Tiziana Ciarambino

Neurotoxicity induced by Cefepime in a very old hemodialysis patient

Neurotoxicity is an unusual complication of cephalosporin therapy. Only few cases of neurotoxicity induced by Cefepime have been described and probably the frequency of Cefepime-induced status epilepticus is underestimated. We report a case of an 82 year-old male, ESRD patient on chronic hemodialysis program affected by pneumonia, who received a treatment with intravenous Cefepime (1 g/day) and developed a seizure 4 days after the starting antibiotic therapy. Cefepime-induced neurotoxicity was suspected and its administration was immediately discontinued. In order to increase Cefepime clearance a hemodialysis session was urgently started and an improvement of his conscious level was observed. On the following day, after a second hemodialysis session his clinical condition and the status of neurotoxicity were completely recovered. The patient was discharged from the hospital in stable clinical condition one week later. At variance with the cases previously reported, the daily dose of Cefepime administrated to our patient was 50% lower and respected drug prescription dosage. Thus, we speculate on the hypothesis that advanced age of our patient and metabolic encephalopathy induced by chronic uremia made him more sensitive to the neurotoxicity induced by the drug. In conclusion, our case suggests that, in very old patients on long-term hemodialysis, it should be considered, to avoid neurotoxicity, to monitor the clinical neurological status, to use Cefepime at lower dosage than that allowed in patients with severe renal impairment (1 g/day) and, when possible, to evaluate Cefepime plasma levels. However, in these patients, other agents of the same class should be considered such as Cefotaxime and Ceftriaxone which are characterized by both an hepatic and renal excretion. In alternative to cephalosporins, antibiotics with the same action spectrum in the absence of neurological toxicity (i.e. Meropenem) should be recommended.

Screening of depressive symptoms in young-old hemodialysis patients: Relationship between beck depression inventory and 15-item geriatric depression scale

Aims: We studied the relationship between the Beck Depression Inventory (BDI) and the 15-item Geriatric Depression Scale (GDS-15) in young–old hemodialysis and hospitalized patients in order to evaluate the possible usefulness of GDS-15 in hemodialysis patients. Methods: Thirty-one hospitalized and 31 young–old hemodialysis patients aged 65–74 (young–old) were enrolled in the study. Comprehensive geriatric assessment (Mini Mental State Examination (MMSE), BDI, GDS-15, Cumulative Illness Rating Scale (CIRS) and Activities of Daily Living (ADL)) was made for all patients. The internal consistency between BDI and GDS-15 was evaluated with Cronbach’s α coefficient. Sensitivity, specificity and receiver operating characteristic (ROC) curves for GDS-15 were determined using BDI as the standard. Results: In the hospitalized group, the prevalence of depressive symptoms, as evaluated by BDI (≧14) and GDS-15 (≧6), were 29 and 32%, respectively. In the hemodialysis group, the prevalence of depressive symptoms, as evaluated by BDI and GDS-15, were 61 and 58%, respectively. A significantly positive correlation between the BDI and GDS-15 was found in hospitalized (r = 0.808; p < 0.001), hemodialysis (r = 0.692; p < 0.001) and both patient groups together (r = 0.777; p < 0.001). The area under the ROC curve was 0.99 in the hospitalized and 0.95 in the hemodialysis groups. The ROC curves indicate a best effectiveness cutoff point (balancing sensitivity and specificity) of ≧6 for GDS-15 compared to BDI. Conclusions: The GDS-15 could be a useful instrument for evaluating depressive symptoms in young–old hemodialysis patients.

Effects of a 6-days-a-week low protein diet regimen on depressive symptoms in young-old type 2 diabetic patients

OBJECTIVES Late-life depression is one of the main health problems among elderly diabetic subjects. In addition, depression is a common psychopathological condition among renal failure patients and most of these patients follow a low protein diet regimen (LPD). However, the effects of LPD on depressive symptoms are unclear. DESIGN In the present study, the effects of LPD regimen on depressive symptoms in elderly type 2 diabetic subjects with renal failure were investigated. PARTICIPANTS Fifty-two young-old type 2 diabetic patients with renal failure were enrolled in the study. All participants after normal protein diet regimen providing 1.2g/kg per d were instructed to consume either a LPD providing 0.8 g/kg per d, 7 d a wk (LPD 7/7), or a LPD providing 0.8 g/kg per d 6 d a wk (LPD 6/7) randomly. RESULTS Mean 15-item Geriatric Depression Scale (GDS-15) (2.0±0.6) and Beck Depression Inventory (BDI) (4.1±1.0), during normal protein diet regimen, significantly increased to (6.7±1.6) and (12.2±1.4), respectively, after LPD 7/7 (P<0.05 versus normal protein diet). However, after LPD 6/7, mean GDS-15 and BDI significantly decreased to (4.4±1.5) and (6.7±1.6), respectively (P<0.05 versus LPD 7/7). CONCLUSION LPD 6/7 regimen significantly decreased depressive symptoms in young-old type 2 diabetic patients.

Light and shadows of dietary protein restriction in elderly with Chronic Kidney Disease

Approximately 45% of the elderly population suffers from chronic kidney disease (CKD). The onset and the course of CKD can be ameliorated to a significant degree by several interventions, such as lowering blood pressure and serum lipid levels and achieving optimal glucose control in diabetes. In elderly patients with more advanced CKD, additional treatment may be needed. In these patients, a low-protein diet (LPD) regimen may delay the need for dialysis therapy. However, in the elderly, feasibility and compliance to LPD could be difficult and its effects are uncertain. In this contribution, we discuss the usefulness and the barriers of LPD regimen in the elderly.

Long term effects of low protein diet on depressive symptoms and quality of life in elderly Type 2 diabetic patients.

OBJECTIVES The long term effects of a low protein diet (LPD) on depressive symptoms and the quality of life in elderly Type 2 diabetic are unclear. METHODS 38 elderly Type 2 diabetic patients with CRD (Stage 3 - 4) were enrolled in the study. After 4 weeks on a normal protein diet regimen (NPD) providing 1.0 g/kg per day, all participants were assigned for 30 months, randomly, to a LPD (0.7 g/kg per day), either 7 days a week (LPD 7/7) or 6 days a week (LPD 6/7). Mini mental state examination (MMSE), activities daily living (ADL), cumulative illness severity (CIRS-IS), geriatric depression scale (GDS-15) and short-form healthy survey (SF- 36) were evaluated every 3 months. RESULTS Before the LPD regimen creatinine clearance (CrCl), MMSE, ADL, CIRS-IS, GDS-15 and SF-36 were similar in both LPD 7/7 and LPD 6/7 groups. After 30 months, the mean GDS- 15 increased significantly more in LPD 7/7 group than in LPD 6/7 group (p < 0.05). Both mean SF-36 MCS and SF-36 PCS were decreased significantly more in LPD 7/7 group than in LPD 6/7 group (p < 0.05). After 30 months, the decline in CrCl observed was similar in LPD 7/7 and LPD 6/7 groups (2.77 ± 0.3 and 2.84 ± 0.3 ml/min/year, respectively). CONCLUSION In elderly Type 2 diabetic patients, long term effects of LPD 6/7 regimen in comparison to LPD 7/7 are associated with a similar decline in CrCl, but with decreased depressive symptoms and a better quality of life.

Diseases associated with electrolyte imbalance in the ED: age-related differences

OBJECTIVE The objective of the study is to investigate the prevalence of electrolyte imbalance (EI) in the emergency department (ED) with systemic diseases in different decades of life. METHODS We enrolled patients admitted to the ED. The population study included 7941 patients, subdivided in 3 groups: young group (Y), middle-aged group (MA), and elderly group (E). RESULTS We observed EI in 13.7% of the whole population. Hyponatremia (hNa+) is the most frequent EI (44%) followed by hypokalemia (hK+) (39%), hyperkalemia (HK+) (13%), and hypernatremia (HNa+) (4.4%). In the Y group, the EI occurred in 7.1% of all patients (P< .05 vs MA and E), whereas in the MA group, they were shown in 11.5% of patients and in the E group in 22% of all patients group (P< .05 vs MA and Y). In the Y group, gastrointestinal diseases are the most frequently associated disease (24.6%; P< .05 vs MA and E). In the MA group, the most frequently associated disease was a current cardiovascular disease (29.7%; P< .05 vs Y and E). In the E group, the frequently associated diseases are cardiovascular (22.8%; P< .05 vs Y) and lung diseases (16.7%; P< .05 vs MA and Y). CONCLUSIONS In our study, 13.7% of all patients showed an EI, and only 2% of cases were alone without any associated systemic disease. Most EIs are associated to other systemic diseases. The present data also depict different age-related and disease-associated prevalence patterns of EI, thus highlighting a complex clinical scenario.

Acute dysphagia in an octogenarian: an unusual case of tetanus

Tetanus is a major worldwide health problem, and its global incidence has been estimated to be approximately 1 million cases per year. In particular, tetanus is more frequent in the elderly as compared with adults. We report a case of an octogenarian who presented with dysphagia and tremors as the only clinical symptoms. During hospitalization, the patients clinical conditions worsened rapidly, and, although in absence of the classic clinical presentation (trisma, nuchal rigidity, and opisthotonus), a diagnosis of tetanus was suspected. Thus, the patient underwent a tetanus immunoglobulin immunization and antibiotic therapy with excellent clinical recovery.

Serum sodium correction rate and the outcome in severe hyponatremia

Study objective: We investigated the serum sodium correction rate on length of hospitalization and survival rate, in severe chronic hyponatremic patients at the Emergency Department (ED). Design: An observational study using clinical chart review. Setting: The ED of the University Hospital of Marcianise, Caserta, Italy with approximately 30,000 patients visits a year. Type of participants: We reviewed sixty‐seven patients with severe hyponatremia subdivided in 2 subgroups: group A consisting of 35 patients with serum sodium correction rate < 0.3 mmol/h and group B consisting of 32 patients with serum sodium correction rate between < 0.5 and ≥ 0.3 mmol/h. Intervention: Emergency patients were evaluated for serum sodium correction rate for hyponatremia by clinical chart review. Measurements and main results: Severe hyponatremia was defined as a serum sodium level < 120 mmol/l. Mean serum sodium correction rate of hyponatremia was of 0.17 ± 0.09% in group A and 0.41 ± 0.05% in group B (p < 0.001 vs group A). The length of hospital stay was 10.7 ± 3.7 days for group A, and it was significantly decreased to 3.8 ± 0.4 days for group B (p < 0.005 vs group A). In addition we observed that correction rate of hyponatremia in group A was associated with a significantly lower survival rate (25%) in comparison to group B (60%) (p < 0.001 vs group A). Conclusion: We observed that serum sodium correction rate ≥ 0.3 and < 0.5 mmol/h was associated with a shorter length of hospital stay and a major survival rate.

Seasonal variations of hyponatremia in the emergency department: Age-related changes

Study objective: We investigated seasonal prevalence of hyponatremia in the emergency department (ED). Design: A cross‐sectional study using clinical chart review. Setting: University Hospital ED, with approximately 28 000 patient visits a year. Type of participants: We reviewed 15 049 patients, subdivided in 2 groups: the adult group consisting of 9822 patients aged between 18 and 64 years old and the elderly group consisting of 5227 patients aged over 65 years presenting to the ED between January 1st, 2014 and December 31st, 2015. Intervention: Emergency patients were evaluated for the presence of hyponatremia by clinical chart review. Measurements and main results: Hyponatremia was defined as a serum sodium level < 135 mmol/l. Mean monthly prevalence of hyponatremia was of 3.74 ± 0.5% in the adult group and it was significantly increased to 10.3 ± 0.7% in the elderly group (p < 0.05 vs adults). During the summer, hyponatremia prevalence was of 4.14 ± 0.2% in adult and markedly increased to 12.52 ± 0.7% (zenith) in elderly patients (p < 0.01 vs adult group; p < 0.05 vs other seasons in elderly group). In the elderly group, we reported a significant correlation between weather temperature and hyponatremia prevalence (r: 0.491; p < 0.05). Conclusion: We observed a major influence of climate on the prevalence of hyponatremia in the elderly in the ED. Decline in renal function, salt loss, reduced salt intake and increased water ingestion could all contribute to developing hyponatremia in elderly patients during the summer. These data could be useful for emergency physicians to prevent hot weather‐induced hyponatremia in the elderly.

Acute rhabdomiolisys in healthy woman

Our patient is a 42-year-old woman with muscle paralysis, muscle weakness, and fever. On admission, a neurologic examination showed proximal and distal weakness in the leg. Serum creatine phosphokinase and serum myoglobin level were markedly increased (5600 UI/L and 5197 UI/L, respectively). There was no sign of renal failure. Nerve conduction study was negative. Serologic studies for virus titers showed the antibody immunoglobulin M cytomegalovirus. Muscle weakness and its paralysis, fever, and serum creatine kinase level gradually improved after the administration of methylprednisolone intravenous. Cytomegalovirus infection was thought to have played a central role in this case, leading to an acute but reversible peripheral muscle paralysis.