Renal failure and cholesterol crystal embolization: a report of 4 surviving cases and a review of the literature.

Four patients with end-stage renal failure (suspected to be) caused by cholesterol crystal emboli are described. Although cholesterol crystal embolization is generally considered to be fatal specifically when it is associated with renal failure, all four patients survived and in three renal function improved after periods of 3 weeks to 14 months of hemo- or peritoneal dialysis. The literature on cholesterol crystal embolization is reviewed and possible mechanisms of (partial) recovery of renal function are discussed.

Unusual consequence of a fall: pressure sores of both breasts resulting in bilateral partial mastectomy.

An elderly patient is described who developed severe pressure sores of both breasts resulting in bilateral partial mastectomy. She presented with hypothermia after lying prone on the floor for over 48 h. Additional contributing factors included medication with benzodiazepines, overweight and age. The pathophysiology of the unusual predilection area of the pressure sores is discussed.

[Adverse drug reactions in three older patients, even without changes in medication]. / Bijwerkingen van geneesmiddelen bij 3 oudere patiënten: ook bij ongewijzigd medicatiegebruik.

Two women, aged 77 and 73 years, and one man, aged 71 years, were admitted because of a serious adverse drug reaction (ADR). The first woman had a probable adverse drug reaction caused by digoxin after the addition of a NSAID (diclofenac) to a combination of digoxin and other drugs (furosemide and hydroquinine). The ADR due to digoxin is an example of a pharmacokinetic interaction. The second woman had serious orthostatic hypotension because of a pharmacodynamic interaction between three different antihypertensives. In the man, the ADR was hypoglycaemia while taking glibenclamide, a second generation sulfonylurea derivative. This was probably caused by declining renal function of a transplanted kidney because of bladder cancer. Doctors should be aware of ADRs in older patients, which also can occur when no changes in medication have taken place. In old age, any decline in vitality or function can be due to an ADR.

Contribution of adverse drug reactions to hospital admission of older patients.

OBJECTIVE: To describe the severity of adverse drug reactions as a factor in hospital admission of older patients, and to identify risk indicators for severe adverse drug reactions in these patients. DESIGN: Observational cross-sectional study. SETTING: Five wards in a university hospital in The Netherlands. SUBJECTS: Patients aged 70 and over admitted to general medical wards. METHODS: Use of statistical comparison and Kramer's algorithm. RESULTS: A severe adverse drug reaction was present in 25 (24%) of 106 patients. Thirteen patients (12%; 95% confidence interval 6.1-18.6%) were admitted probably because of an adverse drug reaction. Risk indicators for a severe adverse drug reaction were a fall before admission (odds ratio 51.3, P = 0.006), gastrointestinal bleeding or haematuria (odds ratio 19.8, P < 0.001) and the use of three or more drugs (odds ratio 9.8, P = 0.04). CONCLUSION: Adverse drug reactions are an important cause of hospital admissions in older people. A fall before admission may indicate a severe adverse drug reaction.

Do older hospital patients recognize adverse drug reactions?

OBJECTIVE: To establish the relationship between subjective complaints of side effects of drugs and the objective presence of adverse drug reactions in older patients. DESIGN: Observational cross-sectional study. SETTING: Five medical wards at the University Hospital Rotterdam Dijkzigt. SUBJECTS: Patients aged 70 and over admitted to the general medical wards over a 3-month period. METHODS: Statistical comparison and Kramer's algorithm. RESULTS: Of 106 patients, 102 used medication, and 93 of these were able to report whether they believed they were experiencing drug side effects. Thirty-six [39% (95% confidence interval 28.8-48.6)] believed that they were experiencing side effects and the number of diagnoses per patient and the proportion of patients with chronic obstructive pulmonary disease was higher in these 36 'complainers' than in the group of the 'non-complainers'. We found a correct opinion (true positive and negative) about the objective presence or absence of mild or severe adverse drug reactions in 79% (95% confidence interval 70.2-86.8). Asking the patient about side effects of drugs had a sensitivity of 0.70 and a specificity of 0.85 patients. The severe adverse drug reactions in 21 patients were not recognized by 14 of them. CONCLUSION: At hospital admission, older patients should be asked about drug side effects because they are often correct in recognizing them. However, severe adverse drug reactions are not easily recognized.

Plasma prorenin as an early marker of microvascular disease in patients with diabetes mellitus.

To test the hypothesis that a high plasma prorenin can be used as an early marker of microvascular complications in patients with diabetes mellitus plasma prorenin was measured in 44 patients with urinary albumin excretion between 30 and 300 mg/24 h (microalbuminuria) and 120 patients with urinary albumin excretion below 30 mg/24 h (normoalbuminuria). A high plasma prorenin was associated with diabetic retinopathy, particularly the proliferative type, serum creatinine and the 24 h urinary albumin excretion rate. Plasma prorenin was not correlated with age, duration of diabetes, glycosylated hemoglobin, blood glucose, and blood pressure. The association between elevated plasma prorenin and retinopathy remained significant after adjustment for serum creatinine and albumin excretion. Independent of the presence or absence of microalbuminuria, the mean plasma level of prorenin was not above normal in patients without retinopathy and was 2 to 3 times normal in patients with proliferative retinopathy. Thus retinopathy appears to be an important determinant of abnormally high plasma prorenin. Angiotensin converting enzyme (ACE) was elevated in the patients with diabetes mellitus as compared to control subjects but the plasma levels of ACE in diabetics with normoalbuminuria was not significantly different from the group with microalbuminuria. Plasma prorenin was not associated with ACE. A plasma level of prorenin of 225 mU/L had a sensitivity of 0.84 and a specificity of 0.82 for detecting the presence of microalbuminuria.