Early detection and intervention using neutrophil gelatinase-associated lipocalin (NGAL) may improve renal outcome of acute contrast media induced nephropathy: a randomized controlled trial in patients undergoing intra-arterial angiography (ANTI-CIN Study).

BACKGROUND: Patients with pre-existing impaired renal function are prone to develop acute contrast media induced nephropathy (CIN). Neutrophil gelatinase-associated lipocalin (NGAL), a new biomarker predictive for acute kidney injury (AKI), has been shown to be useful for earlier diagnosis of CIN; however, urinary NGAL values may be markedly increased in chronic renal failure at baseline. Results from those studies suggested that urinary NGAL values may not be helpful for the clinician. An intravenous volume load is a widely accepted prophylactic measure and possibly a reasonable intervention to prevent deterioration of renal function. The aim of our study is to evaluate NGAL as an early predictor of CIN and to investigate the clinical benefit of early post-procedural i.v. hydration. METHODS/DESIGN: The study will follow a prospective, open-label, randomized controlled design. Patients requiring intra-arterial contrast media (CM) application will be included and receive standardized, weight-based, intravenous hydration before investigation. Subjects with markedly increased urinary NGAL values after CM application will be randomized into one of two study groups. Group A will receive 3-4 ml/kg BW/h 0.9% saline intravenously for 6 hours. Group B will undergo only standard treatment consisting of unrestricted oral fluid intake. The primary outcome measure will be CIN defined by an increase greater than 25% of baseline serum creatinine. Secondary outcomes will include urinary NGAL values, cystatin C values, contrast media associated changes in cardiac parameters such as NT-pro-BNP/troponin T, changes in urinary cytology, need for renal replacement treatment, length of stay in hospital and death.We assume that 20% of the included patients will show a definite rise in urinary NGAL. Prospective statistical power calculations indicate that the study will have 80% statistical power to detect a clinically significant decrease of CIN of 40% in the treatment arm if 1200 patients are recruited into the study. DISCUSSION: A volume expansion strategy showing a benefit from earlier intervention for patients with markedly elevated urinary NGAL values, indicating a CIN, might arise from data from this study. TRIAL REGISTRATION: ClinicalTrials.gov NCT01292317.

Efficacy and safety of anticoagulation with heparin versus heparin plus epoprostenol in patients undergoing extracorporeal liver support with Prometheus.

Anticoagulation for extracorporeal liver support is delicate due to underlying coagulation disorders in patients with liver failure and to the associated elevated bleeding risk. To date, there has been no detailed report on anticoagulation issues in patients treated with Prometheus, a device based on the principle of fractionated plasma separation and adsorption. We studied 17 patients from two centers treated with Prometheus, comparing standard anticoagulation with heparin (15 treatments) and a combination of heparin and the synthetic prostacyclin epoprostenol (22 treatments). Standard coagulation tests, proteins C and S, and thrombin-antithrombin (TAT) complex were determined, and adverse events were recorded. All but two treatments could be completed as scheduled, although filter exchange due to filter clotting was required in 24% of the treatments. Three out of 17 patients developed severe bleeding complications within 24 h of treatment. There were no overt thrombotic events. Addition of epoprostenol neither reduced coagulation-related adverse events nor improved standard coagulation parameters. Protein C, but not protein S, showed a significant reduction (23 +/- 18%) after Prometheus treatments, but levels rebounded to baseline within 18 h. TAT levels--a measure for activation of coagulation--were only altered by Prometheus in patients where TAT was already elevated before treatment. In conclusion, anticoagulation of Prometheus with heparin is feasible but still associated with a relatively high frequency of filter clotting and a considerable risk of severe bleeding in this high-risk patient population. As addition of epoprostenol did not prove beneficial, other strategies, such as regional anticoagulation with citrate, should be further evaluated.

[Polypharmacy is of major concern in cardiology]. / Polypharmazie in der Kardiologie - ein beachtliches Problem bei Synkopen, QT-Zeit-Verlängerung, Bradykardie und Tachykardie.

Quality improvement in cardiology over the past decade focused on management of acute coronary syndrome with invasive and innovative medical therapies, optimizing treatment of congestive heart failure and the development of repair procedures in valvular heart disease. On the other hand cardiologist and the attendant physicians are confronted with changes in the characteristics of patients in the light of demographic facts. Comorbidity and polypharmacy raise the need for clear concepts. Therapeutic and diagnostic tools of geriatric medicine may help in that context.

[Oral anticoagulation and risk of bleeding in elderly patients - the aspect of polypharmacy]. / Blutungskomplikationen bei geriatrischen Patienten unter oraler Antikoagulation - Aspekte der Polypragmasie.

Oral anticoagulant therapy has been shown to be of benefit also in elderly patients in various therapeutic and prophylactic indications. Despite strong evidence in literature, doctors still refuse to prescribe oral anticoagulants to geriatric patients in daily routine. Main reason for this decision is the fear of secondary bleeding complications. According to clinical trial data, distinct risk factors for bleeding attributed to anticoagulant treatment may be determined: age >70 years, female gender, recurrent bleeding events, alcohol/drug abuse, diabetes, anaemia and polypharmacy. The entire article reveals the literature in Medline and Cochrane Library from 1980 to 2009 including the hits "polypharmacy - anticoagulant treatment - elderly patients". It further highlights risk assessment strategies in elderly patients, and possible pharmacokinetic and -dynamic interactions of drugs co-administered with oral anticoagulants.

[Diuretics-related complications in elderly patients]. / Komplikationen durch Diuretikatherapie bei geriatrischen Patienten.

Diuretics are well studied and evaluated for their beneficial use in geriatric patients. However those drugs are often used without taking care of subjects condition or functional impairment. Known side effects of those substances may be increased by combinations of multiple drugs. Polypharmacy is a strong risk factor for the incidence of adverse drug reactions (ADR). ADRs are frequently found in combination with the use of diuretics. The remodelling of human body in aging process and uncontrolled therapeutic strategies seem to be causal for that finding. This article tries to work out the potential risk of the usage of those drugs in geriatric patients and its clinical relevance by using literature published in PubMed.

[Drug-related delirium in elderly patients]. / Medikamenten-induzierte Delirien älterer Menschen.

Drugs have been widely associated with the development of delirium in the elderly and represent the most common reversible cause of this condition. This is of importance since successful treatment depends on identifying the reversible contributing factors. Medications with anticholinergic properties, tranquilizers, analgesics and narcotics are common causes of drug-induced delirium. This article provides practical approach to prevent and recognise this condition, reviews the underlying neurotransmitter imbalances and reconsiders age-related changes of pharmacological effects, which may contribute to the development of delirium.

[Polypharmacy and pain treatment]. / Polypharmazie und Schmerztherapie.

Pain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug-drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.

[Polypharmacy and falls in the Elderly]. / Polypharmazie und Stürze im Alter.

Falls and their consequences are a major problem in geriatric medicine. Main causes are the combination of age-related physiological changes with multimorbidity and subsequent polypharmacy. Elderly patients are more susceptible to adverse drug effects and have less compensatory capacity than younger adults. Therefore careful monitoring of side effects is indicated and prescribing for elderly patients calls for alertness in order to identify symptoms as possible adverse drug effects.

A large-scale investigation of lateralization in cortical anatomy and word reading: are there sex differences?

The authors report findings of a large-scale, multitask investigation of sex differences in both structural asymmetries and lateralization of word reading. Two hundred participants were tested in eight divided visual field lexical tasks, and each received a structural magnetic resonance imaging scan. The authors examined whether there was evidence for sex differences in overall measures of neuroanatomical and behavioral lateralization, in specific language tasks and brain regions, and in variation in asymmetry within and across tasks and brain regions. There was very little evidence for sex differences on any behavioral measure. The few indications of sex differences in the current report accounted for 2% or less of the individual variation in asymmetry and could not be replicated in independent subsamples. No sex differences were observed in the asymmetry of structures in Broca's and Wernicke's areas such as pars triangularis, pars opercularis, the planum temporale, planum parietale, or Heschl's gyrus. There were also no sex differences in the variability of neuroanatomical asymmetries within or between brain regions. However, a significant relationship between planum temporale and behavioral asymmetry was restricted to men.

Neuroanatomical and behavioral asymmetry in an adult compensated dyslexic.

Individual differences in cortical anatomy are readily observable, but their functional significance for behaviors such as reading is not well understood. Here, we report a case of an apparent compensated dyslexic who had attained high achievement in visuospatial mathematics. Data from a detailed background interview, psychometric testing, divided visual field tasks measuring basic word recognition (word naming, nonword naming, and lexical decision), and more controlled word retrieval (verb, category, and rhyme generation), and measurements of his atypical brain structure are described. The findings suggested that enhanced "top-down" processing could provide the means to compensate for deficient "bottom-up" word decoding skills in this case. Relative to controls, this individual also evidenced unusually large asymmetries on several divided visual field lexical tasks, an extreme leftward asymmetry of the planum temporale, and a rare form of Sylvian fissure morphology (Steinmetz type 4, [Steinmetz, H., Ebeling, U., Huang, Y., & Kahn, T. (1990). Sulcus topography of the parietal opercular region: An anatomic and MR study. Brain and Language, 38, 515-533.]). We suggest that certain forms of brain organization may be associated with successful behavioral compensation for dyslexia, and that anatomical variations in the right hemisphere may be important contributors to individual differences in reading acquisition and achievement.

Cerebral asymmetries for language: evidence for structural-behavioral correlations.

The current investigation tested 20 male right-handers in 5 divided visual field lexical tasks. Asymmetries in Heschl's gyrus, planum temporale, and planum parietale were measured using structural magnetic resonance imaging. Composite task asymmetries were positively correlated with asymmetry of the planum temporale only. There was also an association between the consistency of anatomical and behavioral asymmetries: Individuals who departed the most from the modal pattern of cortical asymmetry across regions also tended to show the greatest variability in asymmetry across tasks. Hence, individual differences in language laterality tasks may be affected by variation in asymmetry of posterior language structures. Additionally, when typical anatomical asymmetries fail to co-occur, there may be a less strictly regulated distribution of function across hemispheres.

Effects of a pre-dialysis patient education program on the relative frequencies of dialysis modalities.

BACKGROUND: Pre-dialysis education can guide the choice of the dialysis modality best tailored to meet the needs and preferences of individual patients with chronic kidney disease. METHODS: In a retrospective single-center cohort study, we evaluated the impact of a pre-dialysis education program on the incidence rates of patients using hemodialysis (HD) and peritoneal dialysis (PD) in our unit. The frequency distribution of dialysis modalities between people attending our education program and people not attending the program (control group) was analyzed for the 4-year period 2004 - 2008. RESULTS: From among all the incident chronic kidney disease 5D patients presenting during the 4-year period, we analyzed 227 who started dialysis either with an arteriovenous fistula or a PD catheter. In that cohort, 70 patients (30.8%) took part in the education program, and 157 (69.2%) did not receive structured pre-dialysis counseling. In the group receiving education, 38 patients (54.3%) started with PD, and 32 (45.7%), with HD. In the standard-care group not receiving education, 44 patients (28%) started with PD, and 113 (72%), with HD (p < 0.001). CONCLUSIONS: Our multidisciplinary pre-dialysis program had a significant impact on the frequency distribution of dialysis modalities, increasing the proportion of patients initiating dialysis with PD.

Behavioral correlates of corpus callosum size: anatomical/behavioral relationships vary across sex/handedness groups.

There are substantial individual differences in the size and shape of the corpus callosum and such differences are thought to relate to behavioral lateralization. We report findings from a large scale investigation of relationships between brain anatomy and behavioral asymmetry on a battery of visual word recognition tasks. A sample of 200 individuals was divided into groups on the basis of sex and consistency of handedness. We investigated differences between sex/handedness groups in callosal area and relationships between callosal area and behavioral predictors. Sex/handedness groups did not show systematic differences in callosal area or behavioral asymmetry. However, the groups differed in the relationships between area of the corpus callosum and behavioral asymmetry. Among consistent-handed males, callosal area was negatively related to behavioral laterality. Among mixed-handed males and consistent-handed females, behavioral laterality was not predictive of callosal area. The most robust relationship was observed in mixed-handed females, in whom behavioral asymmetry was positively related to callosal area. Our study demonstrates the importance of considering brain/behavior relationships within sub-populations, as relationships between behavioral asymmetry and callosal anatomy varied across subject groups.

Early and unusual incisor resorption due to impacted maxillary canines.

A very early and severe case of maxillary incisor resorption caused by impacted canines is reported. An estimated 50,000 cases of ectopic eruption and impaction of maxillary canines occur each year in the United States. Although incisor resorption due to ectopically positioned permanent maxillary canines can be swift, silent, and devastating, an effective protocol has been developed for early detection and management of this condition. Palpation and, if indicated, radiographic evaluation are combined with primary canine removal in selected cases. These strategies--particularly when used early--can prevent the vast majority of palatally impacted maxillary canines and the potentially devastating resorption of adjacent incisors.