Rhabdomyolysis in an HIV cohort: epidemiology, causes and outcomes.

BackgroundThe Literature on rhabdomyolysis in the HIV-positive population is sparse and limited. We aimed to explore the incidence, patient characteristics, etiologies and outcomes of rhabdomyolysis in a cohort of HIV-positive patients identified through the Johns Hopkins HIV clinical registry between June 1992 and April 2014.MethodsA retrospective analysis of 362 HIV-positive patients with non-cardiac CK elevation ≥1000 IU/L was performed. Both inpatients and outpatients were included. Incidence rate and potential etiologies for rhabdomyolysis were ascertained. The development of acute kidney injury (AKI, defined as doubling of serum creatinine), need for dialysis, and death in the setting of rhabdomyolysis were determined. Logistic regression was used to evaluate the association of peak CK level with the development of AKI.ResultsThree hundred sixty two cases of rhabdomyolysis were identified in a cohort of 7079 patients with a 38,382 person years follow-up time. The incidence rate was nine cases per 1000 person-years (95% CI: 8.5-10.5). Infection was the most common etiology followed by compression injury and drug/alcohol use. One-third of cases had multiple potential etiologies. AKI developed in 46% of cases; 20% of which required dialysis. Thirteen percent died during follow-up. After adjustment, AKI was associated with higher CK (OR 2.05 for each 1-log increase in CK [95% CI: 1.40-2.99]), infection (OR 5.48 [95% CI 2.65-11.31]) and higher HIV viral load (OR 1.22 per 1-log increase [95% CI: 1.03-1.45]).ConclusionRhabdomyolysis in the HIV-positive population has many possible causes and is frequently multifactorial. HIV-positive individuals with rhabdomyolysis have a high risk of AKI and mortality

The hypokalemia mystery: distinguishing Gitelman and Bartter syndromes from 'pseudo-Bartter syndrome'

The Gitelman and Bartter syndromes (GS and BS, respectively) are characterized by the constellation of hypokalemia, hypochloremia, metabolic alkalosis, hyperreninemic hyperaldosteronism, low to normal blood pressure and juxtaglomerular apparatus hypertrophy. These are due to pathogenic variants in the genes that encode the thiazide-sensitive sodium–chloride cotransporter NCC (SLC12A3) in the distal convoluted tubule or transporters involved in sodium chloride reabsorption in the loop of Henle. ‘Pseudo-Bartter syndrome’ (PBS) is caused by extrarenal or acquired renal salt losses and shares the same plasma electrolyte profile and acid–base disturbances, making the distinction from the genetic forms very challenging. PBS has various etiologies, including diuretic and laxative abuse, self-induced vomiting and the side effects of some antimicrobials. Additionally, congenital chloride diarrhea, cystic fibrosis, Pendred syndrome and chloride-deficient diet can manifest as PBS. In this review we focus on factitious PBS secondary to diuretic abuse, laxative abuse or self-induced vomiting, whereby we point out some clinical and laboratory clues to help clinicians make the correct diagnosis

Evaluation of intensity modulated radiation therapy dose painting for localized prostate cancer using 68 Ga-HBED-CC PSMA-PET/CT: A planning study based on histopathology reference

AbstractPurposeTo demonstrate the feasibility and to evaluate the tumour control probability (TCP) and normal tissue complication probability (NTCP) of IMRT dose painting using 68Ga-HBED-CC PSMA PET/CT for target delineation in prostate cancer (PCa).Methods and materials10 patients had PSMA PET/CT scans prior to prostatectomy. GTV-PET was generated on the basis of an intraprostatic SUVmax of 30%. Two IMRT plans were generated for each patient: Plan77 which consisted of whole-prostate IMRT to 77Gy, and Plan95 which consisted of whole-prostate IMRT to 77Gy and a simultaneous integrated boost to the GTV-PET up to 95Gy (35 fractions). The feasibility of these plans was judged by their ability to adhere to the FLAME trial protocol. TCP-histo/-PET were calculated on co-registered histology (GTV-histo) and GTV-PET, respectively. NTCPs for rectum and bladder were calculated.ResultsAll plans reached prescription doses whilst adhering to dose constraints. In Plan77 and Plan95 mean doses in GTV-histo were 75.8±0.3Gy and 96.9±1Gy, respectively. Average TCP-histo values for Plan77 and Plan95 were 70% (range: 15–97%), and 96% (range: 78–100%, p77 and Plan95 were 55% (range: 27–82%), and 100% (range: 99–100%, p95 (p=0.25). There were no significant differences in rectal (p=0.563) and bladder (p=0.3) NTCPs.ConclusionsIMRT dose painting using PSMA PET/CT was technically feasible and resulted in significantly higher TCPs without higher NTCPs

Peri-renal adipose inflammation contributes to renal dysfunction in a non-obese prediabetic rat model: Role of anti-diabetic drugs

Diabetic nephropathy is a major health challenge with considerable economic burden and significant impact on patients’ quality of life. Despite recent advances in diabetic patient care, current clinical practice guidelines fall short of halting the progression of diabetic nephropathy to end-stage renal disease. Moreover, prior literature reported manifestations of renal dysfunction in early stages of metabolic impairment prior to the development of hyperglycemia indicating the involvement of alternative pathological mechanisms apart from those typically triggered by high blood glucose. Here, we extend our prior research work implicating localized inflammation in specific adipose depots in initiating cardiovascular dysfunction in early stages of metabolic impairment. Non-obese prediabetic rats showed elevated glomerular filtration rates and mild proteinuria in absence of hyperglycemia, hypertension, and signs of systemic inflammation. Isolated perfused kidneys from these rats showed impaired renovascular endothelial feedback in response to vasopressors and increased flow. While endothelium dependent dilation remained functional, renovascular relaxation in prediabetic rats was not mediated by nitric oxide and prostaglandins as in control tissues, but rather an upregulation of the function of epoxy eicosatrienoic acids was observed. This was coupled with signs of peri-renal adipose tissue (PRAT) inflammation and renal structural damage. A two-week treatment with non-hypoglycemic doses of metformin or pioglitazone, shown previously to ameliorate adipose inflammation, not only reversed PRAT inflammation in prediabetic rats, but also reversed the observed functional, renovascular, and structural renal abnormalities. The present results suggest that peri-renal adipose inflammation triggers renal dysfunction early in the course of metabolic disease.This study was supported by American University of Beirut Faculty of Medicine Medical Practice Plan grant #320148 granted to AFE. The funding body had no role in the design of the study or collection, analysis, and interpretation of data or in writing the manuscript

Conservative kidney management and kidney supportive care:core components of integrated care for people with kidney failure

Integrated kidney care requires synergistic linkage between preventative care for people at risk for chronic kidney disease and health services providing care for people with kidney disease, ensuring holistic and coordinated care as people transition between acute and chronic kidney disease and the 3 modalities of kidney failure management: conservative kidney management, transplantation, and dialysis. People with kidney failure have many supportive care needs throughout their illness, regardless of treatment modality. Kidney supportive care is therefore a vital part of this integrated framework, but is nonexistent, poorly developed, and/or poorly integrated with kidney care in many settings, especially in low- and middle-income countries. To address this, the International Society of Nephrology has (i) coordinated the development of consensus definitions of conservative kidney management and kidney supportive care to promote international understanding and awareness of these active treatments; and (ii) identified key considerations for the development and expansion of conservative kidney management and kidney supportive care programs, especially in low resource settings, where access to kidney replacement therapy is restricted or not available. This article presents the definitions for conservative kidney management and kidney supportive care; describes their core components with some illustrative examples to highlight key points; and describes some of the additional considerations for delivering conservative kidney management and kidney supportive care in low resource settings.</p

Bone mass measurement improvement in micro-CT taking into account the physical phenomena

Suite à l'allongement de la survie des patients atteints de la mucoviscidose (CF), des études ont montré la présence d'une perte osseuse chez les patients CF. Dans ce travail de thèse, une étude de l'évolution de la densité minérale osseuse chez des souris atteintes de mucoviscidose a été effectuée en utilisant un système de micro-tomodensitométrie X. Afin d'améliorer les précisions des mesure, deux méthodes de correction de deux phénomènes physiques ont été appliquées. La première méthode est une correction du durcissement de faisceau X et basée sur une segmentation de l'objet reconstruit après une première reconstruction et en utilisant des courbes d'atténuations précalculées. La deuxième méthode est une méthode de correction de la diffusion des rayons dans l'animal basée sur l'estimation des projections des diffusés en utilisant des noyaux de diffusion précalculées. Des améliorations au niveau de la qualité de l'image et les mesures de densité osseuses ont été obtenues.Due to the increased survival of the patients with cystic fibrosis (CF), studies showed the presence of osteoporosis in CF patients. In this work, a follow-up study of the bone mineral density (BMD) formice with CF is done using a micro-CT system. In order to perform accurately the measurements, weapplied two correction methods aiming to reduce artifacts in CT images. The first correction method is abeam hardening correction technique based on a post-reconstruction procedure and usingpre-calculated linearization curves. The second correction method is a hybrid elimination approach of scatter radiations from acquisition projections and based on the use of pre-calculated scatter kernels,simulated analytically. Improvements have been shown concerning image quality (contrast, artifactsreduction) and BMD measurements

Contribution to the study of evidence in French tax law

Selon Henri Levy-Bruhl, « la preuve est inséparable de la décision judiciaire : c'en est l'âme et la sentence n'est qu'une ratification ». Située au cœur du procès, la preuve se trouve aussi liée à l'existence du droit lui-même. Ainsi, selon un adage ancien, « ne pas pouvoir prouver son droit revient à ne pas en avoir ». Cet adage, aussi strict qu'il puisse paraître, ne doit pas être pris à la lettre dans la mesure où le droit à prouver existe même en l'absence de preuve mais c'est la reconnaissance de ce droit sur le plan juridique qui posera problème si la partie concernée ne parvient pas à le prouver. La preuve en droit fiscal revêt la même importance dans la mesure où elle est soumise aux principes généraux de droit qui régissent la preuve en droit civil. Ainsi, cette étude nécessite de développer à la fois les règles relatives à la charge de la preuve et celles relatives à son administration. La charge de la preuve est régie par deux adages selon lesquels « la charge de la preuve incombe au demandeur » et « celui qui allègue une exception en défense doit la prouver. » L’application est limitée à la charge initiale. Quant à l’administration de la preuve en droit fiscal est gouvernée par les règles relatives à la preuve en contentieux administratif. Elle est définie comme étant le moyen par lequel celui sur qui repose la charge de la preuve justifie ses prétentions. En droit fiscal, il n’y a pas de règles quant aux moyens de preuve admis par le juge. Comme en contentieux administratif, le juge n’a pas le droit d’imposer aux parties une preuve spécifique. Tous les moyens de preuve sont acceptés et le juge apprécie leur juste valeur selon son intime convictionAccording to Henri Levy-Bruhl, « the evidence is inseparable from the judicial decision : it is the soul and the sentence is only a ratification ». Located at the heart of the lawsuit, the evidence is also linked to the existence of the right itself. Thus, according to an old adage, « not being able to prove one's right is not to have one ». This adage, as strict as it may seem, should not be taken literally to the extent that the right to prove exists even in the absence of evidence but it is the recognition of this right on the legal plane that will pose problem if the party concerned can not prove it. Evidence in tax law is of equal importance to the extent that it is subject to the general principles of the law governing the civil law evidence. Thus, this study requires the development of both the rules on the burden of evidence and those relating to its administration. The burden of evidence is governed by two statements that « the onus of evidence lies with the plaintiff » and « whoever alleges an objection in defense must prove it ». The application of these adages is limited to the initial charge. As for the administration of evidence in tax law, it is governed by the rules of evidence in administrative litigation. It is defined by the means by which the party on whom the burden of evidence lies to justify its claims. In tax law, there are no rules as to the means of evidence admitted by the judge. As in administrative litigation, the judge has no right to impose specific evidence on the partie

Bone mass measurement improvement in micro-CT taking into account the physical phenomena

Suite à l'allongement de la survie des patients atteints de la mucoviscidose (CF), des études ont montré la présence d'une perte osseuse chez les patients CF. Dans ce travail de thèse, une étude de l'évolution de la densité minérale osseuse chez des souris atteintes de mucoviscidose a été effectuée en utilisant un système de micro-tomodensitométrie X. Afin d'améliorer les précisions des mesure, deux méthodes de correction de deux phénomènes physiques ont été appliquées. La première méthode est une correction du durcissement de faisceau X et basée sur une segmentation de l'objet reconstruit après une première reconstruction et en utilisant des courbes d'atténuations précalculées. La deuxième méthode est une méthode de correction de la diffusion des rayons dans l'animal basée sur l'estimation des projections des diffusés en utilisant des noyaux de diffusion précalculées. Des améliorations au niveau de la qualité de l'image et les mesures de densité osseuses ont été obtenues.Due to the increased survival of the patients with cystic fibrosis (CF), studies showed the presence of osteoporosis in CF patients. In this work, a follow-up study of the bone mineral density (BMD) formice with CF is done using a micro-CT system. In order to perform accurately the measurements, weapplied two correction methods aiming to reduce artifacts in CT images. The first correction method is abeam hardening correction technique based on a post-reconstruction procedure and usingpre-calculated linearization curves. The second correction method is a hybrid elimination approach of scatter radiations from acquisition projections and based on the use of pre-calculated scatter kernels,simulated analytically. Improvements have been shown concerning image quality (contrast, artifactsreduction) and BMD measurements

Amélioration du calcul de la masse osseuse par micro-tomodensitométrie X : prise en compte des phénomènes physiques

Due to the increased survival of the patients with cystic fibrosis (CF), studies showed the presence of osteoporosis in CF patients. In this work, a follow-up study of the bone mineral density (BMD) formice with CF is done using a micro-CT system. In order to perform accurately the measurements, weapplied two correction methods aiming to reduce artifacts in CT images. The first correction method is abeam hardening correction technique based on a post-reconstruction procedure and usingpre-calculated linearization curves. The second correction method is a hybrid elimination approach of scatter radiations from acquisition projections and based on the use of pre-calculated scatter kernels,simulated analytically. Improvements have been shown concerning image quality (contrast, artifactsreduction) and BMD measurements.Suite à l'allongement de la survie des patients atteints de la mucoviscidose (CF), des études ont montré la présence d'une perte osseuse chez les patients CF. Dans ce travail de thèse, une étude de l'évolution de la densité minérale osseuse chez des souris atteintes de mucoviscidose a été effectuée en utilisant un système de micro-tomodensitométrie X. Afin d'améliorer les précisions des mesure, deux méthodes de correction de deux phénomènes physiques ont été appliquées. La première méthode est une correction du durcissement de faisceau X et basée sur une segmentation de l'objet reconstruit après une première reconstruction et en utilisant des courbes d'atténuations précalculées. La deuxième méthode est une méthode de correction de la diffusion des rayons dans l'animal basée sur l'estimation des projections des diffusés en utilisant des noyaux de diffusion précalculées. Des améliorations au niveau de la qualité de l'image et les mesures de densité osseuses ont été obtenues