Search Results (43)

Neuroendoscopy is a minimally invasive surgical technique used to treat brain pathologies such as hydrocephalus, arachnoid cysts, and skull base tumors. While it offers several advantages, including reduced tissue trauma and lower morbidity, it is associated with a high risk of postoperative nausea and vomiting (PONV). This paper provides a narrative review of the literature on the incidence, pathophysiology, and management of PONV in patients undergoing neuroendoscopic procedures. The review includes several studies published between 2001 and 2024, analyzing specific risk factors such as female gender, postoperative opioid use, extended endoscopic approaches, and cavernous sinus dissection. PONV prevention strategies include a multimodal approach combining total intravenous anesthesia (TIVA) with propofol, perioperative hydration, and pharmacological prophylaxis (5-HT3 receptor antagonists, NK1 antagonists, dexamethasone, and droperidol). Despite advances in surgical and anesthetic techniques, further research is needed to develop procedure-specific protocols and optimize PONV management in neuroendoscopy. Full article

Introduction: Oral rehydration reduces thirst sensation (TS), which may negatively affect autonomic function, measured by heart-rate variability (HRV). However, it is unclear if this effect is independent of hydration changes. This study examines whether TS influences autonomic function between intravenous and oral rehydration. Methods: Twelve males (mean ± SD; age, 29 ± 12 years; 74.7 ± 7.9 kg; 179.4 ± 7.0 cm; VO2_max, 49.8± 6.6 mL·kg⁻¹·min⁻¹) cycled at 55% VO_2max for 90 min followed by a 12 km time trial. Two experimental conditions were performed in a counterbalanced, randomized order; (a) the high thirst (HT) group were infused 25 mL of isotonic saline every 5 min via an intravenous tube, and (b) the low thirst (LT) group ingested 25 mL of water every 5 min. TS and heart rate were collected every 5 min. HRV was assessed pre exercise, post steady-state exercise, and post time trial. HRV parameters included time domain, frequency domain, and non-linear measures analyzed by two-way repeated measures ANOVA. Results: There was a significant time x condition for the root mean square of successive RR interval differences (RMSSD_log), high-frequency (HF) power, and SD1 (p < 0.05). In LT, RMSSD_log decreased from Pre to Mid (3.71 ± 0.61 ms to 2.53 ± 1.15 ms, p < 0.01) and Pre to Post (2.18 ± 0.90 ms, p < 0.01) but stabilized from Mid to Post (p = 0.39). High-frequency (HF) power in HT was maintained from Pre (3.7 ± 0.6 nu) to Mid (3.4 ± 0.8 nu, p = 0.21) but decreased from Pre to Post (2.5 ± 0.7 nu, p < 0.01) and Mid to Post (p < 0.01). LT decreased in HF power from Pre (3.7 ± 0.5 nu) to Mid (3.0 ± 0.8 nu, p < 0.01) and Pre to Post (3.0 ± 0.7 nu, p < 0.01); Mid and Post was maintained (p = 0.99). SD1, decreased in HT (Pre: 3.4 ± 0.4 ms, Mid: 2.0 ± 1.1 ms, Post: 1.1 ± 0.5 ms; all comparisons p < 0.05). In LT, SD1 decreased from Pre (3.4 ± 0.6 ms) to Mid (2.18 ± 1.15 ms, p < 0.01) and Pre to Post (1.83 ± 0.90 ms, p < 0.01), but stabilized Mid to Post (p = 0.39). Conclusion: Satiating thirst through oral rehydration increases parasympathetic activity post exercise, reducing stress and increasing recovery between exercise bouts. These findings have implications for optimizing rehydration strategies in sports and occupational settings. Full article

Background: The efficacy of intravenous iron preparations for chronic heart failure with iron deficiency has been reported, but the efficacy of oral iron preparations has not been demonstrated. In this study, we conducted a prospective clinical study using ferric citrate hydrate tablets in patients with chronic heart failure complicated by iron deficiency anemia. Methods and Results: A prospective study was conducted using ferric citrate hydrate in patients with chronic heart failure complicated by iron deficiency anemia. The registered patients were divided into two groups: those administered ferric citrate hydrate and those switched from iron sulfate sustained-release to ferric citrate hydrate. The primary endpoint was hemoglobin level. The secondary endpoints included hematocrit, serum iron, saturation, ferritin, and cardiac-, renal-, and hepatic-related biomarkers. A total of 141 patients were enrolled in this study, including 95 patients who were newly administered ferric citrate hydrate and 46 patients who were switched from iron sulfate sustained-release to ferric citrate hydrate. Conclusions: Ferric citrate hydrate significantly increased hemoglobin, serum iron, transferrin saturation (TSAT), and ferritin levels, and decreased atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. Ferric citrate hydrate could be continued without side effects such as gastrointestinal symptoms. Improvement in iron metabolism and anemia due to iron supplementation with ferric citrate hydrate led to improvement in heart failure biomarkers. Full article

The phenomenon of contrast-induced nephropathy (CIN) and contrast-associated nephropathy (CAN) has been acknowledged for an extensive duration. Recently, there has been a significant rise in research on the topic due to the enhanced availability of imaging investigations. This theory has been thoroughly validated and extensively reported in the scholarly literature. The primary risk factors are chronic kidney disease, diabetes, sepsis, critical illness, circulatory shock, anemia, advanced age, inadequate hydration, and the use of nephrotoxic medications. The principal preventive strategies are the use of iso-osmolar contrast agents and sufficient hydration, which includes the use of intravenous isotonic saline. The administration of N-acetylcysteine has been shown to decrease the occurrence of CIN without impacting outcomes like mortality or the need for dialysis. Recently, a growing number of scholarly studies have contested this phenomenon, or at least, questioned its clinical significance, rendering it primarily a biochemical occurrence. This review aims to evaluate the previously listed studies. Overestimating the possible dangers of post-contrast nephropathy may diminish the sensitivity of imaging tests that may otherwise utilize contrast, so substantially lowering their clinical relevance. This hypothesis is critically significant to science, medicine, and patients, warranting attention despite the necessity for additional research to validate it. The present study demonstrates that the frequency and importance of CIN may be overestimated. Full article

Background. The association between malnutrition and poor outcomes in stroke patients has, to date, been evaluated using composite scores derived from laboratory measurements. However, Bioelectrical Impedance Analysis (BIA) and its advanced application, Bioelectrical Impedance Vector Analysis (BIVA), offer a non-invasive, cost-efficient, and rapid alternative. These methods enable precise assessment of body composition, nutritional status, and hydration levels, making them valuable tools in the clinical evaluation of stroke patients. Objective. This study aimed to compare the ordinal distribution of modified Rankin Scale (mRS) scores at 90 days following an acute ischemic stroke, stratifying patients based on their nutritional status at the time of Stroke Unit admission, as determined by the Bioelectrical Impedance Vector Analysis (BIVA) malnutrition parameter. Methods. We conducted a single-centre prospective observational study on all consecutive patients admitted for acute ischemic stroke to our Stroke Unit between 1 April 2024, and 30 September 2024. We applied the IPW (Inverse Probability Weighting) statistical technique and ordinal logistic regression to compare mRS scores in malnourished and non-malnourished patients. Results. Overall, our study included 195 patients with ischemic stroke assessed using BIVA. Of these, 37 patients (19%) were malnourished. After IPW, we found that malnourished patients had significantly lower rates of favorable 90-day functional outcomes (cOR 3.34, 95% CI 1.74–6.41; p = 0.001). Even after accounting for relevant covariates, malnutrition remained an independent predictor of unfavorable outcomes (acOR 2.79, 95% CI 1.37–5.70; p = 0.005), along with NIHSS score at admission (acOR 1.19, 95% CI 1.11–1.28; p < 0.001), intravenous thrombolysis (acOR 0.28, 95% CI 0.15–0.52; p < 0.001), absolute lymphocyte count (cOR 1.01, 95% CI 1.00–1.02; p = 0.027), and albumin concentration (cOR 0.82, 95% CI 0.75–0.89; p < 0.001). Conclusions. Malnutrition, assessed through Bioelectrical Impedance Vector Analysis (BIVA) at the time of admission to the Stroke Unit, is associated with worse clinical outcomes at 90 days following the ischemic cerebrovascular event. Full article

Background/Objectives: Internal tremor (IT) is often reported by patients with post-acute sequelae of SARS-CoV-2, also known as Long COVID, as a distressing and disabling symptom. Similarly, physicians are typically perplexed by the nature and etiology of IT and find it extremely challenging to manage. Methods: We describe a patient with Long COVID who experienced IT as part of post-COVID postural orthostatic tachycardia syndrome (POTS) and small fiber neuropathy (SFN) and review the limited literature available on this topic. Results: Our patient’s IT improved significantly after intravenous saline infusions, but there was no effect on IT with oral hydration, increased oral sodium chloride intake, neuropathic pain medications, muscle relaxants, or medications used for the treatment of POTS. Conclusions: Based on this case, our clinical experience, and the limited literature available to date, we believe IT is a manifestation of POTS and SFN, which may be driven by hypovolemia, cerebral hypoperfusion, sympathetic overactivity, neuropathic pain, and mast cell hyperactivation. Subjective description, objective findings, and diagnostic and therapeutic considerations in patients with IT and Long COVID are discussed. Full article

Background: Spontaneous intracranial hypotension (SIH) is a rare and frequently misdiagnosed disorder characterized by a low volume of cerebrospinal fluid (CSF) caused by the leakage of CSF through the spinal dural membrane. Patients with Marfan Syndrome (MS) and other connective tissue disorders are at an increased risk for dural ectasia, which may predispose them to spontaneous CSF leaks due to the structural weakness of their dural membranes. The management of SIH in MS patients is debated. Conservative measures, an epidural blood patch (EBP), and surgical treatments are the options generally provided. Methods: Herein, we report on the case of a 52-year-old female affected by MS, genetically confirmed, with a two-month history of sudden-onset, “thunderclap” headache, worsened in an upright position and horizontal diplopia. A Computed Tomography (CT) scan of the brain showed a bilateral chronic subdural hematoma, slit ventricles, and a caudal descent of the brainstem without overt tonsillar herniation. The Magnetic Resonance Imaging (MRI) scan of the whole spine revealed dural ectasia in the lumbosacral area and presacral perineural cyst without extradural CSF collection. The case was successfully managed with bed rest and high-dose corticosteroid therapy. Then, we discuss the pertinent literature, consisting of 25 papers dealing with the treatment of SIH in patients affected by MS. Results: The literature review yielded 25 papers dealing with SIH management in patients with MS, including 28 patients overall; 21 patients underwent EBP, of whom 7 patients had multiple procedures. Overall, in 23 cases (82%), the symptoms improved. In three cases, the patients were managed conservatively with bed rest. In three of these cases, there was an improvement. In one case, the surgical fenestration of two lumbar intradural spinal meningeal cysts was performed and the patient improved after the procedure. Our patient underwent 15 days of steroid therapy (dexamethasone iv 12 mg/day for 7 days, then reduced to 4 mg/day) and intravenous hydration (Ringer lactate 1500 mL/day). In ten days, the symptoms disappeared. At the 6-month follow-up, the patient was in good clinical condition, and a CT scan showed an almost complete regression of the bilateral subdural hematoma. Conclusions: The management of SIH in MS patients is still challenging. Patients with connective tissue disorders such as MS are at an increased risk for SIH. Few studies have assessed the management of these patients and different strategies. Our case and the available literature provide further data for this type of case. Full article

Background and Clinical Significance: Heart failure and kidney diseases often coexist and are difficult to clinically manage. Dysfunction in either organ exacerbates dysfunction in the other, potentially leading to cardiorenal syndrome (CRS). CRS has five different subtypes, with CRS type 5 being the most problematic given that it consists of an acute insult superimposed upon chronic CRS. Additionally, type 5 CRS can be complicated by heart failure-related cardiogenic shock (HF-CS), which is associated with increased hospitalizations and has a high 1-year mortality rate. The standard treatment for patients with HF-CS consists of guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF) as tolerated, along with inotropic therapies and surgical mechanical left ventricular (LV) support, guided by invasive hemodynamic monitoring. Case Presentation: This case study reports the presentation of a 57-year-old man who presented with type 5 CRS who rapidly decompensated to stage E HF-CS and was effectively and safely treated with aggressive intravenous hydration, a defined plant-based diet (DPBD), and reduction of guideline-directed prescription medications without invasive hemodynamic monitoring. Conclusions: Hydration, a DPBD, and a reduction in medication burden may be effective in CRS. Pilot studies are warranted to evaluate the efficacy of this intervention in CRS in a larger cohort. Full article

Background: Positron emission tomography (PET) with ¹⁸F-FDG is being used more frequently to evaluate primary pelvic tumors (PTs). However, a standardized hydration protocol is essential for an optimal diuretic effect and constant results. Methods: We reviewed 109 patients with PTs who had undergone ¹⁸F-FDG PET/CT examinations between November 2006 and April 2013. Four different protocols were used: (a) no hydration (group 1); (b) oral hydration (800 mL) after an early scan (group 2); (c) intravenous (IV) hydration (500 mL) during an early scan followed by oral hydration (800 mL) and IV furosemide (20 mg) after an early scan (group 3); and (d) oral hydration (800 mL) before an FDG injection followed by the protocol from group 3 (group 4). The maximum standardized uptake (SUV_max) of the urinary bladder (UB) and PTs and the PT/UB SUV_max ratios were examined. Results: The UB SUV_max of group 4 was significantly lower in the early scan compared to that in the other three groups. Group 4 had a significantly higher PT/UB SUV_max ratio in the early scan than the other three groups, and it also had a 52.5% positivity rate for PTs. Conclusions: The pre-hydration plus forced diuresis protocol yielded the optimal effect of UB radiotracer washout and had the best PT/UB SUV_max ratio in both scans. Full article

Globally, acute appendicitis has an estimated lifetime risk of 7–8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8–12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients’ baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option. Full article

Background: Shiga toxin-producing Escherichia coli–haemolytic uremic syndrome (STEC-HUS) can result in kidney and neurological complications. Early volume-expansion therapy has been shown to improve outcomes, but caution is required to avoid fluid overload. Lung ultrasound scanning (LUS) can be used to detect fluid overload and may be useful in monitoring hydration therapy. Methods: This prospective observational pilot study involved children with STEC-HUS who were recruited from a regional paediatric nephrology centre. B-line quantification by LUS was used to assess fluid status at the emergency department (ED) admission and correlated with the decrease in patient weight from the target weight. A control group of children on chronic dialysis therapy with episodes of symptomatic fluid overload was also enrolled in order to establish a B-line threshold indicative of severe lung congestion. Another cohort of “healthy” children, without renal or lung-related diseases, and without clinical signs of fluid overload was also enrolled in order to establish a B-line threshold indicative of euvolemia. Results: LUS assessment was performed in 10 children with STEC-HUS at ED admission, showing an average of three B-lines (range 0–10). LUS was also performed in 53 euvolemic children admitted to the ED not showing kidney and lung disease (healthy controls), showing a median value of two B-lines (range 0–7), not significantly different from children with STEC-HUS at admission (p = 0.92). Children with STEC-HUS with neurological involvement during the acute phase and those requiring dialysis presented a significantly lower number of B-lines at admission compared to patients with a good clinical course (p < 0.001). Patients with long-term renal impairment also presented a lower number of B-lines at disease onset (p = 0.03). Conclusions: LUS is a useful technique for monitoring intravenous hydration therapy in paediatric patients with STEC-HUS. A low number of B-lines at ED admission (<5 B-lines) was associated with worse short-term and long-term outcomes. Further studies are needed to determine the efficacy and safety of an LUS-guided strategy for reducing complications in children with STEC-HUS. Full article

Background: Painful vaso-occlusive episodes (VOEs) are the hallmark of sickle cell disease (SCD) and account for frequent visits to the emergency department (ED) or urgent care (UC). Currently, the early administration of analgesics is recommended as initial management; however, there is a need for further understanding of the effect of prompt analgesics and hydration during VOEs. The objective of this study is to analyze the factors associated with the rate of hospital admission in the setting of time to intravenous (IV) analgesics and hydration. Method: This retrospective single-institution study reviewed adult and pediatric patients with SCD who presented with VOEs from January 2018 to August 2023. Results: Of 303 patient encounters, the rates of admission for the overall group, the subgroup which received IV hydration within 60 min of arrival, and the subgroup which received both IV analgesics and hydration within 60 min were 51.8%, 25.6% (RR = 0.46), and 18.2% (RR = 0.33), respectively. Further, factors such as gender and the use of hydroxyurea were found to be significantly associated with the rate of admission. Conclusions: This signifies the importance of standardizing the management of VOEs through the timely administration of IV analgesics and hydration in both adult and pediatric ED/UC. Full article

(1) Background: We present the first real-world-data study on teduglutide-treated SBS patients in the Slovak Republic and the first study to enable the comparison of the effects of teduglutide treatment between the adult and pediatric populations. (2) Methods: This was a non-interventional retrospective cohort study of adult and pediatric SBS patients treated with teduglutide. Primary and secondary endpoints were the results of teduglutide use at 12 weeks and 6 months after the initiation of treatment, compared to baseline. (3) Results: Teduglutide treatment led to a statistically significant reduction in the volume of intravenous hydration, HPN caloric intake, HPN and intravenous hydration applications per week and to increased urine output in adult patients. The results in the pediatric population were similar, but not statistically significant. A complete weaning off HPN was achieved in 57.14% of all patients (50.00% of children; 62.50% of adults) after a median of 0.99 years of teduglutide treatment (1.07 and 0.98 years for children and adults, respectively). (4) Conclusions: Teduglutide treatment in SBS patients leads to considerable reduction in or even weaning off PN in both pediatric and adult patients. Full article

Background: Data on diuretic treatment in nephrotic syndrome (NS) are scarce. Our goal was to assess the non-inferiority of the combined oral diuretics (furosemide/hydrochlorothiazide/amiloride) compared to intravenous (i.v.) furosemide in patients with NS and resistant edema. Methods: We conducted a prospective randomized trial on 22 patients with resistant nephrotic edema (RNE), defined as hypervolemia and a FENa < 0.2%. Based on a computer-generated 1:1 randomization, we assigned patients to receive either intravenous furosemide (40 mg bolus and then continuous administration of 5 mg/h) or oral furosemide (40 mg/day) and hydrochlorothiazide/amiloride (50/5 mg/day) for a period of 5 days. Clinical and laboratory measurements were performed daily. Hydration status was assessed by bioimpedance on day 1 and at the end of day 5 after treatment initiation. The primary endpoint was weight change from baseline to day 5. Secondary endpoints were hydration status change measured by bioimpedance and safety outcomes (low blood pressure, severe electrolyte disturbances, acute kidney injury and worsening hypervolemia). Results: Primary endpoint analysis showed that after 5 days of treatment, there was a significant difference in weight change from baseline between groups [adjusted mean difference: −3.33 kg (95% CI: −6.34 to −0.31), p = 0.03], with a higher mean weight change in the oral diuretic treatment group [−7.10 kg (95% CI: −18.30 to −4.30) vs. −4.55 kg (95%CI: −6.73 to −2.36)]. Secondary endpoint analysis showed that there was no significant difference between groups regarding hydration status change [adjusted mean difference: −0.05 L (95% CI: −2.6 to 2.6), p = 0.96], with a mean hydration status change in the oral diuretic treatment group of −4.71 L (95% CI: −6.87 to −2.54) and −3.91 L (95% CI: −5.69 to −2.13) in the i.v. diuretic treatment group. We observed a significant decrease in adjusted mean serum sodium of −2.15 mmol/L [(95% CI: −4.25 to −0.05), p = 0.04]), favored by the combined oral diuretic treatment [−2.70 mmol/L (95% CI: −4.89 to −0.50) vs. −0.10 mmol/L (95%CI: −1.30 to 1.10)]. No statistically significant difference was observed between the two groups in terms of adverse events. Conclusions: A combination of oral diuretics based on furosemide, amiloride and hydrochlorothiazide is non-inferior to i.v. furosemide in weight control of patients with RNE and a similar safety profile. Full article

Objective: We aimed to test the non-inferiority of oral versus intravenous hydration in the incidence of contrast-associated acute kidney injury (CA-AKI) in elderly outpatients undergoing a contrast-enhanced computed tomography (CE-CT) scan. Methods: PNIC-Na (NCT03476460) is a phase-2, single-center, randomized, open-label, non-inferiority trial. We included outpatients undergoing a CE-CT scan, >65 years having at least one risk factor for CA-AKI, such as diabetes, heart failure, or an estimated glomerular filtration rate (eGFR) of 30–59 mL/min/1.73 m². Participants were randomized (1:1) to oral sodium-chloride capsules or intravenous hydration. The primary outcome was an increase in serum creatinine >0.3 mg/dL or a reduction in eGFR >25% within 48 h. The non-inferiority margin was set at 5%. Results: A total of 271 subjects (mean age 74 years, 66% male) were randomized, and 252 were considered for the main analysis (per-protocol). A total of 123 received oral hydration and 129 intravenous. CA-AKI occurred in 9 (3.6%) of 252 patients and 5/123 (4.1%) in the oral-hydration group vs. 4/129 (3.1%) in the intravenous-hydration group. The absolute difference between the groups was 1.0% (95% CI −4.8% to 7.0%), and the upper limit of the 95% CI exceeded the pre-established non-inferiority margin. No major safety concerns were observed. Conclusion: The incidence of CA-AKI was lower than expected. Although both regimens showed similar incidences of CA-AKI, the non-inferiority was not shown. Full article