The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water(TBW) and total effective solute and is ...The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water(TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment(mainly sodium salts) and in the intracellular compartment(mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume(EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.展开更多
Cytomegalovirus viremia and tissue-invasive disease are common after kidney transplantation. Chemoprophylaxis has made substantial improvement in this clinical problem. Here we report a 29-year-old woman who had kidne...Cytomegalovirus viremia and tissue-invasive disease are common after kidney transplantation. Chemoprophylaxis has made substantial improvement in this clinical problem. Here we report a 29-year-old woman who had kidney allograft rejection and received lymphocyte-depleting therapy. She presented with a new oligo-arthritis that led to 2 successive arthrocenteses. The etiology of the inflammation could not be determined initially. On the second arthrocentesis, a synovial fluid cytomegalovirus polymerase chain reaction test was positive. The patient responded to treatment with valganciclovir, had negative follow-up serum cytomegalovirus polymerase chain reaction tests, and experienced resolution of her joint inflammation. We review briefly the data for cytomegalovirus chemoprophylaxis, preemptive screening, and treatment recommendations.展开更多
BACKGROUND A low proportion of patients admitted to hospital with cirrhosis receive quality care with timely paracentesis an important target for improvement.We hypothesized that a medical educational intervention,del...BACKGROUND A low proportion of patients admitted to hospital with cirrhosis receive quality care with timely paracentesis an important target for improvement.We hypothesized that a medical educational intervention,delivered to medical residents caring for patients with cirrhosis,would improve quality of care.AIM To determine if an educational intervention can improve quality of care in cirrhotic patients admitted to hospital with ascites.METHODS We performed a pilot prospective cohort study with time-based randomization over six months at a large teaching hospital.Residents rotating on hospital medicine teams received an educational intervention while residents rotating on hospital medicine teams on alternate months comprised the control group.The primary outcome was provision of quality care-defined as adherence to all quality-based indicators derived from evidence-based practice guidelines-in admissions for patients with cirrhosis and ascites.Patient clinical outcomesincluding length of hospital stay(LOS);30-d readmission;in-hospital mortality and overall mortality-and resident educational outcomes were also evaluated.RESULTS Eighty-five admissions(60 unique patients)met inclusion criteria over the study period-46 admissions in the intervention group and 39 admissions in the control group.Thirty-seven admissions were female patients,and 44 admissions were for alcoholic liver disease.Mean model for end-stage liver disease(MELD)-Na score at admission was 25.8.Forty-seven(55.3%)admissions received quality care.There was no difference in the provision of quality care(56.41%vs 54.35%,P=0.9)between the two groups.30-d readmission was lower in the intervention group(35%vs 52.78%,P=0.1)and after correction for age,gender and MELD-Na score[RR=0.62(0.39,1.00),P=0.05].No significant differences were seen for LOS,complications,in-hospital mortality or overall mortality between the two groups.Resident medical knowledge and self-efficacy with paracentesis improved after the educational intervention.CONCLUSION Medical education has the potential to improve clinical outcomes in patients admitted to hospital with cirrhosis and ascites.展开更多
文摘The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water(TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment(mainly sodium salts) and in the intracellular compartment(mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume(EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.
文摘Cytomegalovirus viremia and tissue-invasive disease are common after kidney transplantation. Chemoprophylaxis has made substantial improvement in this clinical problem. Here we report a 29-year-old woman who had kidney allograft rejection and received lymphocyte-depleting therapy. She presented with a new oligo-arthritis that led to 2 successive arthrocenteses. The etiology of the inflammation could not be determined initially. On the second arthrocentesis, a synovial fluid cytomegalovirus polymerase chain reaction test was positive. The patient responded to treatment with valganciclovir, had negative follow-up serum cytomegalovirus polymerase chain reaction tests, and experienced resolution of her joint inflammation. We review briefly the data for cytomegalovirus chemoprophylaxis, preemptive screening, and treatment recommendations.
文摘BACKGROUND A low proportion of patients admitted to hospital with cirrhosis receive quality care with timely paracentesis an important target for improvement.We hypothesized that a medical educational intervention,delivered to medical residents caring for patients with cirrhosis,would improve quality of care.AIM To determine if an educational intervention can improve quality of care in cirrhotic patients admitted to hospital with ascites.METHODS We performed a pilot prospective cohort study with time-based randomization over six months at a large teaching hospital.Residents rotating on hospital medicine teams received an educational intervention while residents rotating on hospital medicine teams on alternate months comprised the control group.The primary outcome was provision of quality care-defined as adherence to all quality-based indicators derived from evidence-based practice guidelines-in admissions for patients with cirrhosis and ascites.Patient clinical outcomesincluding length of hospital stay(LOS);30-d readmission;in-hospital mortality and overall mortality-and resident educational outcomes were also evaluated.RESULTS Eighty-five admissions(60 unique patients)met inclusion criteria over the study period-46 admissions in the intervention group and 39 admissions in the control group.Thirty-seven admissions were female patients,and 44 admissions were for alcoholic liver disease.Mean model for end-stage liver disease(MELD)-Na score at admission was 25.8.Forty-seven(55.3%)admissions received quality care.There was no difference in the provision of quality care(56.41%vs 54.35%,P=0.9)between the two groups.30-d readmission was lower in the intervention group(35%vs 52.78%,P=0.1)and after correction for age,gender and MELD-Na score[RR=0.62(0.39,1.00),P=0.05].No significant differences were seen for LOS,complications,in-hospital mortality or overall mortality between the two groups.Resident medical knowledge and self-efficacy with paracentesis improved after the educational intervention.CONCLUSION Medical education has the potential to improve clinical outcomes in patients admitted to hospital with cirrhosis and ascites.
