Mild metabolic alkalosis resulting from standard bicarbonate haemodialysis (32 mmol/l) may induce symptomatic hypotension. While normalizing chronic metabolic acidosis is desirable, reducing bicarbonate concentrations should be considered in cases of significant alkalaemia or otherwise untreatable haemodynamic instability.

AimsTo assess adherence to medical treatment in patients with heart failure (HF) using a specific questionnaire and measurement of the serum concentration of digoxin. Methods and resultsForty patients with symptomatic HF and a clinical indication for digoxin were included in this pilot study. The assessment of adherence to the medical regime was based on two different methods: (i) the CARDIA-Questionnaire and (ii) the measurement of serum digoxin concentration (SDC) at 1 and 6 months. All patients were placed on digoxin treatment (target SDC 0.6-0.8 ng/mL) at baseline. Poor adherence was defined if the patient self-reported taking 75% of the prescribed HF medication or had an SDC , 0.4 ng/mL (subtherapeutic range) at the follow-up visits. During the entire follow-up, the proportion of patients with poor adherence was 15% as assessed by the questionnaire, 20% as assessed by the SDC, and 25% if both methods were combined. ConclusionAlthough HF is a symptomatic disease, the proportion of patients with poor adherence to the medical regime in our study was high (up to 25%). The objective methodology based on the measurement of the SDC identified a higher number of patients with poor adherence when compared with the CARDIA-Questionnaire.--

Background: There are few data on the efficacy of oral antibiotics in the initial empirical management of severe forms of urinary tract infection (UTI).

Dear Sir, Long trips, especially air flights, are considered a risk for venous thromboembolism [1][2][3][4][5]. The frequency of symptomatic thromboembolic events increases with the distance flown, but appears to be low [3]. In a recent study, however, Scurr et al. found symptomless calf vein thrombosis detected by ultrasonography in up to 10% of long-haul travelers [4]. Given the limited sensitivity of the method [6], the true incidence of travel-associated distal thrombi may even be higher. Taken together, these data suggest that subclinical thrombosis may be frequent during air travel but usually resolves once mobility is resumed. Accordingly, symptomatic thromboembolic events would reflect a rare situation where activation of coagulation escapes the natural control systems.The prolonged sitting position during an air trip is associated with venous stasis, decreased blood flow and hemoconcentration, and is widely assumed to be the main causal factor for thrombus formation in this setting. If this assumption is correct, prolonged immobility in a sitting position by itself would be sufficient to activate coagulation. Subclinical activation of coagulation À a so-called prethrombotic state [7] À can be assessed by sensitive biochemical markers of thrombin generation (prothrombin fragment 1 þ 2, F1 þ 2), of ongoing fibrin formation (fibrinopeptide A, FPA) and lysis (D-dimer, DD). The aim of this study was to test the hypothesis that prolonged immobility in a sitting position similar to the one occurring during air traveling activates coagulation.Forty healthy subjects of either sex (median age 29.5 years, range 19-58) with a negative personal and family history and no known risk factor for thromboembolism were kept seated for 6 h on normal chairs, with their knees bent; during this period they were allowed to drink, eat, read or watch television. At baseline and after 3 and 6 h of immobilization, blood was collected in CTADPPACK anticoagulant from sitting probands with a clean venepuncture from an antecubital vein under controlled venous stasis for measurement of F1 þ 2 (Enzygnost F1 þ 2 Behring), FPA (RIA reagents supplied by Imco), and DD (mini-VIDAS, BioMérieux). Hemoglobin concentration and hematocrit were determined as well. In order to control for the circadian variations of the hemostatic system [8], we used the same protocol for blood sampling in a subgroup of 18 volunteers who were allowed to move freely (control group).Statistical probability was assessed with repeated measures ANOVA on ranks followed by pairwise multiple comparison procedures (Student-Newman-Keuls method) for non-normally distributed data. A linear regression was done for correlation between data at baseline and after 6 h. A difference was considered significant when P <0.05.Over the 6 h of sitting position there was no change in the plasma levels of FPA and DD, whereas F1 þ 2 levels decreased from a median of 0.49 to 0.40 nmol L À1 (P < 0.0001, Table 1). The F1 þ 2 decrease was both relevant in quantitative terms (À20% of the baseline...

The authors report 34 cases of Gram-negative bacillary meningitis related to traumatic cranial lesions or neurosurgery observed between 1973 and 1980 at two neurosurgical units (Institut J. Bordet, Brussels, and Inselspital, Bern). As a typical nosocomial infection, meningitis developed after prolonged hospitalization in most patients, and was mainly due to highly resistant organisms, such as P. aeruginosa and Klebsiella sp. At least 65% of the patients were colonized with the pathogen responsible for the meningitis before the onset of the infection. Ventriculitis, including four cases of ventricular empyema, complicated meningitis in all the 17 patients in whom a ventricular tap was performed. The results of treatment were unsatisfactory. Fifty percent of the patients were cured of their infection, but only 30% survived; 15% of the patients died within 48 hours following diagnosis. The optimum treatment of postsurgical Gram-negative meningitis remains in doubt. The choice of initial antibiotics should take into account the sensitivity patterns of colonizing microorganisms. Chloramphenicol is ineffective against most pathogens commonly involved in this infection. Intrathecal aminoglycosides may fail in the presence of ventriculitis. Intraventricular aminoglycosides are probably justified in critically ill patients. The role of the newer cephalosporins and of co-trimoxazole remains to be defined.