Baseline serum sodium and SUN values are predictive of the rapidity of hyponatremia correction following tolvaptan use in SIADH. We advise caution when dosing tolvaptan in patients with both low serum sodium and SUN concentrations.

Limited evidence supports use of oral antibiotics for Enterobacteriaceae-associated bacteremic urinary tract infection. This retrospective cohort study found no statistically significant difference in the composite outcome of treatment failure in patients who received exclusively intravenous versus intravenous/oral antibiotics for the treatment of bacteremic urinary tract infections.

Increasing doses of daptomycin may enhance efficacy without compromising safety, even in patients with some renal dysfunction. The combination of daptomycin and tigecycline may be useful for the treatment of multidrug-resistant E. faecium.

Background: The efficacy of vasoconstrictors in hepatorenal syndrome (HRS) is variable. We hypothesized that the effectiveness of vasoconstrictor therapy in improving kidney function ultimately relates to the magnitude of the achieved mean arterial pressure (MAP) increase. Methods: A retrospective study was conducted to identify cirrhotic individuals treated with vasoconstrictors for acute kidney injury (AKI) presumably caused by HRS to examine the relationship between change in MAP and change in serum creatinine (sCr) using multivariate mixed linear regression. Results: Among 73 patients treated with midodrine/octreotide, change in MAP inversely correlated with change in sCr (p = 0.0005). The quartile with the greatest increase in MAP (+15.9 to +29.4 mm Hg) was associated with a subsequent absolute decrease in sCr. The strength of the correlation increased when the analysis was restricted to those who met the HRS criteria (n = 27, p = 0.002), where the third (+5.3 to +15.6 mm Hg) and fourth (+15.9 to +20.9 mm Hg) quartiles of MAP change were associated with a decrease in sCr. A similar but stronger correlation was found among 14 patients treated with norepinephrine either after failing midodrine/octreotide (n = 10) or de novo (n = 4; p = 0.002), where a rise in MAP of +19.2 to 25 mm Hg was associated with a larger reduction in sCr. Associations remained significant after adjustment for baseline parameters. Conclusions: The magnitude of MAP rise during HRS therapy with midodrine/octreotide or norepinephrine correlated with a reduction in sCr concentration. Our results suggest that achieving a pre-specified target of MAP increase might improve renal outcomes in hepatorenal AKI.

Background The impact of cancer on outcomes was not assessed in major trials of systemic thrombolysis in acute ischemic stroke. Aims To evaluate the association between comorbid cancer and hospital outcomes among patients receiving systemic thrombolysis for the treatment of acute ischemic stroke. Methods The 2013 and 2014 United States National Inpatient Sample was used to identify adult patients hospitalized for acute ischemic stroke who received systemic thrombolysis. Identified admissions were stratified into two cohorts based on the presence or absence of comorbid cancer. Multivariable logistic regression was performed to determine the association between comorbid cancer and the odds of in-hospital mortality and intracerebral hemorrhage after adjustment for age ≥75 years and comorbid atrial fibrillation. Results A total of 13,993 acute ischemic stroke admissions were treated with systemic thrombolysis. Of these, 3.0% ( n = 416) had comorbid cancer. The overall incidence of in-hospital mortality was 7.0% and intracerebral hemorrhage occurred in 7.6% of patients. Upon multivariable adjustment, comorbid cancer was not associated with an increased odds of in-hospital mortality (odds ratio = 1.24; 95% confidence interval = 0.88-1.76). However, the adjusted odds of intracerebral hemorrhage were higher among those with comorbid cancer (odds ratio = 1.60; 95% confidence interval = 1.17-2.17). Conclusions In this retrospective study of admissions for acute ischemic stroke receiving thrombolysis, comorbid cancer was not associated with a higher odds of in-hospital mortality but was associated with an increased odds of intracerebral hemorrhage. Factors driving this observed association should be explored in data sets containing clinical variables.

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A patient receiving daptomycin developed asymptomatic transaminitis and hyperbilirubinemia without concurrent multiorgan dysfunction or elevation of his creatinine kinase level. After ruling out other etiologies, the liver injury was attributed to daptomycin and was subsequently resolved. A single-center retrospective cohort analysis of baseline and follow-up liver function panels (n ‫؍‬ 614) from all admissions from 2008 to 2013 during which daptomycin was administered did not reveal any other cases of probable or definite drug-induced liver injury associated with daptomycin. Drug-induced liver injury (DILI) has been ascribed to Ͼ1,000 medications (1). While various scales have been developed to establish causality (e.g., the Naranjo probability scale, the Roussel Uclaf causality assessment method [RUCAM], the Maria and Victorino [M&V] scale, and the Council for International Organizations of Medical Sciences [CIOMS] scale), none has been adopted as a gold standard (2-5). The U.S. National Library of Medicine suggests that expert opinion is also suitable for attributing causality (see http://livertox.nih.gov/).Daptomycin has been associated with transaminase elevations in 3% of subjects (6) but not with other findings indicating a hepatic origin (e.g., gamma-glutamyl transferase [GGT]) (Cubist Pharmaceuticals Medical Affairs, written communication). Therefore, the elevations likely reflect myocyte injury, a known effect that necessitates creatinine kinase (CK) monitoring. One previous case of daptomycin-associated DILI mirrored this pattern, while another report described a patient with multiorgan failure (7,8). The case discussed below is unique because the patient developed isolated asymptomatic liver injury.Case report. A 31-year-old man with a history of psychiatric disorders, degenerative disc disease with chronic back pain, and intravenous drug abuse presented with suicidal ideation. He also reported a productive cough, left-sided inspiratory chest pain, abdominal pain, and back pain. He denied using ethanol or drugs except previously prescribed oxycodone (30 mg every 4 h as needed) and alprazolam (2 mg daily). The physical exam revealed an abscess involving the left antecubital fossa, into which the patient eventually admitted to injecting crushed morphine tablets. No jaundice or hepatosplenomegaly was identified. He was febrile to 39.3°C. His urine drug screen was positive for opiates and benzodiazepines. His liver function test (LFT) values were elevated, including a total bilirubin level of 2.1 mg/dl, an aspartate aminotransferase (AST) level of 95 IU/liter, an alanine aminotransferase (ALT) level of 95 IU/liter, and an alkaline phosphatase (ALP) level of 150 IU/liter (Fig. 1). After ruling out vertebral osteomyelitis with a gallium-67-tagged white cell scan, the abdominal pain was attributed to opioid withdrawal, and the patient was treated with dicyclomine and an opioid taper.On hospital day 3, the blood cultures started at admission grew Gram-positive cocci, and vancomycin was initiated. Treatment ...

Novel oral anticoagulants present challenges and uncertainties in the management of hemorrhagic emergencies. An 84-year-old man taking dabigatran presented with a subdural hematoma requiring neurosurgical intervention. Routine coagulation assays were prolonged at admission and following administration of Factor VIII Inhibitor Bypassing Activity (FEIBA). Thromboelastography (TEG(®)) was utilized to assess clot dynamics prior to placement of a subdural drain, which was safely inserted despite a prolonged thrombin time (TT). Exclusive reliance on the TT may delay necessary interventions. TEG(®) may be a valuable tool to investigate hemostasis in patients on dabigatran requiring emergent procedures.