Is It Time to Give Peritoneal Dialysis Its Due Place in Managing Acute Kidney Injury: Lessons Learnt from COVID-19 Pandemic.

Despite comparable outcomes with the extracorporeal dialysis modalities, peritoneal dialysis (PD) is seldom considered a viable option for managing acute kidney injury (AKI) in developed and resource-rich countries, where continuous renal replacement therapies (CRRTs) are the mainstay of treating AKI. PD has fewer infrastructure requirements and has been shown to save lives during conflicts, natural disasters, and pandemics. During the ongoing COVID-19 pandemic, the developed world was confronted with a sudden surge in critically ill AKI patients requiring renal replacement therapy. There were acute shortages of CRRT machines and the trained staff to deliver those treatments. Some centres developed acute PD programmes to circumvent these issues with good results. This experience re-emphasised the suitability of PD for managing AKI. It also highlighted the need to review the current management strategies for AKI in developed countries and consider incorporating PD as a viable tool for suitable patients. This article reviews the current evidence of using PD in AKI, attempts to clarify some misconceptions about PD in AKI, and argues in favour of developing acute PD programmes.

Demystifying normal-anion-gap metabolic acidosis: pathophysiology, aetiology, evaluation and diagnosis.

Normal-anion-gap metabolic acidosis (NAGMA) is a common but often under-recognised and poorly understood condition, especially by less-experienced clinicians. In adults, NAGMA might be an initial clue to a more significant underlying pathology, such as autoimmune diseases, hypergammaglobulinemia or drug toxicities. However, identifying the aetiology can be challenging due to the diverse processes involved in the development of acidosis. A better understanding of the pathophysiology of NAGMA can help treating physicians suspect and evaluate the condition early and reach the correct diagnosis. This article provides an overview of renal acid-base regulation, discusses the pathophysiological processes involved in developing NAGMA and provides a framework for evaluation to reach an accurate diagnosis.

DRESS syndrome with multiorgan involvement and HHV-6 reactivation in the absence of a drug trigger.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe drug reaction where patients present with fever, morbilliform rash and multiorgan manifestations, which may include acute renal failure, acute respiratory distress syndrome and eosinophilic myocarditis. We present a case of a 60-year-old woman with acute heart failure, DRESS syndrome features and human herpesvirus 6 reactivation in the absence of a drug trigger. She was diagnosed with eosinophilic myocarditis and successfully treated with corticosteroid therapy.

Epiploic appendagitis: a commonly undiagnosed non-surgical acute abdominal emergency.

Epiploic appendagitis is a rare cause of acute abdomen and is diagnostically challenging as it mimics common causes of acute abdomen. However, advancements in computerised tomography/Ultrasound imaging have improved the frequency and confidence of diagnosing epiploic appendagitis, preventing unnecessary surgeries. We present a case of an acute abdomen who had to undergo laparoscopy before being diagnosed with epiploic appendagitis, underscoring the difficulty in diagnosis.

Association of monoclonal gammopathy of undetermined significance and C3 glomerulopathy.

Monoclonal gammopathy of undetermined significance (MGUS) is usually an asymptomatic pre-malignant condition caused by the proliferation of clonal plasma cells. Often considered a benign condition, it has the potential to progress to malignant plasma cell or lymphoproliferative disorders. Moreover, MGUS can rarely cause glomerular disease by activating the alternative complement pathway resulting in immunoglobulin-negative C3-positive glomerulonephritis called C3 glomerulopathy. Because of its rarity, the diagnosis might not be considered by the treating physicians, leading to delayed diagnosis or misdiagnosis. Untreated C3 glomerulopathy can lead to irreversible glomerular damage and end-stage renal failure, and a high index of suspicion is essential for timely diagnosis and management. Here, we present the case of a patient with a prior diagnosis of MGUS who presented with proteinuria and microscopic haematuria and was diagnosed with C3 glomerulopathy. The patient had complete resolution of the disease after receiving treatment with a combination of dexamethasone, lenalidomide and bortezomib for the underlying MGUS.

Consultation with patients for whom English is not their native language.

Good communication with the patient is the cornerstone of effective and efficient consultation. The absence of a common language between the patient and physician negatively impacts the consultation outcome. Australia is a multicultural and multilingual country, with immigrants from all over the world. In the absence of a common language, it will be a challenging conversation affecting the patient's engagement with the healthcare system and poor treatment adherence. While involving an interpreter may help, it has its downsides and may not be ideal in all situations. Here, we discuss the experiences of various medical practitioners from different cultural and linguistic backgrounds (from Middle Eastern and Asian Countries) in managing non-English-speaking patients with a focus on the impacts of linguistic/cultural barriers in delivering optimal healthcare services and possible solutions to them.

Australian public hospital inpatient satisfaction related to early patient involvement and shared decision-making in discharge planning.

BACKGROUND: Surveys of hospital inpatient satisfaction may help develop actionable plans for quality improvement, and patients have preferred to give feedback during admission at the point of service compared to after discharge. However, patient satisfaction measurement has often been done by questionnaires post-discharge, and without focussing on an Australian general internal medicine setting. AIMS: To understand patients' perceptions of their admission experiences in an Australian public teaching hospital's general internal medicine unit, and to understand the opportunities for quality improvement. METHODS: A prospective study of 50 inpatients of a general internal medicine unit at an Australian public teaching hospital was carried out using a patient satisfaction questionnaire given to patients on the day of discharge. RESULTS: Patients perceived deficits in early communication about discharge destination planning, and provision of written discharge instructions. Responses highlighted the importance of checking with patients to elicit further information that was not previously captured during initial history-taking, patient-centred communication to enable informed consent and decision making, use of language readily understandable to laypersons, and checking for patients' understanding of messages as communicated by the treating clinician. CONCLUSIONS: In an Australian general internal medicine service, early involvement and shared decision-making in discharge planning are valued by patients. Incorporating checking of patients' understanding of diagnoses, management, discharge instructions, and follow-up plans into ward round routines may benefit patient satisfaction. This study stimulates further research into the use of a proforma to capture and check patients' understanding of discharge diagnoses and plans.

Wilson disease: copper deficiency and iatrogenic neurological complications with zinc therapy.

A 17-year-old female was diagnosed with Wilson disease and commenced on oral zinc therapy. She re-presented 6 months later with a fall and had classical signs of subacute combined degeneration of the spinal cord confirmed on nerve conduction studies, as a result of zinc-induced copper deficiency. After 6 months of copper therapy, she made a complete recovery with no residual neurological deficits. Early detection of zinc-induced copper deficiency and stringent follow-up mechanisms are crucial. Early initiation of copper replacement may both limit and completely reverse neurological deficits.

Clinically isolated descending thoracic aortitis in a healthy older woman: a diagnostic challenge.

A woman travelling to Australia in her early 70s presents to a regional emergency department with chest pain and associated shortness of breath. Her medical history was that of seasonal affective disorder treated with citalopram, and an allergy to ibuprofen. Subsequent CT imaging revealed aortic wall thickening and associated periaortic fluid, and a moderate pleural effusion. This was successfully treated with oral prednisolone, responding within 1 day. Further blood tests revealed a high CD4/CD8 T-cell ratio, which can be seen in autoimmune disease, sarcoidosis and haematological malignancies. Without evidence for other autoimmune processes, the patient was given a provisional diagnosis of descending thoracic aortitis secondary to sarcoidosis, prescribed a weaning regimen of prednisolone, and asked to seek further investigation and management in her home country. This is a case with several learning points; rare disease can cause common presentations/reports, and sometimes empirical therapy is the only therapy.

Complications of retained cardiac defibrillator coil left in situ.

A 42-year-old man presented to a regional hospital emergency department with a 4-day history of haemoptysis, shortness of breath, pleuritic chest pain, productive cough and subjective fevers. This episode was the third similar presentation in a 2-month period. The patient was known to have dilated cardiomyopathy secondary to amphetamine use and had previously required insertion of automated implantable cardiac defibrillator (AICD). Due to recurrent complications, the AICD had been replaced on two occasions and a superior vena cava (SVC) lead left in situ on its final removal. Clinical examination and investigations revealed lower respiratory tract infection and transthoracic echocardiogram revealed severe left ventricular failure with an ejection fraction of 16%. The patient was admitted under the general medical team for treatment and investigation of suspected bacteraemia and septicaemia secondary to colonisation of the retained AICD lead. He spent 6 days as an in-patient and was discharged on home where he was to be followed up by the advanced heart failure team in a tertiary centre for consideration of new AICD insertion and to explore possibility of retained coil removal. This case report discusses the concerns surrounding retained SVC leads and potential clinical sequalae. As this patient presented three times within a period of 2 months, it was suspected retained SVC lead was a predisposing factor for recurrent lower respiratory infection.

Acute CMV hepatitis in an immunocompetent patient.

A previously well and immunocompetent 64-year-old woman presented with fever of unknown origin and acute hepatitis. Besides headache and nausea, she had no other symptoms. Her clinical examination was unremarkable with no clear focus of infection. She was thoroughly investigated and her biochemical profile suggested a viral or autoimmune aetiology. Multiple imaging modalities gave no further insight. Her serology and subsequent nucleic acid amplification indicated reactivation of latent cytomegalovirus (CMV). Her symptoms resolved with supportive care and no anti-viral therapy was needed. This case report highlights CMV reactivation leading to acute hepatitis in a well, immunocompetent patient.

Thrombus risk versus bleeding risk: a clinical conundrum.

A 62-year-old man presented to the Emergency Department with dyspnoea and central pleuritic chest pain radiating posteriorly to between the scapulae. His medical history included hypertension, osteoporosis and chronic kidney disease secondary to focal segmental glomerulosclerosis with relapsing nephrotic syndrome. Significant examination findings included a loud palpable P2 and a displaced apex beat. An ECG revealed sinus tachycardia with a right-bundle branch block and p-pulmonale. A CT pulmonary angiogram and aortogram demonstrated extensive bilateral pulmonary emboli and a descending thoracic aortic dissection. Subsequent ultrasound of the lower limbs confirmed an extensive, non-occlusive deep vein thrombosis in the right calf. Management of this patient involved therapeutic anticoagulation and tight blood pressure control, with plans for surgical repair delayed due to worsening renal impairment and subsequent supratherapeutic anticoagulation. Co-existence of an aortic dissection and PE has been rarely described and optimal management remains unclear.