Development and validation of a deep learning model to screen hypokalemia from electrocardiogram in emergency patients / 中华医学杂志(英文版)

BACKGROUND@#A deep learning model (DLM) that enables non-invasive hypokalemia screening from an electrocardiogram (ECG) may improve the detection of this life-threatening condition. This study aimed to develop and evaluate the performance of a DLM for the detection of hypokalemia from the ECGs of emergency patients.@*METHODS@#We used a total of 9908 ECG data from emergency patients who were admitted at the Second Affiliated Hospital of Nanchang University, Jiangxi, China, from September 2017 to October 2020. The DLM was trained using 12 ECG leads (lead I, II, III, aVR, aVL, aVF, and V1-6) to detect patients with serum potassium concentrations <3.5 mmol/L and was validated using retrospective data from the Jiangling branch of the Second Affiliated Hospital of Nanchang University. The blood draw was completed within 10 min before and after the ECG examination, and there was no new or ongoing infusion during this period.@*RESULTS@#We used 6904 ECGs and 1726 ECGs as development and internal validation data sets, respectively. In addition, 1278 ECGs from the Jiangling branch of the Second Affiliated Hospital of Nanchang University were used as external validation data sets. Using 12 ECG leads (leads I, II, III, aVR, aVL, aVF, and V1-6), the area under the receiver operating characteristic curve (AUC) of the DLM was 0.80 (95% confidence interval [CI]: 0.77-0.82) for the internal validation data set. Using an optimal operating point yielded a sensitivity of 71.4% and a specificity of 77.1%. Using the same 12 ECG leads, the external validation data set resulted in an AUC for the DLM of 0.77 (95% CI: 0.75-0.79). Using an optimal operating point yielded a sensitivity of 70.0% and a specificity of 69.1%.@*CONCLUSIONS@#In this study, using 12 ECG leads, a DLM detected hypokalemia in emergency patients with an AUC of 0.77 to 0.80. Artificial intelligence could be used to analyze an ECG to quickly screen for hypokalemia.

Cambios electrocardiográficos asociados a hipopotasemia: alteraciones del segmento ST imitando isquemia miocárdica de múltiples territorios / Electrocardiographic changes associated with hypokalemia: ST-segment abnormalities mimicking ischemia of multiple territories

Resumen: Se presenta el caso de un paciente de sexo femenino de 42 años sin antecedentes clínicos de relevancia, con hipopotasemia severa y cambios electrocardiográficos imitando isquemia miocárdica con enfermedad corona-ria de múltiples vasos.

Abstracts: A 42-year-old woman with no previous medical history developed severe hypokalemia. The ECG changes suggested multivessel coronary artery disease with ischemia in several territories.

Persistent severe hypokalemia: Gitelman syndrome and differential diagnosis / Hipocalemia grave persistente: Síndrome de Gitelman e diagnósticos diferenciais

Abstract The main causes of hypokalemia are usually evident in the clinical history of patients, with previous episodes of vomiting, diarrhea or diuretic use. However, in some patients the cause of hypokalemia can become a challenge. In such cases, two major components of the investigation must be performed: assessment of urinary excretion potassium and the acid-base status. This article presents a case report of a patient with severe persistent hypokalemia, complementary laboratory tests indicated that's it was hypomagnesaemia and hypocalciuria associated with metabolic alkalosis, and increase of thyroid hormones. Thyrotoxic periodic paralysis was included in the differential diagnosis, but evolved into euthyroid state, persisting with severe hypokalemia, which led to be diagnosed as Gitelman syndrome.

Resumo As principais causas de hipocalemia normalmente são evidentes na história clínica dos pacientes em investigação etiológica, com episódios prévios de vômitos, diarréia ou uso de diuréticos. Entretanto, em alguns pacientes, a causa da hipocalemia pode se tornar um desafio. Em tais casos, dois principais componentes da investigação devem ser realizados: avaliação da excreção do potássio urinário e do "status" ácido-básico. Este artigo traz um relato de caso de uma paciente portadora de hipocalemia grave persistente, com investigação laboratorial complementar caracterizada por hipomagnesemia e hipocalciúria, associada à alcalose metabólica e elevação dos hormômios tireoideanos. A apresen- tação inicial do quadro incluiu paralisia periódica tireotóxica como um dos principais diagnósticos diferenciais, porém, a paciente evoluiu para um es- tado eutireoideo e persistiu com grave hipocalemia, sendo, por fim, realizado diagnóstico clínico de Síndrome de Gitelman.

Inusual forma de presentación de hipertiroidismo asociado a parálisis hipokalémica / An unusual presentation of hyperthyroidism associated with hypokalemic paralysis

La parálisis periódica hipokalémica tirotóxica (PPHT) constituye un raro trastorno caracterizado por debilidad muscular severa asociado a hipokalemia en pacientes hipertiroideos. Se reporta en este artículo un paciente masculino de 28 años de edad quien ingresó a un centro de salud de primer nivel, por debilidad muscular generalizada con subsecuente caída desde su altura sin pérdida de la conciencia. Es remitido posteriormente a un Hospital regional (en Colombia), en donde se identifica la presencia de bocio. Se solicitaron pruebas de función tiroidea y niveles de hormona estimulante de la tiroides (TSH) los cuales fueron anormales. Este caso clínico busca difundir el conocimiento de una patología considerada infrecuente en la región, con el fin de resaltar algunos aspectos clínicos y fisiopatológicos, destacando la importancia de tener presente el diagnostico de esta enfermedad y lograr hacer un manejo oportuno teniendo en cuenta sus complicaciones potencialmente fatales.

Hypokalemic thyrotoxic periodic paralysis is a rare disorder characterized by severe muscle weakness with low serum potassium levels in hyperthyroid patients. We describe a 28- years-old man who was admitted to a first level health center with a history of muscle weakness and a fall from his height without loss of consciousness. He was transferred to a regional Hospital (in Colombia) where, in a physical examination, was noticed an enlarged size of thyroid gland. Thyroid function tests and levels of thyroid stimulating hormone (TSH) were requested, which were abnormal. This case report attempts to spread the knowledge of a disease considered rare in the region, in order to highlight some clinical and pathophysiological aspects, the importance of always be considered in patients with this clinical presentation and making an appropriate treatment and diagnosis.

Rabdomiólisis por hipopotasemia severa: Report of six cases / Severe hypokalemic rhabdomyolysis

Rhabdomyolysis results from acute necrosis of skeletal muscle fibers and consequent leakage of muscle constituents into the circulation. It ranges from an asymptomatic state to a severe condition associated with extreme elevations in creatine kinase and acute renal failure. Reported etiologies of rhabdomyolysis include alcohol abuse, drugs, muscle trauma and muscle overexertion. Less common causes include muscle enzyme deficiencies, electrolyte abnormalities, infectious causes, toxins and endocrine disorders. Hypokalemia is a rare cause of rhabdomyolysis. We report six patients aged 31 to 57 years (three women) with a severe hypokalemic rhabdomyolysis, secondary to chronic diarrhea in two patients, treatment with loop diuretics in one and Gitelman syndrome in three. Rhabdomyolysis may be underdiagnosed in the context of hypokalemia, because the neuromuscular symptoms can be attributed solely to the electrolyte disorder.

Utility of F-18 FDG-PET in Detecting Primary Aldosteronism in Patients with Bilateral Adrenal Incidentalomas

In patients with primary aldosteronism who have bilateral adrenal incidentalomas, it is important to identify which adrenal gland is secreting excess aldosterone. Traditionally, adrenal vein sampling (AVS) has been performed for lateralization despite its invasiveness. Here we report a case of bilateral adrenal incidentaloma in which 18-Fluorodeoxyglucose (FDG)-positron emission tomography (PET) was used to identify the functional adrenal mass. A 53-yr-old man was referred to our clinic due to bilateral adrenal incidentalomas (right: 1 cm, left: 2.5 cm) on computed tomography (CT). Given his history of colon cancer, FDG-PET/CT scanning was used to rule out metastasis. Although there was focal hot uptake lesion in the right adrenal gland, the patient was suspected primary aldosteronism clinically more than metastasis because of the patient's underlying hypertension with hypokalemia. It was consistent with the results of AVS. Based on these findings, we propose that FDG-PET/CT can be used instead of AVS to identify the source of primary aldosteronism between two bilateral adrenal incidentalomas.

Hipocalemia persistente: relato de caso / Persistent hypokalemia: case report

JUSTIFICATIVA E OBJETIVOS: Os distúrbios do metabolismo do potássio são comuns e tanto a reposição como o diagnóstico etiológico da hipocalemia grave e refratária em pacientes internados são um grande desafio na prática clínica. A diminuição do potássio plasmático leva a um grande prejuízo na função de nervos e músculos, podendo resultar em arritmias graves, em que o paciente na maioria das vezes apresenta-se assintomático, ou com queixas inespecíficas, como fraqueza muscular. O objetivo deste estudo foi mostrar a dificuldade no diagnóstico etiológico da hipocalemia e trazer alternativas para simplificá-lo. RELATO DO CASO: Paciente do sexo masculino, 34 anos, técnico em enfermagem, que evoluiu com hipocalemia persistentee grave. No período de dois meses evoluiu com quadro de hipertensão arterial, e, posteriormente, acne, confusão mental e diabetes com baixos valores plasmáticos de potássio apesar da reposição vigorosa, por via oral e venosa, de cloreto de potássio. Após descartar o hiperaldosteronismo, investigou-se hipercortisolismo,apesar de discretos achados fenotípicos de síndrome de Cushing. Com a confirmação do diagnóstico de doença de Cushing, o mesmo foi submetido à adrenalectomia bilateral com rápida correção dos valores pressóricos, glicêmicos e de potássio sérico. CONCLUSÃO: Diante de um caso de hipocalemia grave e refratária à reposição, torna-se indispensável o estabelecimento do diagnóstico etiológico para a correção deste grave distúrbio metabólico.

BACKGROUND AND OBJECTIVES: Metabolic disorders of potassium are common and both the replacement and the etiology of severe and refractory hypokalemia in hospitalized patients are a major challenge in clinical practice. The decrease in plasma potassium leads to a large impairment of nerves and muscles function and can result in life-threatening arrhythmias, in which the patient is most often asymptomatic or presents with nonspecific complaints, such as muscle weakness. This study aims to show the difficulty in diagnosing the etiology of hypokalemia and bring alternatives to simplify it. CASE REPORT: Male patient, 34 years-old, technical nursing has developed severe and persistent hypokalemia. In a two-month period he progressed with hypertension, and later, acne, diabetes, mental confusion and low plasma levels of potassium despite vigorous oral and intravenous potassium chloride replacement. After discarding hyperaldosteronism, hypercortisolism was investigated, although discrete phenotypic findings of Cushing's syndrome were present. Just after confirmation of Cushing's disease, the patient has undergone bilateral adrenalectomy with rapid correction of blood pressure values serum glucose and potassium. CONCLUSION: Facing a case of severe hypokalemia refractory to potassium replacement, it is essential to establish an etiological diagnosis for the correction of this serious metabolic disorder.

An unusual cause of failure to thrive in a child.

Classic Bartter syndrome, depending on the severity, presents during childhood or adolescence as failure to thrive and may be incorrectly labelled as protein–energy malnutrition, particularly in children from a low socioeconomic stratum. We encountered a 5-year-old boy who was asymptomatic till the age of 3 years. Despite adequate dietary intake, he was admitted and managed in various hospitals as a case of protein–energy malnutrition. On evaluation, he had unusual features in the form of persistent hypokalaemia and polyuria leading us to suspect a renal tubular disorder. Treatment of the condition resulted in good weight gain and normalization of serum electrolytes.

Disorders of potassium homeostasis: pathophysiology and management.

Disorders of potassium homeostasis are common electrolyte abnormalities encountered in hospitalized patients. Hypokalemia and hyperkalemia have been estimated to occur in about 21% and 3% of hospitalized patients, respectively; though the morbidity and mortality associated with the latter is significantly higher. Potassium is a predominantly intracellular ion and the understanding of its dynamics between intra- and extracellular fluid milieus, along with its handling by the kidneys, is important in the diagnosis and treatment of potassium disorders. This article aims to provide a clinically relevant update on management of potassium disorders for internists.

Hypokalemic periodic paralysis as a manifestation of thyrotoxicosis.

OBJECTIVE: To study the clinical characteristics of patients who suffer from hypokalemic periodic paralysis, as the presenting symptoms of thyrotoxicosis. MATERIAL AND METHOD: A retrospective review of 29 patients who presented with the syndrome of hypokalemic periodic paralysis as the symptom of thyrotoxicosis at Ratchaburi Hospital between January 1,1995 and December 31, 2007. Patients'data, diagnosis, blood chemistry, and thyroid function test were collected from medical records. RESULTS: All patients exhibited muscle weakness for a duration of one to two days, while all patients with hypokalemic periodic paralysis were determined to have high serum thyroid hormone and diagnosed with thyrotoxicosis. Patients with hypokalemic periodic paralysis were the first symptom leading to diagnosis of thyrotoxicosis. The attack of weakness occurred during the night in all patients. The patients, 96.6% being male, showed improvement of their symptoms through potassium replacement and thyrotoxicosis treatment using propylthiouracil and non selective beta adrenergic blocker All patients recovered and did not demonstrate reoccurring hypokalemic periodic paralysis. The degree of muscle weakness was found to correlate significantly (p < 0.05) with level of serum potassium, magnesium, and duration of weakness. CONCLUSION: It is important to determine blood thyroid hormone in all patients with hypokalemic periodic paralysis.

Severe hypertension and hypokalemia as first clinical manifestations in ectopic Cushing's syndrome / Hipertensão grave e hipocalemia como primeiras manifestações clínicas em casos de síndrome de Cushing ectópica

Ectopic ACTH production occurs in about 10 percent of all cases of Cushing's syndrome, and about 25 percent of cases of ACTH-dependent Cushing's syndrome. Diverse tumor types are able to produce ACTH ectopically, including small cell lung carcinoma. Ectopic ACTH secretion by malignant neoplasm has been reported to have earlier and more aggressive metabolic effects. We report a 59-year-old male patient with severe hypertension, metabolic alkalosis and hypokalemia as the first clinical manifestations of an ACTH-secreting small cell lung carcinoma, although the typical phenotypic features of Cushing's syndrome were not present. Ectopic Cushing's syndrome should always be ruled out in patients with severe hypertension and hypokalemia.

A produção de ACTH ectópico ocorre em aproximadamente 10 por cento dos casos de síndrome de Cushing, e em aproximadamente 25 por cento dos casos de síndrome de Cushing dependentes de ACTH. Diversos tipos de tumores são capazes de produzir ACTH ectopicamente, incluindo carcinoma pulmonar de células pequenas. Relatórios indicam que a secreção de ACTH ectópico por neoplasma maligno causa efeitos metabólicos prematuros e mais agressivos. Apresentamos um paciente, 59 anos, com hipertensão grave, alcalose metabólica e hipocalemia, tendo estas como as primeiras manifestações clínicas de um carcinoma pulmonar de células pequenas com secreção de ACTH, embora as características fenótipas típicas da síndrome de Cushing não estavam presentes. A síndrome de Cushing ectópica deveria ser excluída sempre em pacientes com hipertensão grave e hipocalemia.

Evaluating mortality rate caused by electrolyte abnormalities in hospitalized patients

Adjustment of composition of body fluids and electrolytes is one of the most important aspects of patients care. Sodium and Potassium are the most important body cations, the improper adjustment of them will cause sever disorders in neuromuscular, gastrointestinal, respiratory and cardiovascular systems. Acute renal failure indicated by increase in creatinine and nitrogen urea, brings an accumulation of fluids, salts and metabolites of nitrogen in body. This study intends to assess the status of electrolyte abnormalities and mortality rates of the patients hospitalized in ICU wards in our country. This is a descriptive and retrospective study on the records of 378 patients hospitalized in ICU. A questionnaire was prepared and the data were entered in SPSS system. They were statistically analyzed by using chi-square and fisher's Exact test methods. Out of 378 patients hospitalized in ICU, over 2/3 of them were male and over half of them were>45 years old. Frequency distribution of electrolyte abnormalities was as follows: Hyponatremia 59% hypernatremia 23% hypokalemia 37% hyperkalemia 28%, 35% and 21% of patients had respectively BUN and creatinine more than the normal range. 26% of patients hospitalized in ICU had nonsurgical problems and 74% of the patients had surgical problems. Average time of hospitalization in ICU was 85 days and mortality rate was 35%. The most common electrolyte abnormality was related to variation in serum sodium levels in the form of hyponatremia. And the highest prevalence electrolyte abnormality in dead patients was hyponatremia. This study proves that the prevalence of electrolyte abnormalities is directly related to mortality and increase in hospitalization period and those having undergone surgical operations during hospitalization in ICU, manifested more abnormalities

Síndrome de Bartter: diagnóstico diferencial da hipopotassemia intensa e assintomática: relato de caso e revisão de literatura / Batter Syndrome: distinguishing diagnosis of the intense and asymptomatic hypokalemia: case story and review of the literature

Relata-se caso de paciente de 51 anos de idade com hipocalemia intensa e assintomática em que foi iniciada a suplementação de potássio sem sua normalização. A identificação de hiperaldosteronismo hiperreninêmico permitiu estabelecer o diagnóstico de síndrome de Bartter.

Approach to hypokalemia.

Hypokalemia is frequently encountered in clinical practice. It can be due to either potassium deficiency (inadequate potassium intake or excessive potassium loss) or to net potassium shifts from the extracellular to the intracellular compartment. Inadequate dietary intake of potassium alone rarely causes hypokalemia since kidney is able to lower potassium excretion below 15 mmol per day. Hypokalemia due to excessive potassium loss can be due to renal or extrarenal losses. It is not necessary to wait for a timed urine collection for potassium to determine the etiology of hypokalemia. Measurement of spot urine for potassium and creatinine as well as evaluation of acid-base status can be used as an initial step in the diagnosis of hypokalemia. Subsequent evaluations such as measurement of spot urinary chloride, blood pressure, serum aldosterone, renin and cortisol levels may be needed in certain circumstances.

Approach to renal tubular disorders.

The renal tubule plays an important role in fluid and electrolyte homeostasis. Renal tubular disorders may affect multiple ( e.g., Fanconi syndrome) or specific (e.g., nephrogenic diabetes insipidus, renal glucosuria) tubular functions. Most conditions are primary and monogenic but occasionally are secondary to other disorders (focal segmental glomerulosclerosis, cystinosis, Lowe syndrome). Tubular dysfunction should be considered in all children with failure to thrive, polyuria, refractory rickets, hypokalemia and metabolic acidosis. Careful clinical and laboratory evaluation is essential for appropriate diagnosis and specific management of these conditions.