Case report: Resolution of oligo-anuric acute kidney injury with furosemide administration in a cat following lily toxicity.

Objective: To describe the successful outcome of a case of oligo-anuric acute kidney injury in a cat secondary to lily ingestion. Case summary: A 12-week-old intact male domestic short-hair cat weighing 1.64 kg (3.6 lb) presented with a 12-h duration of vomiting and lethargy after exposure to lilies of the genera Lilium species 24 h prior to presentation. Severe azotemia (Creatinine 5.8 mg/dL, BUN > 100 mg/dL) and hyperkalemia (9.36 mmol/L) were noted on the day of presentation. Treatment of hyperkalemia was instituted with calcium gluconate, lactated ringers solution, dextrose, regular short-acting insulin, albuterol, and sodium bicarbonate, Oliguria to anuria was highly suspected based on a lack of urine production 21 h after hospitalization with intravenous fluid administration and a static bladder size. The cat was administered 4 mg/kg of furosemide, and urinated at 6 h following administration and continued to produce over 6 ml/kg/h of urine in the next 24 h. Two days following furosemide administration, the cat's hyperkalemia and azotemia resolved. The cat was discharged after 4 days of hospitalization, and a recheck revealed no persistent azotemia or hyperkalemia. Unique information: Anuric acute kidney injury secondary to lily toxicity is associated with a poor prognosis, and the only treatment modality previously described is hemodialysis. The cat in this report was successfully managed with medical intervention and furosemide administration, with complete resolution of the acute kidney injury.

Acquired Factor V Deficiency: A New Cause of Bleeding in Patients with Chronic Myeloid Leukemia and Extreme Leukocytosis?

Bleeding complications in patients with MPNs are known to be related to acquired von Willebrand disease or platelet dysfunction. Here, we describe two very similar cases of chronic-phase CML with extreme leukocytosis (>500,000/mcL) and deep tissue bleeding after a minor trauma, who had increased PT and PTT, normal VWF antigen and activity. The patients were found to have acquired factor V deficiency. Factor V deficiency as a cause of bleeding in patients with uncontrolled CML has not yet been reported. Bleeding resolved after correction of hyperleukocytosis and FV level improved. We conclude that acquired FV deficiency is possible in patients with uncontrolled CML and extreme leukocytosis.

Actigraphy to Measure Physical Activity in the Intensive Care Unit: A Systematic Review.

OBJECTIVE: In the intensive care unit (ICU), prolonged inactivity is common, increasing patients' risk for adverse outcomes, including ICU-acquired weakness. Hence, interventions to minimize inactivity are gaining popularity, highlighting actigraphy, a measure of activity involving a wristwatch-like accelerometer, as a method to inform these efforts. Therefore, we performed a systematic review of studies that used actigraphy to measure patient activity in the ICU setting. DATA SOURCES: We searched PubMed, EMBASE, CINAHL, Cochrane Library, and ProQuest from inception until December 2016. STUDY SELECTION: Two reviewers independently screened studies for inclusion. A study was eligible for inclusion if it was published in a peer-reviewed journal and used actigraphy to measure activity in ≥5 ICU patients. DATA EXTRACTION: Two reviewers independently performed data abstraction and risk of bias assessment. Abstracted actigraphy-based activity data included total activity time and activity counts. RESULTS: Of 16 studies (607 ICU patients) identified, 14 (88%) were observational, 2 (12%) were randomized control trials, and 5 (31%) were published after 2009. Mean patient activity levels per 15 to 60 second epoch ranged from 25 to 37 daytime and 2 to 19 nighttime movements. Actigraphy was evaluated in the context of ICU and post-ICU outcomes in 11 (69%) and 5 (31%) studies, respectively, and demonstrated potential associations between actigraphy-based activity levels and delirium, sedation, pain, anxiety, time to extubation, and length of stay. CONCLUSION: Actigraphy has demonstrated that patients are profoundly inactive in the ICU with actigraphy-based activity levels potentially associated with important measures, such as delirium, sedation, and length of stay. Larger and more rigorous studies are needed to further evaluate these associations and the overall utility of actigraphy in the ICU setting.

Actigraphy to Evaluate Sleep in the Intensive Care Unit. A Systematic Review.

RATIONALE: Poor sleep quality is common in the intensive care unit (ICU) and may be associated with adverse outcomes. Hence, ICU-based efforts to promote sleep are gaining attention, motivating interest in methods to measure sleep in critically ill patients. Actigraphy evaluates rest and activity by algorithmically processing gross motor activity data, usually collected by a noninvasive wristwatch-like accelerometer device. In critically ill patients, actigraphy has been used as a surrogate measure of sleep; however, its use has not been systematically reviewed. OBJECTIVES: To conduct a systematic review of ICU-based studies that used actigraphy as a surrogate measure of sleep, including its feasibility, validity, and reliability as a measure of sleep in critically ill patients. METHODS: We searched PubMed, EMBASE, CINAHL, Proquest, and Web of Science for studies that used actigraphy to evaluate sleep in five or more patients in an ICU setting. RESULTS: Our search yielded 4,869 citations, with 13 studies meeting eligibility criteria. These 13 studies were conducted in 10 countries, and eight (62%) were published since 2008. Across the 13 studies, the mean total sleep time of patients in the ICU, as estimated using actigraphy, ranged from 4.4 to 7.8 hours at nighttime and from 7.1 to 12.1 hours over a 24-hour period, with 1.4 to 49.0 mean nocturnal awakenings and a sleep efficiency of 61 to 75%. When compared side-by-side with other measures of sleep (polysomnography, nurse assessments, and patient questionnaires), actigraphy consistently yielded higher total sleep time and sleep efficiency, fewer nighttime awakenings (vs. polysomnography), and more overall awakenings (vs. nurse assessment and patient questionnaires). None of the studies evaluated the association between actigraphy-based measures of sleep and outcomes of patients in the ICU. CONCLUSIONS: In critically ill patients, actigraphy is being used more frequently as a surrogate measure of sleep; however, because actigraphy only measures gross motor activity, its ability to estimate sleep is limited by the processing algorithm used. Prior ICU-based studies involving actigraphy were heterogeneous and lacked data regarding actigraphy-based measures of sleep and patient outcomes. Larger, more rigorous and standardized studies are needed to better understand the role of actigraphy in evaluating sleep and sleep-related outcomes in critically ill patients.

Evaluation of a strategy for enrolling the families of critically ill patients in research using limited human resources.

RATIONALE: Clinical trials of interventions aimed at the families of intensive care unit (ICU) patients have proliferated but recruitment for these trials can be challenging. OBJECTIVES: To evaluate a strategy for recruiting families of patients currently being treated in an ICU using limited human resources and time-varying daily screening over 7 consecutive days. METHODS: We screened the Johns Hopkins Hospital medical ICU census 7 days per week to identify eligible family members. We then made daily, in-person attempts to enroll eligible families during a time-varying 2-hour enrollment period until families declined participation, consented, or were no longer eligible. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the proportion of eligible patients for whom ≥1 family member was enrolled. Secondary outcomes included enrollment of legal healthcare proxies, the consent rate among families approached for enrollment, and success rates for recruiting at different times during the day and week. Among 284 eligible patients, 108 (38%, 95% CI 32%-44%) had ≥1 family member enrolled, and 75 (26%, 95% CI 21%-32%) had their legal healthcare proxy enrolled. Among 117 family members asked to participate, 108 (92%, 95% CI 86%-96%) were enrolled. Patients with versus without an enrolled proxy were more likely to be white (44% vs. 30%, P = .02), live in a zip code with a median income of ≥$100,000 (15% vs. 5%, P = .01), be mechanically ventilated (63% vs. 47%, P = .01), die in the ICU (19% vs. 9%, P = .03), and to have longer ICU stays (median 5.0 vs. 1.8 days, P<.001). Day of the week and time of day were not associated with family presence in the ICU or consent rate. CONCLUSIONS: Family members were recruited for more than one third of eligible patients, and >90% of approached consented to participate. There are important demographic differences between patients with vs without an enrolled family member.

Strategies to Reduce Tin and Other Metals in Electronic Cigarette Aerosol.

BACKGROUND: Metals are present in electronic cigarette (EC) fluid and aerosol and may present health risks to users. OBJECTIVE: The objective of this study was to measure the amounts of tin, copper, zinc, silver, nickel and chromium in the aerosol from four brands of EC and to identify the sources of these metals by examining the elemental composition of the atomizer components. METHODS: Four brands of popular EC were dissected and the cartomizers were examined microscopically. Elemental composition of cartomizer components was determined using integrated energy dispersive X-ray microanalysis, and the concentrations of the tin, copper, zinc silver, nickel, and chromium in the aerosol were determined for each brand using inductively coupled plasma optical emission spectroscopy. RESULTS: All filaments were made of nickel and chromium. Thick wires were copper coated with either tin or silver. Wires were joined to each other by tin solder, brazing, or by brass clamps. High concentrations of tin were detected in the aerosol when tin solder joints were friable. Tin coating on copper wires also contributed to tin in the aerosol. CONCLUSIONS: Tin concentrations in EC aerosols varied both within and between brands. Tin in aerosol was reduced by coating the thick wire with silver rather than tin, placing stable tin solder joints outside the atomizing chamber, joining wires with brass clamps or by brazing rather than soldering wires. These data demonstrate the feasibility of removing tin and other unwanted metals from EC aerosol by altering designs and using materials of suitable quality.