Adjunct Use of Continuous Renal Replacement Therapy with Extracorporeal Membrane Oxygenation Achieves Negative Fluid Balance and Enhances Oxygenation Which Improves Survival in Critically Ill Patients without Kidney Failure.

INTRODUCTION: Fluid overload in extracorporeal membrane oxygenation (ECMO) patients has been associated with increased mortality. Patients receiving ECMO and continuous renal replacement therapy (CRRT) who achieve a negative fluid balance have improved survival. Limited data exist on the use of CRRT solely for fluid management in ECMO patients. METHODS: We performed a single-center retrospective review of 19 adult ECMO patients without significant renal dysfunction who received CRRT for fluid management. These patients were compared to a cohort of propensity-matched controls. RESULTS: After 72 h, the treatment group had a fluid balance of -3840 mL versus + 425 mL (p ≤ 0.05). This lower fluid balance correlated with survival to discharge (odds ratio 2.54, 95% confidence interval 1.10-5.87). Improvement in the ratio of arterial oxygen content to fraction of inspired oxygen was also significantly higher in the CRRT group (102.4 vs. 0.7, p ≤ 0.05). We did not observe any significant difference in renal outcomes. CONCLUSIONS: The use of CRRT for fluid management is effective and, when resulting in negative fluid balance, improves survival in adult ECMO patients without significant renal dysfunction.

A rare presentation of an ACTH-producing high-grade large cell neuroendocrine carcinoma with Cushing's syndrome.

High-grade neuroendocrine tumors (HGNET) are rare neoplasms composed of neural and hormonal with only around 42 cases reported in the last 20 years1. Herein, we describe a rare case of pancreatic HGNET, large cell type, associated with a Cushing's syndrome presentation.

Mediastinal Actinomycosis After Esophagogastroduodenoscopy.

Actinomycosis is an uncommon bacterial infection that presents as an indolent, progressive disease that can affect multiple organ systems. We describe the case of a 66-year-old female with end-stage renal disease who presented to the emergency department after developing acute dyspnea and chest pain two weeks after undergoing a diagnostic esophagogastroduodenoscopy (EGD). A CT scan was obtained that revealed a large mediastinal mass, which was initially concerning for a potential malignancy. Biopsy of the mass and Gram stain was consistent with mediastinal actinomycosis. The patient was subsequently treated with an extended course of antibiotics that resulted in significant clinical improvement. Previously reported cases describing a correlation between EGD and mediastinal actinomycosis have been associated with invasive procedures such as esophageal stent placement and transesophageal biopsy. We describe a case of an uncommon infectious complication of a diagnostic EGD that was not associated with intentional mucosal disruption.

Proton Pump Inhibitor-Induced Hypomagnesemia: A Rare, Potentially Fatal Complication.

Hypomagnesemia has been associated with a variety of abnormalities, including neurological, cardiac and secondary electrolyte abnormalities. We present the case of a 77-year-old male who presented to the emergency department with tremor and difficulty walking and was found to have severe hypomagnesemia necessitating hospital admission. After thorough workup, the patient's hospital course concluded that the profound hypomagnesemia was secondary to proton pump inhibitor use. Physicians should be aware of proton pump inhibitor-induced hypomagnesemia as a rare, but easily correctable etiology of hypomagnesemia.

Outcomes among Patients Treated with Renal Replacement Therapy during Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Study.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are modalities used in critically ill patients suffering organ failure and metabolic derangements. Although the effects of CRRT have been extensively studied, the impact of simultaneous CRRT and ECMO is less well described. The purpose of this study is to evaluate the incidence and the impact of CRRT on outcomes of patients receiving ECMO. METHODS: A single center, retrospective chart review was conducted for patients receiving ECMO therapy over a 6-year period. Patients who underwent combined ECMO and CRRT were compared to those who underwent ECMO alone. Intergroup -statistical comparisons were performed using Wilcoxon/Kruskal-Wallis and chi-square tests. Logistic regression was performed to identify independent risk factors for mortality. RESULTS: The demographic and clinical data of 92 patients who underwent ECMO at our center were reviewed including primary diagnosis, indications for and mode of ECMO support, illness severity, oxygenation index, vasopressor requirement, and presence of acute kidney injury. In those patients that required ECMO with CRRT, we reviewed urine output prior to initiation, modality used, prescribed dose, net fluid balance after 72 h, requirement of renal replacement therapy (RRT) at discharge, and use of diuretics prior to RRT initiation. Our primary endpoint was survival to hospital discharge. During the study period, 48 patients required the combination of ECMO with CRRT. Twenty-nine of these patients survived to hospital discharge. Of the 29 survivors, 6 were dialysis dependent at hospital discharge. The mortality rate was 39.5% with combined ECMO/CRRT compared to 31.4% among those receiving ECMO alone (p = 0.074). Of those receiving combined therapy, nonsurvivors were more likely to have a significantly positive net fluid balance at 72 h (p = 0.001). A multivariate linear regression analysis showed net positive fluid balance and increased age were independently associated with mortality. CONCLUSIONS: Use of CRRT is prevalent among patients undergoing ECMO, with over 50% of our patient population receiving combination therapy. Fluid balance appears to be an important variable associated with outcomes in this cohort. Rates of renal recovery and overall survival were higher compared to previously published reports among those requiring combined ECMO/CRRT.

Management of calciphylaxis in a burn center: A case series and review of the literature.

Calciphylaxis is a rare, necrotizing skin disorder usually associated with kidney disease, but also caused by many other systemic illnesses. This disease is associated with mortality rates as high as 80% at 1year. We present the demographic and clinical data of nine patients with calciphylaxis treated at our burn center over a 10year period. We review the literature on the clinical presentation, pathophysiology, diagnosis and treatment of this rare disease. We propose that these patients be treated similar to patients with thermal burn injury; meaning intensive wound care, surgical management, critical care and physical therapy. Burn centers are uniquely capable of caring for these incredibly complex patients due to their experience in managing patients with extensive skin and soft tissue defects, wounds and diseases.

Abatacept efficacy in steroid-resistant minimal-change disease revealed by the speed of proteinuria reduction after the start of abatacept
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A unique characteristic of the response of minimal-change disease (MCD) or focal and segmental glomerulosclerosis (FSGS) to steroid therapy is that the remission of proteinuria occurs quickly, for example, within 4 - 6 weeks of the onset of steroid therapy, even in those with severe nephrotic syndrome. Remission of proteinuria in MCD and FSGS can also occur spontaneously (not steroid induced). However, spontaneous remission usually proceeds over several months or longer. Recently, there have been several reports that abatacept can induce proteinuria remission in MCD and FSGS. These claims, however, are dubious because either the remission occurred slowly over several months of abatacept therapy, or remission occurred within a few weeks of abatacept therapy, but the patient was also receiving therapies that could have accounted for the remission of proteinuria. Our case is unique in that his severe steroid- and cyclosporine-resistant MCD remitted acutely while receiving abatacept, and there was no other plausible explanation for the acute remission of his MCD.
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A Case of Severe Iron Deficiency Anemia Associated with Long-Term Proton Pump Inhibitor Use.

The use of proton pump inhibitors (PPIs) in the treatment of gastrointestinal diseases has evolved over recent years. Initially intended for short-term use, PPIs are increasingly being used, often inappropriately, as long-term maintenance medications. The mechanism of action of PPIs is suppression of gastric basal and stimulated acid secretion by inhibiting the parietal cell H+/K+ ATP pump with a resultant increase in gastric pH and hypo- or achlorhydria. Although short-term use is related to few adverse effects, long-term use is associated with numerous complications. We present the case of a 58-year-old man with severe iron deficiency anemia due to malabsorption suspected to be caused by long-term PPI use. An extensive medical work up failed to reveal any definitive source of bleeding. An iron malabsorption test confirmed that iron was not being absorbed from the gastrointestinal tract. The Naranjo Adverse Drug Reaction Probability Scale and the Horn and Hansten Drug Interaction Probability Scale are suggestive of an association between long-term PPI use and the observed iron deficiency anemia. However, the patient's death and lack of an autopsy prevented confirmatory follow-up data from being obtained to connect long-term PPI use as the culprit. Although there are currently no recommendations regarding screening for iron deficiency and/or anemia in patients on long-term PPI therapy, physicians should be aware of this potential side effect and consider monitoring in high-risk patients.

Segmental zoster abdominal paresis (zoster pseudohernia): a review of the literature.

Herpes zoster is a distinct clinical syndrome that may present with a segmental zoster paresis. Although thoracic dermatomes are the most commonly affected, paresis of the abdominal muscles has been less frequently reported. To review the existing published evidence regarding this unusual clinical entity, a literature search of PubMed and Google was performed. In total, 35 articles that described 36 individual cases were identified. The information from all the cases was tabulated for the analysis. The mean age was 67.5 years. The ratio of men to women was approximately 4:1. The left and right side were approximately equally affected. The most affected associated dermatome was T11. In 88.9% of the patients, the typical herpetic rash preceded the abdominal weakness. The mean latent period from rash to onset of abdominal muscle weakness was 3.5 weeks. Electrodiagnostic studies confirmed the diagnosis in 95% of the tested patients. Complete recovery with conservative measures occurred in 79.3% of the patients who were followed-up for recovery, with a mean time for recovery of 4.9 months. Visceral neuropathy co-occurred in 19.4% of the patients. Because of its self-limited nature and good prognosis, recognition of this complication is important to prevent unnecessary diagnostic studies and procedures. Electrodiagnostic studies can be effectively used to confirm the diagnosis. Because visceral neuropathy commonly co-occurs with segmental zoster abdominal paresis, it should be actively investigated and treated.