Background: Severe hyper- and hyponatraemia is associated with significant risks, yet its correction can also have serious consequences when implemented too fast or inadequately. The safe correction of serum sodium levels is particularly challenging when renal replacement therapy (RRT) is required. Methods: Using 2 case scenarios, we aim to illustrate a simple method of correcting hyper- and hyponatraemia safely by step-wise manipulation of the dialysate/replacement fluid. Results: During continuous RRT, hypernatraemia can be corrected effectively and safely by adding small pre-calculated amounts of 30% NaCl to the dialysate/replacement fluid bags aiming for a [Na⁺] in the fluid that allows safe equilibration and correction of the serum [Na⁺]. To correct hyponatraemia safely, pre-calculated amounts of sterile water can be added in a step-wise manner to achieve a fluid [Na⁺] that equals the desired target serum [Na⁺]. Conclusion: During continuous RRT, the step-wise adjustment of [Na⁺] of dialysate/replacement fluids offers a safe and reliable method to correct sodium disorders.

ObjectivesPatients with cancer frequently require unplanned admission to the intensive care unit (ICU). Our objectives were to assess hospital and 180-day mortality in patients with a non-haematological malignancy and unplanned ICU admission and to identify which factors present on admission were the best predictors of mortality.DesignRetrospective review of all patients with a diagnosis of solid tumours following unplanned admission to the ICU between 1 August 2008 and 31 July 2012.SettingSingle centre tertiary care hospital in London (UK).Participants300 adult patients with non-haematological solid tumours requiring unplanned admission to the ICU.InterventionsNone.Primary and secondary outcomesHospital and 180-day survival.Results300 patients were admitted to the ICU (median age 66.5 years; 61.7% men). Survival to hospital discharge and 180 days were 69% and 47.8%, respectively. Greater number of failed organ systems on admission was associated with significantly worse hospital survival (p<0.001) but not with 180-day survival (p=0.24). In multivariate analysis, predictors of hospital mortality were the presence of metastases (OR 1.97, 95% CI 1.08 to 3.59), Acute Physiology and Chronic Health Evaluation II (APACHE II) Score (OR 1.07, 95% CI 1.01 to 1.13) and a Glasgow Coma Scale Score <7 on admission to ICU (OR 5.21, 95% CI 1.65 to 16.43). Predictors of worse 180-day survival were the presence of metastases (OR 2.82, 95% CI 1.57 to 5.06), APACHE II Score (OR 1.07, 95% CI 1.01 to 1.13) and sepsis (OR 1.92, 95% CI 1.09 to 3.38).ConclusionsShort-term and medium-term survival in patients with solid tumours admitted to ICU is better than previously reported, suggesting that the presence of cancer alone should not be a barrier to ICU admission.

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The Antarctic continent is an environment of extreme conditions. Only few research stations exist that are occupied throughout the year. The German station Neumayer III and the French-Italian Concordia station are such research platforms and human outposts. The seasonal shifts of complete daylight (summer) to complete darkness (winter) as well as massive changes in outside temperatures (down to -80°C at Concordia) during winter result in complete confinement of the crews from the outside world. In addition, the crew at Concordia is subjected to hypobaric hypoxia of ∼650 hPa as the station is situated at high altitude (3,233 m). We studied three expedition crews at Neumayer III (sea level) (n = 16) and two at Concordia (high altitude) (n = 15) to determine the effects of hypobaric hypoxia on hormonal/metabolic stress parameters [endocannabinoids (ECs), catecholamines, and glucocorticoids] and evaluated the psychological stress over a period of 11 months including winter confinement. In the Neumayer III (sea level) crew, EC and n-acylethanolamide (NAE) concentrations increased significantly already at the beginning of the deployment (p < 0.001) whereas catecholamines and cortisol remained unaffected. Over the year, ECs and NAEs stayed elevated and fluctuated before slowly decreasing till the end of the deployment. The classical stress hormones showed small increases in the last third of deployment. By contrast, at Concordia (high altitude), norepinephrine concentrations increased significantly at the beginning (p < 0.001) which was paralleled by low EC levels. Prior to the second half of deployment, norepinephrine declined constantly to end on a low plateau level, whereas then the EC concentrations increased significantly in this second period during the overwintering (p < 0.001). Psychometric data showed no significant changes in the crews at either station. These findings demonstrate that exposition of healthy humans to the physically challenging extreme environment of Antarctica (i) has a distinct modulating effect on stress responses. Additionally, (ii) acute high altitude/hypobaric hypoxia at the beginning seem to trigger catecholamine release that downregulates the EC response. These results (iii) are not associated with psychological stress.

BackgroundForeign body ingestion complicated by perforation of the digestive tract is a well-known occurrence. Contrary to this, perforation by fishbones has most often been described in South East Asian populations, and has the unusual characteristic of often being paucisymptomatic until secondary complications occur.Case presentationWe report the case of a 56 year-old man of asian origin who presented with a liver abscess of unknown origin, complicated by septic shock with multiorgan failure. He was later found to have a fishbone impacted in the left lobe of the liver, which had perforated the stomach and gone by unnoticed until presentation. The fishbone was extracted through laparotomy and the abscess was drained.ConclusionThis report highlights a cause of liver abscesses which is likely underreported in Northern European populations and which, although rare in occurrence, should be part of our diagnostic algorithm of “cryptogenic abscesses” since surgical removal of the foreign object as drainage warrant definitive treatment.

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Exposure to stressful environments weakens immunity evidenced by a detectable reactivation of dormant viruses. The mechanism behind this observation remains unclear. We performed next generation sequencing from RNA extracted from blood samples of 8 male subjects collected before, during and after a 12-month stay at the Antarctic station Concordia. RNA-seq data analysis was done using QIAGEN Ingenuity Pathway Analysis (IPA) software. Data revealed the inactivation of key immune functions such as chemotaxis and leukocyte recruitment which persisted after return. Next to the activation of the stress response eIF2 pathway, interferon signaling was predicted inactivated due to a downregulation of 14 downstream genes involved in antiviral immunity. Among them, the interferon stimulated genes (ISGs) IFITM2 and 3 as well as IFIT3 exhibited the strongest fold changes and IFIT3 remained downregulated even after return. Impairment of antiviral immunity in winter-over crew can be explained by the downregulation of a battery of ISGs.