Fluid and Electrolyte Management in the Neonate: Potassium and Phosphorus.

Maintenance of electrolyte balance in the neonate is challenging in the context of illness or prematurity. Imbalances in potassium and phosphorus can occur in neonates, ranging from benign and clinically insignificant to those that can be life-threatening. An individualized approach to fluid and electrolyte management is based on the neonate's gestational age, day of life, maintenance needs, deficits, and ongoing losses. This article reviews normal and abnormal potassium and phosphorus values along with management strategies. Using a case scenario, the reader can apply concepts outlined in this article to management of critically ill neonates with electrolyte disturbances.

Clinical and laboratory features of female Gitelman syndrome and the pregnancy outcomes in a Chinese cohort.

AIM: Gitelman syndrome (GS) is a rare inherited salt-losing renal tubulopathy. Data on clinical features and the pregnancy outcome for female GS patients in a large cohort are lacking. The study was aimed to explore the phenotype and pregnant issue for female GS patients. METHODS: GS cases from the National Rare Diseases Registry System of China (NRSC) were collected, and detailed clinical, laboratory and genetic data were analysed. Articles on pregnancy in GS were also systemically reviewed. RESULTS: A total of 101 GS patients were included; among them, 42.6% were female and 79.2% showed hypomagnesaemia. A lower proportion of female patients presented before 18 years of age, with less frequently reported polyuria, higher serum potassium and less urine sodium and chloride excretions. There was no gender difference in the sodium-chloride cotransporter (NCC) dysfunction evaluated by hydrochlorothiazide test. Twelve of the 43 female GS patients delivered after disease symptom onset, and their pregnancies were generally uneventful. As a group, pregnant GS patients had lower potassium levels in the first-trimester (P = .002) requiring higher potassium supplementation. After delivery, serum potassium (P = .02) and magnesium (P = .03) increased significantly. Both caesarean section and vaginal delivery were safe. CONCLUSION: Female GS patients may have a less severe phenotype with generally favourable outcomes of pregnancy. Intensive monitoring and increased potassium supplementation are necessary during pregnancy, especially in the first-trimester.

Benefits of peritoneal ultrafiltration in HFpEF and HFrEF patients.

BACKGROUND: Peritoneal ultrafiltration (pUF) in refractory heart failure (HF) reduces the incidence of decompensation episodes, which is of particular significance as each episode incrementally adds to mortality. Nevertheless, there are insufficient data about which patient cohort benefits the most. The objective of this study was to compare pUF in HFrEF and HFpEF, focusing on functional status, hospitalizations, surrogate endpoints and mortality. METHODS: This study involves 143 patients, who could be classified as either HFpEF (n = 37, 25.9%) or HFrEF (n = 106, 74.1%) and who received pUF due to refractory HF. RESULTS: Baseline eGFR was similar in HFrEF (23.1 ± 10.6 mg/dl) and HFpEF (27.8 ± 13.2 mg/dl). Significant improvements in NYHA class were found in HFpEF (3.19 ± 0.61 to 2.72 ± 0.58, P <  0.001) and HFrEF (3.45 ± 0.52 to 2.71 ± 0.72, P <  0.001). CRP decreased in HFrEF (19.4 ± 17.6 mg/l to 13.7 ± 21.4 mg/l, P = 0.018) and HFpEF (33.7 ± 52.6 mg/l to 17.1 ± 26.3 mg/l, P = 0.004). Body weight was significantly reduced in HFrEF (81.1 ± 14.6 kg to 77.2 ± 15.6 kg, P = 0.003) and HFpEF (86.9 ± 15.8 kg to 83.1 ± 15.9 kg, P = 0.005). LVEF improved only in HFrEF (25.9 ± 6.82% to 30.4 ± 12.2%, P = 0.046). BCR decreased significantly in HFrEF and HFpEF (55.7 ± 21.9 to 34.3 ± 17.9 P > 0.001 and 50.5 ± 68.9 to 37.6 ± 21.9, P = 0.006). Number of hospitalization episodes as well as number of hospitalization days decreased significantly only in HFpEF (total number 2.88 ± 1.62 to 1.25 ± 1.45, P <  0.001, days 40.4 ± 31.7 to 18.3 ± 22.5 days, P = 0.005). CONCLUSIONS: pUF offers various benefits in HFpEF and HFrEF, but there are also substantial differences. In particular, hospitalization rates were found to be significantly reduced in HFpEF patients, indicating a greater medical and economical advantage. However, LVEF was only found to be improved in HFrEF patients. While pUF can now be regarded as an option to supplement classical HF therapy, further studies are desirable to obtain specifications about pUF in HFpEF, HFmEF and HFrEF patients.

Hypomagnesemia and hypermagnesemia.

Introduction:Magnesium is an essential element which also has pleiotropic effects in humans. Recent studies have altered our interpretation of a disturbed magnesium balance both leading to hypomagnesemia and hypermagnesemia. Methods: a narrative review of their clinical relevance is presented. Results: Although magnesium balance is strictly controlled by the kidneys, hypomagnesemia is fairly common, especially in people with comorbid conditions. Increased renal magnesium wasting, often aggravated by drugs, is commonly found in conditions associated with unfavorable outcomes such as diabetes mellitus and sepsis. Depending on its severity hypomagnesemia may reveal itself by potentially hazardous neurological and cardiovascular symptoms. Intravenous magnesium is an evidence-based treatment of torsades de pointes and preeclampsia irrespective of the presence of preexisting hypomagnesemia. Magnesium deficiency and/or hypomagnesemia has been linked to cardiovascular disease, vascular calcification and endothelial function both in vitro and in vivo. (Severe) hypermagnesemia can be life-threatening but is almost exclusively observed in patients with substantially decreased kidney function associated with high magnesium intake through supplements or magnesium containing cathartics or antacids. Conclusion:It remains unclear whether mild hypermagnesemia confers survival benefit especially in subjects with decreased kidney function. The role of oral magnesium supplementation of chronic mild asymptomatic hypomagnesemia also merits further exploration through interventional studies in various study populations.

Parenteral Nutrition Electrolyte Abnormalities and Associated Factors Before and After Nutrition Support Team Initiation.

BACKGROUND: Studied since the 1940s, refeeding syndrome still has no universal definition, thus making comparison of studies difficult. Negative outcomes (eg, metabolic abnormalities) may occur with the use of specialized nutrition, such as parenteral nutrition (PN). Less than half of medical institutions have a nutrition support team (NST) managing PN. Interdisciplinary team management of PN may reduce negative outcomes of PN. The objective of this study was to show the value of the NST by measuring differences in PN variables, especially electrolyte abnormalities (EAs), before and after NST initiation at a large medical center and to identify factors associated with EAs among adult subjects receiving PN. MATERIALS AND METHODS: During this retrospective study, computerized medical charts (N = 735) from 2007-2010 were reviewed for electrolyte changes (particularly potassium, magnesium, and phosphorus) the first 3 days following PN initiation in hospitalized adults. Changes in EAs with other variables were compared before and after NST implementation. Equivalent samples sizes were collected to better evaluate the impact of the team. RESULTS: Following the implementation of the NST, fewer EAs were seen in PN patients (53%; χ2  = 10.906, P = .004); significantly less potassium, phosphorus, and magnesium intravenous piggyback supplementation (88.8% vs 94%; χ2  = 5.05, P = .026) was used; and mortality within 30 days of PN cessation was significantly less (12.7% vs 10.6%, P = .012). CONCLUSION: Our study complements existing research, finding that an NST was associated with a decreased occurrence of EAs and mortality in the hospitalized adult receiving PN.

Intervenção nutricional em adolescente com anorexia nervosa e componente bulímico: relato de caso / Nutritional intervention in adolescents with anorexia nervosa and bulimic component: case report

Introduçâo: Anorexia nervosa é uma doença psiquiátrica que apresenta alta taxa de morbimortalidade e afeta primariamente adolescentes com idade entre 15 e 19 anos. O objetivo deste trabalho foi relatar a evolução nutricional de paciente com diagnóstico de anorexia nervosa em uso de terapia nutricional enteral. Métodos: Trata-se de um estudo relato de caso do tipo observacional descritivo, de uma paciente diagnosticada com anorexia nervosa e componente bulímico. Resultados: A adolescente foi acompanhada por uma equipe multidisciplinar e interdisciplinar formada pelo clínico, psiquiatra, psicólogo, terapeuta ocupacional, nutricionista e enfermeiro, recebendo alta hospitalar após 60 dias de internamento com aumento dos seus parâmetros antropométricos. O ganho de peso final foi de 4,6 kg, resultando em alteração do seu índice de massa corporal para 13 kg/m2 e os valores de circunferência do braço e prega cutânea tricipital aumentaram 2 cm e 2,4mm, respectivamente. Discussão: Apesar do aumento observado nesses parâmetros, a classificação do estado nutricional da paciente permaneceu na mesma categoria do início, com o indicador índice de massa corporal/idade abaixo do percentil 3, entretanto, estudos demonstram que a recuperação do peso durante o internamento é um dos principais fatores que predizem resultados favoráveis e está associado a um melhor prognóstico clínico. Conclusão: A instituição de uma terapia nutricional adequada torna-se de fundamental importância na evolução clínica e nutricional de uma paciente com anorexia nervosa e componente bulímico e o tratamento com uma equipe multidisciplinar e interdisciplinar favorece um desfecho positivo

Introduction: Anorexia nervosa is a psychiatric disease with high mortality rate and affects primarily adolescents aged between 15 and 19 years. The objective of this study was to report the patient's nutritional status diagnosed with anorexia nervosa in use of enteral nutritional therapy. Methods: This is a descriptive observational case report of a patient diagnosed with anorexia nervosa and bulimic component. Results: The adolescent was accompanied by a multidisciplinary and interdisciplinary team formed by the clinician, psychiatrist, psychologist, occupational therapist, nutritionist and nurse, being discharged after 60 days of hospitalization with anthropometric parameters increase. The final weight gain was 4.6 kg, resulting in a change in body mass index to 13 kg / m2 and the circumference of arm and triceps skinfold increased 2 cm and 2.4 mm, respectively. Discussion: Despite the observed increase in these parameters, the classification of the nutritional status of the patient remained in the same category as the first, with body mass index/age indicator below the 3rd percentile, however, studies have shown that weight regain during hospitalization is one of the main factors that predict favorable results and is associated with a better clinical outcome. Conclusion: The establishment of adequate nutritional therapy becomes of fundamental importance in the clinical and nutritional evolution of a patient with anorexia nervosa and bulimic component and the treatment with a multidisciplinary and interdisciplinary team favors a positive outcome

Introducción: La anorexia nerviosa es una enfermedad psiquiátrica que presenta una alta tasa de morbimortalidad y afecta principalmente a los adolescentes de entre 15 y 19 años. El objetivo de este trabajo fue relatar la evolución nutricional de paciente con diagnóstico de anorexia nerviosa en uso de terapia nutricional enteral. Métodos: Se trata de un estudio relato de caso del tipo observacional descriptivo, de una paciente diagnostica da con anorexia nerviosa y componente bulímico. Resultados: La adolescente fue acompañada por un equipo multidisciplinario e interdisciplinario formado por el clínico , psiquiatra, psicólogo, terapeuta ocupacional, nutricionista y enfermero, recibiendo alta hospitalaria tras 60 días de internamiento con aumento de sus parámetros antropométricos. La ganancia de peso final fue de 4,6 kg, resultando en alteración de su índice de masa corporal a 13 kg / m2 y los val ores de circunferencia del brazo y pliegue cutáneo tricipital aumentaron 2 cm y 2,4 mm, respectivamente. Discusión: A pesar del aumento observado en estos parámetros, la clasificación del estado nutricional de la paciente permaneció en la misma categoría del inicio, con el indicador índice de masa corporal / edad por debajo del percentil 3, sin embargo, estudios demuestran que la recuperación del peso durante el internamiento es uno de los siguientes: los principales factores que predice resultados favorables y está asociado a un mejor pronóstico clínico. Conclusión: La institución de una terapia nutricional adecuada se vuelve de fundamental importancia en la evolución clínica y nutricinal de una paciente con anorexia nerviosa y componente bulímico y el tratamiento con un equipo multidisciplinario e interdisciplinario favorece un desenlace positivo

Avaluació de les aportacions nutricionals en els lactants amb bronquiolitis aguda greu / Evaluación de los aportes nutricionales en los lactantes con bronquiolitis aguda grave / Nutritional support for infants with severa bronchiolitis

Fonament: la bronquiolitis és la causa més freqüent d'infecció de les vies respiratòries baixes en els lactants, i d'ingrés hospitalari en menors d'un any. Segons la litera-tura, entre el 3 i l'11% dels pacients haurà d'ingressar a una unitat de cures intensives pediàtriques (UCIP), i veurà compromesa la ingesta oral, tenint en compte la gravetat clínica del pacient. En la literatura s'ha demostrat que la nutrició enteral (NE) precoç és beneficiosa i que un balanç hídric i ingesta calòrica adequats en milloren l'evolució. Objectiu: conèixer el tipus d'alimentació i l'aportació calòrica que reben els pacients amb bronquiolitis aguda ingressats en una UCIP, així com el balanç de líquids. Mètode: estudi prospectiu, descriptiu i observacional dels pacients amb diagnòstic de bronquiolitis aguda que van ingressar a la UCIP, entre l'1 d'octubre de 2014 i el 15 de maig de 2015. Entre altres variables, es van analitzar el tipus d'alimentació, la via d'administració, l'aportació calòrica, les entrades i sortides de líquids, i el balanç hídric diari, durant l'ingrés de cada pacient. Resultats: es van incloure 36 pacients. Durant el primer dia d'ingrés, 21 pacients (58,3%) van restar a dieta absoluta i 12 (33,3%) van iniciar NE de forma progressiva. Posteriorment les entrades enterals i, conseqüentment, l'aportació calòrica van anar ascendent progressivament; tot i així la mediana d'aportacions calòriques va ser de 70,5 kcal/kg/dia (rang interquartílic 1,30-83,10). Conclusions: l'aportació nutricional no va ser òptima durant l'estada a la UCIP, especialment els primers dies d'ingrés. Recomanem iniciar precoçment la NE i, si les condicions clíniques no ho permeten, valorar l'administració de nutrició parentera

Fundamento. La bronquiolitis es la causa más frecuente de infección de las vías respiratorias bajas en lactantes, y de ingreso hospitalario en menores de un año. Según la literatura, entre el 3 i el 11% de pacientes tendrá que ingresar en una unidad de cuidados intensivos pediátricos (UCIP), y verá comprometida la ingesta oral, dada la gravedad clínica del paciente. En la literatura se ha demostrado que la nutrición enteral (NE) precoz es beneficiosa y que un balance hídrico e ingesta calórica adecuados mejoran su evolución. Objetivo. Conocer el tipo de alimentación y el aporte calórico que reciben los pacientes con bronquiolitis aguda ingresados en una UCIP. Método. Estudio prospectivo, descriptivo y observacional de los pacientes con diagnóstico de bronquiolitis aguda que ingresaron en la UCIP entre el 1 de octubre de 2014 y el 15 de mayo de 2015. Entre otras variables, se recogieron y analizaron el tipo de alimentación y vía de alimentación, el aporte calórico, las entradas y salidas de líquidos, y el balance hídrico diario, para cada paciente. Resultados. Se incluyeron 36 pacientes. Durante el primer día de ingreso, 21 pacientes (58,3%) estuvieron a dieta absoluta y 12 (33,3%) iniciaron NE de forma progresiva. Posteriormente, las entradas enterales y el aporte calórico fueron aumentando progresivamente; aun así, la mediana de aportes calóricos fue de 70,5 kcal/kg/día (rango intecuartílico 61,30-83,10). Conclusiones. El aporte nutricional no fue óptimo durante la estancia en la UCIP, especialmente en los primeros días de ingreso. Recomendamos iniciar precozmente la NE y, si las condiciones clínicas no lo permiten, valorar la administración de nutrición parenteral (AU)

Background. Bronchiolitis is the most frequent cause of lower respiratory tract infection and hospitalization in infants. Reports suggest that between 3% and 11% of children with bronchiolitis require admission in the pediatric critical care unit (PICU) and have severe limitations to caloric intake. The early introduction of enteral nutritional support is beneficial, and an appropriate fluid balance and caloric intake has shown to impact outcome. Objective. To investigate the type of nutrition, caloric intake, and fluid balance in patients with acute bronchiolitis admitted to a PICU. Method. Prospective, descriptive, and observational study of patients with acute bronchiolitis admitted to the PICU at our center between October 1st 2014 and May 15th 2015. Among other variables, we collected and analyzed the type and route of nutrition, the caloric intake, and the fluid balance throughout the admission of each patient. Results. 36 patients were included. During the first day of admission 21 patients (58.3%) were kept nil per os and 12 patients (33.3%) started enteral nutrition. Subsequently the enteral support increased gradually in all patients; nevertheless, the mean of caloric intake was 70.5 kcal/kg/day (interquartile range 62.3-83.1). Conclusions.The nutritional intake was not optimal during the PICU admission, especially during the first days of admission. We recommend starting early enteral nutrition and if the clinical condition contraindicates this approach, consider the administration of parenteral nutrition (AU)

Nutritional Problems Affecting Older Adults.

Nutritional problems, such as malnutrition, dehydration, and electrolyte imbalance, are multifaceted and complex issues for older adults. This article describes these potential nutritional problems and then discusses evidence-based assessment strategies and treatment modalities that target these problems. Micronutrient deficiency is explored and evidence-based supplementation discussed. Many factors contribute to weight loss and malnutrition in older adults. These factors are classified as social, psychological, and/or biological. Addressing these issues and the influence of oral health on food intake are imperative to enhancing the overall quality of life for older adults.

Electrolytes: Oral Electrolyte Solutions.

Oral electrolyte solutions are used widely for rehydration in diarrheal illness and to maintain hydration during vigorous exercise. In diarrheal illness, an oral rehydration solution (ORS) typically is preferred over intravenous fluids except for patients with severe dehydration. The preferred ORS is one similar to the glucose-containing reduced osmolarity World Health Organization ORS. There also are polymer-based solutions that use rice or wheat as the source of carbohydrates but these are not widely recommended. Use of other liquids, such as sport drinks, juice, soft drinks, and chicken broth is not recommended, though these can be considered for patients with no or mild dehydration. For maintaining hydration during exercise, particularly vigorous high-intensity exercise, recommendations are to consume fluids (ie, 5 to 7 mL/kg) and a sodium-containing snack at least 4 hours before. During exercise, individuals require 200 to 800 mL/hour of liquid that should contain 20 to 30 mEq/L of sodium. Carbohydrate intake is recommended during high-intensity exercise. Intake of excessive sodium-free fluids should be avoided to prevent exercise-induced hyponatremia. Additional fluids (ie, 1.5 L/kg of weight lost) can be consumed after exercise to restore hydration. Vitamin and mineral supplements are not recommended routinely for athletes unless known deficiencies exist.

Peptide Receptor Radionuclide Therapy-Induced Gitelman-like Syndrome.

Peptide receptor radionuclide therapy (PRRT) is a molecular-targeted therapy in which a somatostatin analogue (a small peptide) is coupled with a radioligand so that the radiation dose is selectively administered to somatostatin receptor-expressing metastasized neuroendocrine tumors, particularly gastroenteropancreatic. Reported toxicities include myelotoxicity and nephrotoxicity, the latter manifesting as decreased kidney function, often developing months to years after treatment completion. We present a case of PRRT-induced kidney toxicity manifesting as a severe Gitelman-like tubulopathy with preserved kidney function. Because profound hypokalemia and hypocalcemia can lead to life-threatening arrhythmias, we highlight the necessity for careful monitoring of serum and urine electrolytes in patients receiving PRRT.

Fluid and Electrolyte Therapy in Diabetic Ketoacidosis.

Diabetic ketoacidosis is a dynamic disease that requires regular reassessment of an affected patient. Typical treatment regimens include crystalloid fluid therapy, insulin, and supplementation of dextrose, phosphorus, and potassium. This article presents an approach to and considerations for treatment of a diabetic ketoacidotic dog or cat.

Parenteral Nutrition in Very Low Birth Weight Preterm Infants.

Parenteral nutrition (PN) must be initiated as soon as possible after delivery in very low birth weight (VLBW) preterm infants in order to prevent postnatal growth failure and improve neurodevelopmental outcome. When administered early, high levels of parenteral amino acids (AA) are well tolerated and prevent negative nitrogen balance. Although proteins are the driving force for growth, protein synthesis is energy-demanding. Intravenous lipid emulsions (ILE) constitute a good energy source because of their high energy density and provide essential fatty acids (FA) along with their long-chain polyunsaturated fatty acid (LC-PUFA) derivatives necessary for central nervous system and retinal development. Early supply of ILE is not associated with increased morbidity. No significant differences were found between ILE based on soybean oil only and mixed ILE containing soybean oil in combination with other fat sources, except for a reduction in the incidence of sepsis with non-pure soybean ILE, and possibly less PN-associated liver disease with mixed ILE containing some fish oil. In preterm infants glucose homeostasis is still immature in the first days of life and abnormalities of glucose homeostasis are common. VLBW infants may not tolerate high levels of glucose infusion without hyperglycemia. Administering lower levels of glucose infusion as part of full early PN seems more successful than insulin at this stage. Postpartum there is a transition period when the water and electrolyte balance may be severely disturbed and should be closely monitored. Avoiding fluid overload is critical for preventing respiratory and other morbidities.

Eghindi among Sahrawi refugees of Western Sahara.

Eghindi is an illness built around a set of pathological states experienced by Sahrawi in the desert environment of Western Sahara. Its core symptoms are caused by osmotic imbalances related to salt consumption. In 1975, many Sahrawi were exiled into refugee camps, and they have since experienced radical sociocultural changes, which are reflected in changing explanatory models of eghindi. Older and conservative refugees, attached to traditional Sahrawi culture, have expanded its conceptualization to include new pathogenic factors, while younger and progressive refugees, acculturated with Western culture, began challenging its existence. Eghindi became embodied within a broader process of negotiation of Sahrawi cultural identity. Our findings provide a framework for thinking about the evolution of illness in response to displacement, and highlight that when explanatory models evolve, intracultural tensions can arise within a population.

Management of prolonged post-operative ileus: evidence-based recommendations.

BACKGROUND: Prolonged post-operative ileus (PPOI) occurs in up to 25% of patients following major elective abdominal surgery. It is associated with a higher risk of developing post-operative complications, prolongs hospital stay and confers a significant financial load on health-care institutions. Literature outlining best-practice management strategies for PPOI is nebulous. The aim of this text was to review the literature and provide concise evidence-based recommendations for its management. METHODS: A literature search through the Ovid MEDLINE, EMBASE, Google Scholar and Cochrane databases was performed from inception to July 2012 using a combination of keywords and MeSH terms. Review of the literature was followed by synthesis of concise recommendations for management accompanied by Strength of Recommendation Taxonomy (either A, B or C). RESULTS: Recommendations for management include regular evaluation and correction of electrolytes (B); review of analgesic prescription with weaning of narcotics and substitution with regular paracetamol, regular non-steroidal anti-inflammatory drugs if not contraindicated, and regular or as-required Tramadol (A); nasogastric decompression for those with nausea or vomiting as prominent features (C); isotonic dextrose-saline crystalloid maintenance fluids administered within a restrictive regimen (B); balanced isotonic crystalloid replacement fluids containing supplemental potassium, in equivalent volume to losses (C); regular ambulation (C); parenteral nutrition if unable to tolerate an adequate oral intake for more than 7 days post-operatively (A) and exclusion of precipitating pathology or alternate diagnoses if clinically suspected (C). CONCLUSIONS: Recommendations have a variable and frequently inconsistent evidence base. Further research is required to validate many of the outlined recommendations and to investigate novel interventions that may be used to shorten duration of PPOI.

[Early diagnosis and treatment of compartment syndrome caused by landslides:a report of 20 cases].

OBJECTIVE: To summarize early diagnosis and treatment methods of 20 patients with compartment syndrome caused by landslides during coal mine accidents in order to improve the level of diagnosis and treatment of compartment syndrome and reduce disability. METHODS: From September 2006 to April 2010,20 patients with compartment syndrome were treated with the methods of early decompression, systemic support. All the patients were male with an average age of 42 years (ranged, 23 to 54). All the patients with high tension limb swelling, pain, referred pain passive positive; 5 extremities feeling diminish or disappear and the distal blood vessel beat were normal or weakened or disappeared; myoglobinuria, hyperkalemia, serum urea nitrogen and creatinine increased in 5 cases and oliguria in occurred 1 case. The function of affected limbs was observed according to disability ratings. RESULTS: Three cases complicated with infection of affected limb and 6 cases occurred with renal function insufficiency. Total recovery was in 16 cases, basically recovery in 3, amputation in 1 case. All patients were followed up for 6-15 months with an average of 12 months. The ability to work according to national standard identification--Employee work-related injuries and occupational disability rating classification (GB/T16180-2006) to assess, grade 5 was in 1 case, grade 8 in 2 cases, grade 10 in 1 case, no grade in 16 cases. CONCLUSION: Arteriopalmus of dorsalis pedis weaken and vanished can not be regard as an evidence in early diagnosis of compartment syndrome. Early diagnosis and decompression, systemic support and treatment is the key in reducing disability.

Critical points in the management of pseudohypoaldosteronism type 1.

Pseudohypoaldosteronism type 1 (PHA-1, MIM #264350) is caused by defective transepithelial sodium transport. Affected patients develop life-threatening neonatal-onset salt loss, hyperkalemia, acidosis, and elevated aldosterone levels due to end-organ resistance to aldosterone. In this report, we present a patient diagnosed as PHA-1 who had clinical and laboratory findings compatible with the diagnosis and had genetically proven autosomal recessive PHA-1. The patient received high doses of sodium supplementation and potassium-lowering therapies; however, several difficulties were encountered in the management of this case. The aim of this presentation was to point out the potential pitfalls in the treatment of such patients in the clinical practice and to recommend solutions.

The side effects of phototherapy for neonatal jaundice: what do we know? What should we do?

Neonatal phototherapy (NNPT), a noninvasive, easily available therapy, has been widely used for the treatment of neonatal jaundice for more than half a century. Its efficiency in decreasing plasma bilirubin concentration is well documented, and NNPT leads to greatly reduced exchange transfusion rates for neonates with hyperbilirubinemia. It is generally accepted that the side effects of NNPT are not serious and seem to be well controlled. This review will focus on these possible side effects as well as the approaches to minimize them.

Refeeding syndrome: treatment considerations based on collective analysis of literature case reports.

Refeeding syndrome (RFS) represents a group of clinical findings that occur in severely malnourished individuals undergoing nutritional support. Cardiac arrhythmias, multisystem organ dysfunction, and death are the most severe symptoms observed. As the cachectic body attempts to reverse its adaptation to the starved state in response to the nutritional load, symptoms result from fluid and electrolyte imbalances, with hypophosphatemia playing a central role. Because guidelines for feeding the malnourished patient at risk for refeeding syndrome is scarce, we have provided management recommendations based on the knowledge derived from a collection of reported English literature cases of the RFS. A MEDLINE search using keywords including "refeeding syndrome," "RFS," and "refeeding hypophosphatemia" was performed. References from initial cases were utilized for more literature on the subject. We have emphasized the continued importance of managing patients at risk for RFS, compared how management of the severely malnourished patients have evolved over time, and provided comprehensive clinical guidelines based on the sum of experience documented in the case reports for the purpose of supplementing the guidelines available. Based on our review, the most effective means of preventing or treating RFS were the following: recognizing the patients at risk; providing adequate electrolyte, vitamin, and micronutrient supplementation; careful fluid resuscitation; cautious and gradual energy restoration; and monitoring of critical laboratory indices.

Management of yellow oleander poisoning.

BACKGROUND: Poisoning due to deliberate self-harm with the seeds of yellow oleander (Thevetia peruviana) results in significant morbidity and mortality each year in South Asia. Yellow oleander seeds contain highly toxic cardiac glycosides including thevetins A and B and neriifolin. A wide variety of bradyarrhythmias and tachyarrhythmias occur following ingestion. Important epidemiological and clinical differences exist between poisoning due to yellow oleander and digoxin; yellow oleander poisoning is commonly seen in younger patients without preexisting illness or comorbidity. Assessment and initial management. Initial assessment and management is similar to other poisonings. No definite criteria are available for risk stratification. Continuous ECG monitoring for at least 24 h is necessary to detect arrhythmias; longer monitoring is appropriate in patients with severe poisoning. Supportive care. Correction of dehydration with normal saline is necessary, and antiemetics are used to control severe vomiting. Electrolytes. Hypokalemia worsens toxicity due to digitalis glycosides, and hyperkalemia is life-threatening. Both must be corrected. Hyperkalemia is due to extracellular shift of potassium rather than an increase in total body potassium and is best treated with insulin-dextrose infusion. Intravenous calcium increases the risk of cardiac arrhythmias and is not recommended in treating hyperkalemia. Oral or rectal administration of sodium polystyrene sulfonate resin may result in hypokalemia when used together with digoxin-specific antibody fragments. Unlike digoxin toxicity, serum magnesium concentrations are less likely to be affected in yellow oleander poisoning. The effect of magnesium concentrations on toxicity and outcome is not known. Hypomagnesaemia should be corrected as it can worsen cardiac glycoside toxicity. Gastric decontamination. The place of emesis induction and gastric lavage has not been investigated, although they are used in practice. Gastric decontamination by the use of single dose and multiple doses of activated charcoal has been evaluated in two randomized controlled trials, with contradictory results. Methodological differences (severity of poisoning in recruited patients, duration of treatment, compliance) between the two trials, together with differences in mortality rates in control groups, have led to much controversy. No firm recommendation for or against the use of multiple doses of activated charcoal can be made at present, and further studies are needed. Single-dose activated charcoal is probably beneficial. Activated charcoal is clearly safe. Arrhythmia management. Bradyarrhythmias are commonly managed with atropine, isoprenaline, and temporary cardiac pacing in severe cases, although without trial evidence of survival benefit, or adequate evaluation of possible risks. Accelerating the heart rate with atropine or beta-adrenergic agents theoretically increases the risk of tachyarrhythmias, and it has been claimed that atropine increases tachyarrhythmic deaths. Further studies are required. Tachyarrhythmias have a poor prognosis and are more difficult to treat. Lidocaine is the preferred antiarrhythmic; the role of intravenous magnesium is uncertain. Digoxin-specific antibody fragments. Digoxin-specific antibody fragments are effective in reverting life-threatening cardiac arrhythmias; prospective observational studies show a beneficial effect on mortality. High cost and lack of availability limit the widespread use of digoxin-specific antibody fragments in developing countries. CONCLUSIONS: Digoxin-specific antibody fragments remain the only proven therapy for yellow oleander poisoning. Further studies are needed to determine the place of activated charcoal, the benefits or risks of atropine and isoprenaline, the place and choice of antiarrhythmics, and the effect of intravenous magnesium in yellow oleander poisoning.

Therapeutic approach to electrolyte emergencies.

Hypokalemia, hyperkalemia, hyponatremia, hypernatremia, hypocalcemia, and hypercalcemia are commonly seen in emergency medicine. Severe abnormalities in any of these electrolytes can cause potentially life-threatening consequences to the patient. It is essential that the clinician understand and correct (if possible) the underlying cause of each disorder and recognize the importance of the rates of correction, especially with serum sodium disorders. The recommended doses in this article might have to be adjusted to the individual patient, and these modifications must be adjusted again to the pathophysiology of the primary underlying disorder.