We conducted this review to heighten the awareness and describe pathologic manifestations of hypophosphatemia. We present 3 cases of varied manifestations of hypophosphatemia where recognition was delayed. In certain settings, severe hypophosphatemia has significant morbidity and potential mortality. Appreciation of the pathophysiologic basis for organ dysfunction in severe hypophosphatemia should result in early recognition and treatment. We reviewed the English-language literature for reported cases and research studies dealing with pathophysiologic mechanisms subserving clinical manifestations. We observed that depletion of adenosine triphosphate (ATP) would explain most of the derangement noted in cellular functions. Phosphate plays a key role in the delivery of oxygen to the tissue. Lack of phosphate, therefore, leads to tissue hypoxia and hence disruption of cellular function. Severe hypophosphatemia becomes clinically significant when there is underlying phosphate depletion. Otherwise, short-term acute hypophosphatemia is not usually associated with any specific disorder. Chronic hypophosphatemia, on the other hand, results in hematologic, neuromuscular, and cardiovascular dysfunction, and unless corrected, the consequences can be grave. Most of the time hypophosphatemia results from renal loss of phosphate, diagnosed by a fractional secretion of phosphate > 5%. It is hard to provide precise estimates of how many patients are seen with hypophosphatemia annually at academic medical centers. This is complicated by use of chemistry panels that do not measure inorganic phosphate unless specifically ordered. This often leads to delay in correct diagnosis, and, therefore, additional delay in providing appropriate management. A high index of suspicion alone avoids the unnecessary withholding of treatment that can be life saving.

The objective of this study was to perform a hemodynamic evaluation of moderate (50-90%) renal artery stenosis (RAS) under conditions of rest and maximum hyperemia. Identifying patients with RAS who have hemodynamically significant stenoses and are most likely to benefit from revascularization is clinically important. Current methods used to evaluate RAS, including angiography, have limitations. Physiologic evaluation of RAS may have a role in identifying patients with hemodynamically significant stenosis. Patients with suspected renovascular hypertension due to aorto-ostial RAS were included in the study. Hyperemia was induced by administration of intrarenal papavarine. Translesional pressure gradients were measured and renal fractional flow reserve (FFR) was calculated using a 0.014'' pressure guidewire. Thirteen patients and 14 arteries with moderately severe (50-90%) RAS were studied. The mean translesional pressure gradient rose from a baseline of 6.3 +/- 3.9 to 17.5 +/- 10.8 mm Hg with maximal hyperemia. The renal FFR ranged from 0.58 to 0.95. There was a poor correlation between angiographic stenosis measurement and the renal FFR (r = -0.18; P = 0.54) and the hyperemic translesional mean pressure gradient (r = 0.22; P = 0.44). There was an excellent correlation between renal FFR and the resting mean translesional pressure gradient (r = -0.76; P = 0.0016) and the hyperemic mean translesional pressure gradient (r = -0.94; P < 0.0001). Selective renal arterial papavarine administration induces maximum hyperemia, permitting the calculation of renal FFR in renal arteries with aorto-ostial stenoses. The renal FFR correlates well with other hemodynamic parameters of lesion severity, but poorly with angiographic measures of lesion severity.

Renal FFR is a promising tool to identify patients likely to benefit following renal stent placement. This finding was independent of translesional pressure gradients, which did not predict blood pressure improvement. The ability to segregate patients with RAS and coexisting hypertension from those with renovascular hypertension may help clinicians select patients most likely to benefit from revascularization.

Several patients developed sterile inflammation at their radial arterial access site. Pathologic examination of biopsy material from one patient demonstrated a foreign-body reaction to material most likely from the gel-coated arterial access sheath. Surgical excision of the inflamed tissue resulted in healing.

Background and Purpose-We present our single-center experience using catheter-based therapy for acute ischemic stroke patients who were not candidates for intravenous thrombolytic therapy. Methods-Neurologic outcomes were assessed in patients with acute ischemic stroke, ineligible for intravenous thrombolysis, treated with an emergent catheter-based therapy. Results-Nonparametric analysis of neurological outcomes demonstrated a benefit in National Institutes of Health Stroke Scale (NIHSS) at long-term follow-up (Pϭ0.036). Independence in daily activities and improvement in NIHSS of Ն4 points were achieved in 38% and 56% of patients, respectively. Four patients (25%) died, including 2 patients (12.5%) who died from intracranial hemorrhage. Conclusions-Catheter-based treatment offers a promising treatment strategy in patients with acute ischemic stroke ineligible for intravenous thrombolysis.

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Objective: This article explores the effects of earlier emergency medical services (EMS) or automatic collision notification (ACN) and EMS arrival on passenger/driver survivability within the short time frame following traffic crashes.Methods: Survival analysis techniques are used extensively in this study, because traffic crash and EMS data are closely associated with time. The Kaplan-Meier estimator and life curves are applied to compare the survival rates between 2 or more conditions (e.g., earlier verus late EMS notification); The Weibull model with 3 parameters is used to predict mortality over time; furthermore, the Cox proportional hazard model explores multiple risk factors related to traffic mortality.Results: Based on Fatality Analysis Reporting System (FARS) data from 2005 to 2009, Kaplan-Meier life curves clearly showed the benefits associated with earlier notifications (approximately 1.84% fatality reduction within a time frame of 6 h after a crash) and earlier arrivals, and the Weibull model with 3 parameters reasonably predicted the fatality trends. The relative risks (RRs) associated with collision notification, arrival, location, and age were obtained from a multiple Cox regression model, and the relatively higher fatality hazard (2.4% higher) associated with the later notification of more than 1 min was studied in detail.Conclusions: This article obtains the driver/passenger survival probabity differences over time under different conditions of collision notifications, EMS arrivals, and crash locations; furthermore, this analysis provides an estimation of the lives that could potentially be saved (approximately 154 to 290 per year) due to earlier ACN.

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