Lithium-Induced Arginine Vasopressin Resistance (AVP-R): A Case of Chronic Exposure to Lithium

Lithium salts (lithium) is a psychotropic drug widely used as a pharmacological option in managing bipolar disorder. Regular monitoring of serum levels is necessary due to the narrow therapeutic range of lithium. Typically, the diagnosis of lithium intoxication is based on the presence of elevated plasma levels. Nevertheless, poisoning can ensue from either acute ingestion or chronic use, even in patients with normal plasma levels. The utilization of lithium has been decreasing due to its potential for multiorgan toxicity. Lithium accumulation in renal distal tubular cells is a prevalent cause of acquired arginine vasopressin resistance (AVP-R), previously known as nephrogenic diabetes insipidus (DI). Some patients might also experience neurologic persistent symptoms after plasma level normalization, a condition known as the syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). We present a case report of acquired AVP-R following prolonged lithium use. This case report aims to increase awareness, particularly among those who may be unfamiliar with the use of lithium and its associated adverse reactions. In addition, it seeks to highlight the dissociation between clinical manifestations and lithium plasma levels, emphasizing the need for careful evaluation in patients receiving lithium treatment.

[Digital home-based multidisciplinary cardiac rehabilitation: How to counteract physical inactivity during the COVID-19 pandemic]

Introduction and Objectives

Center-based cardiac rehabilitation (CR) programs have been forced to close due to COVID-19. Alternative delivery models to maintain access to CR programs and to avoid physical inactivity should be considered. The aim of this study was to assess physical activity (PA) levels after completing a home-based digital CR program.

Methods

A total of 116 cardiovascular disease (CVD) patients (62.6±8.9 years, 95 male) who had been attending a face-to-face CR program were recruited and assessed (baseline and at three months) on the following parameters: PA, sedentary behavior, adherence, cardiovascular and non-cardiovascular symptoms, feelings toward the pandemic, dietary habits, risk factor control, safety and adverse events. The intervention consisted of a multidisciplinary digital CR program, including regular patient assessment, and exercise, educational and psychological group sessions.

Results

Ninety-eight CVD patients successfully completed all the online assessments (15.5% drop-out rate). A favorable main effect of time was an increase in moderate to vigorous PA and a decrease in sedentary time at three months. Almost half of the participants completed at least one online exercise training session per week and attended at least one of the online educational sessions. No major adverse events were reported and only one minor event occurred.

Conclusion

During the pandemic, levels of moderate to vigorous PA improved after three months of home-based CR in CVD patients with previous experience in a face-to-face CR model. Diversified CR programs with a greater variety of content tailored to individual preferences are needed to meet the motivational and clinical requirements of CVD patients.

Management of patients with type 2 diabetes in cardiovascular rehabilitation

The clinical benefits of rehabilitation in cardiovascular disease are well established. Among cardiovascular disease patients, however, patients with type 2 diabetes mellitus require a distinct approach. Specific challenges to clinicians and healthcare professionals in patients with type 2 diabetes include the prevalence of peripheral and autonomic neuropathy, retinopathy, nephropathy, but also the intake of glucose-lowering medication. In addition, the psychosocial wellbeing, driving ability and/or occupational status can be affected by type 2 diabetes. As a result, the target parameters of cardiovascular rehabilitation and the characteristics of the cardiovascular rehabilitation programme in patients with type 2 diabetes often require significant reconsideration and a multidisciplinary approach. This review explains how to deal with diabetes-associated comorbidities in the intake screening of patients with type 2 diabetes entering a cardiovascular rehabilitation programme. Furthermore, we discuss diabetes-specific target parameters and characteristics of cardiovascular rehabilitation programmes for patients with type 2 diabetes in a multidisciplinary context, including the implementation of guideline-directed medical therapy.

How to Improve the Transition from Pediatric to Adult Health Care Services?

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[Solitary fibrous tumor of the pleura]

Solitary fibrous tumors of the pleura are rare tumors originating from the mesenchymal cells of the submesothelial tissue of the pleura. In half of the cases, the neoplasm presents as an asymptomatic mass, often with quite large dimensions. It is a benign tumor in 80% of the cases and even when considered malignant has a good prognosis if totally removed. We present the case of a 78-year-old female, who was evaluated for lower respiratory infection, in whom the diagnosis of Giant Solitary Fibrous Tumor of the Pleura was made. She was submitted to surgical en bloc resection and is asymptomatic and with no evidence of recurrence in the 4th month follow-up evaluation.

[Unknown primary neoplasm: a retrospective 3-year study at a service of internal medicine]

The authors review all the cases of Carcinoma of Unknown Primary Site admitted to a medical service during a 3-year period (1987-1989). These cases represented 9% of all the neoplastic diseases admitted during the aforementioned period. Most of the patients presented extensive metastatic disease. The main histologic type was adenocarcinoma. The most useful of all the ancillary exams requested for primary localization and staging purposes was the computerized axial tomography (CT). The primary localization was achieved in two cases (one while the patient was still alive, and one on autopsy). The low performance status of the patients, together with the existence of advanced metastatic disease, precluded more than palliative therapy in most of the cases. The mortality of this series was 40% (4/10), with 3 autopsies performed. The authors compare their experience with the literature available, focusing the need for a work-up based on strict diagnostic criteria based on the histology and supported by specific laboratory tests. They also underline the value of the CT scan as the most useful exam in these circumstances.