Osmotic diuresis due to urea as the cause of hypernatraemia in critically ill patients

Background. Hypernatraemia is common in critically ill patients and has been shown to be an independent predictor of mortality. Osmotic urea diuresis can cause hypernatraemia due to significant water losses but is often not diagnosed. Free water clearance (FWC) and electrolyte free water clearance (EFWC) were proposed to quantify renal water handling. We aimed to (i) identify patients with hypernatraemia due to osmotic urea diuresis and (ii) investigate whether FWC and EFWC are helpful in identifying renal loss of free water. Methods. In this retrospective study, we screened a registry for patients, who experienced intensive care unit (ICU)-acquired hypernatraemia. Among them, patients with hypernatraemia due to osmotic urea diuresis were detected by a case-by-case review. Total fluid and electrolyte balances together with FWC and EFWC were calculated for days of rising serum sodium and stable serum sodium. Results. We identified seven patients (10% of patients with ICU-acquired hypernatraemia) with osmotic diuresis due to urea. All patients were intubated during development of hypernatraemia and received enteral nutrition. The median highest serum sodium level of 153 mmol (Q1: 151-Q3: 155 mmol/L) was reached after a 5-day period of rise in serum sodium. During this period, FWC was −904 mL/day (Q1: −1574-Q3: −572), indicating renal water retention, while EFWC was 1419 mL/day (Q1: 1052-Q3: 1923), showing renal water loss. While FWC did not differ between time of stable serum sodium and development of hypernatraemia, EFWC was significantly higher during rise in serum sodium. Conclusion. Osmotic urea diuresis is a common cause of hypernatraemia in the ICU. EFWC was useful in the differential diagnosis of polyuria during rising serum sodium levels, while FWC was misleadin

Rising serum sodium levels are associated with a concurrent development of metabolic alkalosis in critically ill patients

Purpose: Changes in electrolyte homeostasis are important causes of acid-base disorders. While the effects of chloride are well studied, only little is known of the potential contributions of sodium to metabolic acid-base state. Thus, we investigated the effects of intensive care unit (ICU)-acquired hypernatremia on acid-base state. Methods: We included critically ill patients who developed hypernatremia, defined as a serum sodium concentration exceeding 149mmol/L, after ICU admission in this retrospective study. Data on electrolyte and acid-base state in all included patients were gathered in order to analyze the effects of hypernatremia on metabolic acid-base state by use of the physical-chemical approach. Results: A total of 51 patients were included in the study. The time of rising serum sodium and hypernatremia was accompanied by metabolic alkalosis. A transient increase in total base excess (standard base excess from 0.1 to 5.5mmol/L) paralleled by a transient increase in the base excess due to sodium (base excess sodium from 0.7 to 4.1mmol/L) could be observed. The other determinants of metabolic acid-base state remained stable. The increase in base excess was accompanied by a slight increase in overall pH (from 7.392 to 7.429, standard base excess from 0.1 to 5.5mmol/L). Conclusions: Hypernatremia is accompanied by metabolic alkalosis and an increase in pH. Given the high prevalence of hypernatremia, especially in critically ill patients, hypernatremic alkalosis should be part of the differential diagnosis of metabolic acid-base disorder

Erich Fromm and the Critical Theory of Communication

Erich Fromm (1900-1980) was a Marxist psychoanalyst, philosopher and socialist humanist. This paper asks: How can Fromm’s critical theory of communication be used and updated to provide a critical perspective in the age of digital and communicative capitalism? In order to provide an answer, the article discusses elements from Fromm’s work that allow us to better understand the human communication process. The focus is on communication (section 2), ideology (section 3), and technology (section 4). Fromm’s approach can inform a critical theory of communication in multiple respects: His notion of the social character allows to underpin such a theory with foundations from critical psychology. Fromm’s distinction between the authoritarian and the humanistic character can be used for discerning among authoritarian and humanistic communication. Fromm’s work can also inform ideology critique: The ideology of having shapes life, thought, language and social action in capitalism. In capitalism, technology (including computing) is fetishized and the logic of quantification shapes social relations. Fromm’s quest for humanist technology and participatory computing can inform contemporary debates about digital capitalism and its alternatives

Sodium and potassium disorders in patients with COPD exacerbation presenting to the emergency department.

BACKGROUND Electrolyte disorders are common in the emergency department. Hyponatremia is known to be associated with adverse outcome in community-acquired pneumonia (CAP) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD). No studies investigating the prevalence and influence of hypernatremia or potassium disorders in patients with AECOPD exist. METHODS In this retrospective cohort analysis, the prevalence of sodium and potassium disorders was investigated in patients with AECOPD presenting to an emergency department (ED) between January 1st 2017 and December 31st 2018 and compared to all ED patients with electrolyte measurements and patients presenting with CAP. Exclusion criteria were age younger than 18 years, written or verbal withdrawal of consent and outpatient treatment. Additionally, the influence of dysnatremias and dyskalemias on outcome measured by ICU admission, need for mechanical ventilation, length of hospital stay, 30-day re-admission, 180-day AECOPD recurrence and in-hospital mortality and their role as predictors of disease severity measured by Pneumonia Severity Index (PSI) were investigated in patients with AECOPD. RESULTS Nineteen point nine hundred forty-eight ED consultations with measurements of sodium and potassium were recognized between January 1st 2017 and December 31st 2018 of which 102 patients had AECOPD. Of these 23% had hyponatremia, 5% hypernatremia, 16% hypokalemia and 4% hyperkalemia on admission to the ED. Hypo- and hypernatremia were significantly more common in patients with AECOPD than in the overall ED population: 23 versus 11% (p = 0.001) for hypo- and 5% versus 0.6% (p < 0.001) for hypernatremia. In the logistic regression analysis, no association between the presence of either sodium or potassium disorders and adverse outcome were found. CONCLUSION Dysnatremias and dyskalemias are common in patients with AECOPD with as many as 1 in 5 having hyponatremia and/or hypokalemia. Hypo- and hypernatremia were significantly more common in AECOPD than overall. No significant association was found for dysnatremias, dyskalemias and adverse outcomes in AECOPD

Comparison of the novel simultaneous biplane versus in-plane imaging technique in ultrasound-guided biopsy: a prospective randomized multi-operator cross-over phantom study

PURPOSE: To evaluate and compare the in-plane and novel biplane imaging techniques in ultrasound-guided biopsies (USBx). USBx are effective for obtaining tissue samples in suspected malignancy or infection. The in-plane technique is the gold standard, offering continuous needle visualization. The biplane technique enables simultaneous in-plane and out-of-plane visualization, potentially improving biopsy outcomes. A study was conducted using gel phantoms to simulate USBx, with the goal of determining whether one technique offers distinct advantages over the other. METHODS: A total of 30 participants (mean age: 30 ± 7 years; 20 men) were recruited, primarily consisting of physicians in training with varying levels of experience. Each participant performed biopsies on gel phantoms using both the in-plane and biplane techniques in a randomized order after watching a standardized tutorial video. Procedure-related parameters were analyzed, and post-intervention questionnaires, including the NASA task load index (NASA-TLX), were collected to assess cognitive workload and personal preferences. RESULTS: All participants achieved successful biopsies with both techniques. The first-puncture success rate was significantly higher with the biplane technique (83% vs. 63%; P = 0.01). The biplane technique required significantly fewer biopsy attempts than the in-plane approach (37 vs. 43; P = 0.03). Although the biplane technique had a longer “mean time to first successful biopsy” (120 seconds vs. 72 seconds), this difference was not statistically significant (P = 0.09), likely due to high variability. No significant differences were found in safety-related parameters, including the number of skin punctures, needle retractions, percentage of time the needle tip was visible, and the number of biopsy attempts without needle tip visualization. The NASA-TLX indicated higher mental demand with the biplane technique (P = 0.013), but other dimensions showed no significant differences. Overall, 83% of participants, including 88% of more experienced operators, preferred the biplane technique, citing enhanced visualization and perceived safety. CONCLUSION: In this study, the biplane technique in USBx was substantially superior in terms of total biopsy attempts and first-puncture success rate compared with the in-plane approach. It may offer safety and efficiency advantages, particularly for less-experienced operators. Further studies with larger sample sizes and experienced operators, especially in clinical settings, are needed to determine clear superiority. CLINICAL SIGNIFICANCE: These findings suggest that biplane imaging may be especially beneficial for training less-experienced operators and in cases with elevated complication risk

Increased brachial intima-media thickness is associated with circulating levels of asymmetric dimethylarginine in patients with COPD

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with an increased cardiovascular risk. However, the mechanisms for this association are yet unclear. The aim of this study was to investigate the relationship between brachial intima-media thickness (B-IMT), an independent predictor of cardiovascular risk, systemic inflammation, and asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, in patients with COPD and respective controls. METHODS: The study sample consisted of 60 patients with stable COPD, free from overt cardiovascular disorders, as well as 20 smoking and 20 nonsmoking controls. Ultrasound assessment of B-IMT, spirometry, venous blood sampling for quantification of inflammatory markers and ADMA levels were carried out, and individual cardiovascular risk was calculated via the Framingham risk score. RESULTS: Patients with COPD showed significantly higher B-IMT compared to smoking (P=0.007) and nonsmoking controls (P=0.033). COPD patients with elevated B-IMT had a twofold increased calculated 10-year risk for cardiovascular events compared to those below the recommended cutoff (P=0.002). B-IMT was significantly associated with systemic inflammation (interleukin-6 [IL-6]; r=0.365, P=0.006) and ADMA (r=0.331, P=0.013) in COPD. Multivariate linear regression revealed male sex and ADMA as independent predictors of B-IMT in this study sample. CONCLUSION: B-IMT is significantly increased in patients with COPD and is associated with systemic inflammation and ADMA levels

Electrolyte disorders and in-hospital mortality during prolonged heat periods: a cross-sectional analysis

BACKGROUND Heat periods during recent years were associated with excess hospitalization and mortality rates, especially in the elderly. We intended to study whether prolonged warmth/heat periods are associated with an increased prevalence of disorders of serum sodium and potassium and an increased hospital mortality. METHODS In this cross-sectional analysis all patients admitted to the Department of Emergency Medicine of a large tertiary care facility between January 2009 and December 2010 with measurements of serum sodium were included. Demographic data along with detailed data on diuretic medication, length of hospital stay and hospital mortality were obtained for all patients. Data on daily temperatures (maximum, mean, minimum) and humidity were retrieved by Meteo Swiss. RESULTS A total of 22.239 patients were included in the study. 5 periods with a temperature exceeding 25 °C for 3 to 5 days were noticed and 2 periods with temperatures exceeding 25 °C for more than 5 days were noted. Additionally, 2 periods with 3 to 5 days with daily temperatures exceeding 30 °C were noted during the study period. We found a significantly increased prevalence of hyponatremia during heat periods. However, in the Cox regression analysis, prolonged heat was not associated with the prevalence of disorders of serum sodium or potassium. Admission during a heat period was an independent predictor for hospital mortality. CONCLUSIONS Although we found an increased prevalence of hyponatremia during heat periods, no convincing connection could be found for hypernatremia or disorders of serum potassium

Measurements of the pp → ZZ production cross section and the Z → 4ℓ branching fraction, and constraints on anomalous triple gauge couplings at √s = 13 TeV

Four-lepton production in proton-proton collisions, pp -> (Z/gamma*)(Z/gamma*) -> 4l, where l = e or mu, is studied at a center-of-mass energy of 13 TeV with the CMS detector at the LHC. The data sample corresponds to an integrated luminosity of 35.9 fb(-1). The ZZ production cross section, sigma(pp -> ZZ) = 17.2 +/- 0.5 (stat) +/- 0.7 (syst) +/- 0.4 (theo) +/- 0.4 (lumi) pb, measured using events with two opposite-sign, same-flavor lepton pairs produced in the mass region 60 4l) = 4.83(-0.22)(+0.23) (stat)(-0.29)(+0.32) (syst) +/- 0.08 (theo) +/- 0.12(lumi) x 10(-6) for events with a four-lepton invariant mass in the range 80 4GeV for all opposite-sign, same-flavor lepton pairs. The results agree with standard model predictions. The invariant mass distribution of the four-lepton system is used to set limits on anomalous ZZZ and ZZ. couplings at 95% confidence level: -0.0012 < f(4)(Z) < 0.0010, -0.0010 < f(5)(Z) < 0.0013, -0.0012 < f(4)(gamma) < 0.0013, -0.0012 < f(5)(gamma) < 0.0013

Severe early onset preeclampsia: short and long term clinical, psychosocial and biochemical aspects

Preeclampsia is a pregnancy specific disorder commonly defined as de novo hypertension and proteinuria after 20 weeks gestational age. It occurs in approximately 3-5% of pregnancies and it is still a major cause of both foetal and maternal morbidity and mortality worldwide1. As extensive research has not yet elucidated the aetiology of preeclampsia, there are no rational preventive or therapeutic interventions available. The only rational treatment is delivery, which benefits the mother but is not in the interest of the foetus, if remote from term. Early onset preeclampsia (<32 weeks’ gestational age) occurs in less than 1% of pregnancies. It is, however often associated with maternal morbidity as the risk of progression to severe maternal disease is inversely related with gestational age at onset2. Resulting prematurity is therefore the main cause of neonatal mortality and morbidity in patients with severe preeclampsia3. Although the discussion is ongoing, perinatal survival is suggested to be increased in patients with preterm preeclampsia by expectant, non-interventional management. This temporising treatment option to lengthen pregnancy includes the use of antihypertensive medication to control hypertension, magnesium sulphate to prevent eclampsia and corticosteroids to enhance foetal lung maturity4. With optimal maternal haemodynamic status and reassuring foetal condition this results on average in an extension of 2 weeks. Prolongation of these pregnancies is a great challenge for clinicians to balance between potential maternal risks on one the eve hand and possible foetal benefits on the other. Clinical controversies regarding prolongation of preterm preeclamptic pregnancies still exist – also taking into account that preeclampsia is the leading cause of maternal mortality in the Netherlands5 - a debate which is even more pronounced in very preterm pregnancies with questionable foetal viability6-9. Do maternal risks of prolongation of these very early pregnancies outweigh the chances of neonatal survival? Counselling of women with very early onset preeclampsia not only comprises of knowledge of the outcome of those particular pregnancies, but also knowledge of outcomes of future pregnancies of these women is of major clinical importance. This thesis opens with a review of the literature on identifiable risk factors of preeclampsia