Endocrine problems in the critically ill 2: endocrine emergencies

Key points

• Most endocrine emergencies are triggered by a secondary insult, which should be sought and managed appropriately.
• Clinical features may be non-specific, mimicking other disease processes. Maintain a high index of suspicion.
• Derangement of thyroid/adrenal function is common in the critically ill; correction of these derangements in the absence of underlying adrenal or thyroid disease is not required.
• Confirmation of diagnosis should not delay treatment in suspected acute adrenal insufficiency.
• Vitamin D deficiency is associated with increased all-cause mortality, yet there is no current evidence to support its routine replacement in critical illness.

Endocrine emergencies account for approximately 1.3% of UK critical care admissions. Although relatively uncommon, many of these emergencies are potentially life-threatening. Most endocrine crises are triggered by a secondary insult, commonly infection, and clinical features are often vague and potentially attributable to other causes, such as the precipitating illness. Consequently, the underlying endocrine disorder may easily be overlooked. This article will outline the presentation, investigation, and acute management of adult endocrine emergencies. Diabetic emergencies and glycaemic control in critical illness are discussed in the accompanying article, 'Endocrine problems in the critically ill 1: diabetes and glycaemic control'.¹

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A new type of distance metric and its use for clustering

Abstract

In order to address high dimensional problems, a new 'direction-aware' metric is introduced in this paper. This new distance is a combination of two components: (1) the traditional Euclidean distance and (2) an angular/directional divergence, derived from the cosine similarity. The newly introduced metric combines the advantages of the Euclidean metric and cosine similarity, and is defined over the Euclidean space domain. Thus, it is able to take the advantage from both spaces, while preserving the Euclidean space domain. The direction-aware distance has wide range of applicability and can be used as an alternative distance measure for various traditional clustering approaches to enhance their ability of handling high dimensional problems. A new evolving clustering algorithm using the proposed distance is also proposed in this paper. Numerical examples with benchmark datasets reveal that the direction-aware distance can effectively improve the clustering quality of the k-means algorithm for high dimensional problems and demonstrate the proposed evolving clustering algorithm to be an effective tool for high dimensional data streams processing.

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Effects of salinity on oil dispersant toxicity in the eastern mud snail, Ilyanassa obsoleta

Abstract

Chemical dispersants can be a beneficial method for breaking up oil slicks; however, their use in mitigation could pose potential toxic effects on the marine ecosystem. Dispersants may be transported to lower salinity habitats, where toxicity data for aquatic species have not been established. This study examined the effect of salinity on oil dispersant toxicity in the eastern mud snail, Ilyanassa obsoleta, using two dispersants authorized for oil spill response, Corexit® 9500A and Finasol® OSR 52. Median lethal toxicity values (LC50) and sublethal effects were examined at 10, 20, and 30 ppt salinity in adult and larval mud snails. Two biomarkers (lipid peroxidation and acetylcholinesterase) were used to measure sublethal effects. The 96-h static renewal LC50 values indicated significant differences in toxicity between dispersants and salinities. Larval snails were significantly more sensitive than adult snails to both dispersants, and both life stages were significantly more sensitive to Finasol than to Corexit. Larval snails were more sensitive to dispersants at lower salinity, but adult snails were more sensitive at higher salinities. Dispersants increased lipid peroxidation and decreased acetylcholinesterase activity. These results demonstrate that dispersant toxicity varies among compounds and organism life stages, and that physicochemical properties of the environment, such as salinity, can affect the potential toxicity to estuarine species.

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Central Retinal Vein Occlusion in 2 Patients Using Antipsychotic Drugs

Purpose: To report our findings in 2 patients who developed a central retinal vein occlusion (CRVO) and were chronic users of antipsychotic medications. Case Presentation: Case 1 was a 62-year-old woman who had a sudden reduction of vision in her right eye to 20/2,000. Her fundus showed signs of an impending CRVO with marked macular edema. She had been taking antipsychotic drugs (quetiapine fumarate and risperidone) for about 2 years. She refused anti-VEGF therapy for her macular edema but selected systemic kallidinogenase. Two days later, the macular edema was significantly reduced but the number of cotton wool spots (CWS) was increased. Ten days later, the macular edema was resolved and her BCVA improved to 20/60. The CWS gradually disappeared, and her BCVA improved to 20/20. Case 2 was a 43-year-old man who presented with vision reduction in his right eye of 1 week's duration. His BCVA was 20/50 and his fundus showed signs of a CRVO-related macular edema with CWS in the peripapillary area. He had been taking sulpiride (Dogmatyl^TM) for depression for 1 year, and his blood test showed an increase in red blood cells and hematocrit. Anti-VEGF therapy was performed, and the macular edema was resolved with vision improving to 20/20. There has been no recurrence to date in both cases. Conclusions: These results indicate that a CRVO can be a complication of chronic use of antipsychotic medications. However, early treatment can lead to good outcomes. Clinicians should question patients who develop a sudden CRVO whether they are using antipsychotic medications.
Case Rep Ophthalmol 2017;8:410–415

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Fundus Findings in Wernicke Encephalopathy

Wernicke encephalopathy (WE) is an acute neuropsychiatric syndrome resulting from thiamine (vitamin B₁) deficiency, classically characterized by the triad of ophthalmoplegia, confusion, and ataxia. While commonly associated with chronic alcoholism, WE may also occur in the setting of poor nutrition or absorption. We present a 37-year-old woman who underwent laparoscopic sleeve gastrectomy and presented with visual disturbance with bilateral horizontal nystagmus, confusion, and postural imbalance. Fundus examination revealed bilateral optic disc edema with a retinal hemorrhage in the left eye. Metabolic workup demonstrated thiamine deficiency. Her symptoms resolved after thiamine treatment. This case raises the awareness of the possibility of posterior segment findings in WE, which are underreported in WE.
Case Rep Ophthalmol 2017;8:406–409

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Neuroanesthesiology: the ineludible path toward super-specialty.

No abstract available

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Neuroanesthesiology: the ineludible path toward super-specialty.

No abstract available

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