To evaluate the possible effect of opiates on blood rheology, the plasma fibrinogen, prothrombin time and leukocyte aggregation were measured in 75 heroin addicts categorized by the time of abstention from heroin and the administration of naltrexone (25 active heroin abusers, 25 abstaining for 1 week, 11 abstaining for at least 5 months and 14 abstaining for 1 month and taking naltrexone during this period). No difference was detected in prothrombin time, but the leukocyte aggregation and fibrinogen were significantly different among the four groups (p = 0.028 and p = 0.0001, respectively). In particular, fibrinogen was 318 +/- 10.9 mg/dL in heroin abusers, significantly higher than that of the remaining three groups; the percentage of aggregated leukocytes was 5.01 +/- 0.77 in heroin users, significantly higher than that of subjects abstaining for at least 5 months. The fibrinogen levels declined sharply with abstention and an additive effect was noted with the administration of naltrexone, but leukocyte aggregation changed more slowly, and the effect of naltrexone (if any) was weaker. These data indicate an adverse effect of opiates on blood rheology and suggest that further studies should be performed to evaluate whether naltrexone may be useful in the prevention of major ischemic syndromes in patients with hyperfibrinogenemia and, perhaps, in those with high levels of leukocyte aggregation.
Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding areas, characterized by the presence of gas within the kidney and perinephric tissue. 1 It occurs almost exclusively in patients with diabetes mellitus.2,3 The disease predominantly affects women. Escherichia coli is the causative bacterial source in approximately 70% of the cases, with Klebsiella, Candida and Pseudomonas species less frequently isolated.4,5 Gas formation in EPN is due to pathogenic bacteria causing mixed acid fermentation in a hyperglycemic environment in tissues that are ischemic. The clinical manifestations are those of pyelonephritis such as dysuria, fever, nausea, vomiting, flank pain. Other potential clinical manifestations include acute renal dysfunction, hyperglycemia, thrombocytopenia, lethargy, acid-base irregularities. EPN is a life-threatening disease associated with septic complications. EPN requires a radiological diagnosis. Computed tomography (CT) is the imaging test of choice to confirm the presence and extent of the parenchymal gas. Case ReportA 68-year-old woman was admitted to the medical ward with a one-day history of left lower abdominal pain, vomiting and fever. She had a history of hypertension and type 2 diabetes mellitus, treated with oral anti-diabetic drugs. On examination she presented with fever (39.1°C), her blood pressure was 160/80 mm/Hg and the heart rate was 87 beats per minute. She had left flank pain, accentuated by local palpation. Cardiorespiratory examination was normal. She presented without any focal neurological deficit.Her blood tests showed renal impairment, decompensated diabetes, a high leukocyte count with a neutrophil segment, high inflammatory markers and a very high pro-calcitonin (Table 1). Urinalysis showed the presence of hyaline cylinders. Urine and blood samples were collected for bacterial culture analysis. A plain abdominal radiograph revealed no pathological findings; a renal ultrasound was performed revealing dilatation of the pelvicalyceal system and upper ureter of the left kidney (0.6 cm diameter). The patient was managed with intravenous fluids and insulin to achieve euglycemia. In suspicion of pyelonephritis, empiric intravenous antibiotics in the form of levofloxacin and meropenem were administered. A plain non-contrast CT (NCCT) scan demonstrated the presEmphysematous pyelonephritis: a case report ABSTRACTEmphysematous pyelonephritis is a severe, life-threatening, necrotizing kidney disease. It occurs almost exclusively in patients with diabetes mellitus. The clinical manifestations are those of pyelonephritis such as dysuria, fever, nausea, vomiting and abdominal pain. The diagnosis is radiological. The treatment strategies are controversial. They include medical management only, percutaneous catheter drainage plus medical management, emergency nephrectomy plus medical treatment or percutaneous drainage plus medical management and emergency nephrectomy. We present the case of a 68-year-old woman affected by e...
Introduction The number of autoptic controls is progressively dropping worldwide during the last decades. Several social, cultural and normative causes may underlie this phenomenon. However, a hidden cause may be represented by the scepticism of physicians about the gain in information given by this practice. There is in fact a general thinking that available diagnostic techniques may be adequate for a correct diagnosis, even in the case of a mortal outcome. Nevertheless, several studies have shown quite relevant discrepancies between premortem and postmortem diagnosis. In this study, the authors evaluate the accuracy of clinical diagnosis in diseases leading the patient to death.Materials and methods Retrospective analysis including all patients died in the Department of Internal Medicine of a General Hospital in Rome during a three year time period (1st January 2007–31 December 2009). Age, sex, period of hospitalization, clinical diagnosis, autoptic diagnosis, cause of death, and level of discrepancy between clinical diagnosis and autoptic control have been collected. Main diagnoses have been classified as follows: (1) discrepancy with a possible influence on survival; (2) discrepancy with no or questionable influence on survival.Results Ninety-two cases (42 males, 50 females; mean age 79.3 years) have been included. Thirty-four main diagnoses (36.9%) have been classified as discrepant (15.2% classified as type 1 discrepancy and 21.7 as type 2).DiscussionA substantial discrepancy between clinical diagnosis and autoptic control is confirmed by the current study, which supports the role of autopsy as a tool for the improvement of medical practice.
Patients affected by diabetes mellitus (DM) are at a high risk to develop chronic kidney disease (CKD). CKD is defined by the presence of structural or functional abnormalities, as persistent proteinuria or decreased glomerular filtration rate, for three months or more. CKD is estimated to affect about one-third of diabetic patients and DM is the leading cause of endstage renal disease.1 A recent American study confirmed the high prevalence of CKD in type 2 diabetes mellitus (T2DM), impacting around 40% of this population.2 An Australian study revealed that 23% of patients affected by T2DM had an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m 2 . The authors concluded that about 40% of patients had evidence of CKD.3 Recent Italian data from RIACE (renal insufficiency and cardiovascular events) study documented, in a large cohort of 15,773 Italian subjects with T2DM, CKD was observed in 37.5% of individuals, with a prevalence of stage 1-2 of 18.7% and stage 3-5 of 17.8%. 4 Therapeutic options for patients with renal failure are limited because a reduced GFR results in the accumulation of insulin and oral antidiabetic agents and an increased risk of hypoglycemia. There are no significant restrictions on the use of drugs in CKD stage 1 and 2, while in moderate and severe renal disease (stage 3-5) some antidiabetic agents are not recommended and others need dose adjustment. [5][6][7][8][9][10][11] The objective of the present study is to evaluate the appropriateness of DM treatment in patients with CKD in the real world. Materials and MethodsThe study included 265 diabetic patients consecutively admitted to internal medicine department of two Quality of diabetes mellitus therapy in patients with chronic kidney disease in the real world ABSTRACTChronic kidney disease (CKD) is very often among diabetic patients. Some oral antidiabetic agents are not recommended in the presence of CKD. Aim of the study was to evaluate the quality of diabetes mellitus (DM) treatment in nephrophatic patients in the real world. A total of 265 subjects with type 2 DM, consecutively admitted to the internal medicine departments of two hospitals in Rome, were recruited. Patients hospitalized for hypoglycemia, decompensated DM, acute kidney failure or worsening nephropathy were excluded. For each patient, the following data were collected: age, gender, estimated glomerular filtration rate (eGFR) using the MDRD (modification of diet in renal disease) study equation, type of antidiabetic drug treatment. A total of 265 subjects were studied, 127 male (47.9%) and 138 female (52.1%). The mean age was 77.5 years. The mean of glycemia glycated hemoglobin (HbA1c) value was 57.5 mmol/mol (7.4%). 137 patients (51.7%) were treated with oral antidiabetic agents, 29 (10%) with both oral antidiabetic agents and insulin, 90 (34%) with insulin alone, 8 (3%) with dipeptidyl peptidase-4 inhibitors, 1 (0.4%) with incretin agents plus oral antidiabetic drugs. According to the Kidney Disease Outcomes Quality Initiative (KDOQI) classification of CK...
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