Fenoldopam and renal hemodynamics in shiga toxin-related hemolytic uremic syndrome.

BACKGROUND: Fenoldopam, a vasodilating agent, may represent a potential therapeutic opportunity to increase renal perfusion in those conditions where renal hemodynamics are severely impaired by vascular sub-occlusion, as, indeed, is the case in thrombotic microangiopathies. METHODS: The renal resistance index (RRI) was measured, on and off fenoldopam, in 27 children with STEC-HUS. RESULTS: A 12% decrease in RRI was observed on fenoldopam compared to off treatment without changes in the systemic hemodynamics and with no side effects. CONCLUSIONS: If confirmed in larger series, fenoldopam may become an important addition to supportive care to reduce ischemic damage in STEC-HUS and improve long-term outcomes.

Steroid Pulse Therapy for Severe Central Nervous System Involvement in Shiga Toxin-Producing Escherichia coli-Related Hemolytic Uremic Syndrome.

We report on the case of a 7-year-old boy with Shiga toxin-producing Escherichia coli-related hemolytic uremic syndrome (STEC-HUS), initially presenting with abdominal pain as the only clinical feature and thus requiring differential diagnosis with a surgical emergency. Diagnosis of STEC-HUS was made with the appearance of bloody diarrhea and renal function impairment, and the clinical picture rapidly progressed to multiorgan failure. Relatively late and severe central nervous system (CNS) involvement was present, characterized by subacute encephalitis progressing to coma, which became apparent when the acute phase of thrombotic microangiopathy was resolving. Therefore, neurologic manifestations were thought to be related to reperfusion damage to the CNS and high-dose IV steroid pulse therapy was empirically administered. Following this therapeutic scheme, neurologic involvement resolved with no sequelae. This case offers several points of discussion on the clinical presentation and the diagnostic approach to STEC-HUS, on the related neurologic complications, and on a novel approach to their management.

Implementing a global integrative rehabilitation medicine rotation: a physical medicine and rehabilitation residency program's experience.

An innovative international rotation in integrative rehabilitation medicine was implemented as part of the physical medicine and rehabilitation residency program at the Medical College of Wisconsin. Rotation objectives were to introduce medical knowledge of integrative medicine treatments into physical medicine and rehabilitation practice and to initiate collaboration with international academic partners. Residents were approved based on their academic record, completion of prerequisites, and personal statement. During a 4-wk rotation located in Italy, residents developed an integrative treatment strategy for each patient using conventional medical care and other therapeutic options, including acupuncture, biofeedback, aquatic therapy, yoga, and others. Postrotation assessment included evaluations by Italian team and patients, residents' evidence-based presentations, and postrotation self-reflection. Participating residents reported high achievement in clinical performance, improved application of integrative medicine, broader appreciation of cultural diversity in patient care, and increased personal and professional development. This reciprocal program model serves as an example for other programs interested in implementing similar international rotations.

Scrambler therapy may relieve chronic neuropathic pain more effectively than guideline-based drug management: results of a pilot, randomized, controlled trial.

CONTEXT: Neuropathic pain is common, disabling, and often difficult to treat. OBJECTIVES: To compare guideline-based drug management with Scrambler therapy, a patient-specific electrocutaneous nerve stimulation device. METHODS: A clinical trial with patients randomized to either guideline-based pharmacological treatment or Scrambler therapy for a cycle of 10 daily sessions was performed. Patients were matched by type of pain including postsurgical neuropathic pain, postherpetic neuralgia, or spinal canal stenosis. Primary outcome was change in visual analogue scale (VAS) pain scores at one month; secondary outcomes included VAS pain scores at two and three months, pain medication use, and allodynia. RESULTS: Fifty-two patients were randomized. The mean VAS pain score before treatment was 8.1 points (control) and 8.0 points (Scrambler). At one month, the mean VAS score was reduced from 8.1 to 5.8 (-28%) in the control group, and from 8 to 0.7 points (-91%) in the Scrambler group (P<0.0001). At two and three months, the mean pain scores in the control group were 5.7 and 5.9 points, respectively, and 1.4 and 2 points in the Scrambler group, respectively (P<0.0001). More relapses were seen in polyradicular pain than monoradicular pain, but retreatment and maintenance therapy gave relief. No adverse effects were observed. CONCLUSION: In this pilot randomized trial, Scrambler therapy appeared to relieve chronic neuropathic pain better than guideline-based drug management.

Noninvasive continuous positive airway pressure in acute respiratory failure: helmet versus facial mask.

OBJECTIVE: Noninvasive continuous positive airway pressure (nCPAP) is applied through different interfaces to treat mild acute respiratory failure (ARF) in infants. Recently a new pediatric helmet was introduced in clinical practice to deliver nCPAP. The objective of this study was to compare the feasibility of the delivery of nCPAP by the pediatric helmet with delivery by a conventional facial mask in infants with ARF. PATIENTS AND METHODS: We conducted a single-center physiologic, randomized, controlled study with a crossover design on 20 consecutive infants with ARF. All patients received nCPAP by helmet and facial mask in random order for 90 minutes. In infants in both trials, nCPAP treatment was preceded by periods of unassisted spontaneous breathing through a Venturi mask. The primary end point was the feasibility of nCPAP administered with the 2 interfaces (helmet and facial mask). Feasibility was evaluated by the number of trial failures defined as the occurrence of 1 of the following: intolerance to the interface; persistent air leak; gas-exchange derangement; or major adverse events. nCPAP application time, number of patients who required sedation, and the type of complications with each interface were also recorded. The secondary end point was gas-exchange improvement. RESULTS: Feasibility of nCPAP delivery was enhanced by the helmet compared with the mask, as indicated by a lower number of trial failures (P < .001), less patient intolerance (P < .001), longer application time (P < .001), and reduced need for patient sedation (P < .001). For both delivery methods, no major patient complications occurred. CONCLUSIONS: The results of this current study revealed that the helmet is a feasible alternative to the facial mask for delivery of nCPAP to infants with mild ARF.

Platelet monoamine oxidase B activity as a state marker for alcoholism: trend over time during withdrawal and influence of smoking and gender.

AIMS AND METHODS: The present study evaluated time-related changes in platelet monoamine oxidase B (MAO-B) activity in an Italian cohort of alcohol-dependent subjects (n = 98) during early abstinence, and the effect of potential confounding factors, such as gender and smoking status, on the temporal trend of the enzyme activity. RESULTS: While still under the influence of ethanol (time point T1), the mean value of platelet MAO-B activity in alcoholics was 6.4 +/- 3.1 nmol/mg of protein/h. This increased by >40% (to 9.3 +/- 4.4 nmol/mg of protein/h) after 8 days of withdrawal (T2), and remained stable thereafter (T3 and T4: 15 and 22 days of abstinence, respectively). In a cohort of 138 healthy subjects, MAO activity levels averaged 9.9 +/- 0.9 nmol/mg of protein/h. In the group of alcoholic patients, alcohol intake cessation was confirmed by the progressive decrease of serum % carbohydrate-deficient transferrin (CDT), which was pathologically above the reference limits (6%) at T1 (7.8 +/- 3.3%), declined to 6.6 +/- 2.1% at T2 and reached physiological values at T3 and T4. In a subgroup of cirrhotic alcoholics, %CDT did not decrease over time, while MAO activity rose after the first week of abstinence, without further change at T3 and T4. During early withdrawal, neither gender nor tobacco smoking affected the temporal pattern of MAO activity. CONCLUSIONS: MAO-B can be regarded as a state marker of alcohol consumption. The temporal pattern of platelet MAO-B activity may be used for the diagnostic assessment of alcoholism and early abstinence, regardless of gender and smoking status.