Trauma risk perception related to alcohol, cannabis, and cocaine intake.

OBJECTIVE: A high perception of risk may exert a preventive effect against the initiation of risky activities. The aims of the present study were (1) to analyze the risk perception for traumatic incidents according to drug intake (alcohol, cannabis, cocaine, no consumption) by trauma patients admitted to our hospital, and (2) to explore the influence of drugs on trauma recidivism. METHODS: Between 1 November 2011 and 1 April 2012, 404 patients aged between 16 and 70 years were admitted to our hospital for trauma cases. In 363 (89.9 %) of the patients, data were gathered on age, the trauma mechanism, and the consumption of alcohol and other drugs. Out of these 363 patients, 286 (78.8 %) attended a motivational interview and reported their consumption habits and their perception of the risk of trauma after alcohol and/or illegal drug consumption, as well as the antecedents of previous traumatisms. RESULTS: Alcohol and/or illegal drugs were detected in 37 % of the sample, with alcohol being the most frequently detected, followed by cannabis, cocaine, and other drugs. Among the trauma patients with no consumption, a high perception of trauma risk was associated with alcohol intake by 95.9 %, with cannabis consumption by 68.4 %, and with cocaine consumption by 53.4 %, whereas these percentages were significantly lower for patients testing positive for substances (79.3, 21.1, and 8.3 % respectively). Among the patients experiencing their first trauma, the mean age was almost 15 years younger in those who were positive for these substances than in those who were negative (p < 0.001). Finally, a history of previous trauma was reported by a majority (64 %) of the trauma patients testing positive for alcohol and/or drugs, but by a minority (36 %) of those testing negative (p < 0.001). CONCLUSIONS: The low perception of risk associated with alcohol, cannabis, or cocaine consumption by trauma patients under the influence of these substances on admission may be a predisposing factor for recidivism. Recommendations for both primary and secondary prevention are presented.

Análisis de la efectividad y seguridad de la derivación sin visita médica desde el triaje del servicio de urgencias hospitalario por personal de enfermería acreditado utilizando el Programa de Ayuda al Triaje del Sistema Español de Triaje / Safety and efficacy of hospital emergency department discharge from triage by nurses

Objetivo: Investigar la efectividad y la seguridad de la derivación sin visita médica desde el triaje del servicio de urgencias hospitalario (SUH) en base a la evaluación inicial realizada por enfermería acreditada utilizando el Programa de Ayuda al Triaje (PAT).Método: Se analizaron los resultados del primer año de aplicación del PAT en el SUHdel Hospital Clínic de Barcelona, sede Villarroel (SVll), en todas las consultas sometidas a triaje y en las consultas asignadas y derivadas para visita al dispensario de urgencias de la calle Valencia (Sede Valencia, SVa).Resultados: De 102.063 consultas en SVll, 64.425 se realizaron cuando la SVa estaba operativa, y a ella se asignaron 3.589 (3,5%) de las que 3.384 (94,3%) realmente acudieron. El nivel V de triaje, la residencia externa a la ciudad de Barcelona y los periodos vacacionales tuvieron valor predictivo independiente para la no consumación de la visita en la SVa. Se dio el alta a 3.270 pacientes (96,6%) de la SVa y 114 (3,4%) necesitaron traslado a otros centros. Los antecedentes de consulta previa en la SVll, la edad más avanzada, día laborable y el nivel V de triaje tuvieron valor predictivo independiente de necesidad de traslado a otros centros. Únicamente 11 de estos traslados (10%) necesitaron ingreso (0,3% del total de las consultas derivadas). No hubo variables predictivas de ingreso hospitalario y ningún paciente falleció. Conclusiones: La derivación sin visita médica realizada por enfermería acreditada utilizando el PAT es efectiva y segura. Las variables predictoras de no finalización del episodio en el centro propuesto de derivación pueden ser de utilidad para futuros desarrollos del PAT como herramienta de asignación de dispositivo para la atención urgente (AU)

Objective: To assess the safety and efficacy of discharge from a hospital emergency department with referral to another point of care based on the application of an algorithmic aid to triage (AAT) by nurses without physician evaluation of thepatient. Methods: Analysis of results for the first year’s application of the AAT in the emergency department of the Villaroell center of Hospital Clínic de Barcelona (CVill). The AAT was used to assess all patients entering triage and in the visits referred to the hospital’s emergency clinic on Carrer Valencia (CVal).Results: Of 102 063 visits to CVill, 64 425 occurred when the CVal was operating. Of the 3589 patients (3.5%) referred to the CVal, 3384 (94.3%) actually went to the referral clinic. A level V triage classification, residence outside the city of Barcelona, and visits made during holiday periods were independent predictors of a patient’s failure to go to the CV alclinic. Of the 3384 patients who went to the CVa, 3270 (96.6%) were discharged and 114 (3.4%) were transferred to other centers. A history of prior visits to the CVill, advanced age, visiting on a working day, and level V triageclassification were independent predictors of transfer to another center from the CVal. Only 11 of the transferred patients(10%) required hospital admission (0.3% of the initial visits discharged by the nurses with referral). No independent variables predicted hospital admission and no patient died.Conclusions: Referral without physician evaluation by nurses accredited to use the AAT is safe and effective. Variables that predicted failure to go to the referral center may be useful for further development of the AAT as a tool for deciding where to send a patient for emergency care (AU)

Descripción clínica y epidemiológica de los primeros casos de la gripe nueva A (H1N1) atendidos en España / New influenza virus A (H1N1) infection in Spain: clinical and epidemiologic description

Objetivo: Describir las consultas atendidas en urgencias durante el primer día de brote de gripe nueva A (H1N1), descripción de los primeros casos diagnosticados, su contexto epidemiológico y la organización que se estableció en urgencias durante las 24 horas de la guardia de dicho día. Método: Se revisan las historias clínicas de las consultas recibidas en urgencias el día 26de abril de 2009 en relación al brote de gripe nueva A (H1N1), y a partir de ella se recogen datos clínicos y epidemiológicos. En los casos sospechosos se realizó una analítica general, una radiología de tórax, un frotis nasal y faríngeo para la detección de ácidos nucleicos del nuevo virus de la la gripe A (H1N1) y una extracción de sangre para la determinación de anticuerpos específicos. Además, se han recogido también las principales medidas organizativas que se tomaron durante la guardia. Resultados: Durante la guardia se atendieron un total de 99 pacientes, de los cuales 12(12%) estuvieron relacionados con el brote de nueva gripe en México. Estos 12 pacientes procedían de 6 viajes diferentes, con un tiempo transcurrido desde el vuelo de retorno de entre 3 y 25 días. De los 12 casos, en cuatro de ellos se consideró que no había contexto epidemiológico compatible, por lo que fueron dados de alta sin realizárseles determinación de ácidos nucleicos. De los ocho restantes, cuatro se ingresaron en el hospital (todos ellos en habitaciones individuales que reúnen los requisitos para el aislamiento respiratorio y de contacto) y cuatro fueron dados de alta. De estos 8 pacientes, tres fueron diagnosticados de gripe nueva A (H1N1), uno de ellos por transmisión secundaria doméstica sin haber estado previamente en México. Las características clínicas del cuadro no difieren de la gripe epidémica humana que habitualmente (..) (AU)

Objective: To describe emergency consultations during the first day of the new influenza outbreak. The description covers the first cases of new influenza virus infection diagnosed, the epidemiologic context, and the organization of emergency services during the first 24 hours of care provided on that day. Material and Methods: The medical records for emergency consultations on April 26, 2009 at an urban tertiary care hospital were reviewed to identify cases related to the new influenza virus. Clinical and epidemiologic data were extracted. When the new influenza was suspected, the attending physician ordered a complete laboratory and blood workup, chest x-ray, and nasal swab and throat swab to detect nucleic acids from new influenza virus A (H1N1). Blood was extracted for influenza viral specific antibodies testing. Information on the main organizational measures taken during the 24-hour period were also recorded. Results: Ninety-nine patients were attended over the course of the day. Twelve (12%) had had some contact with cases of the new Mexican flu outbreak. The 12 cases all bore some relationship with 6 different trips (with between 3 and 25 days passing since the return flight). In 4 cases, it was considered that epidemiologic features were not consistent with a diagnosis of the new influenza. Those patients were therefore discharged without viral antigen testing. Four of there maining 8 patients were admitted (all placed in private rooms that allowed for respiratory and contact isolation), and 4 were discharged. Three of the 8 patients were diagnosed with the new influenza. One case was the result of secondary transmission in the home, as the patient (..) (AU)

Gestión de los servicios de urgencias / Management of emergency services

Los Servicios de Urgencias juegan un papel crítico en todas las comunidades. Las personas que tienen un problema de salud y no saben dónde acudir, suelen escoger las Urgencias como primera fuente de cuidados. Los problemas aparecen cuando el excesivo uso de los servicios de Urgencias acaba derivando en un colapso de los mismos, las Urgencias se saturan y es entonces cuando la calidad de la asistencia y la seguridad del paciente pueden quedar comprometidas. En este artículo se analizan los factores que pueden provocar el mencionado colapso (AU)

The Emergency Services play a critical role in all communities. People who have a health problem and don´t know where to go usually choose the Emergency Department as a first resource for nursing care. The problems appear when the excessive use of the Emergency Services leads to a collapse; they become saturated and this is when the quality of the care and safety of the patient may be jeopardized. This article analyses the factors which may cause such collapses (AU)

Renal failure after upper gastrointestinal bleeding in cirrhosis: incidence, clinical course, predictive factors, and short-term prognosis.

To assess the incidence, clinical course, predictive factors, and prognosis of renal failure in patients with cirrhosis and gastrointestinal bleeding, 175 consecutive episodes of gastrointestinal bleeding in 161 patients were analyzed. Renal failure occurred in 20 (11%) episodes and was transient in 8 episodes and nontransient in 12. Renal failure was more common in patients with cirrhosis than in a control population of bleeding patients without cirrhosis matched by age and severity of the bleeding episode. Among 39 clinical and laboratory variables obtained at admission or during hospitalization related with the bleeding episode or with liver and renal function, the presence of hypovolemic shock, number of packed red blood cells transfused, Child-Pugh class at admission, and baseline platelet count were independent predictors of renal failure. The development of renal failure and hypovolemic shock was the only independent predictors of in-hospital mortality. Mortality rate among the 20 episodes with renal failure was 55% (11 deaths) as compared with only 3% (5 deaths) in the 155 episodes without renal failure (P <.01). The development of nontransient renal failure entailed a much greater mortality as compared with transient renal failure (10 of 12 [83%] vs. 1 of 8 [12%]; P <.01). In conclusion, renal failure is a common event in patients with cirrhosis and gastrointestinal bleeding, the occurrence of which is mainly related to the severity of bleeding and baseline liver function. Renal failure is a strong predictor of mortality in patients with cirrhosis and gastrointestinal bleeding.

Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma.

Radiofrequency (RF) ablation is an alternative to percutaneous ethanol injection (PEI) for single nonsurgical hepatocellular carcinoma (HCC) and is currently used as adjuvant therapy before liver transplantation. This phase II study assesses the treatment-related complications and response rate of RF for the treatment of single HCC < or = 5 cm. Percutaneous RF was performed under conscious sedation and ultrasound (US) guidance with an electrical generator connected to a single cooled-tip electrode. Neoplastic cells in peripheral blood (reverse transcription-polymerase chain reaction for alpha fetoprotein [AFP] messenger RNA) were analyzed before and after RF. Treatment response was assessed by spiral computed tomography (CT) at 1 month and every 3 months by US or spiral CT thereafter. Thirty-two patients (20 men; age 67 +/- 4 years; 78% hepatitis C virus; 24 Child-Pugh A) with a mean tumor size of 2.8 cm (25 patients < or = 3 cm) were treated by RF (1.25 sessions; mean time, 22.1 +/- 2 minutes). Adjuvant PEI was performed in 9 cases. Complete response was achieved in 21 patients (65%), being significantly higher for HCC < or = 3 cm (76% vs. 29%, P = .03). After a median follow-up of 10 months, 8 patients showed treatment-related morbidity. Four of them (12.5%) showed biopsy-proven needle-track seeding detected between 4 to 18 months. Neoplastic seeding was related to subcapsular location (P = .009), poor differentiation degree (P = .02), and baseline AFP levels (P = .02). Thus, RF ablation with cooled-tip needle for HCC is associated with a high risk of neoplastic seeding. Iatrogenic dissemination was related to subcapsular location or an invasive tumoral pattern, and has to be considered when selecting curative treatments for HCC or adjuvant therapies before liver transplantation.

Transfusion of incompatible RBCs to a patient with alloanti-Kp(b).

BACKGROUND: The finding of an antibody that reacts against a high-incidence blood group antigen always constitutes a complex transfusion problem because of the difficulty in finding compatible units. When the transfusion of incompatible RBCs is imperative, it would be of great interest to have access to techniques facilitating the prediction of the transfusion outcome. STUDY DESIGN AND METHODS: The case of a patient with alloanti-Kp(b) who required RBC transfusions is reported. The functional activity of this antibody was assessed by both the chemiluminescence test (CLT) and the survival of 51Cr-labeled RBCS: RESULTS: The CLT showed an opsonic index of 0.8 with Kp(b)-positive RBCs (normal values up to 1.6) in pretransfusion studies. During an elective surgical procedure, the patient required the transfusion of one incompatible unit of RBCs, which did not produce hemolysis. Two weeks after this incompatible transfusion, the opsonic index had risen to 11. Results of the 51Cr in vivo study, also performed at that time, indicated 24.3 percent survival of Kp(b)-positive RBCs at 60 minutes and 2.0 percent at 24 hours. CONCLUSION: Results of the CLT correlated with the in vivo transfusion outcome and later with the 51Cr survival study.

Early detection of hepatic artery thrombosis after liver transplantation by Doppler ultrasonography: prognostic implications.

We assessed the usefulness of routine Doppler ultrasonography for early detection of hepatic artery thrombosis after orthotopic liver transplantation and repercussions in patient prognosis. Seventeen confirmed cases of early hepatic artery thrombosis initially diagnosed by Doppler ultrasonography (10 of them before clinical indication) were reviewed. All patients underwent Doppler ultrasonographic studies in the first 3 days after orthotopic liver transplantation. Twelve cases of hepatic artery thrombosis (70.6%) were detected by this early Doppler ultrasonography. All 10 unsuspected cases of hepatic artery thrombosis and 5 of the 7 cases diagnosed after clinical indication were treated by revascularization. Grafts were salvaged in 80% of asymptomatic patients and in 42.8% of symptomatic patients. Furthermore, biliary complications were less serious in the first group. In conclusion, Doppler ultrasonography performed routinely in the first 3 days after orthotopic liver transplantation may permit early detection of hepatic artery thrombosis, even before clinical indications. This allows hepatic artery repermeabilization before liver function damage, improving graft rescue and patient prognosis.

[Bioartificial liver support for acute liver failure. First case treated in Spain]. / Soporte hepático bioartificial en la insuficiencia hepática aguda grave. Primer caso tratado en España.

BACKGROUND: Research aimed at developing artificial liver support systems has experienced a notable increase in the last decade. Hybrid systems including bioreactors containing hepatocytes which are perfused by liver failure patients blood or plasma have been deviced for the first time. The purpose of such a strategy is to substitute, at least in part, the impaired hepatic function thus improving the prognosis of patients with severe acute or chronic liver diseases. CASE REPORT: In the present paper, we report the first such a case treated in Spain in the context of a controlled, randomized, multicenter international study aimed at investigating the usefulness and safety of a bioartificial liver support system based on cryopreserved porcine hepatocytes in patients with acute liver failure or having a non-functioning primary graft after liver transplantation. RESULTS: In this first experience, two sessions of treatment could be completed before a patient with acute liver failure underwent a successful emergency liver transplantation. After more than two years of follow-up, the patient is in her normal life activities and she has not presented any adverse event related to the bioartificial liver support therapy so far. CONCLUSION: Bioartificial liver support systems are starting to be available for use in clinical practice. Yet it is mandatory to establish their safety and efficacy before a widespread recommendation.

[Massive vesicoinguinal hernia and acute renal failure. An infrequent association]. / Hernia vesicoinguinal masiva y fracaso renal agudo. Una asociación poco frecuente.

OBJECTIVE: To report a rare complication of acute renal failure secondary to massive vesicoinguinal hernia. To our knowledge, only 4 cases have been previously reported in the literature. METHODS: Herein we describe a case of massive vesicoinguinal hernia in a patient that had presented at the emergency services with symptoms of acute renal failure. The diagnostic and therapeutic aspects of this rare complication are discussed. RESULTS: Patient evaluation showed a left inguinal hernia and benign hyperplasia of the prostate. Blood analytical findings were compatible with acute renal failure. A left massive vesicoinguinal hernia was detected on ultrasound evaluation and confirmed by retrograde cystography. Treatment was by surgical repair of the inguinal hernia, bladder repositioning and cervicoprostatotomy plus TUR of the excrescent bladder lesions to resolve the obstruction. CONCLUSIONS: Massive vesicoinguinal hernia may go undetected if the symptoms are unremarkable and may mimick those of acute renal failure.

Terlipressin plus albumin infusion: an effective and safe therapy of hepatorenal syndrome.

BACKGROUND/AIM: Ornipressin, a vasopressin analog with potent splanchnic vasoconstrictor action, has been shown to reverse hepatorenal syndrome. However, its usefulness in clinical practice is limited by frequent ischemic complications. The aim of this study was to assess the efficacy of terlipressin, an analog of vasopressin with a low profile of side effects, plus albumin in this condition. METHODS: Nine consecutive patients with cirrhosis and hepatorenal syndrome were included in a pilot study of terlipressin (0.5-2 mg/4 h i.v.) therapy associated with iv albumin. RESULTS: Treatment (9 days, range 5-15) was associated with a marked reduction of serum creatinine (3.9+/-0.7 to 1.3+/-0.1 mg/dl, p<0.001, mean+/-SE). Reversal of hepatorenal syndrome (reduction of creatinine below 1.5 mg/dl) was observed in seven of the nine patients. There was a remarkable improvement in circulatory function, with an increase in mean arterial pressure (68+/-2 to 80+/-4 mmHg, p<0.05) and suppression of vasoconstrictor systems activity (plasma renin activity and plasma norepinephrine decreased from 23+/-12 ng/ml x h and 1549+/-373 pg/ml to 3.5+/-2 ng/ml x h and 373+/-98 pg/ml, respectively, p<0.01 for both). No patient developed signs of intestinal, myocardial or distal ischemia. CONCLUSIONS: Terlipressin associated with albumin appears to be a safe and effective treatment of hepatorenal syndrome.

Etiology and microbial patterns of pulmonary infiltrates in patients with orthotopic liver transplantation.

STUDY OBJECTIVE: To evaluate the etiology and microbial patterns of pulmonary infiltrates in liver transplant patients using a bronchoscopic diagnostic approach and the impact of diagnostic results on antimicrobial treatment decisions. DESIGN: A prospective cohort study. SETTING: A 1,000-bed tertiary-care university hospital. PATIENTS AND METHODS: Fifty consecutive liver transplant patients with 60 episodes of pulmonary infiltrates (33 episodes during mechanical ventilation) were studied using flexible bronchoscopy with protected specimen brush (PSB) and BAL. RESULTS: A definite infectious etiology was confirmed in 29 episodes (48%). Eighteen episodes corresponded to probable pneumonia (30%), 10 episodes had noninfectious etiologies (17%), and 3 remained undetermined (5%). Opportunistic infections were the most frequent etiology (16/29, 55%, including 1 mixed etiology). Bacterial infections (mainly Gram-negative) accounted for 14 of 29 episodes (48%), including 1 of mixed etiology. The majority of bacterial pneumonia episodes (n = 10, 71%) occurred in period 1 (1 to 28 days posttransplant) during mechanical ventilation, whereas opportunistic episodes were predominant in periods 2 and 3 (29 to 180 days and > 180 days posttransplant, respectively; n = 14, 82%). Microbial treatment was changed according to diagnostic results in 21 episodes (35%). CONCLUSIONS: Microbial patterns in liver transplant patients with pulmonary infiltrates corresponded to nosocomial, mainly Gram-negative bacterial pneumonia in period 1, and to opportunistic infections in period 2 and, to a lesser extent, period 3. A comprehensive diagnostic evaluation including PSB and BAL fluid examination frequently guided specific antimicrobial therapy.

Prognostic value of early measurements of portal pressure in acute variceal bleeding.

BACKGROUND & AIMS: Variceal bleeding is the most important complication of portal hypertension. However, the relationship between the increase in portal pressure and the outcome of variceal bleeding has not been well defined. METHODS: We measured the hepatic venous pressure gradient (HVPG) of 65 cirrhotic patients with acute variceal hemorrhage, early after admission (20.6 +/- 15.6 hours). RESULTS: Twenty-three patients had a poor evolution (failure to control bleeding or early variceal rebleeding), and 42 had an uneventful evolution. The only variable associated with outcome was the HVPG, which was higher in patients with a poor evolution (23.7 +/- 6.1 vs. 19.2 +/- 3.3 mm Hg; P < 0.0004). This was confirmed by multivariate analysis. HVPG was >/=20 mm Hg in 19 of 23 patients with poor evolution vs. 12 of 42 patients with uneventful evolution (P < 0.0001). An initial HVPG of >/=20 mm Hg was associated with a significantly longer intensive care unit stay (7 +/- 5 vs. 4 +/- 2 days; P < 0.02), longer hospital stay (19 +/- 10 vs. 14 +/- 6 days; P < 0.02), greater transfusion requirements (9.0 +/- 7.7 vs. 4.7 +/- 3.2 UU; P < 0.007), and a worse actuarial probability of survival (1-year mortality, 64% vs. 20%; P < 0.002). CONCLUSIONS: Early measurement of HVPG in cirrhotic patients during acute variceal bleeding provides useful prognostic information on the evolution of the bleeding episode and long-term survival.

Acute quadriplegic myopathy with myosin-deficient muscle fibres after liver transplantation: defining the clinical picture and delimiting the risk factors.

BACKGROUND: In the last few years, rare cases of acute quadriplegic myopathy (AQM*) with myosin-deficient muscle fibres occurring after solid organ transplantation has been reported. The aim of the present study was to review all cases of AQM with myosin deficient fibres seen at our institution among a large series of patients after orthotopic liver transplants (OLT), with special attention to clinical aspects and associated risk factors. Additionally, an extensive review of all ultrastructurally demonstrated cases of AQM in transplant recipients is also included. PATIENTS AND METHODS: Among patients involved in 281 consecutive liver transplant procedures performed in a 4-year period, 3 men and 1 woman developed an arreflexic, flaccid quadriplegia in the immediate postoperative period of OLT. After ruling out other causes of weakness, a muscle biopsy was performed and a loss of thick (myosin) filaments was confirmed by ultrastructural analysis in all cases. Accurate clinical, epidemiological, and evolutive data were recorded. RESULTS: Corticosteroids had been used at usual dosage given to liver transplant recipients; all four patients had several intra- and postoperative complications leading to receiving significantly higher amounts of hemoderivates, to develop renal failure in all cases, and to require a significantly higher number of reoperations within a few days after transplantation than our contemporaneous global series of liver transplant recipients. AQM patients required a significantly longer intensive care unit and hospital stay. Muscular recovery was the rule, but currently a mild myopathic gait remains in three patients. These and other reported cases of AQM do not histologically and clinically differ from AQM seen in other critically ill patients who have not had transplants. CONCLUSIONS: Patients with a complicated intra- and postoperative course of OLT who develop newly acquired acute muscle weakness should be suspected as having acute AQM with myosin-deficient muscle fibres. In this setting, differential diagnosis with other causes of weakness should be carried out, because the prognosis of this myopathy is good with early muscle rehabilitation therapy.

Ecstasy: a common cause of severe acute hepatotoxicity.

BACKGROUND/AIMS: Ecstasy is a synthetic amphetamine recently identified as a possible cause of acute liver injury. This drug is consumed by young people and has a marked effect on improving sociability. The extent of ecstasy-associated severe hepatic damage is unknown to date. METHODS: The clinical histories of 62 patients with acute liver failure admitted to the Intensive Care Liver Unit between January 1994 and December 1996 were reviewed to assess the frequency, the epidemiological, clinical and histological characteristics and the outcome of ecstasy-induced severe hepatitis. RESULTS: Over this period of time, five patients (8%) were admitted because of ecstasy-induced acute liver failure, representing 31% of the cases with drug hepatotoxicity. Ecstasy was the second most common cause of liver injury in patients under the age of 25 years, being 20% in this subset of patients and 36% after ruling out the cases of viral etiology. All the patients had severe liver disease of acute onset, with jaundice, high peak of serum transaminases activity, hypoglycemia and low prothrombin activity, but no hepatic encephalopathy. Full recovery was observed in all cases from 3 to 12 months. CONCLUSIONS: Ecstasy is responsible for a relatively high number of cases of acute liver failure in young people. Therefore, the use of this drug should be investigated in all patients with severe hepatitis of unclear origin. Efforts must be made to advise young people of the risks of ecstasy consumption.

Reversibility of hepatorenal syndrome by prolonged administration of ornipressin and plasma volume expansion.

Hepatorenal syndrome is caused by a marked vasoconstriction of the renal circulation. It is suggested that the renal vasoconstriction is related to an overactivity of vasoconstrictor systems secondary to a vasodilation of the arterial circulation that causes a reduction in effective arterial blood volume. To test this hypothesis, 16 cirrhotic patients with hepatorenal syndrome were treated with a combination of ornipressin, a potent vasoconstrictor agent, and plasma volume expansion with albumin to improve effective arterial blood volume. The combined treatment was administered either for 3 or 15 days (8 patients each), and the effects on renal function, vasoactive systems, and systemic hemodynamics were assessed. The 3-day treatment with ornipressin and albumin was associated with a normalization of the overactivity of renin-angiotensin and sympathetic nervous systems, a marked increase in atrial-natriuretic peptide levels, and only a slight improvement in renal function. However, when ornipressin and albumin were administered for 15 days, a remarkable improvement in renal function was observed, with normalization of serum-creatinine concentration, a marked increase in renal plasma flow and glomerular filtration rate, and a persistent suppression in the activity of vasoconstrictor systems. However, 3 of 8 patients on 15-day therapy treatment had to be discontinued because of ischemic complications. In conclusion, the decrease in effective arterial blood volume and the activation of vasoconstrictor systems play a crucial role in the pathogenesis of hepatorenal syndrome. Although the prolonged administration of ornipressin combined with plasma volume expansion reverses hepatorenal syndrome, this treatment should be used with great caution in clinical practice because of the risk of ischemic complications.