Continuous Intravenous Therapy Research Articles

Association Between Vegetation Size and Outcome in the Partial Oral Antibiotic Endocarditis Treatment Trial

Step-down oral antibiotic therapy is associated with a non-inferior long-term outcome compared with continued intravenous antibiotic therapy in the treatment of left-sided infective endocarditis. We aimed to analyze whether step-down oral therapy compared with continued intravenous antibiotic therapy is also associated with a non-inferior outcome in patients with large vegetations (vegetation length ≥ 10 mm) or among patients who underwent surgery before step-down oral therapy. We included patients without presence of aortic root abscess at diagnosis from the POET (Partial Oral Antibiotic Endocarditis Treatment) study. Multivariable Cox regression analyses were used to find associations between large vegetation, cardiac surgery, step-down oral therapy, and the primary end point (composite of all-cause mortality, unplanned cardiac surgery, embolic event, or relapse of positive blood cultures during follow-up). A total of 368 patients (age 68 ± 12, 77% men) were included. Patients with large vegetations (n = 124) were more likely to undergo surgery compared with patients with small vegetations (n = 244) (65% vs 20%, p <0.001). During a median 1,406 days of follow-up, 146 patients reached the primary end point. Large vegetations were not associated with the primary end point (hazard ratio 0.74, 95% confidence interval 0.47 to 1.18, p = 0.21). Step-down oral therapy was non-inferior to continued intravenous antibiotic in all subgroups when stratified by the presence of a large vegetation at baseline and early cardiac surgery. Step-down oral therapy is safe in the presence of a large vegetation at diagnosis and among patients who underwent early cardiac surgery.

14 Yıllık Bir Port Kateterin Sık Karşılaşılmayan Komplikasyonu

Percutaneous subclavian catheters or port-catheters are commonly used for oncology patients who require long-term or continuous intravenous therapy. There are several reported complications related to port-catheters like arterial puncture, pneumothorax and hematoma. We aimed to report an unusual port-catheter case. Our patient was a 45-year-old male who had a port-catheter inserted after the diagnosis of rectum cancer in 2009 and has never showed up for a catheter removal after his chemotheraphy regimen had been completed. The silicone port of the catheter was found to be disintegrated during the catheter removal procedure. Removal was performed but distal 5 cm of the catheter was missing. At the end of the procedure, control X-ray was obtained , but the last part of the catheter could not be visualized. There are reported cases of pinch-off syndrome in the literature however we couldn’t find any such case as we report. Following port-catheter implantation and throughout the course of treatment, patients should be consistently monitored, and an appropriate time should be scheduled for removal. Physicians should be aware of complications and multidisciplinary approaches should be made to avoid serious events and further harm. Keywords: Port-catheter complication, port-catheter removal, port-catheter detachment, pinch-off syndrome

Sustaining Patency of Peripherally Inserted Venous Catheter (PIVC) among Patients in Continuous Intra Venous Therapy

Background: Phlebitis is still a common complication of peripheral venous catheters. Finding a suitable solution to prevent and reduce the incidence of this complication continues to be a challenge. Various strategies were used to reduce the incidence of phlebitis. Mostly non-pharmacological measures were taken as first preference. Intially, when patients come to any hospital for their treatment, the first is the peripherally inserted venous catheter access conducted inpatient for medication administration, fluid administration and blood transfusion in both the hospital setting and ambulatory setting. About 70% of thepatients admitted to the hospital requires peripherally inserted venous catheters (PIVCs). The incidence of phlebitis is higher in patients who undergo continuous intravenous therapy. Objectives: To find out the effect of hand grip exercise in the sustaining patency of peripherally inserted venous catheters among patients in continuous intravenous therapy. Methods: During the 8 weeks the hand grip exercise was evaluated in patients, who had undergone continuous intravenous infusion through the peripherally inserted venous catheter for at least 3 days. The measurement of data is based on the patient’s socio-demographic Performa, patency checklist, visual infusion phlebitis score and visual analogue scale. The post-test was conducted in both experimental and control groups. Result: Till the end of the study, 76 participants were taken. On day 3 of the hand grip exercise maximum of 24 (61.5%) PIVC were patent, whereas in control group 5 (13.5%) PIVC were able to maintain their patency. On day 5 of exercise 34 (91.9%) PIVC were replaced with a cause of phlebitis 33(89.2%) in the control group in comparison with the experimental group only 22 (56.4%) lines were replaced with the same cause of phlebitis 24 (61.5%). Conclusion: Hand grip exercise is important for clients, to reduce the need for the potentially painful process of placing vascular lines and also helps to control costs by reducing the number of devices used for each client and the development of phlebitis.

Use of the Guardian Connect glycemic monitoring system in patients after total duodenopancreatectomy in the early postoperative period on intravenous insulin therapy

BACKGROUND: Among different subtypes of pancreatogenic diabetes mellitus the biggest difficulties of glycemic control arise in patients after total duodenopancreatectomy (TDPE), first of all due to the presence of absolute insulin insufficiency.AIM: Estimating safety and cost-effectiveness Guardian Connect CGM system in early postoperative period in hospitalized patients after TDPE on continuous intravenous insulin therapy (CIVIT).MATERIALS AND METHODS: Glucose measurement results of 26 patients in early postoperative period after TDPE were analyzed. In 12 of them, we used Guardian Connect CGM system. In this group 43 cycles (1 cycle — 6 days, 258 days total) of CGM and 971 glucometer measurements used for CGM calibration were analyzed; in other 14 patients in whom only glucometer was used we analyzed 2496 glycemic values.Cost-effectiveness was calculated over 6 days for CGM and only glucometer use (including cost of CGM, glucometers, disposable materials, clinic wage-costs to medical staff for time required for glucose control).RESULTS: Glucose levels of group #1 were in the target range 5.6 to 10.0 mmol/L (66.7 vs 61.2%, p=0.003) and the range 4.3–11.6 mmol/L (85.2% vs 82.2%, p=0.038) more than in comparison with group #2.The frequency of hypoglycemic episodes (&lt;3.9 mmol/L) was statistically significantly lower in the CGM group (6 vs 54, p&lt;0.001, RO 8.463 [3.579; 20.015], RR 1.746 [1.551; 1.966]).Cost analysis of glucose control using Guardian Connect CGM system for one cycle (6 days) and cost of glucose control using glucose meter for the same period showed that using Guardian Connect CGM system in patients after TDPE on intravenous insulin therapy reduced clinic costs by 21.7% in ICU and by 25.7% in the hospital department.CONCLUSION: Guardian Connect CGM have demonstrated its safety and cost-effectiveness during glucose control in patients in early postoperative period after TDPE on CIVIT.

Fetal Long QT Syndrome - Challenges in Perinatal Management: A Review and Case Report. Induction of Labor and Vaginal Birth Under Continuous Magnesium Therapy.

Congenital LQTS is an often undetected inherited cardiac channel dysfunction and can be a reason for intrauterine fetal demise. It can present in utero as CTG and ultrasound abnormalities, i. e., bradycardia, ventricular tachycardia, or fetal hydrops. Diagnosis is made by CTG, echocardiography, or fMCG. Intrauterine therapy with a ß blocker and i. v. magnesium should be started. Our objective was to examine the current knowledge about diagnosis and treatment of LQTS and in particular to highlight the opportunity of vaginal birth under continuous intravenous magnesium therapy. Therefore, a thorough MEDLINE and Google Scholar search was conducted. Randomized controlled trials, meta-analyses, prospective and retrospective cohort trials, and case reports were considered. We showed the possibility of vaginal delivery under continuous magnesium therapy in a case of suspected fetal LQTS. A stepwise concept for diagnosis, monitoring, and peripartum management in low, intermediate, and high risk cases of fetal LQTS is presented. If risk is low or intermediate, a vaginal delivery under continuous monitoring is reasonable. Induction of labor at term should be evaluated.

'The Year of Living Dangerously': Successful Rhodococcus Equi Therapy in an Immunosuppressed Patient with Minimal Toxicity by One Year of Continuous Intravenous Vancomycin Therapy Combined with Oral Levofloxacin And Rifampicin.

Rhodococcus equi is a Gram-positive microorganism that causes infections, particularly in immunocompromised patients. Treatment duration can be prolonged. While vancomycin is an effective drug in this scenario, its use may lead to renal damage. Studies have shown that continuous vancomycin infusion appears to be a safe strategy in terms of adverse effects compared to bolus administration. We present the case of a 71-year-old female liver transplant recipient. After being diagnosed with a mediastinal infection caused by Rhodococcus equi with poor response to initial therapy, she required 12 months of continuous intravenous domiciliary infusion of vancomycin combined with oral levofloxacin and rifampicin. There was no drug-related complication throughout the follow-up. The use of continuous vancomycin infusion has emerged as a safer, more efficient, and cost-effective alternative to intermittent administration. We want to emphasise the uniqueness of this case, where despite the unprecedented treatment duration, no adverse effects occurred. Vancomycin therapy based on continuous infusion represents a safer and cheaper strategy than classic intermittent administration.The use of continuous infusion facilitates the management of complex infections with outpatient antimicrobial therapy.

#3056 IMPACT OF ALBUMIN BINDING FUNCTION ON PHARMACOKINETICS AND PHARMACODYNAMICS OF FUROSEMIDE

Abstract Background and Aims Albumin binding of furosemide forms the basis for its transport to the kidney and subsequent tubular secretion, which is a prerequisite for the effect of furosemide. Accordingly, high albumin concentrations should result in higher efficacy of furosemide. However, study results on the combination of furosemide in conjunction with albumin and on the efficacy of furosemide in hypoalbuminemia did not confirm this hypothesis. The aim of this study was to determine the efficacy of furosemide not only in relation to concentration, but also to take albumin function into account. Method In a prospective and non-interventional clinical observational trial, blood and urine samples from 50 intensive care patients receiving continuous intravenous furosemide therapy were evaluated. Albumin binding capacity (ABiC) determination allowed conclusions to be drawn about the binding site-specific loading state of albumin by quantifying the unbound fraction of the fluorescent marker dansylsarcosine. In addition, assessment of the total concentration of furosemide in plasma and urine as well as the concentration of free furosemide fraction in plasma was performed by HPLC-MS. The efficacy of furosemide was evaluated by the ratio of urine excretion to fluid intake. Results In patients with an ABiC ≥ 60% free furosemide fraction was significantly lower compared to patients with a lower ABiC (p &amp;lt; 0.001), urinary furosemide concentration was higher (p = 0.136), and a significantly higher proportion of infused furosemide was excreted renally (p = 0.010). ABiC was positively correlated (r = 0.908, p = 0.017) with the increase in urine excretion to fluid input ratio after initiation of furosemide therapy. Conclusion ABiC could serve as a marker for individual response to furosemide and could be used to generate patient-specific therapeutic regimens. In view of the relatively low number of patients in this study, the relationship between furosemide efficacy and albumin function should be investigated in larger studies in the future.

Uncomplicated Streptococcal Bacteremia: The Era of Oral Antibiotic Step-down Therapy?

BackgroundThe purpose of this study was to compare the clinical outcomes of adults with uncomplicated streptococcal bacteremia who received either oral (PO) step-down or continued intravenous (IV) therapy. MethodsThis was a retrospective, single-center, cohort study, including adults admitted with Streptococcal bloodstream infection between January 1, 2013, and December 31, 2020. Only patients with uncomplicated Streptococcal bloodstream infections were included. Patients who transitioned to PO therapy within 5 days from bacteremia onset were compared to patients receiving continued IV therapy. The primary outcome was clinical failure, defined by either 90-day hospital readmission or mortality. Secondary outcomes included hospital length of stay (LOS) and antibiotic-related adverse events (AAEs). ResultsOf the 264 patients included, 42% were transitioned to PO therapy. Group B Streptococcus (22.7%) was the most common isolate. The most common sources of infection were skin and soft tissue (35%) and pulmonary (25%). Intensive care unit (ICU) stay was more common in the continued IV therapy group (22.2%) than in the PO step-down group (5.4%). The frequency of clinical failure was similar in the IV and PO groups (24.2% vs. 18.0%, P=0.23). The IV group had longer hospital LOS (median, [interquartile range (IQR)]) compared with the PO group (7 [5-13.5] vs. 4 [3–5] days, P<0.001). The incidence of AAEs was similar in the IV and PO groups (1.3% vs. 1.8%, P=0.74). ConclusionOral antibiotic step-down therapy may be appropriate for the treatment of uncomplicated Streptococcal bacteremia, with consideration of factors such as patient comorbidities, type of infection, source control and clinical progress.

Impact of Albumin Binding Function on Pharmacokinetics and Pharmacodynamics of Furosemide.

Background and Objectives: Albumin binding of the loop diuretic furosemide forms the basis for its transport to the kidney and subsequent tubular secretion, which is a prerequisite for its therapeutic effects. Accordingly, high albumin concentrations should result in higher efficacy of furosemide. However, study results on the combination of furosemide in conjunction with albumin, and on the efficacy of furosemide in hypoalbuminemia, did not confirm this hypothesis. The aim of this study was to determine the efficacy of furosemide not only in relation to albumin concentration, but also taking albumin function into account. Materials and Methods: In a prospective and non-interventional clinical observational trial, blood and urine samples from 50 intensive care patients receiving continuous intravenous furosemide therapy were evaluated. Albumin binding capacity (ABiC) determination allowed conclusions to be drawn about the binding site-specific loading state of albumin, by quantifying the unbound fraction of the fluorescent marker dansylsarcosine. In addition, assessment of the total concentration of furosemide in plasma and urine, as well as the concentration of free furosemide fraction in plasma, was performed by HPLC-MS. The efficacy of furosemide was evaluated by the ratio of urine excretion to fluid intake. Results: In patients with an ABiC ≥ 60% free furosemide fraction was significantly lower compared to patients with a lower ABiC (p &lt; 0.001), urinary furosemide concentration was higher (p = 0.136), and a significantly higher proportion of infused furosemide was excreted renally (p = 0.010). ABiC was positively correlated (r = 0.908, p = 0.017) with increase in the urine excretion to fluid input ratio after initiation of furosemide therapy. Conclusions: ABiC could serve as a marker for individual response to furosemide and could be used to generate patient-specific therapeutic regimens. In view of the relatively low number of patients in this study, the relationship between furosemide efficacy and albumin function should be investigated in larger studies in the future.

Intravenous to oral antibiotics versus intravenous antibiotics: a step-up or a step-down for extended spectrum β-lactamase (ESBL)-producing urinary tract infections without concomitant bacteraemia?

The Infectious Diseases Society of America (IDSA) recommends numerous antibiotics for the treatment of urinary tract infections (UTIs) caused by extended-spectrum β-lactamase (ESBL)-producing bacteria. The purpose of this study was to evaluate clinical outcomes of oral step-down antibiotics compared with continued intravenous therapy in UTIs without bacteraemia. This multicentre, retrospective, cohort study was conducted in hospitalised patients with ESBL-producing UTIs between July 2016 and March 2020. The primary outcome was a composite all-cause clinical failure, defined as 30-day re-admission, 30-day hospital mortality or a change in oral antibiotics during hospitalisation. Secondary outcomes included individual primary outcome components, re-admission due to a recurrent UTI, change in antibiotic during hospitalisation, hospital length of stay (LOS), antibiotic costs and adverse events. The study included 153 patients. The primary outcome occurred in 28% of both groups (27/95 vs. 16/58; P=0.91). The primary outcome components were similar: re-admission (26% vs. 26%; P=0.95); hospital mortality (2% vs. 2%; P=1.0); and change in antibiotics (0% vs. 2%; P=0.38). Mean hospital LOS and direct antibiotic costs were 8 ± 6 days vs. 5 ± 2 days (P < 0.01) and US$278 ± 244 vs. US$180 ± 104 (P < 0.01), respectively. Adverse events were similar, except diarrhoea (15% vs. 2%; P=0.01). There was no difference in clinical failure, re-admission rate, re-admission due to a recurrent UTI, mortality rate or antibiotic change between groups. The switch group was associated with reduced hospital LOS and inpatient antibiotic costs.

Üç Yollu Musluk ve Split Septumlu Enjeksiyon Valfi Kullanımının Kateter Enfeksiyonu ve Kolonizasyonuna Etkileri: Yarı Deneysel Çalışma

Objective: Connectors are frequently and necessarily used in patients undergoing intravenous fluid therapy. All of the catheters and connectors may be a risk factor for catheter infections if aseptic techniques were not used. This study was conducted to determine the effect of 3-way stopcock (3WSC) and Split Septum Injection Valve (SSIV) Usage on peripheral intravenous catheter colonization and infection. Material and Methods: This is a quasi-experimental study. The sample of the study consists of 216 patients (108 control, and 108 experimental group). 3WSC was integrated to the control group and SSIV was integrated to the experiment group peripheral venous catheters. Catheters were observed for 72 hours in terms of complications such as bleeding, leakage, and phlebitis infiltration. Catheters were removed for culture sampling 72 hours after catheterization. Descriptive statistics and Pearson chi-square were used in the analysis of the data. Results: The rate of colonization was 5.6% in 3WSCs and 2.8% in SSIVs. When the colonization rates were compared, there was no statistically significant difference between 3WSCs and SSIVs about catheter colonization and infection (p>0.05). Conclusion: Both connectors can be used safely in the administration of continuous intravenous solution and drug therapy. Development of continuous in-service training programs for the prevention of catheter related blood system infections are suggested.

Evaluation of step-down oral antibiotic therapy for uncomplicated streptococcal bloodstream infections on clinical outcomes.

Background:Despite the severity and frequency of streptococcal bloodstream infections (BSIs), the effectiveness of oral definitive therapy remains unknown. The objective of this study was to evaluate the clinical outcomes of step-down oral antibiotics for the treatment of uncomplicated streptococcal BSIs.Methods:In this retrospective cohort study, adult patients admitted with uncomplicated streptococcal BSI between June 2015 and June 2017 were included. Patients were excluded if they received <48 h of antibiotic therapy; therapy was started >48 h after first positive culture; had complicated infections of endocarditis, bone and joint infections, or central nervous system infections; Pitt bacteremia score (PBS) ⩾ 4; or failed to respond to effective therapy necessitating continued intravenous (IV) therapy. Patients were grouped by receipt of step-down oral antibiotic therapy (PO group) versus continued IV therapy (IV group). Outcomes included hospital length of stay (LOS), 30-day recurrence of BSI, 30-day readmission, 30-day all-cause mortality, and catheter-related or drug-related adverse events (AEs).Results:Of 244 patients included, 40% received step-down oral therapy (n = 98). Overall, the most common source of BSI was pneumonia (22%), followed by skin and soft tissue infections (SSTI) (18%). Severity of illness measured by intensive care unit (ICU) admission and PBS was similar. The IV group had significantly longer LOS [median 10 (interquartile range [IQR] = 5–21) versus 5 (4–6) days, p < 0.01] compared with the PO group. BSI recurrence, readmission, all-cause mortality within 30 days, and AEs were similar between the groups (p = ns).Conclusion:In uncomplicated streptococcal BSI, patients treated with step-down oral antibiotic therapy had significantly shorter LOS compared with continued IV therapy without compromise of clinical outcomes.

198. Evaluation of Oral Step-down versus Continued Intravenous Antimicrobial Therapy in Immunocompromised Patients Hospitalized with Gram-Negative Bacteremia

BackgroundBloodstream infections are associated with considerable morbidity and mortality in the United States. Most patients initially receive parenteral antibiotics for gram-negative bacteremia, and more data is emerging supporting de-escalation to oral (PO) antibiotics to complete treatment. Previous studies evaluating PO antibiotics for gram-negative bacteremia often exclude or have underrepresented immunocompromised patients. This study evaluated clinical failure in immunocompromised patients receiving intravenous (IV) antibiotics compared to patients transitioned to PO antibiotics for gram-negative bacteremia.MethodsA single center, retrospective cohort study was conducted at 446-bed academic medical center. Patients were included if they were immunocompromised and admitted with a positive blood culture for E. coli, Klebsiella spp., Citrobacter spp., Serratia spp., Enterobacter spp., Proteus spp., P. aeruginosa. between November 4, 2017 to November 4, 2020. Patients were excluded from this study if they had polymicrobial bacteremia, no source control within the first 5 days, or an indication for prolonged duration of treatment. The primary endpoint of this study was clinical failure defined as an escalation from PO to IV antibiotics, worsening clinical status, or readmission for the same infection within 30 days of discharge. The secondary endpoints included 30-day mortality, 90-day mortality, 30-day readmission, and time to microbiologic clearance.ResultsA total of 31 immunocompromised patients were included in the study with 26 patients receiving PO step-down therapy and 5 patients being continued on IV treatment for gram-negative bacteremia. There was no difference in the primary outcome of clinical failure between the PO step-down group versus the IV therapy group (15.4% vs 20%; p = 0.613). The most common immunocompromised state in both groups was being HIV positive. Patients in the PO step-down group had a significantly shorter hospital length of stay (7.4 days vs. 13.6 days; p = 0.016).ConclusionOral step-down therapy for gram-negative bacteremia showed similar clinical failure rates to continuous IV therapy in the immunocompromised patient population and may be an option to shorten hospital length of stay.Disclosures All Authors: No reported disclosures

195. Intravenous to Oral Antibiotics Versus Intravenous Antibiotics: A Step-Up or a Step-Down for Extended Spectrum Beta-Lactamase Producing Urinary Tract Infections?

BackgroundThe treatment of extended-spectrum beta-lactamase (ESBL)-producing urinary tract infections (UTI) may include either intravenous (IV) or oral (PO) antibiotics, according to the Infectious Diseases Society of America guidelines for resistant gram negative infections. The purpose of this study is to evaluate if PO step-down antibiotics, the switch group, compared to continued IV therapy in these UTIs affects clinical outcomes.MethodsThis multicenter retrospective cohort study was conducted in hospitalized patients with an ESBL-producing UTI between July 2016 and March 2020. The control group received a complete antibiotic course with a carbapenem. The switch group was transitioned to an oral agent within five days from initiation of a carbapenem. The primary endpoint was a composite all-cause clinical failure, which was defined as readmission or hospital mortality within 30 days of hospital discharge or a change in antibiotic during hospital admission. The secondary endpoints included individual components of the primary outcome, readmission indication, inpatient length of stay, direct antibiotic costs, and adverse events. ResultsThe study included 153 patients: 95 and 58 patients in the control and switch groups, respectively. Demographics between the two groups were similar (Table 1). The mean ± SD duration of therapy was 8.7 ± 3.1 and 7.1 ± 3.3 days, respectively. Four oral agents were used for step-down therapy (Figure 1). The primary outcome occurred in 28% in both groups (27 vs 16 patients, p=0.91). The individual components of the primary outcome and readmission indication were also similar: readmission (93% vs 94%, p=0.95), readmission due to a recurrent UTI (33% vs 25%, p=0.73), hospital mortality (7% vs 6%, p=1.0), and change in antibiotic (0% vs 2%, p=0.38). The median (IQR) length of stay and direct antibiotic cost in the control and switch groups were 8 (6) vs 5 (2) days (p< 0.01) and &278 (&244) vs &180 (&104) (p< 0.01), respectively. Adverse events were similar in both groups except for diarrhea (15% vs 2%, p=0.01).Table 1. Baseline Demographics. SD: standard deviation, ICU: intensive care unit, qSOFA: quick Sequential Organ Failure Assessment, ESBL: extended spectrum beta-lactamase, UTI: urinary tract infection Figure 1. Oral Antibiotics. QD: once daily, BID: twice daily, Q2D: every 2 days, Q3D: every 3 days, DS tab: double strength tablet ConclusionThere was no difference in clinical failure, readmission rate, mortality rate, or change in antibiotic between the control and switch groups; however, the switch group was associated with reduced hospital length of stay and direct antibiotic cost. Disclosures All Authors: No reported disclosures

Avidity-Engineered CD3 Engaging DARPin ® Targeting Three Tumor Associated Antigens Induce Strong and Specific T Cell Dependent Killing of AML Cells with Potential for Improved Safety

Avidity-Engineered CD3 Engaging DARPin ® Targeting Three Tumor Associated Antigens Induce Strong and Specific T Cell Dependent Killing of AML Cells with Potential for Improved Safety

Comparative Trial of Continuous Flow Enteral and Intravenous Fluid Therapy in Horses.

Continuous flow enteral fluid therapy with isotonic and hypotonic enteral electrolyte solutions are as safe and effective as intravenous fluid therapy. The aim of this study was to carry out a comparative assessment between continuous flow enteral and intravenous (IV) fluid therapy in adult experimentally dehydrated horses. Six experimentally dehydrated adult mares were used in a study carried out in a 6 × 3 crossover design, which each animal received three different treatments (isotonic enteral fluid therapy—EsISO, hypotonic enteral fluid therapy—EsHYPO and intravenous fluid therapy with Lactate Ringer Solution—LR IV, all in continuous flow). Solutions were administered at a rate of 15 mL−1.kg−1.h−1 for 8 h, after 36 h of water and food deprivation. Serum and urinary biochemical assessment; urinary volume, pH and specific gravity; and blood gas analysis were measured at −36, 0, 2, 4, 6, and 8 h. The dehydration period (DP) caused discrete hydroelectrolytic and acid base imbalances. The EsISO, EsHYPO and LR IV increased blood volume. Enteral solutions restored the imbalances yielded by the DP and all treatments increased urine volume. Also, the EsHYPO and LR IV showed no effects in acid base balance, while EsISO showed slightly acidifying effect. The present study certifies the efficacy and safety of isotonic and hypotonic continuous flow enteral fluid therapy in comparison to IV fluid therapy in dehydrated horses.

Long-term administration of intravenous inotropes in advanced heart failure.

BackgroundPatients in heart transplantation (HTx) waiting list for advanced heart failure (HF) are susceptible to acute deterioration refractory to standard HF medical therapies. Limited data are available on long‐term in‐hospital continuous intravenous (IV) inotropic therapy as bridge to definite therapies.Methods and resultsWe reviewed medical records of all heart transplant recipients treated in the pre‐HTx phase with in‐hospital continuous IV inotropes at our institution between 2012 and 2018. We analysed data before the beginning of continuous IV therapy and at the moment of HTx. We report data of 24 patients (mean age of 43.5 ± 15.7 years) treated with IV inotropes as bridge to HTx (median follow‐up of 28 months after HTx). The main length of IV inotropic therapy was 84 ± 66 days (min 22; max 264 days). At the beginning, the most frequently used inotrope was dopamine (median dosage of 3 mcg/kg/min, interquartile range 2.5–3.75), alone (n = 11, 46%) or in combination with other inotropes (n = 13, 54%). In 18 patients, the class of inotropes was changed during the hospitalization. We registered a progressive improvement of perfusion markers and neuro‐hormonal activation.ConclusionIn‐hospital continuous parenteral inotropic therapy may serve as a temporary pharmacological bridge to HTx in patients with advanced HF that are actively listed to HTx with good reply in terms of prognosis and perfusion markers.

Recurrent cervical hemorrhages and thromboses associated to pulmonary thrombembolism in a hereditary thrombophilia with heterozygous mutants of MTHFR and PAI-1. Case Report and Pathophysiology Hypotheses

A 30 years Caucazian nullipara, 1 blighted ovum, former Yasmin user (1 year), without antiphospholipid antibodies, prophylactic cervical cerclage at 19 weeks pregnancy, is readmitted in emergency at 21 weeks gestation for heavy pelvic pains, and abundant vaginal red blood loss, with cerclage suppression. Under tocolysis and vaginal progesterone, she presents 3 new episodes of intense pains and red, pulsatile blood loss from different cervical areas at 24- 36 hours after admittance, with mechanical hemostasis by nylon sutures at cervico- vaginal junction. The 4th episode is followed by severe anemia (Hb= 6.03mg/dL, Ht= 18.32%), haemodinamic instability, coagulation disorders- hematomas, generalized petaechia, and at 24 hours after last vaginal sutures she claims thoracic pains, dyspneea, cianosis. There are not registered fetal distress, placental abnormalities, cervical shortness below 2.5 cm (when cerclage), and maternal heart abnormalities at repeated ultrasound examinations. No thoracic computer tomography because maternal refuse. After a cardiologist consultation it is appreciated a mild/moderate pulmonary thrombembolism, without deep legs venous thrombosis, and it is started continuous intravenous anticoagulant therapy – heparine 25,000UI/day x 6 days, then fraxiparine in increased dosages continued to term, and 6 weeks postpartum. The laboratory test confirms intravascular disseminated coagulation with secondary fibrinolysis, and positivity for heterozygous mutants of MTHFR (methylene tetrahydrofolate reductase deficiency C677T and A1298C), and PAI (plasminogen activator inhibitor)-1 (4G). Cesarean delivery is performed at 37 weeks for fetal distress at labor onset, with extraction of a girl 3340g, Apgar=7/8, premature senescent placenta, thin umbilical cord. No maternal and neonate postpartum complications.

Long term continuous Trastuzumab use for HER2-positive advanced breast cancer

Objectives: Trastuzumab is the standard of care for locally advanced / metastatic her2-positive breast cancer. However, most of these patients will progress within 12 months of trastuzumab therapy. In contrast, there is a paucity of data available on the long-term treatment of patients with Trastuzumab. Our study was conducted to report efficacy and safety data for patients with locally recurrent / metastatic her2-positive breast cancer who received long-term therapy with Trastuzumab (≥5 years).&#x0D; Methods: This study was a prospective single-arm study of continuous Trastuzumab in patients who were histologically her2-positive and radiologically confirmed inoperable locally recurrent or metastatic breast cancer after complete one year of Trastuzumab plus chemotherapy (in hormone negative/hormone resistance) treatment then continuous Trastuzumab alone , or with hormone therapy (in sensitive hormone positive) without progression [complete or partial response or stable disease]. A total of 50 inoperable local recurrent and metastatic breast cancer patients were treated with continuous intravenous Trastuzumab therapy administered according to the standard Trastuzumab every 3-weeks (8 mg/kg loading dose followed by 3-weekly 6 mg/kg maintenance doses starting 3 weeks after the loading dose) schedule, from January 2014 to January 2019 at the Najaf Cancer Clinic (NCC).&#x0D; Results: All 50 patients were evaluated with CR occur only in 20% (10/50) with an OAR of 50% (25/50). The cardiac status of these patients remained stable over time for the majority of patients with no marked changes in LVEF%. No treatment-related death was observed. The median OS and median PFS is 61 months and 20 months, respectively.&#x0D; Conclusion: In her2-positive recurrent and metastatic breast cancer patients, who initially respond to palliative treatment with trastuzumab, continuous trastuzumab can achieve a long-term tumor remission of several years and had significantly improved survival with tolerated and acceptable adverse events.

Safety and Clinical Outcomes of Hospital in the Home.

The aim of the study was to evaluate clinical outcomes and adverse events (AEs) experienced by patients treated within the Hospital in the Home (HITH) service of a major metropolitan hospital in South Australia. A retrospective case note audit of 100 HITH episodes among adults who received continuous intravenous antimicrobial therapy via an elastomeric or electronic infusion device was undertaken. Age- and sex-adjusted binomial logistic regression analyses were undertaken to identify factors associated with major and minor AEs. Of the 100 patients included, 71 were male and the mean (SD) patient age was 62.8 (17.19) years. Elastomeric infusion devices were used for 98 patients. The mean (SD) HITH treatment duration was 20.1 (11.9) days. Overall, 130 AEs were documented for 72 patients (72%), of whom 12 patients experienced a major AE and 68 patients experienced a minor AE. There were 45 occasions among 23 patients where an infusion administered through an elastomeric device did not run to completion. Fifteen patients were readmitted to hospital. Minor AEs were more likely among people with more vascular line days (adjusted odds ratio [aOR] = 1.05; 95% confidence interval (CI) = 1.01-1.10 per day increase) and females (aOR = 4.43; 95% CI = 1.14-17.17). An increased number of vascular line days was associated with an increased likelihood of an incomplete infusion (aOR = 1.05; 95% CI = 1.01-1.09). Hospital readmission was more likely with increasing age (aOR = 1.06; 95% CI = 1.01-1.11 per year increase). Adverse events need to be monitored carefully when HITH treatment is provided for extended periods.