Syndrome of inappropriate antidiuretic hormone secretion

Hyponatremia is the most frequent electrolytic disorder in hospitalized patients, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), the most frequent cause of hiponatremia with clinically normal extracellular volume. It consists of a disorder of the regulation of body water that obeys to different causes, mainly cancer, pulmonary illnesses, disorders of the central nervous system and diverse drugs. As in any hiponatremia it a physiological knowledge of the regulation of body water and sodium is essential as well as the application of precise diagnostic criteria in order to manage the problem with an effective treatment. The available data until the moment show that the clinical diagnosis of SIADH made by professionals is mainly not supported on the established criteria drawn by experts and this lack of accuracy probably hits in the therapeutic result. The basis of the treatment of the SIADH is to correct its cause, water restriction, solutes (sodium chloride) and the use of vaptans in case of failure of the previous measures.

Management of acute renal replacement therapy in critically ill cirrhotic patients

Renal replacement therapy (RRT) in cirrhotic patients encompasses a number of issues related to the particular characteristics of this population, especially in the intensive care unit (ICU) setting. The short-term prognosis of cirrhotic patients with acute kidney injury is poor, with a mortality rate higher than 65% in patients with RRT requirement, raising questions about the futility of its initiation. Regarding the management of the RRT itself, there is still no consensus with respect to the modality (continuous versus intermittent) or the anticoagulation required to improve the circuit life, which is shorter than similar at-risk populations, despite the altered haemostasis in traditional coagulation tests frequently found in these patients. Furthermore, volume management is one of the most complex issues in this cohort, where tools used for ambulatory dialysis have not yet been successfully reproducible in the ICU setting. This review attempts to shed light on the management of acute RRT in the critically ill cirrhotic population based on the current evidence and the newly available tools. We will discuss the timing of RRT initiation and cessation, the modality, anticoagulation and fluid management, as well as the outcomes of the RRT in this population, and provide a brief review of the albumin extracorporeal dialysis from the point of view of a nephrologist.

Thrombotic microangiopathies assessment: mind the complement

When faced with microangiopathic haemolytic anaemia, thrombocytopenia and organ dysfunction, clinicians should suspect thrombotic microangiopathy (TMA). The endothelial damage that leads to this histological lesion can be triggered by several conditions or diseases, hindering an early diagnosis and aetiological treatment. However, due to systemic involvement in TMA and its low incidence, an accurate early diagnosis is often troublesome. In the last few decades, major improvements have been made in the pathophysiological knowledge of TMAs such as thrombotic thrombocytopenic purpura [TTP, caused by ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin Type 1 motif, member 13) deficiency] and atypical haemolytic uraemic syndrome (aHUS, associated with dysregulation of the alternative complement pathway), together with enhancements in patient management due to new diagnostic tools and treatments. However, diagnosis of aHUS requires the exclusion of all the other entities that can cause TMA, delaying the introduction of terminal complement blockers, which have shown high efficacy in haemolysis control and especially in avoiding organ damage if used early. Importantly, there is increasing evidence that other forms of TMA could present overactivation of the complement system, worsening their clinical progression. This review addresses the diagnostic and therapeutic approach when there is clinical suspicion of TMA, emphasizing complement evaluation as a potential tool for the inclusive diagnosis of aHUS, as well as for the improvement of current knowledge of its pathophysiological involvement in other TMAs. The development of both new complement activation biomarkers and inhibitory treatments will probably improve the management of TMA patients in the near future, reducing response times and improving patient outcomes.

The impact of functional delayed graft function in the modern era of kidney transplantation - A retrospective study

The dialysis-based definition of Delayed Graft Function (dDGF) is not necessarily objective as it depends on the individual physician's decision. The functional definition of DGF (fDGF, the failure of serum creatinine to decrease by at least 10% daily on 3 consecutive days during the first week post-transplant), may be more sensitive to reflect recovery after the ischemia-reperfusion injury. We retrospectively analyzed both definitions in 253 deceased donor kidney transplant recipients for predicting death-censored graft failure as primary outcome, using eGFR < 25 ml/min/1.73 m² as a surrogate end-point for graft failure. Secondary outcome was a composite outcome that included graft failure as above and also patient's death. Median follow-up was 3.22 [2.38-4.21] years. Seventy-nine patients developed dDGF (31.2%) and 127 developed fDGF (50.2%). Sixty-three patients fulfilled criteria for both definitions (24.9%). At multivariable analysis, the two definitions were significantly associated with the primary [HR (95%CI) 2.07 (1.09-3.94), P = 0.026 for fDGF and HR (95%CI) 2.41 (1.33-4.37), P = 0.004 for dDGF] and the secondary composite outcome [HR (95%CI) 1.58 (1.01-2.51), P = 0.047 for fDGF and HR (95%CI) 1.67 (1.05-2.66), P = 0.028 for dDGF]. Patients who met criteria for both definitions had the worst prognosis, with a three-year estimates (95%CI) of survival from the primary and secondary outcomes of 2.31 (2.02-2.59) and 2.20 (1.91-2.49) years for fDGF+/dDGF+, in comparison with the other groups (P < 0.01 for trend). fDGF provides supplementary information about graft outcomes on top of the dDGF definition in a modern series of kidney transplantation.

Lost forever? Ecosystem functional changes occurring after agricultural abandonment and forest recovery in the semiarid Chaco forests

Semiarid forests are worldwide threatened by land use changes, particularly agriculture. However, in some cases, due to particular economic or social processes, agriculture ends and forests may or may not recover to their original state. Using different databases and satellite images integrated into a geographical information system, we located in the central region of the semiarid Chaco forests of Argentina adjacent land use patches of secondary forest (SF), remnant forest (RF) and crops (CP). Using a chronosequence approach, we evaluated changes in the fraction of the photosynthetic active radiation absorbed by the vegetation (FAPAR) between SF and RF and CP, using the enhanced vegetation index (EVI). We evaluated both intra and inter-annual changes in EVI mean (EVI_mean), EVI maximum (EVI_max), EVI minimum (EVI_min), and EVI relative range (EVI_rr) as descriptors of FAPAR dynamics and analyzed their changes through time (2000 to 2010) and their relation to rainfall. Secondary forests showed higher seasonality and higher EVI_mean values than RF, but differences disappeared as time since agricultural abandonment increased, suggesting that SF recover their functioning (when compared to RF) after 10 to 15 years. Our results suggest that Chaco's SF have intermediate seasonal patterns in-between RF and CP, as expected by successional theory, and that FAPAR interception by RF appears to be dependent on previous year's precipitation. We found that, although all land uses showed similar precipitation use efficiency (PUE), SF and cropland's productivity were less stable across the years and showed faster increases or decreases compared to RF, depending on precipitation (higher precipitation marginal response- PMR). Our results suggest that at least some aspects of ecosystem functioning can be restored after agricultural abandonment. Future research that combines floristic and structural changes is necessary to fully understand secondary forests regrowth process after agricultural abandonment in the Chaco region.

Using Forest Resources to Develop High Performance Plastic Compounds for the Automotive Industry

This study explores new applications for wood fibres through their incorporation on plastic matrices, developing high performance compounds for the automotive interior. Different automotive grades of polypropylene were reinforced with pine and eucalyptus fibres, in order to compare their properties with the specifications of different vehicle parts. The composites were produced using conventional plastics processing technologies, namely compounding with twin-screw extruder and injection molding. Mechanical properties, density, heat deflection temperature and Vicat softening point were determined. Other specific tests were carried to understand the feasibility of these composites use in automotive parts, namely fogging and flammability and also the determination of the tensile properties after climatic aging tests. The fibres morphology and its distribution and dispersion in the polymer matrices were evaluated by optical and scanning electron microscopy. The results show that it is possible to reinforce the raw-materials using wood and achieve the high standards of the automotive industry, producing environmentally friendlier materials, through the effective reduction of the use of plastic. This work enabled important conclusions regarding the incorporation of wood into PP matrices without compromising the specifications of certain dashboard parts and it also allowed evaluating the processability of these composites.

Cross-sectional study of adherence to venous thromboembolism prophylaxis guidelines in hospitalized patients. The Trombo-Brit study

BACKGROUND

DVT is the main cause of death in hospitalized patients and thromboprophylaxis is the only way to prevent these deaths. International recommendations suggested that active monitoring of DVT/PE prophylaxis can improve the efficacy in Hospitals.

METHODS

We performed a cohort study in three consecutives periods to evaluate DVT prophylaxis in 388 adults hospitalized in a General Hospital.

RESULTS

85% of the population had high risk factors for DVT. Thromboprophylaxis was in accordance with local and International guidelines (ACCP 2008) in 72.7% and 86% of the patients respectively. No significant difference could be founded between clinical and surgical patients. One every 10 patients received higher prophylaxis than suggested by guidelines and two out of ten received deficient or no prophylaxis. The worst 2 groups of patients were those with moderate/low risk of DVT and the group with a contraindication to pharmacologic prophylaxis. We observed a progressive improvement of the DVT prophylaxis in the 3 periods of evaluation.

CONCLUSIONS

Although the rate of recommended thromboprophylaxis is higher than many other reports in the region we still have some areas where we need to improve. Regular audits like these are very helpful to find out what specific areas of the hospital needs some careful attention in order to have a better quality of assistance.

[Micronutrients in parenteral nutrition]

At a multidisciplinary debate, and after reviewing the evidence available as well as experts' opinion, the IV Baxter-SENPE Working Panel established the indications and managemente guidelines for micronutrients (water-soluble and fat-soluble vitamins, and oligoelements or trace elements) in parenteral nutrition. It was concluded about the convenience of daily intake of micronutrients with diferent options regarding deficiente or excessive dosages, administration systems, interactions, monitoring, and cots-effectiveness.

[Management models in clinical nutrition: weaknesses and strengths]

At the 6th Abbott-SENPE Debate Forum a multidisciplinary and multiprofessional discussion was established in order to seek for the model or the models of clinical management most appropriate for Clinical Nutrition and Dietetics Units (CNAD) in Spain. The weaknesses and strengths as well as opportunities for the current systems were assessed concluding that a certain degree of disparity was observed not only due to regional differences but also to different hospital types. It was proposed, from SENPE, the creation of a working group helping to standardize the models and promote the culture of Integral Control and Change Management.

[IV Debate Forum of the SENPE: questions on nutrition research]

The IV Debate Forum of the SENPE values from a multidisciplinary and multi-professional perspective the questions on clinical research in nutrition in Spain, focusing on enteral nutrition due to the lack of legislation on this issue. The concluding remarks point out the SENPE commitment with promoting quality, education and facilitation of research, greater help to emergent groups, looking for financial support, and timely information on the several summons from public systems and reference centers

[Inflammatory response in spontaneous intracerebral haemorrhage]

INTRODUCTION

At date, there is increasing evidence that inflammatory processes are involved in cerebrovascular events. Trauma and ischemic injury are characterized by acute local inflammation and changes in levels of inflammatory cytokines in body fluids of human patients. However, very few studies have been directed to establish the role and the relationship between inflammation and hemorrhagic stroke.

DEVELOPMENT

After intracerebral hemorrhage, inflammatory mediators from the blood might enter to the brain and induce an inflammatory reaction, although the brain cells itself are capable of producing many of these agents. Whatever, this markers of inflammation contributes to the development of a systemic response. High levels of C reactive protein (CRP), an acute and sensitive phase protein to inflammatory reactions, are present among individuals at risk for future cerebro or cardiovascular event. Elevated CRP also predicts the outcome.

CONCLUSION

We present the little evidence about the relationship between inflammation and hemorrhagic stroke.