Obese Patients in Medical Intensive Care Unit: Influence of Counseling on Weight Loss and Cardiovascular Parameters

A case series of 12 obese patients admitted to medical intensive care unit (ICU) due to life-threatening diseases and the influence of weight loss on cardiovascular parameters is presented. We assessed body weight, body mass index (BMI), blood pressure, pulse, and laboratory values on admission. At discharge from ICU patients were counseled on how to lose weight. They were examined one and six months later. Statistically significant (p<0.05) decrease of body weight (median at the beginning of a treatment 134 kg, after six months 127.5 kg), BMI (median 41.5 kg/m2 at the beginning of a treatment; 38.9 kg/m2 after six months), systolic blood pressure (medians 145 mmHg and 130 mmHg), diastolic blood pressure (medians 95 mmHg and 85 mmHg) and pulse (medians 104 beats per minute, 78 beats per minute) was found. The reduction of the waist circumference was not significant. One patient died due to severe acute pancreatitis. Patients reported feeling much better after losing weight

Obese Patients in Medical Intensive Care Unit: Influence of Counseling on Weight Loss and Cardiovascular Parameters

A case series of 12 obese patients admitted to medical intensive care unit (ICU) due to life-threatening diseases and the influence of weight loss on cardiovascular parameters is presented. We assessed body weight, body mass index (BMI), blood pressure, pulse, and laboratory values on admission. At discharge from ICU patients were counseled on how to lose weight. They were examined one and six months later. Statistically significant (p<0.05) decrease of body weight (median at the beginning of a treatment 134 kg, after six months 127.5 kg), BMI (median 41.5 kg/m2 at the beginning of a treatment; 38.9 kg/m2 after six months), systolic blood pressure (medians 145 mmHg and 130 mmHg), diastolic blood pressure (medians 95 mmHg and 85 mmHg) and pulse (medians 104 beats per minute, 78 beats per minute) was found. The reduction of the waist circumference was not significant. One patient died due to severe acute pancreatitis. Patients reported feeling much better after losing weight

Prospektivno istraživanje prevencije kontrastne nefropatije u Republici Hrvatskoj

Aim: To explore the protective role of hydration, urine alkalization (Na bicarbonate) and high doses of antioxidant (N-acetylcysteine) in the prevention of CIN. Material and methods: In a prospective, randomized, single-blinded study patients were divided into three groups: 1) peroral hydration, 2) Na bicarbonate infusion and 3) N-acetylcysteine (NAC) plus NaHCO3 infusion. Serum creatinine (SCr), blood urea nitrogen (BUN), and neutrophil gelatinase-associated lipocalin (NGAL) were measured before and 48 hours after the angiography. Mehran score was calculated for each patient. Results: The study included 106 patients. Groups were comparable regarding the baseline characteristics. According to Mehran risk score 70 % of patients had a low risk, 24% medium and 6% high risk score for development of CIN. After the procedure renal function was preserved in all patients (SCr 103(87.0-121.5), BUN 5.8 (4.9-7.6), creatinine clearance 74.7(55.3-97.6), NGAL 11.4(5.4-19.9)) regardless of the Mehran risk score. The follow up was completed for 73 patients (68 %). Twenty two patients (32 %) developed chronic kidney disease, mostly classified as G3a and G3b according to KDIGO guidelines. Chronic kidney disease developed in patients with the positive history of diabetes and in patients who had higher Mehran score before the diagnostic procedure. Conclusion: The study showed that patients with preserved renal function are not prone to CIN. Regardless of the protocol used, no case of CIN was observed. Our results indicate that adequate hydration is a key component in maintaining the renal function. Higher Mehran score might be useful in predicting the development of chronic kidney disease.Cilj: Ispitati protektivnu ulogu hidracije, alkalizacije mokraće (natrijevim bikarbonatom) i visokih doza antioksidansa (N-acetilcistein) u prevenciji kontrastne nefropatije. Materijali i metode: U prospektivnom istraživanju pacijenti su bili podijeljeni u tri skupine: 1) peroralna hidracija, 2) infuzija natrijevog bikarbonata i 3) infuzija N-acetilcisteina (NAC) i NaHCO3. Serumska vrijednost kreatinina, ureje i neutrophil gelatinase-associated lipocalin (NGAL) izmjerene su prije i 48 sati nakon angiografije. Svakom pacijentu izračunati su Mehran bodovi koji predstavljaju rizik razvoja kontrastne nefropatije. Rezultati: U istraživanje je uključeno 106 pacijenata. Sve tri skupine pacijenata imale su usporedive osnovne karakteristike. Prema bodovima po Mehranu, 70 % pacijenata imalo je niski rizik, 24 % srednji i 6 % visoki rizik razvoja kontrastne nefropatije. Nakon kontrastne pretrage bubrežna funkcija bila je očuvana u svih pacijenata (serumski kreatinin 103 (87.0 – 121.5), urea 5.8 (4.9 – 7.6), klirens kreatinina 74.7 (55.3 – 97.6), NGAL 11.4 (5.4 – 19.9)) neovisno o riziku procijenjenom bodovima po Mehranu. Praćenje je završeno za 73 pacijenta (68 %). Dvadeset i dva pacijenta (32 %) razvila su kroničnu bubrežnu insuficijenciju, klasificiranu prema KDIGO smjernicama kao G3a i G3b. Kronična bubrežna insuficijencija razvila se u pacijenata sa šećernom bolesti i u pacijenata koji su imali viši broj bodova prema Mehranu prije dijagnostičke pretrage. Zaključak: Istraživanje je pokazalo da pacijenti s normalnom bubrežnom funkcijom imaju mali rizik razvoja kontrastne nefropatije. U ispitivanoj skupini pacijenata nije zabilježen niti jedan slučaj kontrastne nefropatije bez obzira na vrstu protokola koji je korišten za hidraciju. Naši rezultati ukazuju na to da je adekvatna hidracija ključna u prevenciji kontrastne nefropatije. Nadalje, postoji mogućnost da viši broj bodova po Mehranu može poslužiti kao prediktor razvoja kronične bubrežne bolesti

Sarcoidosis or miliary tuberculosis – a case report

Prikazan je bolesnik u dobi od 59 godina s dugotrajnim febrilitetom i kašljem koji je razvio oštećenje jetre. Biopsijom jetre je dokazana nekazeozna granulomatozna upala. Vrijednost angiotenzin konvertirajućeg enzima je bila povišena (85 U/L). Opetovano uzimane hemokultura, kultura urina i kultura likvora su bile sterilne. U iskašljaju nije detektiran mikobakterij. Obzirom na navedeno, postavljena je sumnja na sarkoidozu te je započeta terapija kortikosteroidom. Usprkos terapiji, stanje bolesnika se pogoršavalo. Razvilo se akutno zatajenje bubrega do potrebe za hemodijalizom te parcijalna respiratorna insuficijencija. MSCT toraksa je pokazao sitnonodularni intersticijski infiltrat, pretežno u gornjim režnjevima pluća, uz povećane medijastinalne limfne čvorove, te konglomerat uvećanih mjestimično kolikviranih limfnih čvorova subkarinarno. Direktni preparat bronhoalveolarnog lavata u dva navrata i transbronhalna aspiracija iglom bili su negativni na bacil tuberkuloze. Nakon pregleda očne pozadine postavljena je sumnja na diseminiranu tuberkulozu. Mycobacterium tuberculosis, osjetljiv na streptomicin, izonijazid, etambutol, rifampicin, pirazinamid, naknadno je porastao u kulturi koštane srži. Uz antituberkulotsku terapiju bolesnik je trajno bio febrilan 21 dan. Nakon pet mjeseci terapije bolesnik se potpuno oporavio, uključujući i potpuni oporavak bubrežne funkcije.We present a previously healthly 59-year-old patient with fever, cough and liver disease. Liver biopsy showed non-necrotizing ("non-caseating") granulomas. The level of angiotensin-converting enzyme was above the reference range (85 U/L). Blood, urine and cerebrospinal fluid cultures were repeatedly sterile. No mycobacteria were detected in the sputum. Given the above findings, sarcoidosis was suspected and corticosteroid therapy was initiated. However, the patient was getting worse and developed acute kidney injury together with partial respiratory insufficiency. The chest CT showed interstitial infiltrate, mainly in the upper lobes of the lung, mediastinal lymph node enlargement with partial colliquation. Bronchoscopic aspiration and bronchoalveolar lavage was performed two times; no Mycobacterium was detected. Transbronchial needle aspiration also found no Mycobacterium. Ophthalmologic examination revealed choroiditis and antituberculosis therapy was initiated. Mycobacterium tuberculosis was later detected in culture of bone marrow. After five months of antituberculosis therapy the patient completely recovered, his liver tests were normal as well as renal function

Multiple myeloma presenting with lower extremity gangrene and hyperviscosity syndrome

Hyperviscosity syndrome and cryoblobulinemia associated with lymphoproliferative disorder is a rare but life threatening condition. The delay of diagnosis can lead to severe mutilation and multiple organ damage. The plasma exchange therapy and the targeted treatment of the underlying disorder can lead to significant improvement. We present a patient who developed extensive soft tissue necroses, mimicking the peripheral artery disease. Despite surgical treatment, the skin lesions progressed involving fingers, earlobes and scrotum. Finally, the patient was diagnosed with multiple myeloma and hyperviscosity syndrome. The clinical condition improved after plasma exchange and myeloma treatment with thalidomide and dexamethasone

Acute kidney injury, uncontrolled arterial hypertension and resulting chronic kidney disease after severe COVID-19 infection

Osobe s teškim oblikom COVID-19 najčešće se prezentiraju respiracijskom insuficijencijom i razvojem akutnoga plućnog distres sindroma (ARDS), ali su moguće i razne izvanplućne komplikacije. Prikazali smo četrdesetdevetogodišnjeg bolesnika s ranije poznatom arterijskom hipertenzijom koji je razvio teški oblik infekcije COVID-19 komplicirane akutnim bubrežnim oštećenjem i kasnije nekontroliranom arterijskom hipertenzijom. Pacijent je hospitaliziran desetog dana bolesti zbog pogoršanja plućne funkcije koja je progredirala do globalne respiracijske insuficijencije i potrebe za orotrahealnom intubacijom. Bolesnik je ispunjavao kriterije ARDS-a. U ranom tijeku liječenja razvio je treći stupanj akutnoga bubrežnog oštećenja prema smjernicama KDIGO. Bilo je potrebno dugotrajno nadomještanje bubrežne funkcije. Uz oporavak diureze zabilježena je značajna proteinurija uz arterijsku hipertenziju, zbog čega je učinjena imunološka obrada i biopsija bubrega. Biopsija bubrega pokazala je akutno tubularno oštećenje bez značajnih promjena glomerula. Rezultati imunoloških testova bili su neupadljivi. Unatoč redovitoj procjeni volumnog statusa i nadomještanja bubrežne funkcije u bolesnika je perzistirala nekontrolirana arterijska hipertenzija koja je zahtijevala uvođenje niza antihipertenziva. Bolest je dodatno komplicirana krvarenjima iz probavnog i dišnog trakta te sekundarnim bolničkim infekcijama. Četiri mjeseca nakon izlječenja akutne bolesti bolesnik ima sniženu glomerularnu filtraciju (e-GFR 55 ml/min/1,73m2 ) bez albuminurije koja se može svrstati u 3A stadij kronične bubrežne bolesti. Cilj ovog rada bio je prikazati razvoj teškog oblika COVID-19 komplicirane akutnim bubrežnim oštećenjem i razvojem nekontrolirane arterijske hipertenzije u kasnijem tijeku liječenja. Navedeni poremećaji prezentirali su se u relativno mlađeg, prethodno zdravog pacijenta te također ostavili kronične posljedice na bubrežnu funkciju. Navedeno bi trebalo potaknuti kliničare na razmatranje i uvrštenje redovite evaluacije bubrežne funkcije i arterijske hipertenzije kao sastavnog dijela praćenja bolesnika nakon COVID-19.The primary clinical feature in patients suffering from severe COVID-19 is respiratory insufficiency and acute respiratory distress syndrome (ARDS). However, extrapulmonary complications are also possible. We present a case of a forty-nine-year-old male patient with arterial hypertension who developed a severe form of COVID-19 complicated with acute kidney injury and later with uncontrolled arterial hypertension. The patient was hospitalized on the 10th day of the disease due to deterioration of pulmonary function, which progressed to global respiratory insufficiency and necessitated orotracheal intubation and mechanical ventilation. The patient met the criteria of severe ARDS. In the early course of the disease the patient developed grade 3 acute kidney injury according to KDIGO guidelines. Long-term renal replacement therapy was necessary. Along with the recovery of diuresis, significant proteinuria was noted accompanied by high blood pressure values, for which immunological assessment and kidney biopsy were performed. Kidney biopsy showed acute tubular necrosis without significant glomerular changes. The results of immunological tests were unremarkable. The disease was also complicated by gastrointestinal and respiratory haemorrhage and secondary hospital infections. Four months after the acute illness, the patient had decreased glomerular filtration (e-GFR 55 ml/min/1.73m2) without albuminuria, which could be classified as stage 3A of chronic kidney disease. This case report aims to present a case of a severe form of COVID-19, complicated by acute kidney injury followed by uncontrolled arterial hypertension in the later course of the treatment. The mentioned disorders occurred in a relatively younger, previously healthy patient and caused chronic consequences on kidney function. The above should encourage clinicians to consider and introduce regular evaluation of renal function and arterial hypertension as part of the follow-up of patients after the COVID-19

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Obese patients in medical intensive care unit: influence of counseling on weight loss and cardiovascular parameters [Pretili pacijenti u internisičkoj jedinici intezivne skrbi: utjecaj savjetovanja na smanjenje tjelesne mase i kardiovaskularne parametre]

A case series of 12 obese patients admitted to medical intensive care unit (ICU) due to life-threatening diseases and the influence of weight loss on cardiovascular parameters is presented. We assessed body weight, body mass index (BMI), blood pressure, pulse, and laboratory values on admission. At discharge from ICU patients were counseled on how to lose weight. They were examined one and six months later. Statistically significant (p < 0.05) decrease of body weight (median at the beginning of a treatment 134 kg, after six months 127.5 kg), BMI (median 41.5 kg/m2 at the beginning of a treatment; 38.9 kg/m2 after six months), systolic blood pressure (medians 145 mmHg and 130 mmHg), diastolic blood pressure (medians 95 mmHg and 85 mmHg) and pulse (medians 104 beats per minute, 78 beats per minute) was found. The reduction of the waist circumference was not significant. One patient died due to severe acute pancreatitis. Patients reported feeling much better after losing weight