Intravenous Loading Research Articles

Implementation of an intravenous sotalol initiation protocol: Implications for feasibility, safety, and length of stay.

Oral sotalol initiation requires a multiple-day, inpatient admission to monitor for QT prolongation during loading. A 1-day intravenous (IV) sotalol loading protocol was approved by the United States Food and Drug Administration in March 2020, but limited data on clinical use and administration currently exists. This study describes implementation of an IV sotalol protocol within an integrated health system, provides initial efficacy and safety outcomes, and examines length of stay (LOS) compared with oral sotalol initiation. IV sotalol was administered according to a prespecified initiation protocol to adult patients with refractory atrial or ventricular arrhythmias. Baseline characteristics, safety and feasibility outcomes, and LOS were compared with patients receiving oral sotalol over a similar time period. From January 2021 to June 2022, a total of 29 patients (average age 66.0 ± 8.6 years, 27.6% women) underwent IV sotalol load and 20 patients (average age 60.4 ± 13.9 years, 65.0% women) underwent oral sotalol load. The load was successfully completed in 22/29 (75.9%) patients receiving IV sotalol and 20/20 (100%) of patients receiving oral sotalol, although 7/20 of the oral sotalol patients (35.0%) required dose reduction. Adverse events interrupting IV sotalol infusion included bradycardia (seven patients, 24.1%) and QT prolongation (three patients, 10.3%). No patients receiving IV or oral sotalol developed sustained ventricular arrhythmias before discharge. LOS for patients completing IV load was 2.6 days shorter (mean 1.0 vs. 3.6, p < .001) compared with LOS with oral load. IV sotalol loading has a safety profile that is similar to oral sotalol. It significantly shortens hospital LOS, potentially leading to large cost savings.

Considerations for Intravenous Anesthesia Dose in Obese Children: Understanding PKPD.

The intravenous induction or loading dose in children is commonly prescribed per kilogram. That dose recognizes the linear relationship between volume of distribution and total body weight. Total body weight comprises both fat and fat-free mass. Fat mass influences the volume of distribution and the use of total body weight fails to recognize the impact of fat mass on pharmacokinetics in children. Size metrics alternative to total body mass (e.g., fat-free and normal fat mass, ideal body weight and lean body weight) have been proposed to scale pharmacokinetic parameters (clearance, volume of distribution) for size. Clearance is the key parameter used to calculate infusion rates or maintenance dosing at steady state. Dosing schedules recognize the curvilinear relationship, described using allometric theory, between clearance and size. Fat mass also has an indirect influence on clearance through both metabolic and renal function that is independent of its effects due to increased body mass. Fat-free mass, lean body mass and ideal body mass are not drug specific and fail to recognize the variable impact of fat mass contributing to body composition in children, both lean and obese. Normal fat mass, used in conjunction with allometry, may prove a useful size metric but computation by clinicians for the individual child is not facile. Dosing is further complicated by the need for multicompartment models to describe intravenous drug pharmacokinetics and the concentration effect relationship, both beneficial and adverse, is often poorly understood. Obesity is also associated with other morbidity that may also influence pharmacokinetics. Dose is best determined using pharmacokinetic-pharmacodynamic (PKPD) models that account for these varied factors. These models, along with covariates (age, weight, body composition), can be incorporated into programmable target-controlled infusion pumps. The use of target-controlled infusion pumps, assuming practitioners have a sound understanding of the PKPD within programs, provide the best available guide to intravenous dose in obese children.

P667 USTEkinumAb Double intravenous loading induction therapY at week 0,4 in patients with Crohn’s Disease– results from STEADY study

Abstract Background Ustekinumab (UST) is a safe and effective therapy for moderate to severe Crohn’s disease (CD). Standard induction therapy involves a single weight-based intravenous dose followed by a subcutaneous dose at week eight. Accelerated or dose intensified induction regimens have been associated with better clinical outcomes for various biologic therapies, however, these have not been investigated in patients commencing UST. UST re-induction has been shown to be effective in recovering response in patients who have previously lost clinical response. We aim to compare clinical outcomes in a group of CD patients who received standard intravenous induction (SII) of UST compared to double intravenous induction (DII). Methods A retrospective observational cohort study of all patients that commenced UST, aged ≥ 18 from a single tertiary inflammatory bowel disease (IBD) centre. Patients received either standard IV dosing or double IV dosing (IV dose at week 0 and 4) based on the discretion of the treating physician. Data was collected from a prospectively maintained database between the period October 2015 to October 2022. The primary outcome was clinical remission, defined as Harvey Bradshaw Index (HBI) &amp;lt;5 with scores collected at baseline and at week 52. Patients that discontinued therapy due to a lack or loss of response or progressed to require surgery were considered treatment failures. Two sample t-test was used for comparisons between groups for continuous variable and chi-square for categorical variables. Results 47 patients were included of which 38 received SII and 9 had DII. There were no significant differences in baseline HBI or previous biologic exposures between groups (Table 1). All 9 patients that received DII were in clinical remission at week 52 compared to 29 out of the 38 that received SII, however, this was not clinically significant (Figure 1; 100% vs 76%, p=0.10). Of the 9 patients, not in clinical remission in the SII group, 5 were due to treatment failures (3 required surgery, 2 switched medical therapy) with the other 4 remaining on UST till week 52 (1 had a clinical response and 3 had no clinical response). There were no safety concerns (serious infections or malignancy) reported in the DII group. Conclusion ● All Crohn’s patients that commenced double intravenous induction were in clinical remission at week 52. ● A higher proportion of patients that received DII vs SII were in clinical remission at week 52, however this was not statistically significant. Further larger studies and studies with longer duration of follow-up are required to determine a clinical difference. ● Double intravenous induction of UST is a safe and effective option for Crohn’s disease.

Evaluation of Safety and Efficacy of Intravenous Digoxin Loading Doses Based on Ideal Body Weight.

Intravenous digoxin loading dose recommendations differ between clinical guidelines and Food and Drug Administration packaging for acute rate control. The objective of this study was to assess the safety and efficacy of intravenous digoxin loading in patients who received ≤12 µg/kg and >12 µg/kg of digoxin using ideal body weight (IBW). This single center retrospective cohort study with exempt status from the local Institutional Review Board included patients who received intravenous digoxin and had a serum digoxin concentration (SDC) drawn. Digoxin doses >36 hours after the first dose were excluded. Patients who received a total of >12 µg/kg and ≤12 µg/kg IBW were compared. The primary endpoint was frequency of SDCs ≥1.2 ng/mL, which have been shown to be associated with increased mortality. A total of 244 patients were included (144 receiving >12 µg/kg and 100 receiving ≤12 µg/kg). There were significantly more SDC ≥1.2 ng/mL in the >12 µg/kg group than the ≤12 µg/kg group (50.6% vs. 30.0%; adjusted odds ratio, 3.19; 95% confidence interval [CI]: 1.79-5.84), with no difference in rate control failure. Major limitations of the study include retrospective nature and possible selection bias. Compared to patients who received digoxin doses ≤12 µg/kg IBW, patients who received >12 µg/kg IBW had higher rates of SDC ≥1.2 ng/mL. This suggests that appropriate weight-based dosing with 8 to 12 µg/kg IBW has the potential to be a safer approach to digoxin loading, rather than frequently used dosing strategies that result in doses >12 µg/kg.

Effects of levetiracetam treatment on autonomic nervous system functions in pediatric epilepsy patients.

This study investigated the effects of levetiracetam (LEV) treatment on cardiac rhythm and heart rate variability. The study included two groups of patients diagnosed with non-lesional epilepsy who had not yet been treated and who presented to the outpatient pediatric neurology clinic at Van Training and Research Hospital, Van, Turkey, between 2019 and 2020. The heart rate variability (HRV) of 47 patients in the first group, before and at the 3rd month of treatment, and intravenous (IV) LEV loading in 13 patients in the second group was evaluated by Holter electrocardiography (ECG). It was determined that the values of triangular index, standard deviation of the RR intervals over a 24-hour period (SDNN), standard deviation of all 5-minute mean RR intervals (SDANN), mean of standard deviations of all normal RR intervals (SDNNI), the percentage of RR intervals with >50-millisecond variation (PNN50), and the square root of mean squared differences of successive RR intervals (RMSSD). HRV of 47 patients under LEV treatment significantly increased in the 3rd month of treatment compared to baseline (p < 0.05). No difference was found in HRV between the intravenous loading and the control group (p > 0.05). Our study suggests that the sympathovagal balance before treatment in the patient group is in favor of the sympathetic nervous system and that the sympathovagal imbalance improves after treatment. Our results show that LEV monotherapy and loading have no negative effect on HRV and potential cardiac arrhythmia risk in children with epilepsy.

Managing SVT attacks in NICU: A single tertiary center experience

Aim: This study aimed to assess the efficiency of adenosine and amiodarone in ceasing supraventricular tachycardia (SVT) attacks and enduring 1-hour attack-free period in neonates. Materials and Methods: We included all SVT attacks detected in our NICU and recorded adenosine success in enduring 1-hour attack-free period, postnatal day, birth week, and clinical status. All patients underwent vagal maneuvers as the initial intervention; then, they were administered intravenous adenosine via a central line, the dose of which was increased from 0,05 mg/kg/dose up to 0.2 mg/kg/dose if the SVT attack persisted. We included each SVT attack separately. Results: We observed 21 SVT attacks (gestational age 39.8+/-2.3 weeks) in 10 patients. There was a significant correlation between adenosine success and the postnatal day for SVT attacks (Kendall’s tau b: 0.584, p=0.002). Multivariate analysis showed that the most effective confounder for adenosine success was the postnatal day [odds ratio 1.9 (%95 CI: 1.03-3.5) per day]. Intravenous amiodarone loading therapy aborted SVT attack in all adenosine-resistant patients. Conclusion: Amiodarone infusion may be considered earlier in cases where there is a need for repeated adenosine, especially in the early neonatal period.

PS-B02-3: FGF23 EXACERBATES CARDIAC FIBROSIS IN DOCA-SALT HYPERTENSIVE MICE THROUGH LOCALLY ABNORMAL VITAMIN D METABOLISM

Backgrounds: Fibroblast growth factor 23 (FGF23) is associated with cardiovascular disease in patients with chronic kidney disease (CKD), but the mechanisms underlying the effect of FGF23 on cardiac function remain to be investigated. Herein, we studied the effect of continuous intravenous (CIV) FGF23 loading in a deoxycorticosterone acetate (DOCA)-salt mouse model that has mild CKD and hypertension, and heart failure with a preserved ejection fraction (HFpEF). Design and method: Wild type male mice (n = 16) were allocated randomly to four groups: normal control (NC), vehicle-treated DOCA-salt mice (V), FGF23-treated DOCA-salt mice (F), and FGF23 and calcitriol-treated DOCA-salt mice (C). The DOCA-salt mice received agents by CIV for ten days via an infusion mini-pump, uninephrectomized, and cardiac changes were evaluated in these mice. Results: DOCA-salt mice that received FGF23 showed a marked increase in serum FGF23 (249 pg/mL in V, 1416 pg/mL in F, and 1261 pg/mL in C) than NC (51 pg/mL). Echocardiography in these DOCA-salt mice revealed HFpEF. These mice also showed exacerbation of myocardial fibrosis area (7.0% in V, 13.2% in F, and 3.8% in C) concomitant with an inverse and significant correlation with Cyp27b1 expression (r = -0.79, P &lt; 0.01). Calcitriol treatment attenuated the FGF23-induced cardiac fibrosis (F vs. C, P &lt; 0.01) and improved diastolic function (early-to-atrial wave ratio in doppler echocardiography, 0.7 in F vs. 2.0 in C; P &lt; 0.01) via inhibition of transforming growth factor (TGF)-beta signaling. Protein expression levels of TGF-beta was significantly higher in F (1.32-fold to NC; P &lt; 0.01) than in NC, and significantly lower in C (0.96-fold to NC; P &lt; 0.05) than in F. This effect was independent of systemic and local FGF23 levels. Conclusions: These results suggest that CIV FGF23 loading induced cardiac fibrosis concomitantly with locally abnormal vitamin D metabolism, and this might have contributed to HFpEF progression in the DOCA-salt mice model. Thus, cardiac toxicity of FGF23 may be partly due to vitamin D inactivation in cardiac tissue. Calcitriol has cardioprotective effects by mediating TGF-beta signaling, independently of local and systemic FGF23 levels.

Fibroblast Growth Factor 23 Exacerbates Cardiac Fibrosis in Deoxycorticosterone Acetate-Salt Mice With Hypertension

Fibroblast growth factor 23 (FGF23) is associated with cardiovascular disease in patients with chronic kidney disease; however, the mechanisms underlying the effect of FGF23 on cardiac function remain to be investigated. Herein, we studied the effect of continuous intravenous (CIV) FGF23 loading in a deoxycorticosterone acetate (DOCA)-salt mouse model with mild chronic kidney disease and hypertension as well as heart failure with a preserved ejection fraction. Wild-type male mice were randomly allocated to 4 groups: normal control, vehicle-treated DOCA-salt mice, FGF23-treated DOCA-salt mice, and FGF23- and calcitriol-treated DOCA-salt mice. The DOCA-salt mice received the agents via the CIV route for 10 days using an infusion minipump. DOCA-salt mice that received FGF23 showed a marked increase in the serum FGF23 level, and echocardiography in these mice revealed heart failure with a preserved ejection fraction. These mice also showed exacerbation of myocardial fibrosis, concomitant with an inverse and significant correlation with Cyp27b1 expression. Calcitriol treatment attenuated FGF23-induced cardiac fibrosis and improved diastolic function via inhibition of transforming growth factor-β signaling. This effect was independent of the systemic and local levels of FGF23. These results suggest that CIV FGF23 loading exacerbates cardiac fibrosis and that locally abnormal vitamin D metabolism is involved in this mechanism. Calcitriol attenuates this exacerbation by mediating transforming growth factor-β signaling independently of the FGF23 levels.

Transient asystole associated with vasovagal reflex in an oral surgery patient: A case report

The perioperative cardiac events may be brought about by a relative imbalance of autonomic activities due to excessive psychological and physical stress. The present case study focuses on the asystole that can occur as a serious cardiac adverse event associated with vasovagal reflex likely to be triggered by venipuncture for securing an intravenous line during dental care. In addition, we describe and discuss herein the management of intravenous sedation for a dental phobic patient who experienced the vasovagal reflex involved in an unexpected transient asystole. The patient with vasovagal reflex episodes in daily life, who had no past medical history relevant to cardiovascular disorders, was scheduled for dental extraction under intravenous sedation. Immediately after peripheral intravenous catheterization, she complained of discomfort and nausea, and a II-lead electrocardiogram revealed asystole following bradycardia associated with vasovagal reflex. Oxygenation and intravenous fluid loading in the supine position with elevation of the lower extremities restored sinus rhythm and normal hemodynamics without the intervention of cardiopulmonary resuscitation. With administration of intravenous atropine and betamethasone as premedication, she was uneventfully treated in stress-free psychosomatic conditions under optimal sedation with midazolam without any signs of cardiovascular disorders. After administration of flumazenil, the patient satisfactorily recovered from sedation without re-sedation. The present case suggests that an asystole associated with vasovagal reflex can be triggered by venipuncture for intravenous catheterization during dental anxiety likely to affect the imbalance between sympathetic and parasympathetic activities.

Protocol Development and Initial Experience With Intravenous Sotalol Loading for Atrial Arrhythmias.

Oral sotalol is a class III antiarrhythmic commonly used for the maintenance of sinus rhythm in patients with atrial fibrillation (AF). Recently, the Food and Drug Administration (FDA) approved the use of IV sotalol loading, based primarily on modeling data for the infusion. We aimed to describe a protocol and experience with IV sotalol loading for elective treatment of adult patients with AF and atrial flutter (AFL). We present our institutional protocol and retrospective review of initial patients treated with IV sotalol for AF/AFL at the University of Utah Hospital between September 2020 and April 2021. Eleven patients received IV sotalol for initial loading or dose escalation. All patients were male, aged 56-88 years (median 69). Mean QT interval (QTc) intervals increased from baseline (mean 384 ms) immediately after infusion of IV sotalol (mean change 42ms), but no patient required discontinuation of the medication. Six patients were discharged after 1 night; 4 patients were discharged after 2 nights; and 1 patient was discharged after 4 nights. Nine patients underwent electrical cardioversion prior to discharge (2 prior to load; 7 post-load on the day of discharge). There were no adverse events during the infusion or within 6 months of discharge. Persistence of therapy was 73% (8 of 11) at mean 9.9 weeks to follow up, with no discontinuations for adverse effects. We employed a streamlined protocol that was successfully implemented to facilitate the use of IV sotalol loading for atrial arrhythmias. Our initial experience suggests feasibility, safety, and tolerability while reducing hospitalization duration. Additional data are needed to augment this experience as IV sotalol use is broadened across different patient populations.

First survey on the diagnosis and treatment of primary aldosteronism by Spanish Endocrinology and Nutrition specialists

ObjectiveTo evaluate the indication and the resources for the screening/diagnosis of primary aldosteronism (PA) in Endocrinology units in Spain. Material and methodsAn anonymous 2-phase (2020/2021) online survey was conducted by the AdrenoSEEN group among SEEN members with data about screening, confirmation tests, availability of catheterisation and the treatment of PA. ResultsEighty-eight (88) specialists completed the survey. Plasma aldosterone concentration and plasma renin activity were available at all centres; urinary aldosterone was available in 55% of them. The most frequent indications for determining the aldosterone/renin ratio (ARR) were adrenal incidentaloma (82.6%), hypertension with hypokalaemia (82.6%), hypertension in patients <40 years (79.1%) and a family history of PA (77.9%). 61% and 18% of the respondents used an ARR cut-off value of PA of ≥30 and 20ng/dl per ng/mL/, respectively. The intravenous saline loading test was the most commonly used confirmatory test (66.3%), followed by the captopril challenge test (24.4%), with the 25mg dose used more than the 50mg dose (65% versus 35%). 67.4% of the participants confirmed the availability of adrenal vein catheterization (AVC). 41% of this subgroup perform it with a continuous infusion versus 30.5% with an ACTH (1–24) bolus, whereas 70.3% employ sequential adrenal vein catheterization. 48% of the participants reported an AVC success <50%. Total laparoscopic adrenalectomy was the treatment of choice (90.6%), performed by specialists in General and Digestive Surgery specialising in endocrinological pathology. ConclusionPA screening and diagnostic tests are extensively available to Spanish endocrinologists. However, there is a major variability in their use and in the cut-off points of the diagnostic methods. The AVS procedure remains poorly standardised and is far from delivering optimal performance. Greater standardisation in the study and diagnosis of PA is called for.

Abstract 14784: Outcomes Associated With Implementation of an Intravenous Sotalol Initiation Protocol

Introduction: Oral sotalol initiation frequently requires a multi-day hospitalization for electrocardiographic monitoring. A one-day intravenous (IV) sotalol loading protocol was approved by the FDA in March 2020, but limited data on its clinical use currently exists. The aim of this study was to describe the outcomes of implementation of the IV sotalol initiation protocol within an integrated health system. Methods: An IV sotalol loading protocol was started in August 2021 for adult patients who were candidates for oral sotalol and had a creatinine clearance (CrCl) &gt; 30 mL/min. Patients with a heart rate &lt; 60 bpm or QTc &gt; 450 ms (500 ms for those with widened QRS) were excluded. Patients with persistent atrial arrhythmias were cardioverted prior to drug infusion. IV sotalol infusion was administered in the Cardiac Recovery and Observation Unit with one-on-one nursing and was stopped for a heart rate &lt; 50 bpm or QTc &gt; 500 ms (550 ms for those with widened QRS). Patients were admitted for monitoring post-infusion and received two oral sotalol doses prior to discharge. Serial EKGs were performed according to protocol. Expected length of stay (LOS) with oral initiation was calculated for the same patients using CrCl. Results: A total of 27 patients (average age 66 years, 26% women) underwent IV sotalol initiation. Average LVEF was 52% and average CrCl was 91.4 ± 24.8 mL/min. Primary indication was atrial arrhythmia for 74% and ventricular arrhythmia for 26%. Sotalol loading was successfully completed in 21 (78%) patients. Adverse events interrupting sotalol load included bradycardia (5 patients, 19%) and QT prolongation (2 patients, 7%). No patients developed sustained ventricular arrhythmias. LOS for patients completing IV load was 2.3 days shorter (mean 1.0 vs 3.3, p&lt;0.001) compared to expected LOS with oral load. Conclusions: A one-day IV sotalol loading protocol is a safe alternative to a multi-day oral sotalol initiation protocol and significantly shortens hospital LOS, potentially leading to significant cost savings.

The Calcium Loading Test in Primary Hyperparathyroidism – Does it Provide Useful Information?

Abstract Objective: to describe the results from intravenous calcium loads in patients with suspected PHPT. Methods: This was a retrospective cross-sectional study with inpatients’ data review. Baseline serum calcium, phosphates, magnesium, creatinine, alkaline phosphatase, beta-crosslinks were recorded. The calcium loading had been performed after an overnight fasting. Calcium gluconate 0.25 mmol/kg body weight (10 mg/kg) dissolved in 0.9% Sodium Chloride was infused intravenously for 3 hours. Blood samples for total serum calcium, phosphates and iPTH were drawn before and up to 60 minutes after the calcium load. The intact parathyroid hormone (iPTH) and 25(OH)-vitamin D were determined by electro-hemi-luminescence (Elecsys, Roche Diagnostics). The PTH inhibition rate in % (PTH-IR), the calcium increment, the ratio R (ΔPTH/ΔCalcium) and the product P (calcium X PTH at test end) were calculated. Results: 23 patients with PHPT had complete data from calcium loading tests. The PTH suppression was &lt; 30% in 17.4% of the participants, 30% to 50% – in 21.7% and &gt; 50% in the remaining 60.9%. One patient displayed PTH suppression &gt; 75%. The Ratio R was &lt; 4.0 in all but one patient. Product P was above 1100 mg/dl x pg/ml in 9 participants (39.1%). Sixteen patients (69.6%) had positive localization results from US or SPECT-CT. The level of PTH suppression was not related to any parameter except the volume of the suspected lesion. Conclusion: The calcium loading test was unable to differentiate the forms of PHPT. It did not add great value in the diagnostic work-up of PHPT.

Evaluation of Cardiovascular Concerns of Intravenous Lacosamide Therapy in Epilepsy Patients.

ObjectiveVoltage-gated sodium channels (VGSCs) play an important role in neuronal excitability and epilepsies. In addition to the brain, VGSCs are also abundant enriched in cardiac tissues and are responsible for normal cardiac rhythm. Theoretically, sodium channel blocking antiseizure medications (SCB-ASMs) may have unwanted cardiac side effects. Lacosamide (LCM) is increasingly used in patients with status epilepticus (SE) due to the availability of intravenous formula. The concerns about the proarrhythmic effect are even higher due to the need for rapid administration of LCM. There were limited data on the cardiac safety of intravenous LCM. Hereby, we performed a study to observe the effect of intravenous loading of LCM in patients with seizures in our Neurological Intensive Care Unit (NICU).MethodsWe retrospectively reviewed the patients using parenteral LCM for seizures in NICU. A routine infusion time of 30 min was performed. The electrocardiogram (ECG) and blood pressure were recorded before and after LCM injection.ResultsWe retrospectively reviewed the clinical data of 38 patients using LCM for treating seizures. Two patients had cardiac side effects after LCM loading, one (3.0%) with new-onset first-degree AV block and the other (3.0%) with atrial premature complex. For the quantitative changes of ECG parameter analysis, there was no change in QRS complex, corrected QT intervals, and heart rate except that the PR interval was mildly increased. A mild decrease in the diastolic blood pressure and mean arterial pressure were also observed. None of the above-mentioned parameter alterations required clinical intervention.ConclusionWe evaluated the cardiac safety concern in real-world epilepsy patients requiring intravenous LCM. Near half of this cohort responded to LCM therapy and there was no life-threatening cardiac adverse effect. Intravenous LCM does have some effects on the ECG parameters and blood pressure but without clinical relevance. Despite the theoretical concern of cardiac adverse effects of LCM, the benefit of seizure control outweighed the risk in patients with status epilepticus or seizure clusters, such as hyperthermia, pulmonary edema, cardiac arrhythmias, or cardiovascular collapse.

Primera encuesta sobre el diagnóstico y tratamiento del hiperaldosteronismo primario por especialistas españoles en Endocrinología y Nutrición

ObjectiveTo evaluate the indication and the resources for the screening/diagnosis of primary aldosteronism (PA) in Endocrinology units in Spain. Materials and methodsAn anonymous 2-phase (2020/2021) online survey was conducted by the AdrenoSEEN group among SEEN members with data about screening, confirmation tests, availability of catheterisation and the treatment of PA. ResultsEighty-eight (88) specialists completed the survey. Plasma aldosterone concentration and plasma renin activity were available at all centres; urinary aldosterone was available in 55% of them. The most frequent indications for determining the aldosterone/renin ratio (ARR) were adrenal incidentaloma (82.6%), hypertension with hypokalaemia (82.6%), hypertension in patients <40 years (79.1%) and a family history of PA (77.9%). 61% and 18% of the respondents used an ARR cut-off value of PA of ≥30 and 20ng/dL per ng/mL/, respectively. The intravenous saline loading test was the most commonly used confirmatory test (66.3%), followed by the captopril challenge test (24.4%), with the 25mg dose used more than the 50mg dose (65% versus 35%). 67.4% of the participants confirmed the availability of adrenal vein catheterization (AVC). 41% of this subgroup perform it with a continuous infusion versus 30.5% with an ACTH (1-24) bolo, whereas 70.3% employ sequential adrenal vein catheterization. 48% of the participants reported an AVC success <50%. Total laparoscopic adrenalectomy was the treatment of choice (90.6%), performed by specialists in General and Digestive Surgery specialising in endocrinological pathology. ConclusionPA screening and diagnostic tests are extensively available to Spanish endocrinologists. However, there is a major variability in their use and in the cut-off points of the diagnostic methods. The AVS procedure remains poorly standardized and is far from delivering optimal performance. Greater standardisation in the study and diagnosis of PA is called for.

Strengths, weaknesses, opportunities, and threat analysis of dual-energy CT in head and neck imaging

Technological development of dual-energy computed tomography (DECT) can play an important role in head and neck area. Multiple innovative applications have evolved, optimizing images, achieving metallic artifact reduction, differentiating materials with better primary tumor delineation, thyroid cartilage and bone invasion. Furthermore, quantification algorithms allow measuring iodine concentration, reflecting the blood supply of a lesion indirectly.DECT enables acquiring images with lower radiation doses and iodine intravenous contrast load to obtain the same CT values.. However, DECT uses ionizing radiation, which does not occur with MRI, and requires long post-processing times. Artifacts on iodine maps may be a potential source of pseudolesions. Besides, photon-counting CT scanners are a promising technique that may displace some DECT advantages.A review analyzing the current status of DECT applied to head and neck imaging from the scope of strengths, weaknesses, opportunities, and threatsanalysis would be very interesting to facilitate a realistic, fact-based, data-driven look of this technique.

Análisis de las fortalezas, oportunidades, debilidades y amenazas de la tomografía computarizada de doble energía en el diagnóstico por la imagen de la cabeza y el cuello

Technological development of dual-energy computed tomography (DECT) can play an important role in head and neck area. Multiple innovative applications have evolved, optimizing images, achieving metallic artifact reduction, differentiating materials with better primary tumor delineation, thyroid cartilage and bone invasion. Furthermore, quantification algorithms allow measuring iodine concentration, reflecting the blood supply of a lesion indirectly.DECT enables acquiring images with lower radiation doses and iodine intravenous contrast load to obtain the same CT values. However, DECT uses ionizing radiation, which does not occur with MRI, and requires long post-processing times. Artifacts on iodine maps may be a potential source of pseudolesions. Besides, photon-counting CT scanners are a promising technique that may displace some DECT advantages.A review analyzing the current status of DECT applied to head and neck imaging from the scope of strengths, weaknesses, opportunities, and threatsanalysis would be very interesting to facilitate a realistic, fact-based, data-driven look of this technique.

Valproate in status epilepticus: Correlation between loading dose, serum levels, and clinical response.

Background and purposeIntravenous valproate (VPA) is an established treatment of status epilepticus (SE), but optimal loading dose was not fully assessed. We aimed at analyzing the correlation between VPA loading dose and subsequent plasma levels with clinical response in SE.MethodsThis was a retrospective study in one referral center of all consecutive VPA‐naïve SE episodes treated with VPA between January 2013 and June 2019, in which total VPA trough plasma levels after intravenous loading dose were available. Response to VPA, defined as last antiseizure medication introduced before SE resolution (without the need for additional treatment), was correlated with VPA loading dose and trough level. Correlations were adjusted for other SE characteristics.ResultsAmong 128 SE episodes, 53 (41%) responded to VPA. Median VPA loading dose was 25.2 mg/kg (range, 7–58 mg/kg). Loading doses and total plasma levels were not associated with the probability of response or mortality. Correcting for other possible confounders (number of previously tried treatment, demographics, SE severity) did not alter these findings. Only 3.8% of SE episodes that responded to VPA received >30 mg/kg.ConclusionsA high loading dose (>30 mg/kg) is not associated with a greater response rate in patients with SE. Therefore, it seems to bring little benefit. If confirmed in further studies, a dosage of 25–30 mg/kg appears adequate in SE.

Effect of initial serum chloride level on the association between intravenous chloride load and mortality in critically ill patients: A retrospective cohort study.

To assess the effect of intravenous chloride load on prognosis in intensive care unit (ICU) patients with different initial serum chloride levels. Participants from the Medical Information Mart for Intensive Care IV database were divided into low, normal (>100 and ≤110 mEq/L), and high chloride groups according to initial chloride levels. Records of intravenous fluids were extracted to calculated the volume adjusted chloride load (VACL) and VACL per body weight (VACL-W). The associations of VACL, VACL-W, and changes in serum chloride concentration (ΔCl) with mortalities were investigated in different initial chloride groups. Respectively, 4593 (20.9%), 13,364 (60.9%), and 3978 (18.1%) patients had a low, normal, and high initial chloride level. Interactions were found between initial chloride levels and VACL, VACL-W, and ΔCl on mortality risks. In normal and high chloride groups, increased VACL, VACL-W, and ΔCl were associated with higher ICU and hospital mortalities. However, in the low chloride group, multivariable models found no associations between VACL, VACL-W, or ΔCl with mortalities. High chloride load and increased serum chloride level were associated with poor outcomes in patients with normal or high initial chloride levels, but not in those with a low initial chloride level.

Methylene blue versus vasopressin analog for refractory septic shock in the preterm neonate: A randomized controlled trial.

Refractory septic shock in neonates is still associated with high mortality, necessitating an alternative therapy, despite all currently available treatments. This study aims to assess the vasopressor effect of methylene blue (MB) in comparison to terlipressin (TP) as adjuvant therapy for refractory septic shock in the preterm neonate. A double-blinded randomized controlled trial was conducted in the Neonatal Intensive Care Units at Ain Shams University, Egypt. Thirty preterm neonates with refractory septic shock were randomized to receive either MB or TP as an adjuvant to conventional therapy. Both MB and TP were administered as an intravenous loading dose followed by continuous intravenous infusion. The hemodynamic variables, functional echocardiographic variables, and oxidant stress marker were assessed over a 24 h period together with the side effects of MB. MB causes significant improvement in mean arterial blood pressure with a significant decrease of the norepinephrine requirements (1.15±0.21μm/kg/min at baseline vs. 0.55±0.15μm/kg/min at 24 h). MB infusion causes an increase of the pulmonary pressure (44.73±8.53 mmHg at baseline vs. 47.27±7.91 mmHg after 24 h) without affecting the cardiac output. Serum malonaldehyde decreased from 5.45±1.30 nmol/mL at baseline to 4.40±0.90 nmol/mL at 24 h in the MB group. Administration of MB to preterm infants with refractory septic shock showed rapid increases in systemic vascular resistance and arterial blood pressure with minimal side effects.