Real-world characteristics and outcomes of patients with intermediate high risk acute pulmonary embolism.

BACKGROUND: Exact benefits of currently recommended close monitoring in intermediate high risk acute pulmonary embolism (PE) patients are unknown. METHODS: This prospective observational cohort study determined clinical characteristics, and disease course of intermediate high risk acute PE patients in an academic hospital setting . Frequency of hemodynamic deterioration, use of rescue reperfusion therapy and PE related mortality, were outcomes of interest. RESULTS: Of 98 intermediate high risk PE patients included for analysis, 81 patients (83%) were closely monitored. Two deteriorated hemodynamically and were treated with rescue reperfusion therapy. One patient survived after this. CONCLUSIONS: In these 98 intermediate high risk PE patients, hemodynamic deterioration occurred in three patients and rescue reperfusion therapy of two closely monitored patients led to survival of one. Underlining the need for better recognition of patients benefitting from and research in the optimal way of close monitoring.

[Anaemia]. / Anemie.

The first scientific article on anaemia was published in 1807, marking a tipping point in modern medicine. Despite a vast bulk of literature on this topic, the interpretation of anaemia is not always straight forward. The most common form of anaemia, the iron deficiency anaemia, shares several characteristics with another common form of anaemia, the anaemia of chronic disease, or better: 'inflammatory anaemia'.This article provides the clinician with several factors which could aid in differentiating both forms of anaemia, such as parameters of iron transport, bone marrow investigation as well as atrial with iron supplements. Furthermore, this article discusses iron metabolism and methods of supplementing iron, gives guidance in the use of cut-off values for haemoglobin in the elderly and interpretation of the adequacy of the reticulocyte response. Lastly this article discusses the added value of a manual differentiation to determine the nature of the anaemia.

[Crystal meth - a new kid on the block]. / Crystal meth ­ een nieuwkomer.

In this article we describe epidemiological, pharmacological and clinical aspects of abuse of metamphetamines, also known as crystal meth. These aspects are illustrated by two cases of methamphetamine abuse and the complications associated with it. Metamphetamine abuse is often associated with sexual activity, a combination known as 'chemsex'. A chronic addiction to chemsex can have devastating effects on the user's social, psychological, and physical wellbeing. We describe a patient suffering from recurrent relapses in his addiction to chemsex. Acute crystal meth intoxications can result in very serious complications. We describe a patient suffering from severe neurological complications and rhabdomyolysis.

[Pulse oximetry: principles, limitations and practical applications]. / Pulsoximeters: werking, valkuilen en praktische tips.

Pulse oximetry detects hypoxemia non-invasively by measuring light absorption at different wave lengths, depending on the oxygenation of hemoglobin. The plethysmographic signal is caused by volume changes in the arterial blood during systole. In this pulsatile flow, oxygen saturation is calculated using an algorithm. Use of the pulse oximeter has increased massively, especially in the COVID-era, and has a central role in managing patients at the emergency department. However, interpretation of the plethysmogram is frequently incorrect which may lead to incorrect conclusions. Moreover, an irregular plethysmographic signal may well 'give' a saturation percentage. We will discuss how pulse oximeters work and discuss some pitfalls. We hope that understanding the mechanism behind pulse oximetry, as well as an awareness of pitfalls, leads to improved management of patients with consequently less unnecessary care, as demonstrated in our case.

[Ayahuasca in the Netherlands: what the doctor should know about its side effects]. / Ayahuasca in de polder.

In the past few months, ayahuasca has received quite a bit of coverage in the lay press. Ayahuasca is a South American hallucinogenic tea that is gaining popularity in Europe and North America. In the Netherlands, ayahuasca is usually used in a group ceremony called an 'ayahuasca ceremony'. Use of ayahuasca is not associated with the development of substance dependency. The side effects of ayahuasca are considered mild. We describe a 36-year-old woman who developed severe hyponatremia after participating in an ayahuasca ceremony. We also discuss the mechanism of action, the effects, the therapeutic potential and the risks of this hallucinogenic agent.

Pre-awakening diastolic hypotension in treated hypertensive patients: prevalence and predictors.

In the pre-awakening hours, diastolic blood pressure (DBP) is normally at its lowest, and diastolic hypotension is a risk factor for cardiac ischemia. We investigated pre-awakening DBP values and its predictors in treated hypertensive patients who underwent ambulatory blood pressure monitoring. The pre-awakening period was defined as the 3-h period ending 1 h before awakening (most frequently 03:00-06:00). In 269 included subjects, office DBP was 86.4±12.0 mm Hg, 24-h DBP was 78.6±9.6 mm Hg, mean pre-awakening DBP was 70.3±10.9 mm Hg, and trough pre-awakening DBP was 62.5±11.2 mm Hg. Half of the patients (51%) had a mean pre-awakening DBP <70 mm Hg, and 14% had <60 mm Hg. Trough pre-awakening DBP <60 mm Hg was seen in 36% and <50 mm Hg in 12% of patients. Office DBP was the most important predictor of mean and trough pre-awakening DBP (both beta=0.4; P<0.001), and of pre-awakening DBP <70 mm Hg and <60 mm Hg (both P⩽0.001). Diabetes mellitus was associated with a lower trough pre-awakening DBP (beta=-3.2; P=0.02). Among variables that failed to independently predict low pre-awakening DBP were age, a history of vascular disease, and classes and number of antihypertensive drugs. We found that many hypertensive patients have low DBP in the pre-awakening period. Office DBP is the main predictor of low pre-awakening DBP. Further studies are needed to define the prognostic relevance and potential risks of low pre-awakening DBP.

Treatment of hyperglycaemia in diabetic ketoacidosis: natura non facit saltus.

In the treatment of severe diabetic ketoacidosis the gradual correction of glucose, electrolyte and fluid derangements is of utmost importance. In this paper the authors provide practical recommendations for these corrections based on novel pathophysiological insights.

[Volume replacement therapy; what is the solution?]. / Volumeresuscitatie, wat is de oplossing?

2 types of infusion solutions are used for volume replacement: crystalline fluids (such as NaCl 0.9% and lactated Ringer's solution) and colloidal fluids made of hydroxyethyl cellulose, albumin or gelatine. The choice of fluids used appears to be determined by the personal preference of the physician or the department. Infusion of colloidal solutions results in rapid recovery of the circulating volume but can cause anaphylaxis, renal insufficiency and an increased bleeding tendency. The use of hydroxyethyl cellulose (HEC) is associated with higher mortality and renal impairment, and is therefore not very justifiable. Albumin-based infusions appear to be predominantly indicated for septic patients with hypoalbuminaemia. Gelatin-based infusion fluids have not yet been extensively studied. The balanced lactated Ringer's solution, the composition of which is closer to plasma than that of NaCl 0.9%, is being used with ever-increasing frequency. Lactated Ringer's infusion solution does not cause hyperchloremic acidosis and probably less often leads to renal insufficiency than when NaCl 0.9% is infused.

Acute idiopathic thrombocytopenic purpura in adults following viral infection: report of two cases.

Idiopathic thrombocytopenic purpura (ITP) can follow a viral infection. We describe severe thrombocytopenia in two adult patients preceded by varicella zoster and Epstein-Barr virus infection, respectively. The differences between acute and chronic ITP are discussed, as well as therapeutic options.