Impact of laser fiber tip cleavage on power output for ureteroscopy and stone treatment.

PURPOSE: Holmium:YAG laser is the most used laser for urolithiasis. Generally, we use metallic scissors to cut the fiber tip to restore its effectiveness. Many cleaving methods have been described to avoid fiber damage and to restore its greatest power to the fiber. There is a lack of information regarding which cleaving method should be used and its effect on the fiber. In order to compare these effects, we studied different cleavage methods in terms of power output and its effects on the fiber. METHODS: New single-use 272-µm fibers were used with a holmium:YAG laser lithotripter. Five kinds of fiber tips were compared: a new intact fiber, cleaved with ceramic scissors, cleaved with metallic scissors, first cleaved then stripped and first stripped then cleaved. The fibers were used against synthetic stones (BegoStone®) similar to calcium oxalate monohydrate, with fragmentation (SP, 5 Hz, 1.5 J) and dusting (LP, 15 Hz, 0.5 J) settings. We measured power output at 0, 1, 5, 10 and 15 min. RESULTS: For fragmentation parameters, there was a statistical difference between the 5 groups at 0 and 1 min of laser use (p < 0.05) and none for time period over 1 min (p = 0.077-0.658). For dusting parameters, there was a statistical difference between the 5 groups at 0 min of laser use (p < 0.05) and none for time period over 0 min (p = 0.064-1). CONCLUSION: Cleaving the fiber tip may restore its effectiveness to the fiber, but only for a limited time, although it may preserve the scopes from damage.

[Organ preservation in oropharyngeal cancers treatment: What arguments for radiotherapy?] / Préservation d'organe dans la prise en charge des cancers de l'oropharynx : quels arguments en faveur de la radiothérapie ?

Management of oropharyngeal cancer depends on several factors. Immediate surgery or radiotherapy may be considered. If the patient is operable, the choice depends on the extent of the disease, the contributing factors, and the expected functional results. For HPV-positive cancers, studies show comparable efficacy between surgery and radiotherapy. For early-stage cancers, unimodal treatment should be preferred. For HPV-negative cancers, the results of retrospective and observational studies are in favor of surgery. These studies have some limitations. In observational and/or retrospective studies, reclassification biases and the applicability of propensity scores weaken the validity of studies showing differences in management. Tumor and patient comparability are others majors interpretation biases. It is precipitate to conclude that surgery is superior for HPV-negative oropharyngeal cancers. Toxicity, therefore, becomes a criterion of choice for treatment. Unimodal management by surgery allows limited toxicity for the early stages. Surgery has less impact on salivation. Radiotherapy is rather less deleterious for swallowing in the early stages. For the advanced stages of HPV-induced tumors, the non-superiority of surgery should lead to the choice of radiochemotherapy. For oropharyngeal cancers, the possible benefit of surgery in HPV-negative oropharyngeal cancers must be confirmed in randomized studies. For the early stages of oropharyngeal cancer with unimodal treatment, management could be decided by shared decision making.

Nontraumatic acute anterior mediastinitis in two HIV-positive heroin addicts.

We present the cases of two young heroin addicts seropositive for HIV who had life-threatening spontaneous acute anterior mediastinitis due to Staphylococcus aureus. This was the consequence of the spreading to the mediastinum of an infection of the chest wall. Complete cure was achieved with antibiotics and surgical drainage. Spontaneous mediastinitis should arouse suspicion of the possibility of HIV infection.

Atrial septal aneurysm plus a patent foramen ovale. A predisposing factor for paradoxical embolism and refractory hypoxemia during pulmonary embolism.

We report three consecutive cases of patients who had refractory hypoxemia and paradoxical embolism during the course of pulmonary embolism. Transesophageal echocardiography showed an atrial septal aneurysm and a patent foramen ovale in all patients. The latter was detected by an early and massive passage of contrast from the right to the left atrium. We suggest that the presence of an atrial septal aneurysm plus a patent foramen ovale greatly enhances both magnitude of shunting and the risk of systemic embolism. The presence of an atrial septal aneurysm plus a patent foramen ovale should be considered and checked using transesophageal echocardiography in every patient with significant pulmonary embolism.

Prospective evaluation of the incidence of bacteremia after protected specimen brushing in ICU patients with and without pneumonia.

To test the hypothesis that the use of protected specimen brushing (PSB) via flexible bronchoscopy does not predispose to bacteremia in ICU patients, we prospectively performed aerobic and anaerobic blood cultures immediately following bronchoscopy with PSB. A total of 123 episodes in 68 consecutive patients with suspected pneumonia were analyzed. Blood cultures were negative in 110 cases (89 percent) and positive in 13 cases (11 percent) (p < 0.001). Twelve of these 13 patients with positive blood cultures had quantitative PSB specimen cultures showing nonsignificant growth (< 10(3) CFU/ml). In nine patients, the bacteria recovered from blood cultures (coagulase-negative staphylococci or sarcina) were considered nonpathogenic according to conventional criteria. Blood cultures grew a Staphylococcus aureus in two patients with previously documented staphylococcal septicemia. In one patient with no identifiable site of infection, the blood culture yielded Enterococcus faecalis. The only patient with both a positive blood culture and PSB culture results indicating pneumonia had different organisms recovered from the two samples. Blood cultures taken after PSB in the 17 other episodes of pneumonia (PSB specimen cultures > or = 10(3) CFU/ml) were negative. At the time of brushing and blood sampling for culture, none of these patients was receiving antibiotics active on the organisms found. In conclusion, the incidence of bacteremia after PSB in ICU patients seems very low even in patients with documented pneumonia. Substantial savings would result from not performing routine blood cultures after PSB.

Comparison of the effects of heat and moisture exchangers and heated humidifiers on ventilation and gas exchange during weaning trials from mechanical ventilation.

Heat and moisture exchangers (HME) are increasingly used to warm and humidify inspired gases in intubated ventilated patients. But these devices add dead space that may alter the alveolar ventilation. This could impair the efficiency of spontaneous ventilation (SV) during weaning trials from mechanical ventilation. Fifteen patients were tested with an HME (Hygrobac-DAR) and a heated humidifier (HH) (Fischer-Paykel MR 450) in a random order during weaning trials in SV with inspiratory pressure support. Minute ventilation VE, tidal volume), and respiratory rate were recorded and arterial blood was sampled for blood gas analysis with each device. The HME gave a significantly greater VE than the HH (9.3 +/- 0.8 L/min vs 8.1 +/- 0.8 L/min; p < 0.005), because of increased respiratory rate (21 +/- 2/min vs 19 +/- 2/min; p < 0.05). Tidal volume was unchanged for HME and HH (470 +/- 32 mL vs 458 +/- 39 mL). The higher PaCO2 with HME than with HH (44 +/- 2 mm Hg vs 42 +/- 2 mm Hg; p < 0.005) revealed an insufficient alveolar ventilation response to the increase in dead space. Arterial Po2 rose with the HME, but not significantly above the HH values (103 +/- 6 mm Hg vs 97 +/- 6 mm Hg; p = 0.055), possibly because of a positive end-expiratory pressure effect of the HME. The need to increase VE in SV when an HME is used should be taken into account during difficult weaning from mechanical ventilation.

Bedside evaluation of efficient airway humidification during mechanical ventilation of the critically ill.

STUDY OBJECTIVE: To determine the correlation between simple rating of condensation seen in the flex-tube connecting the heating and humidifying device used with the endotracheal tube and hygrometric parameters (absolute and relative humidity and tracheal temperature) measured by psychrometry. DESIGN: Prospective randomized clinical trial. SETTING: Medical ICU of Louis Mourier Hospital, Colombes, France, a university-affiliated teaching hospital. PATIENTS: Forty-five consecutive mechanically ventilated critically ill patients. INTERVENTIONS: Patients undergoing mechanical ventilation were randomly assigned to receive humidification with one of the four heat and moisture exchangers (HMEs) tested or with a conventional heated humidifier. MEASUREMENTS: The hygrometric performances of four HMEs (BB2215, BB50, and BB100 from Pall Biomedical, Saint-Germaine-en-Laye, France; and Hygrobac-Dar from Mallinckrodt, Mirandola, Italy) and a heated humidifier (Fisher & Paykel; Auckland, New Zealand) were studied after 3 h and also after 48 h of use for the Hygrobac-Dar and correlated to a clinical visual inspection rating the amount of condensation in the flex-tube of the endotracheal tube. RESULTS: A total of 95 measurements in 45 patients were performed. The best hygrometric parameters were obtained with the heated humidifier (p < 0.001). The Hygrobac-Dar yielded significantly higher values for both humidities and tracheal temperature than the other three HMEs (p < 0.001). The performance of Hygrobac-Dar was unchanged after 48 h of use. There was a significant correlation between the condensation seen in the flex-tube and the hygrometric parameters measured by psychrometry (absolute humidity, rho = 0.7; relative humidity, rho = 0.7; tracheal temperature, rho = 0.5, p < 0.0001). CONCLUSION: In mechanically ventilated ICU patients, visual evaluation of the condensation in the flex-tube provides an estimation of the heating and humidifying efficacy of the heating and humidifying device used, thus allowing the clinician bedside monitoring of airway humidification.

Measurement of cardiac output by transesophageal echocardiography in mechanically ventilated patients. Comparison with thermodilution.

OBJECTIVE: The determination of basal cardiac output (CO) and of its variations during different therapeutic interventions liable to increase or decrease it in mechanically ventilated patients using transesophageal echocardiography (TEE). DESIGN: To compare CO measurements simultaneously obtained by transmitral single-plane TEE and thermodilution. SETTING: Medical intensive care unit. PATIENTS: Twenty-two consecutive mechanically ventilated patients hospitalized for various medical conditions were included. INTERVENTIONS: The comparisons between transmitral single-plane TEE and thermodilution measurements were made at baseline and after different therapeutic interventions affecting CO (fluids or dobutamine infusion or positive end-expiratory pressure titration). MEASUREMENTS: Seventy-four measurements were obtained. Cardiac output using TEE was the product of the mitral valve area, the time-velocity integral of flow at the same site and the heart rate. RESULTS: A significant correlation was observed between thermodilution and TEE measurements of CO (n = 74, r = 0.78, p < 0.001) despite wide limits of agreement (mean +/- 2SD = -0.3 +/- 3.1 l/min). Thermodilution and TEE CO determinations both had significant inverse correlation with the arterial-venous oxygen content difference in ten consecutive patients (r = 0.77, p < 0.01 and r = 0.71, p < 0.01, respectively). The correlation between variations of CO greater than 20% obtained by thermodilution and TEE was significant (r = 0.89, p < 0.001). The operative characteristics implied the ability of TEE to predict significant variations of thermodilution CO (sensitivity 85% and negative predictive values 86%). Moreover, arterial-venous oxygen content difference changes of 5% or more were better detected using TEE than thermodilution. CONCLUSIONS: These results suggest that although transesophageal CO measurements cannot replace thermodilution ones, the determination of CO variations obtained using TEE may be useful in the management of critically ill mechanically ventilated patients. This technique may make it possible to monitor hemodynamics during initial therapeutic interventions in those patients in whom right heart catheterization cannot be performed immediately.

Does the stress of admission to an intensive care unit influence arginine vasopressin secretion and renal diluting ability?

The pathogenesis of excessive arginine vasopressin (AVP) release and hyponatraemia in euvolaemic intensive care unit (ICU) patients is poorly understood. Stress has frequently been proposed as a possible determinant, but its actual responsibility has not been adequately assessed. Therefore, water-load tests were prospectively performed in 11 patients admitted to the ICU for severe or potentially severe diseases, but who had no other condition which could result in excessive AVP release or impairment of renal diluting ability. Renal diluting ability was normal in 9 patients. Two patients exhibited very slight defects, which might be the consequence of subclinical haemodynamic alterations, since one had a pulmonary embolism and the other manifested a gastrointestinal haemorrhage just after the completion of the water load. Nevertheless, plasma AVP levels decreased in response to the water load in all the patients, resulting in a significant decrease in mean values. Plasma norepinephrine values were found to be elevated both before and after water loading. A highly significant correlation existed between the levels of norepinephrine and those of AVP measured before the load, but was lost after it. In addition, norepinephrine values were markedly elevated in two patients who exhibited strictly normal renal diluting abilities, and no correlation was found between plasma norepinephrine values and any parameter of renal water excretion. Our study shows that the stress of a serious illness and of admission to an ICU does not seem to interfere, by itself, with osmotic regulation of AVP secretion and renal diluting ability, and that sympathetic activation is not, under such circumstances, a predominant stimulus for AVP release.(ABSTRACT TRUNCATED AT 250 WORDS)

Is penicillin G an adequate initial treatment for aspiration pneumonia? A prospective evaluation using a protected specimen brush and quantitative cultures.

OBJECTIVE: To evaluate the bacteriology of early aspiration pneumonia using a protected specimen brush and quantitative culture techniques, and whether penicillin G is adequate as initial treatment pending culture results. PATIENTS AND METHODS: 52 patients (of which 45 required mechanical ventilation) meeting usual clinical criteria for aspiration pneumonia were prospectively included. On admission, patients were given intravenous penicillin G and a protected specimen brush was performed < or = 48 h after. RESULTS: Cultures of the brush were negative (< 10(3) CFU/ml) in 33 patients (1 had blood cultures positive with S. pneumoniae) and positive (> or = 10(3) CFU/ml) for S. pneumoniae in 2 patients. Seventeen patients had a positive culture (> or = 10(3) CFU/ml) for at least one penicillin G resistant microorganism, with a total of 20 organisms (S. aureus: 6; H. influenzae: 2; Enterobacteriaceae: 8; P. aeruginosa: 3; C. albicans: 1). In 4 of these patients, a penicillin-sensitive pathogen was also recovered in significant concentrations (S. pneumoniae: 2; Streptococcus sp.: 2). These 17 patients with a resistant pathogen did not differ from the 35 other patients with respect to need for ventilatory support and mortality rate. By contrast, they were older (61.1 +/- 21.9 vs. 42.9 +/- 18.8 years; p < 0.005) and required longer mechanical ventilation (6.1 +/- 4.6 vs. 3.5 +/- 2.7 days; p < 0.03) and hospitalization (11.2 +/- 8.8 vs. 6.7 +/- 4.7 days; p < 0.02). Of 17 patients 12 with penicillin G resistant organisms versus 0/35 without, were in-hospital patients and/or had a digestive disorder (p < 0.001). CONCLUSION: The broad range of offending organisms seen in early aspiration pneumonia precludes use of any single empiric regimen, making protected specimen brush mandatory in many patients. Nevertheless, the involvement of S.pneumoniae in a notable proportion of our patients suggests that routine penicillin prophylaxis after early aspiration (at least in most patients with community-acquired aspiration) is warranted given the potential severity of pneumococcal sepsis in such patients.

Use of cross-reactive antigens of the microsporidian Glugea atherinae for the possible detection of Enterocytozoon bieneusi by western blot.

The microsporidia Enterocytozoon bieneusi is reported in 10-30% of those infected with the human immunodeficiency virus. The parasite appears to be a cause of gastralgia, malabsorption, and diarrhea. A Western blot technique using another microsporidian species, Glugea atherinae, has demonstrated an antigenic similarity between this parasite and E. bieneusi. Preliminary results show the variability of the antigenic profiles obtained from the sera of immunodeficient patients infected with E. bieneusi and also of the cross-reactivity to Glugea sp. antigens of some sera from patients with cryptosporidiosis. The origin of this cross-reactivity is undetermined. The possibility of coinfection with undetected microsporidia is not excluded. These results raise questions concerning the interpretation of serologic data and of the potential immunodiagnostic value of microsporidian antigens.

Validation of reconstructed bremsstrahlung spectra between 6 MV and 25 MV from measured transmission data.

We have previously investigated a method of high-energy x-ray spectral reconstruction from transmission data by direct resolution of a matrix system. This technique uses the spectral vectorial algebra formalism. The resolution has previously been tested on a 12 MV photon beam. To extend and to test the validity of the results to the entire radiotherapy energy range, we have performed the method on photon beams with nominal energies of 6, 12, 15, and 25 MV. The influence on the 6 MV spectrum of a 60 degrees built-in wedge has also been investigated to test the sensitivity of the method and the results are reported. To validate our reconstructed spectra, dosimetric quantities such as tissue phantom ratios (TPR), water-to-air stopping power ratios (S/p) air water, and quality indexes TPR 10 (20) have been calculated. The results show good agreement between the measured and calculated data. Mean mass energy absorption coefficient ratios for different materials have also been computed and compared to data published recently and the results are very close (within +/- 0.5%). Primary depth dose functions in water have also been computed to deduce primary dose attenuation coefficients.

[Description of unused drugs collected in pharmacies in the Puy-de-Dôme region in France]. / Description des Médicaments Non Utilisés (MNU) collectés dans les pharmacies du Puy-de-Dôme.

BACKGROUND: An unused drug (UD) is defined as a drug which is purchased, after prescription or not, but which is not taken. Public health campaigns in France have requested people to return these drugs to their pharmacy. To data, few data have been available concerning the quantity of collected UD and their potential re-use. A study was performed in the pharmacies of the Puy-de-Dôme region in France to describe the UD circuit. METHODS: A random sample of 1 out of 5 pharmacies in the Puy-de-Dôme region (France) were defined by single level stratified sampling from the list of all pharmacies operating in the region. An exhaustive record of all UD people brought back to these pharmacies was made in 1998 during three 1-week periods. The following data were recorded for each UD: the name of the drug, the pharmaceutical industry code (CIP), the price, the rate of social Security refunding, the mention of "free specimen" on the package, the inscription on the list of poisonous substances and on the list of essential drugs defined by the World Health Organization (WHO), the registration on the list of drugs reserved for hospital use, the packaging notice (opened or not), the therapeutic class, and the formulation. RESULTS: 10,254 US (717kg) were collected during the study period. The therapeutic classes of the UD were similar to those of drugs purchased in France. According to the selling price, these UD had an economic value of 405,845FF (i.e. 3.6% of Social Security refundings paid in the Puy-de-Dôme region during this same period). Only 20% of the UD were potentially reusable for humanitarian purposes. Their estimated economic value was 87,456FF (i.e. 0.78% of the annual Puy-de-Dôme Social Security refunding). Moreover, 43.4% of the reusable drugs were on the WHO list of essential drugs. CONCLUSION: Although the volume of collected UD is high, use by humanitarian associations is on the decline because of the cost of collection and low economic yield. Furthermore, UD must be collected in a systematic manner to preserve the environment and prevent domestic accidents.

[Autoimmune biological anomalies in 35 patients with chronic viral hepatitis C treated over 6 months with interferon and followed-up over a year]. / Anomalies biologiques autoimmunes chez 35 malades atteints d'hépatite chronique viral C traités pendant six mois par interféron (IFN) et suivis pendant un an.

Several clinical or biological autoimmune disorders, particularly lupoid diseases, are associated with chronic hepatitis C. They may be exacerbated by alpha IFN, but they are not involved in the response to therapy.

[Chronic viral hepatitis C and interferon: results after a year and predictive factors of response (a multivariate study with 35 patients)]. / Hépatite chronique virale C et interféron: résultats à un an et facteurs prédictifs de réponse (étude multivariée sur 35 sujets).

Six months alpha IFN therapy was efficient for chronic viral hepatitis C in 31% patients after six months and in 17% after one year. Cirrhosis, low serum albumin or prealbumin levels and elevated IgA seric level were non responsiveness predictive factors.

[Post-traumatic thrombosis of the portal vein]. / Thrombose de la veine porte post-traumatique.

Blunt trauma to the abdomen is an exceptional cause of portal vein thrombosis. To our knowledge, 8 cases have been reported in the literature. When thrombosis of the portal vein occurs, a complete search for all the known main causes must be carried out before entertaining this diagnosis. Other causes may be cirrhosis, tumors and inflammation of the abdomen, coagulation disorders and hematologic diseases including latent myeloproliferative syndrome. We report a case in a 25-year-old man with an uneventful past history who presented with thrombosis of the portal vein after a violent blunt trauma which occurred during a rugby play. In this young man, none of the other potential causes was found, in particular bone marrow culture on medium with low growth-factor concentration allowed us to eliminate a latent myeloproliferative syndrome. The only triggering factor remaining was the recent abdominal trauma. After an 18-month follow-up, no other element has been observed which could have caused thrombosis of the portal vein.

[Fatal massive intravascular coagulation during phlebography. Responsibility of epsilon-aminocaproic acid?]. / Coagulation intravasculaire massive fatale au cours d'une phlébographie. Responsabilité de l'acide epsilon aminocaproïque?

The occurrence during phlebography of massive intravascular coagulation involving the inferior vena cava, the right cardiac cavities and the entire pulmonary arterial network suggested that epsilon-aminocaproic acid administered before phlebography was responsible for this complication. The mechanisms of reactions to contrast media are still poorly understood, but these reactions are known to include, in some cases, disseminated intravascular coagulation. This phenomenon was histologically demonstrated in our patient, and it may be suggested that its strong enhancement by the antifibrinolytic agent had resulted in the fatal accident. In view of the possibility of such lethal reactions, the advisability of administering epsilon-aminocaproic acid--a drug widely used in France for the prevention and treatment of contrast media reactions--should be reconsidered.

[Chondrosarcoma secondary to multiple cartilage diseases. Study of 29 clinical cases and review of the literature]. / Chondrosarcomes secondaires à des maladies cartilagineuses multiples. Etude de vingt neuf cas cliniques et revue de la littérature.

PURPOSE OF THE STUDY: Several studies have demonstrated better prognosis of chondrosarcomas arising in hereditary multiple exostosis or Ollier's disease. The aim of this study was to evaluate their clinical, radiological and histological features and compare their prognosis with other chondrosarcomas. MATERIAL AND METHODS: We reviewed twenty nine secondary chondrosarcomas among seventeen patients with osteochondroma (group A), and eight with Ollier's disease (group B). These tumors represented 12 p. 100 of all chondrosarcomas treated between 1950 and 1994 in Cochin Hospital. Two group B patients successively developed three multicentric chondrosarcomas. Twenty six resections (eight intra and eighteen extra-lesional), two disarticulations and one amputation were performed as primary treatment. The average follow-up of the study was 10.5 years. The results were evaluated by means of survival curves. The significance of the difference between the curves was determined by the log-rank test. RESULTS: The mean age of malignant change was 36 years old. The most frequent tumoral site was the innominate bone for group A and the femur for group B. In three cases, radiographs showed no malignant features. All chondrosarcomas were classified as grade 1 or 2. The ten-year survival rate was 82 p. 100 with no significant difference between the two groups. The survival rates were significantly different after carcinologic surgery (extra-lesional resection or amputation) and contaminated surgery (intralesional resection), with 5 and 88 p. 100 of local recurrences respectively. DISCUSSION AND CONCLUSION: These secondary chondrosarcomas represent about 10 p. 100 of all chondrosarcomas. They appear 15 years earlier. According to O'Neal and Ackerman classification, most of the tumors are well-differentiated (60 p. 100 grade I, 39 p. 100 grade II and 1 p. 100 grade III). Carcinologic surgery is generally curative. Ten-year survival rate is 94 p. 100. With equivalent grade and surgery, their prognosis is better as compared to primary chondrosarcomas.

[Profiles of people who return unused medicine to pharmacies in Puy-de-Dôme, and their motivations for doing so]. / Profils et motivations des personnes déposant des Médicaments Non Utilisés (MNU) dans les officines du Puy-de-Dôme (France).

An unused drug (U.D.) is described as a drug which is purchased, whether according to a prescription or not, but which is not taken. In the past few years, French people have acquired the habit of returning U.D.s to pharmacies. Nevertheless, few studies have been performed to define their typical features and the motivations of these individuals. A descriptive study was carried out in 1/5 of the pharmacies in Puy de Dôme (France) over three 1 week periods between February and June 1998. 377 people (that is, 82% of those who bring U.D. back to the pharmacies) accepted to participate in this study. The main results are as follows: 1. the U.D. are primarily brought back by women (of all ages); 2. these women mainly return U.D. from the family medicine cabinet; 3. the donations result essentially from "the force of habit", "cleaning out the family medicine cabinet" and also, although in lesser proportion, for "humanitarian reasons". This behaviour is contradictory with the communication messages of Cyclamed, the official French association whose mission is to collect drug waste and unused drugs in order to preserve the environment and to promote energy development and valorisation.

[Hyponatremia of acute pulmonary infections]. / Hyponatrémie des pneumopathies infectieuses aiguës.

The mechanism of hyponatremia associated with pneumonia has been debated. In particular, the responsibility of inappropriate antidiuretic hormone secretion has been questioned. We have shown that inappropriate antidiuretic hormone secretion is a nearly constant finding during pneumonia and is roughly proportional to the extent of pneumonia. Nevertheless, it must be emphasized that extracellular fluid volume may be increased, diminished or normal during pneumonia, depending on the underlying condition (congestive heart failure, cirrhosis) or on the importance of extrarenal losses (sweats, fever). Careful clinical and laboratory assessment of extracellular fluid volume should enable adequate therapy.