUSION: By augmenting myocardial energy state and protecting creatine kinase activity, pyruvateenriched resuscitation stabilized cardiac electrical function during central hypovolemia and hindlimb ischemiareperfusion.展开更多
Objective: Use of an epidural self-blood patch (EBP) is the most effective form of therapy for patients with cerebrospinal fluid (CSF) hypovolemia. However, even if the symptoms are resolved, other clinical aspects of...Objective: Use of an epidural self-blood patch (EBP) is the most effective form of therapy for patients with cerebrospinal fluid (CSF) hypovolemia. However, even if the symptoms are resolved, other clinical aspects of this condition frequently prevent patients resuming social activity. In the present study, we investigated the clinical course of patients with CSF hypovolemia after treatment with an EBP to assess the factors affecting return to work or school, and considered the treatment of patients with progressive chronic subdural hematoma. Patients and Results: We investigated a group of 10 patients with CSF hypovolemia. After initial application of an EBP, 8 of these patients were completely relieved of postural headache and associated symptoms, and the other 2 recovered after a second application. However, 3 patients who had cervical spondylosis or psychosis were still unable to return to work or school. Two patients who were forced to retire have potential for rehabilitation after EBP. One patient has recovered from the illness, but could not return to school due to persistent medical history of psychosis. These patients had suffered symptoms for a long period before EBP (mean, 17.8 months;range 7 months to 3 years) relative to those who were able to resume social activity (mean, 2.0 months;range 7 days to 5 months) (P < 0.05). Three had progressive bilateral chronic subdural hematoma. One of these patients required emergency burr-hole drainage to resolve the neurological deterioration. Conclusions: Both physicians and patients need to be aware of CSF hypovolemia, and the fact that it requires appropriate treatment without delay. While application of an EBP is a fundamentally important therapy even for patients with hematoma, careful follow-up is required for patients showing marked neurological deterioration or an increasing hematoma volume with a brain midline shift, and burr-hole drainage must sometimes be considered in combination with EBP.展开更多
<strong>Background:</strong> Elderly patients have a high risk of acute Kidney Injury (AKI) due to aging, decreased renal function and the presence of comorbidities. There is limited data on AKI in elderly...<strong>Background:</strong> Elderly patients have a high risk of acute Kidney Injury (AKI) due to aging, decreased renal function and the presence of comorbidities. There is limited data on AKI in elderly patients in low income regions, especially in Sub-Saharan Africa. We therefore sought to describe the clinical profile and outcome of AKI in elderly in a tertiary hospital in Cameroon. <strong>Methods and Materials:</strong> We reviewed the medical records of all patients admitted with the diagnosis of AKI in the internal medicine unit of the Yaounde University Teaching Hospital, from January 2015 to February 2018. Records of elderly patients (≥65 years) were retrieved and analysed. AKI was diagnosed and classified using the KDIGO (Kidney Disease Improving Global Outcomes) 2012 classification. The diagnosis, aetiologies and mechanisms of AKI were clinical. Renal outcomes were evaluated on day 7, 14, 28, 60 and 90 of hospital stay. <strong>Results:</strong> We included 76 elderly (66% males) patients with a median [interquartile rate—IQR] age of 69 [65 - 75] years. Hypertension (60.5%), diabetes mellitus (36.8%) and heart failure (26.3%) were the most common comorbidities. The median [IQR] Charlson index was 4 [3 - 5]. Infections (47.4%) and hypovolemia (69.7%) were the most frequent risk factors for AKI. AKI was mainly community acquired (89.5%) and most of the patients were in stage 2 (34.2%) or 3 (29%). Pre-renal AKI (58%) was the leading mechanism involved. Hypovolemia and sepsis were the most common aetiologies. Of the 14.5% with indication for dialysis, only 2.6% had access to it. The overall prognosis was good with a mortality rate of 2.6%, complete and partial renal recovery at 3 months of 70%, and 26.3% respectively. <strong>Conclusion:</strong> AKI in the elderly, in our setting was community-acquired and affected mainly those with comorbidities. Pre-renal AKI was the main mechanism;hypovolemia and sepsis were the major aetiologies. Most participants had complete renal recovery at 3 months.展开更多
Background: Post-operative hyponatremia occurs after 30% of orthopedic surgeries, increasing morbidity, mortality and hospital length of stays and hospital costs. The cause of the hyponatremia can be varied, hard to d...Background: Post-operative hyponatremia occurs after 30% of orthopedic surgeries, increasing morbidity, mortality and hospital length of stays and hospital costs. The cause of the hyponatremia can be varied, hard to diagnose and impact management. The goal of this study was to determine the causes of post-operative orthopedic hyponatremia and to evaluate the accuracy with which nephrologists and internists interpret the data. Methods: This was a retrospective chart review of patients >21 years old on the adult total joint service who developed postoperative hyponatremia. A hyponatremic order set was developed and patient fluid status was charted by the presence or absence of edema in non-surgical extremities. The patients were treated by their managing physicians. After one year, data on 51 patients were assembled and sent to three nephrologists and three internists to analyze and diagnose the etiology of the hyponatremia. Results: The most common causes of post-operative hyponatremia were hypovolemia (33.7%), the syndrome of inappropriate antidiuretic hormone, SIADH (32.4%), hypotonic fluid (8.2%), acute kidney injury (5.2%) and medications (5.9%). The interrater agreement, measured by kappa coefficient, was moderate (0.43;95% CI 0.34, 0.53) for the nephrologists and fair (0.38;95% CI 0.30, 0.46) for the internists. Conclusions: The majority of post-operative hyponatremia following total joint surgery in adults is from hypovolemia and SIADH. The treatment for these is very different: the first requires fluid resuscitation and the latter, free water restriction. Due to an interplay of peri-operative factors, the diagnosis can be difficult for both internists as well as nephrologists.展开更多
基金Supported by Grant#W911NF0910086 from the United States Department of DefensePredoctoral fellowships from the Graduate School of Biomedical Sciences,University of North Texas Health Science Center to Gurji HA and White DW
文摘AIM: To test the hypothesis that fluid resuscitation with Ringer's solution enriched with pyruvate(PR), a physiological antioxidant and energy substrate, affords protection of myocardial metabolism and electrophysiological performance superior to lactated Ringer's(LR) during hypovolemia and hindlimb ischemia-reperfusion.METHODS: Male domestic goats(25-30 kg) were exsanguinated to a mean arterial pressure of 48 ± 1 mm Hg. Right hindlimb ischemia was imposed for 90 min by applying a tourniquet and femoral crossclamp. LR or PR, infused iv, delivered 0.05 mmol/kg per minute L-lactate or pyruvate, respectively, from 30 min hindlimb ischemia until 30 min post-ischemia. Time controls(TC) underwent neither hemorrhage, hindlimb ischemia nor resuscitation. Goats were sacrificed and left ventricular myocardium biopsied at 90 min fluid resuscitation(n = 6 per group) or 3.5 h later(n = 9 LR, 10 PR, 8 TC).RESULTS: Myocardial 8-isoprostane content, phosphocreatine phosphorylation potential, creatine kinase activity, and heart rate-adjusted QT interval(QTc) vari- ability were evaluated at 90 min resuscitation and 3.5 h post-resuscitation. PR sharply lowered pro-arrhythmic QTc variability vs LR(P < 0.05); this effect persisted 3.5 h post-resuscitation. PR lowered myocardial 8-isoprostane content, a product of oxidative stress, by 39 and 37% during and 3.5 h after resuscitation, respectively, vs LR. Creatine kinase activity fell 42% post-LR vs TC(P < 0.05), but was stable post-PR(P < 0.02 vs post-LR). PR doubled phosphocreatine phosphorylation potential, a measure of ATP free energy state, vs TC and LR(P < 0.05); this energetic enhancement persisted 3.5 h post-resuscitation.CONCLUSION: By augmenting myocardial energy state and protecting creatine kinase activity, pyruvateenriched resuscitation stabilized cardiac electrical function during central hypovolemia and hindlimb ischemiareperfusion.
文摘Objective: Use of an epidural self-blood patch (EBP) is the most effective form of therapy for patients with cerebrospinal fluid (CSF) hypovolemia. However, even if the symptoms are resolved, other clinical aspects of this condition frequently prevent patients resuming social activity. In the present study, we investigated the clinical course of patients with CSF hypovolemia after treatment with an EBP to assess the factors affecting return to work or school, and considered the treatment of patients with progressive chronic subdural hematoma. Patients and Results: We investigated a group of 10 patients with CSF hypovolemia. After initial application of an EBP, 8 of these patients were completely relieved of postural headache and associated symptoms, and the other 2 recovered after a second application. However, 3 patients who had cervical spondylosis or psychosis were still unable to return to work or school. Two patients who were forced to retire have potential for rehabilitation after EBP. One patient has recovered from the illness, but could not return to school due to persistent medical history of psychosis. These patients had suffered symptoms for a long period before EBP (mean, 17.8 months;range 7 months to 3 years) relative to those who were able to resume social activity (mean, 2.0 months;range 7 days to 5 months) (P < 0.05). Three had progressive bilateral chronic subdural hematoma. One of these patients required emergency burr-hole drainage to resolve the neurological deterioration. Conclusions: Both physicians and patients need to be aware of CSF hypovolemia, and the fact that it requires appropriate treatment without delay. While application of an EBP is a fundamentally important therapy even for patients with hematoma, careful follow-up is required for patients showing marked neurological deterioration or an increasing hematoma volume with a brain midline shift, and burr-hole drainage must sometimes be considered in combination with EBP.
文摘<strong>Background:</strong> Elderly patients have a high risk of acute Kidney Injury (AKI) due to aging, decreased renal function and the presence of comorbidities. There is limited data on AKI in elderly patients in low income regions, especially in Sub-Saharan Africa. We therefore sought to describe the clinical profile and outcome of AKI in elderly in a tertiary hospital in Cameroon. <strong>Methods and Materials:</strong> We reviewed the medical records of all patients admitted with the diagnosis of AKI in the internal medicine unit of the Yaounde University Teaching Hospital, from January 2015 to February 2018. Records of elderly patients (≥65 years) were retrieved and analysed. AKI was diagnosed and classified using the KDIGO (Kidney Disease Improving Global Outcomes) 2012 classification. The diagnosis, aetiologies and mechanisms of AKI were clinical. Renal outcomes were evaluated on day 7, 14, 28, 60 and 90 of hospital stay. <strong>Results:</strong> We included 76 elderly (66% males) patients with a median [interquartile rate—IQR] age of 69 [65 - 75] years. Hypertension (60.5%), diabetes mellitus (36.8%) and heart failure (26.3%) were the most common comorbidities. The median [IQR] Charlson index was 4 [3 - 5]. Infections (47.4%) and hypovolemia (69.7%) were the most frequent risk factors for AKI. AKI was mainly community acquired (89.5%) and most of the patients were in stage 2 (34.2%) or 3 (29%). Pre-renal AKI (58%) was the leading mechanism involved. Hypovolemia and sepsis were the most common aetiologies. Of the 14.5% with indication for dialysis, only 2.6% had access to it. The overall prognosis was good with a mortality rate of 2.6%, complete and partial renal recovery at 3 months of 70%, and 26.3% respectively. <strong>Conclusion:</strong> AKI in the elderly, in our setting was community-acquired and affected mainly those with comorbidities. Pre-renal AKI was the main mechanism;hypovolemia and sepsis were the major aetiologies. Most participants had complete renal recovery at 3 months.
文摘Background: Post-operative hyponatremia occurs after 30% of orthopedic surgeries, increasing morbidity, mortality and hospital length of stays and hospital costs. The cause of the hyponatremia can be varied, hard to diagnose and impact management. The goal of this study was to determine the causes of post-operative orthopedic hyponatremia and to evaluate the accuracy with which nephrologists and internists interpret the data. Methods: This was a retrospective chart review of patients >21 years old on the adult total joint service who developed postoperative hyponatremia. A hyponatremic order set was developed and patient fluid status was charted by the presence or absence of edema in non-surgical extremities. The patients were treated by their managing physicians. After one year, data on 51 patients were assembled and sent to three nephrologists and three internists to analyze and diagnose the etiology of the hyponatremia. Results: The most common causes of post-operative hyponatremia were hypovolemia (33.7%), the syndrome of inappropriate antidiuretic hormone, SIADH (32.4%), hypotonic fluid (8.2%), acute kidney injury (5.2%) and medications (5.9%). The interrater agreement, measured by kappa coefficient, was moderate (0.43;95% CI 0.34, 0.53) for the nephrologists and fair (0.38;95% CI 0.30, 0.46) for the internists. Conclusions: The majority of post-operative hyponatremia following total joint surgery in adults is from hypovolemia and SIADH. The treatment for these is very different: the first requires fluid resuscitation and the latter, free water restriction. Due to an interplay of peri-operative factors, the diagnosis can be difficult for both internists as well as nephrologists.
