Iatrogenic chylothorax due to pleural cavity extravasation of total parenteral nutrition in two adults receiving nutrition through a peripherally inserted central catheter.

Extravasation of total parenteral nutrition (TPN) delivered via central lines is a known potential complication, but significant extravasations of infusate into the pleural space when using peripherally inserted central catheters (PICCs) have not been reported in adults. We report 2 cases ofpleural cavity extravasation ofTPN delivered via a PICC. Measurement of the glucose level of the effusate is a quick way to determine the presence of TPN and should be considered in any patient receiving TPN via any type of central line with a rapidly developing effusion.

Case report: acute renal failure after administering intravenous immunoglobulin.

We report the case of an 87-year-old white woman with myasthenia gravis who presented with nausea, shortness of breath, azotemia, and hyperkalemia shortly after completing a course of intravenous immunoglobulin (IVIG). She had been receiving monthly transfusions of IVIG, but this time had received daily infusions for 5 days rather than 1 day. She had received this same dose in the past without incident. Her history was significant for coronary artery disease, atrial fibrillation, deep venous thrombosis, pulmonary embolism, chronic steroid use, and recurrent urinary tract infection. On examination, she was slightly confused, mildly dehydrated, had a grade II systolic ejection murmur along the upper left sternal border, had bilateral and symmetric mild weakness of the upper and lower extremities, and exhibited mild edema of the lower extremities. Before transfer from the emergency room, she was found to have an elevated serum urea nitrogen and creatinine of 55 and 5.8 mg/dL (19.6 mmol/L and 512.7 micromol/L, respectively). Creatinine 8 days earlier was 0.9 mg/dL (79.6 micromol/L). The hospital course of the acute renal failure is presented with a review of the literature on cases of acute renal failure after IVIG.

Immunogenic yeast-based fermentate for cold/flu-like symptoms in nonvaccinated individuals.

BACKGROUND: The common cold has a profound impact on employee attendance and productivity. Seasonal influenza is responsible for approximately 200,000 hospitalizations and 36,000 deaths per year in the United States alone. Over-the-counter medication efficacy has been questioned, and seasonal vaccination compliance issues abound. Our previously reported randomized trial of an oral fermentation product found an adjuvant benefit for vaccinated individuals in terms of a significantly reduced incidence and duration of cold and flu-like symptoms. METHODS: A concurrent 12-week, randomized, double-blind, placebo-controlled clinical trial of 116 subjects with no recent history of seasonal influenza vaccination was conducted. Participants received once-daily supplementation with 500 mg of a dried modified Saccharomyces cerevisiae oral fermentate (EpiCor) or placebo. Clinical outcome measurements included periodic interval-based in-clinic examinations and serologic analysis at baseline, 6 weeks, and 12 weeks. Participants utilized a standardized self-report symptom diary. RESULTS: Subjects receiving the intervention experienced a statistically significant reduction in the incidence (p = 0.01), a nonsignificant reduction in duration (p = 0.10), and no impact on the severity (p = 0.90) of colds or flu-like symptoms, but a more favorable safety profile compared with subjects receiving placebo. CONCLUSIONS: This nutritional-based fermentate appeared to be safe and efficacious in a unique at-risk population and should receive more clinical research as a potential method to reduce the incidence of cold and flu-like symptoms, in individuals with and without a history of influenza vaccination.

Impact of an intensive care unit telemedicine program on a rural health care system.

We evaluated the impact of a 15-hospital, rural, multi-state intensive care unit (ICU) telemedicine program. Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) scores, raw mortality rates, and actual-to-predicted length of stay (LOS) ratios and mortality ratios were used. Surveys evaluated program impact in smaller facilities and satisfaction of the physicians staffing the remote center. Smaller facilities' staff reported improvements in the quality of critical care services and reduced transfers. In regional hospitals, acuity scores increased (retention of sicker patients) while raw mortality was the same or lower. Length of stay ratios were reduced in these hospitals. In the tertiary hospital, actual-to-predicted ICU and hospital mortality and LOS ratios decreased.

Effects of a modified yeast supplement on cold/flu symptoms.

A yeast-based product (EpiCor, a dried Saccharomyces cerevisiae fermentate) was compared to placebo to determine effects on the incidence and duration of cold and flu-like symptoms in healthy subjects recently vaccinated for seasonal influenza. In a 12-week, randomized, double-blind, placebo-controlled clinical trial, 116 participants received daily supplementation with 500 mg of EpiCor or placebo for 12 weeks. Data collected included periodic in-clinic examinations and serologic evaluations at baseline, 6- and 12-weeks. Subjects also utilized a standardized self-report symptom diary during the study. Participants receiving the yeast-based product had significantly fewer symptoms and significantly shorter duration of symptoms when compared with subjects taking a placebo.

Prognostic outcomes after the initiation of an electronic telemedicine intensive care unit (eICU) in a rural health system.

APACHE (Acute Physiology and Chronic Health Evaluation) mortality predictions and other outcomes are reported after the initiation of a telemedicine intensivist staffing program to monitor the intensive care unit patients of a rural health system. Mortality, length of ICU stay, and length of hospital stay were significantly less than predicted. Length of stay was identical to one year previously in the largest hospital reported, but the case mix index of severity had increased. More severely ill patients were being treated without increase in length of stay.

Psychosocial profiling: a holistic management tool for non-compliance.

We introduce a new concept of psychosocial profiling as a tool that provides the transplant team with a psychosocial framework for identification, intervention and management of non-compliance. This will also increase our understanding of emotional problems experienced by patients before transplant, as a result of living with the uncertainty and medical side effects of chronic illness. Psychosocial profiling is adaptable throughout the transplant process and gives every patient an opportunity of psychosocial support to help him or her into a position of emotional stability and compliance with their medications and postoperative care. Implementation of this strategy will move health care professionals from being gatekeepers to managers and facilitators of holistic care in recipients of transplants.

Ischemic nephropathy in South Dakota: case reports and review.

Ischemic nephropathy, a relatively new term coined to describe renal insufficiency due to renal artery disease, is neither a new subject for medicine throughout the country, nor a new problem here in South Dakota. It is an important and overlooked cause of renal insufficiency and is almost certainly under-diagnosed. Five case reports and a review of the entity are described to illustrate the diversity of this clinical presentation. Intervention in such cases was thought to preserve, or even improve renal function, delaying the onset of end stage renal disease (ERSD).

Obesity and kidney transplantation.

There is a worldwide epidemic of obesity, and an increasing number of patients who are obese are presenting for solid-organ transplantation. Obesity increases the risk for delayed graft function and local wound complications after technically successful kidney transplantation. Obese patients are more likely to have comorbid factors leading to premature death with a functioning kidney transplant. We suggest the use of World Health Organization criteria when reporting the impact of obesity on recipients of solid-organ transplants. Prospective multicenter studies are indicated to evaluate long-term outcomes in obese patients who successfully receive a kidney transplant. Rigorous efforts should be made to optimize weight before and after solid-organ transplantation by a judicious combination of diet, exercise, minimization of steroid therapy, surgery, and psychological therapies.

Hypothyroid acute renal failure.

Muscular disorders and even hypothyroid myopathy with elevated muscle enzymes are commonly seen in hypothyroidism. In this paper, we report a case of acute renal failure in a 35-year old male patient with myalgia. His serum creatinine reached a level of 2.4 mg/dl. Later, his myalgia was found to be due to hypothyroidism with TSH of over 500 uiv/ml. With thyroid replacement therapy, myalgia and his serum creatinine stabilized and subsequently improved. Hypothyroidism, although rare, has been reported as a definite and authentic cause of rhabdomyolysis. As a result, hypothyroidism must be considered in patients presenting with acute renal failure and elevated muscle enzymes.

Early onset polycystic kidney disease: how early is early?

We report a case of a six-month-old infant with autosomal dominant polycystic kidney disease. He was a full term baby with an uneventful pre and postnatal period. He was delivered by uncomplicated vaginal delivery without forceps or fetal distress. His father was recently diagnosed with adult onset autosomal dominant polycystic kidney disease (APKD) with creatinine clearance around 25%-30%. The parents requested renal ultrasound of the baby to screen for APKD. It revealed normal sized and normal shaped kidneys, but with multiple bilateral cysts in the renal cortices, each measuring about 5 mm-7 mm in diameter. Subsequent DNA analysis showed presence of PKD1 gene, present on chromosome 16. His renal function was within normal range. The baby needs to be regularly followed-up for the most common complications of APKD, including hypertension and renal insufficiency.

Prevention of obesity-linked renal disease: age-dependent effects of dietary food restriction.

BACKGROUND: Hyperphagic obese Zucker rats develop glomerular injury and die of renal disease, an outcome prevented by food restriction at an early age. We examined the effects of food restriction imposed at different ages on systemic, renal hemodynamic, and hormonal changes to gain insight into the mechanisms of obesity-linked glomerular injury. METHODS: At 6 weeks of age obese Zucker rats were either fed ad libitum or were restricted in food intake at various ages (6, 12, 26, or 50 weeks) to that consumed by lean Zucker rats (14 g/day). Every four weeks 24-hour urine collections, blood pressure, and venous blood samples were obtained until the end of study (60 weeks). RESULTS: Food restriction at 6 or 12 weeks of age prevented glomerular injury and hypertrophy and delayed the development of hypertension, hypercholesterolemia, and hyperinsulinemia. Food restriction at 26 weeks of age reduced proteinuria, while restriction at 50 weeks prevented further increases in proteinuria without altering pre-existing hypercholesterolemia, hypertension, or hyperinsulinemia. Hypertriglyceridemia and glomerular hyperfiltration in the obese animals were reversed at any age by food restriction. Plasma leptin levels were elevated in all obese groups. CONCLUSIONS: (1) Early food restriction provided the greatest metabolic and renal benefits; (2) glomerular injury correlated with hyperphagia-induced hyperfiltration and hypertriglyceridemia and both were prevented by food restriction; (3) hypercholesterolemia was due to an increase in LDL and/or VLDL cholesterol; and (4) leptin does not directly contribute to glomerular injury in the obese Zucker rat.

Protective effects of a soy diet in preventing obesity-linked renal disease.

BACKGROUND: Hypertension, hyperlipidemia, hyperfiltration, hyperinsulinemia, glomerular hypertrophy, and ultimately glomerular injury and renal failure are associated with obesity in the Zucker rat. Evidence from other laboratories suggests that soy protein might offer renal protection. METHODS: At five weeks of age obese rats were placed on diets containing either soy or casein as a protein source and studied until 24 weeks of age. At six weeks of age and every four weeks thereafter, 24-hour urine collections were obtained along with measurements of systolic blood pressure (tail cuff) and blood from the tail vein. At the end of the study the kidneys were fixed and sectioned for histology. RESULTS: Both groups gained weight and developed systemic hypertension and hyperinsulinemia at the same rate. Glomerular filtration rate (creatinine clearance) also was similar between groups throughout the study and both groups developed glomerular hypertrophy to the same extent. The development of hypertriglyceridemia was actually accelerated in the soy-fed rats compared to the casein-fed animals. The soy diet, however, virtually completely prevented the development of hypercholesterolemia, primarily low-density lipoprotein (LDL) and/or very low-density lipoprotein (VLDL) cholesterol, and slowed the development of proteinuria and glomerular injury. CONCLUSIONS: The data suggest that an important determinant of the protective effects of soy was related to the prevention of hypercholesterolemia in this model. Other unmeasured differences between groups, such as differences in glomerular capillary blood pressure or the effects of the antioxidant properties of soy components also may have contributed to the protective effects of soy.