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In recent years, understanding of the role of aldosterone has expanded beyond the known classic effects of promoting renal sodium retention and potassium and magnesium loss. It is now well documented that aldosterone causes myocardial and perivascular fibrosis, blocks the myocardial uptake of norepinephrine, and increases plasminogen activator inhibitor levels. In conjunction with angiotensin II, aldosterone causes vascular damage, endothelial dysfunction, and decreased vascular compliance. Thus, the renin-angiotensin-aldosterone system (RAAS) plays a major role in the development of both hypertension and heart failure and is, therefore, a key target for therapeutic interventions. Commonly prescribed medications for control of hypertension and congestive heart failure are inhibitors of the RAAS, including angiotensin converting enzyme inhibitors (ACE-Is) and angiotensin II (A-II) receptor antagonists. A well-documented increase in aldosterone levels occurs over several months during chronic treatment with an ACE-I or an A-II receptor antagonist. Such suppression of circulating aldosterone, however, is transient, as exemplified by the term "escape" used to describe the phenomenon. This rebound of aldosterone even occurs when patients receive both an ACE-I and an A-II receptor antagonist. In addition, ACE-Is and A-II receptor antagonists are less effective in controlling blood pressure in the estimated 60% of hypertensive patients who are salt-(volume-) sensitive and more prone to hypertension-associated morbidity, such as black patients and type 2 diabetics. Thus, chronic and complete blockade of aldosterone action requires an aldosterone receptor antagonist. The Randomized Aldactone Evaluation Study (RALES) trial results in patients with severe heart failure (New York Heart Association class III or IV) and a left ventricular ejection fraction of no more than 35% showed that administration of a subhemodynamic dose of spironolactone (25 mg/day) as an add-on therapy to ACE-Is plus standard treatment resulted in a significant mortality reduction due to decreases in both death from progressive heart failure and sudden cardiac death. These findings support the pivotal role of aldosterone in the pathophysiology of progressive heart failure. Although it is an effective antialdosterone agent, widespread use of spironolactone in humans is limited by its tendency to produce undesirable sexual side effects. At standard doses, impotence and gynecomastia can be induced in men, whereas premenopausal women may experience menstrual disturbances. Data on a selective aldosterone receptor antagonist, eplerenone, show that it appears promising for the effective blockade of aldosterone and its harmful effects without the sexual disturbances of spironolactone. Recently, eplerenone was successfully introduced for the treatment of hypertension and heart failure. A growing number of experimental studies are finding a broader role for aldosterone in driving the pathophysiology of both heart failure and hypertension. When added to conventio...

A 66-year-old female patient developed severe Serratia liquefaciens sepsis following vitamin C infusion treatment by a naturopathic practitioner. The clinical course of the infection was characterized by several complications, and the direct costs of the hospital stay amounted to about 40,000 Euro. Genotypically identical S. liquefaciens was isolated from the residue of the infusate given to the patient, as well as from the washbasin overflow and from two other infusion bottles. A careful inspection of the dispensing facilities and review of procedures used to prepare the infusate revealed several indications of poor hygiene. However, the source of contamination could not be fully clarified. This case report raises questions about the local facilities and personal qualifications required for naturopathic practitioners to conduct invasive procedures and demonstrates that lapses in hygiene can lead to severe morbidity and high cost. CASE REPORTA 66-year-old female patient presented with symptoms of septic shock, meningism, and loss of consciousness. Her medical history revealed a carcinoma of the cervix (stage IIIb) successfully treated by primary radiotherapy 3 years previously. The day before, she had received an intravenous infusion containing 200 ml (i.e., 30 g) of vitamin C, 50 ml of lactopurum (homeopathic dilution [D4] of lactic acid in water for injection), and 250 ml of isotonic 0.9% sodium chloride solution via a peripherally inserted venous catheter. Immediately after termination of the infusion, the patient suffered from neck pain, vomiting, and fever. First, she was given symptomatic medication (i.e., antipyretic and antiemetic drugs), but during the night, her state worsened dramatically.On admission to the intensive care unit, the patient was comatose, her skin was pale and cyanotic, and the peripheral pulses were not palpable. Clinically, we found signs of meningism. The leukocyte count was 22.8 ϫ 10 9 /liter, and the level of vitamin C in serum was 55.9 mg/liter (reference value, 5.0 to 15.0 mg/liter). Blood cultures revealed growth of S. liquefaciens that was sensitive to piperacillin plus tazobactam, cotrimoxazole, cefotaxime, ceftriaxone, and gentamicin, but insensitive to ampicillin, cefazolin, cefuroxime, and nitrofurantoin. At the time of admission, piperacillin and tazobactam were given empirically as antibiotic medication. A sample from the remainder of the original infusate was obtained for culture and also revealed growth of S. liquefaciens, as confirmed by API 20E (BioMerieux). The initial antibiotic therapy was conducted until the 11th day after admission, and S. liquefaciens could not be isolated any longer after this initial period.The further clinical course was characterized by a protracted septic shock with disseminated intravascular coagulation (Ddimers Ͼ 20 mg/liter); the clinical picture of systemic inflammatory response syndrome, with a great need for catecholamines to support circulation; adult respiratory distress syndrome; reversible acute renal failure; severe anasarca;, a...

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