Introduction. Emphysematous pyelonephritis (EPN) is an uncommon infection characterized by gas in the renal parenchyma and surrounding tissues. It is rapidly progressive, requiring appropriate therapy to salvage the infected kidney. Case Description. The case series presents 5 patients with a clinical and radiologic diagnosis of EPN. Each patient had a unique predisposing factor for developing EPN. Early goal directed therapy with intravenous fluids and antibiotics was given. This was followed by less invasive urologic interventions in an attempt to avoid nephrectomy and thereby salvage the infected kidney. All five patients were discharged in clinically stable conditions. Discussion and Conclusion. This case series provides added practice based support to available literature for managing EPN. Early goal directed medical therapy for sepsis coupled with interventional urologic procedures is a valuable alternative to circumvent an upfront emergent nephrectomy, except in cases where a fulminant infection may be present at the time of admission or develop later on in the course of the patients illness despite conservative line of therapy. It also highlights the importance of considering a diagnosis of EPN in patients with urinary infections, who have certain common predisposing factors listed in our case series.
Blood pressure elevations after ischemic stroke are regarded as the body's response to maintain cerebral perfusion. Extremes of blood pressure have correlated with poor stroke recovery. Recently, blood pressure variability was shown to predict outcome better than mean blood pressures. Variables such as age, National Institute of Health stroke scale (NIHSS) and diabetes are established predictors of poor outcome and may potentially affect the degree of blood pressure variability. Our hypothesis was that age, NIHSS and diabetes would influence the association between blood pressure variability and stroke recovery. Methods: a retrospective chart review of consecutive patients discharged with an acute ischemic stroke based on ICD-9 codes was conducted. Successive blood pressure recordings during the 1st 5 days of hospitalization were noted. Blood pressure variability was calculated for systolic, diastolic and mean arterial pressures separately using published methods. Demographics, comorbidities, and modified Rankin score (mRS) at discharge were abstracted. Results: The study included 295 stroke patients, (median age 60 years; median NIHSS of 4.0). Age >60, NIHSS 4-9, NIHSS ≥ 10 and diabetes were associated with poor recovery (mRS 3-6). The mean pressures in the study group ranged from 105-195 mmHg for systolic blood pressure (SBP), 51-159 mm Hg for diastolic blood pressure and 70-163 mm Hg for mean arterial pressure. The median variability for SBP was 21.0mmHg; diastolic blood pressure was 12.7mmHg; mean arterial pressure was 13.6mmHg. Subjects with higher SBP variability (greater than the median of 21.0) had significantly higher rates of poor recovery. Stratifying by age, the association of SBP variability and poor outcome was significant for age > 60(OR: 2.16; 95%CI 1.06-4.38) but not for the younger subgroup with age≤ 60. Stratifying by stroke severity, the association of SBP variability and poor recovery was significant for NIHSS 4-9 (OR 3.41; 95%CI 1.55-8.23). All patients with high SBP variability in the NIHSS ≥ 10 group had poor recovery. The association was also significant in the subgroup without diabetes (OR 1.97; 95%CI 1.10-3.51), not in the subgroup of diabetic patients. Overall, the odds of a poor recovery due to high SBP variability were highest among subjects > 60 years with moderate to high NIHSS. Conclusions: SBP variability in acute ischemic stroke is especially harmful among the elderly, nondiabetic and the more severe strokes. Extreme caution is advised when prescribing blood pressure lowering medications in these subgroups.
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