Persistent Congestion Research Articles

Optimizing Hypertensive Acute Heart Failure Management with Afterload Reduction.

In spite of advances in our understanding of acute heart failure (AHF) and its different phenotypic expressions, AHF management is still centered on volume removal with intravenous diuretics. This narrative review describes the pathophysiology underlying hypertensive AHF and appraises therapies targeting these mechanisms. Vascular redistribution rather than volume overload may be the primary determinant of elevated cardiac filling pressures and subsequent pulmonary congestion in patients with hypertensive AHF; in these patients, vasodilators should be the predominant treatment. Additional therapy with diuretics in hypertensive AHF should be relegated to the treatment of overt volume overload or persistent congestion in spite of optimized hemodynamics. Intravenous nitroglycerin at high doses can rapidly achieve pulmonary decongestion and reduce downstream critical care needs in these patients. The therapeutic role for synthetic peptides with vasodilator properties has yet to be defined. Evidence supporting both old and new vasodilator therapies is limited by a paucity of well-designed studies and failure to demonstrate improvement in long-term outcomes. Targeted study of this phenotype of AHF is needed before vasodilator therapies become incorporated into treatment guidelines.

Policy Implications of Third-Party Measurement of Interdomain Congestion on the Internet

Internet engineering, science, and public policy communities have significant interest in understanding the extent and scope of, as well as potential consumer harm induced by, persistent interdomain congestion on the Internet. In recent work, we developed and implemented a lightweight active measurement method and system to measure evidence of congestion on thousands of interconnection links between broadband access ISPs and major interconnecting parties, including directly connected content providers. This method provides empirical grounding for discussions of interconnection congestion, without requiring direct access to interconnection links. We first review the previous work to provide context. We then present new techniques for visualizing the data in ways we believe are conducive to policy analysis, e.g, of infrastructure resilience, performance metrics, and potential harm to consumers of persistently under-provisioned interconnection links. We presenting data in ways that allow us to compare different access providers, and show how congestion varies over time. We focus on seven large U.S. broadband access networks, but there is nothing U.S.-specific about the methods we use. Finally, we describe policy-relevant limitations and implications of the work.

Optimising Heart Failure Therapies in the Acute Setting.

Acute heart failure (AHF) is a life-threatening condition requiring immediate treatment. The initial therapy should take into account the clinical presentation, pathophysiology at play, precipitating factors and underlying cardiac pathology. Particular attention should be given to polymorbidity and the avoidance of potential iatrogenic harm. Patient preferences and ethical issues should be integrated into the treatment plan at an early stage. The average survival of AHF patients is 2 years and the most vulnerable period is the 3-month time window directly after discharge. Reducing both persistent subclinical congestion and underutilisation of disease-modifying heart failure therapies as well as ensuring optimal transitions of care after hospital discharge are essential in improving outcomes for AHF patients.

175 - Readiness for Discharge of Heart Failure Patients Based on ReDS Lung Fluid Measurement

Background: Accurate assessment of volume status is a key factor in the management of patients with heart failure (HF). Inadequate inpatient decongestion is considered to be a contributing factor in HF readmissions. The ReDS system is an FDA-approved vest that can rapidly and non-invasively measure lung fluid. Methods: The ReDS Discharge trial is a single-center randomized trial designed to investigate the efficacy and safety of using the ReDS system to guide the timing of HF discharge. The primary outcome of the study is to determine the percentage of HF patients deemed ready for discharge who have persistent lung congestion (ReDS ≥ 39%, normal 25–35%). Important secondary endpoints include length of stay, volume of additional diuresis, change in renal function, and readmission rates.To date, 100/120 patients have been enrolled. All trial patients underwent a ReDS assessment on the day the primary team deemed them ready for discharge. Readings for patients in the intervention arm were provided to the care team. Patients with readings ≥ 39% were considered to be inadequately decongested and, per protocol, required a HF Team consultation to direct care prior to discharge. Readings for patients in the usual care arm were blinded and once these readings were obtained the patients were discharged home. Results:Tabled 1% patients in intervention arm with ReDS ≥ 39%32% (15/47)Mean wt loss from initial ReDS reading to actual d/c3 kgMean added LOS in intervention arm2.3d% patients with rise SCr > 0.5 g/dl after additional diuresis7.2% (1/14)30 & 90 day readmission rates intervention vs controlpending Open table in a new tab Conclusion: A non-invasive lung fluid measurement performed at the time of proposed HF discharge led to improved decongestion in over 30% of hospitalized HF patients without adversely affecting renal function. The effect on HF readmission rates will be reported at the completion of the study.

Efficacy and Safety of Spironolactone in Acute Heart Failure

Persistent congestion is associated with worse outcomes in acute heart failure (AHF). Mineralocorticoid receptor antagonists administered at high doses may relieve congestion, overcome diuretic resistance, and mitigate the effects of adverse neurohormonal activation in AHF. To assess the effect of high-dose spironolactone and usual care on N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels compared with usual care alone. This double-blind and placebo (or low-dose)-controlled randomized clinical trial was conducted in 22 US acute care hospitals among patients with AHF who were previously receiving no or low-dose (12.5 mg or 25 mg daily) spironolactone and had NT-proBNP levels of 1000 pg/mL or more or B-type natriuretic peptide levels of 250 pg/mL or more, regardless of ejection fraction. High-dose spironolactone (100 mg) vs placebo or 25 mg spironolactone (usual care) daily for 96 hours. The primary end point was the change in NT-proBNP levels from baseline to 96 hours. Secondary end points included the clinical congestion score, dyspnea assessment, net urine output, and net weight change. Safety end points included hyperkalemia and changes in renal function. A total of 360 patients were randomized, of whom the median age was 65 years, 129 (36%) were women, 200 (55.5%) were white, 151 (42%) were black, 8 (2%) were Hispanic or Latino, 9 (2.5%) were of other race/ethnicity, and the median left ventricular ejection fraction was 34%. Baseline median (interquartile range) NT-proBNP levels were 4601 (2697-9596) pg/mL among the group treated with high-dose spironolactone and 3753 (1968-7633) pg/mL among the group who received usual care. There was no significant difference in the log NT-proBNP reduction between the 2 groups (-0.55 [95% CI, -0.92 to -0.18] with high-dose spironolactone and -0.49 [95% CI, -0.98 to -0.14] with usual care, P = .57). None of the secondary end point or day-30 all-cause mortality or heart failure hospitalization rate differed between the 2 groups. The changes in serum potassium and estimated glomerular filtration rate at 24, 48, 72, and 96 hours. were similar between the 2 groups. Adding treatment with high-dose spironolactone to usual care for patients with AHF for 96 hours was well tolerated but did not improve the primary or secondary efficacy end points. clinicaltrials.gov Identifier: NCT02235077.

Oxidative stress and respiratory symptoms due to human exposure to polycyclic aromatic hydrocarbons (PAHs) in Kumasi, Ghana

Studies of polycyclic aromatic hydrocarbons (PAHs) and its metabolites in PM10, soils, rat livers and cattle urine in Kumasi, Ghana, revealed high concentrations and cancer potency. In addition, WHO and IARC have reported an increase in cancer incidence and respiratory diseases in Ghana. Human urine were therefore collected from urban and control sites to: assess the health effects associated with PAHs exposure using malondialdehyde (MDA) and 8-hydroxy-2-deoxyguanosine (8-OHdG); identify any association between OH-PAHs, MDA, 8-OHdG with age and sex; and determine the relationship between PAHs exposure and occurrence of respiratory diseases. From the results, urinary concentrations of the sum of OH-PAHs (∑OHPAHs) were significantly higher from urban sites compared to the control site. Geometric mean concentrations adjusted by specific gravity, GMSG, indicated 2-OHNaphthalene (2-OHNap) (6.01 ± 4.21 ng/mL) as the most abundant OH-PAH, and exposure could be through the use of naphthalene-containing-mothballs in drinking water purification, insect repellent, freshener in clothes and/or “treatment of various ailments”. The study revealed that exposure to naphthalene significantly increases the occurrence of persistent cough (OR = 2.68, CI: 1.43–5.05), persistent headache (OR = 1.82, CI: 1.02–3.26), tachycardia (OR = 3.36, CI: 1.39–8.10) and dyspnea (OR = 3.07, CI: 1.27–7.43) in Kumasi residents. Highest level of urinary 2-OHNap (224 ng/mL) was detected in a female, who reported symptoms of persistent cough, headache, tachycardia, nasal congestion and inflammation, all of which are symptoms of naphthalene exposure according to USEPA. The ∑OHPAHs, 2-OHNap, 2-3-OHFluorenes, and -OHPhenanthrenes showed a significantly positive correlation with MDA and 4-OHPhenanthrene with 8-OHdG, indicating possible lipid peroxidation/cell damage or degenerative disease in some participants. MDA and 8-OHdG were highest in age group 21–60. The present study showed a significant sex difference with higher levels of urinary OH-PAHs in females than males.

Willingness to pay to improve air quality: A study of private vehicle owners in Klang Valley, Malaysia

The growing number of private passenger vehicles in the Klang region of Malaysia has not only resulted in persistent traffic congestion during peak hours, but also resulted in considerable vehicular emissions causing both environmental and human health hazards. To reduce these externalities, this study examines the prospect for a transport modal shift from the use of private vehicles to the public transport system. Contingent valuation method was used to estimate how much current private passenger vehicle users are willing to pay to continue using their private vehicles. On average, private passenger vehicle users were found to be willing to pay a maximum amount of RM 4.99 (USD 1.55) per trip to avoid using the public transport system. Respondents with previous health issues were found more likely to shift to the public transportation system. Public transportation efficiency was found to have a significant impact on the respondents WTP value to maintain the current commuting system.

Case 1: Prolonged Nasal Discharge and Facial Pain in a 17-year-old Girl

1. Elizabeth Ninan, MD* 2. Stefan Hagmann, MD, MSc* 1. *Albert Einstein College of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY. A 17-year-old girl who has a history of asthma and chronic allergic rhinitis presents with a 12-month history of persistent nasal congestion, rhinorrhea, facial pain, and headache. The diagnosis of asthma had been established at age 8 years and chronic allergic rhinitis at age 12 years. Her routine home medications include albuterol, nasal corticosteroids, antihistamines, and topical nasal decongestants. Her symptoms worsened over the last several months, and an 8-week course of oral antibiotics followed by oral corticosteroids for 2 weeks did not lead to notable symptomatic relief. At initial presentation, she is afebrile (36.9°C [98.5°F]), with a heart rate of 96 beats per minute, respiratory rate of 18 breaths per minute, blood pressure of 96/62 mm Hg, and oxygen saturations of 99% in room air. On physical examination she is a BMI of 24.5 and appears uncomfortable. Head and neck examination reveals a nasal crease, allergic “shiners,” bilateral nasal polyps, and frontal and maxillary sinus tenderness. On auscultation, clear breath sounds without any added sounds are audible over both lungs. Findings of the remainder of the physical examination are unremarkable. Laboratory studies reveal a white blood cell count of 6,200/μL (6.2 × 109/L), with 8.4% eosinophils on the differential cell count. Computed tomography (CT) scan of …

Non invasive adjustment of fluid status in critically ill patients on renal replacement therapy. Role of Electrical Cardiometry

Background: Electrical Cardiometry allows measurement of fluid status using thoracic fluid content (TFC), cardiac output, cardiac index, systemic vascular resistance index which could be ideal noninvasive hemodynamic monitoring for patients undergoing hemodialysis (HD). Objectives: Investigating the relation between changes in TFC and amount of fluid removal during HD session and to monitor hemodynamic parameters to avoid episodes of hemodynamic compromise during HD session. Methods: Thirty critically ill patients on HD were enrolled. Clinical assessment of volume overload and hemodynamics (BP, MAP, CVP), monitored by Electrical Cardiometry ICON® before HD and all through sessions. Results: Out of studied patients males represented 46.7% (n=14) with mean age 48±16years. There was positive correlation between UF volume and TFC (r=0.410, P=0.025). Out of the 30pts studied 18pts (60%) were hemodynamically stable vs 12pts (40%) that had hypotension represented by non responders group and had lower TFC compared to the hemodynamically stable group (26.45kohm−1 vs 37.8kohm−1) with P value of 0.004 indicating that they were hypovolemic. Out of the 30pts studied 18pts (60%) weren’t congested vs 12pts (40%) remained persistently congested after accomplishing HD session with significantly higher TFC when compared to those who got rid of congestion (43.14±9.9kohm−1 vs 25.44±5.5kohm−1) with P value of 0.0001 indicating that they were still hypervolemic. Using analysis of ROC curve TFC at 25.34kohm−1 was a significant predictor of hypotension with P value of 0.002, AUC 83.4%, sensitivity 67% and specificity 100%. Also TFC cutoff value predicting persistent congestion was 37.02kohm−1 with P value of 0.0001, AUC 95.8%, sensitivity 83% and specificity 100%. Conclusion: Electrical Cardiometry is an evolving noninvasive tool for adjusting fluid status of critically ill patient on RRT using thoracic fluid content as an indicator of fluid status that could be used to avoid hemodynamic instability and persistent volume overload and congestion during and after HD session.

Use of the retrograde limb of the internal mammary vein to avoid venous congestion in DIEP flap breast reconstruction: Further evidences of a reliable and time-sparing procedure.

Venous congestion is a common cause of DIEP flap failure. When identified intraoperatively, an additional venous anastomosis can improve the venous outflow and prevent flap failure. The aim of this study was to assess if the retrograde limb of the internal mammary vein (IMV) could be considered a good recipient vessel to be used when persistent flap congestion is present, and a second venous anastomosis is required. A retrospective study was conducted in 74 patients who had undergone DIEP flap breast reconstruction. Patients were classified into two groups: SVA (single venous anastomosis) and DVA (dual venous anastomosis). In the SVA group (n = 38), the IMV antegrade limb was used for venous drainage. A single DIEV (Deep Inferior Epigastric Vein) was anastomosed to the superior arm of the IMV. In the DVA group (n = 36), both the antegrade (superior) and retrograde (inferior) stumps of the IMV were used, connecting the larger DIEV to the antegrade IMV and the other DIEV or the SIEV (Superficial Inferior Epigastric Vein) to the IMV retrograde limb. No venous congestion or flap loss was observed when two venous anastomoses were performed using both the IMV antegrade and retrograde limbs (P = 0.3271). In the DVA group, no major complication occurred (P = 0.0453). Operative explorations were significantly reduced in the DVA group (P = 0.0242). These findings suggest that when an additional venous outflow is required, the use of the IMV retrograde limb may help to avoid flap venous congestion. © 2016 Wiley Periodicals, Inc. Microsurgery 36:447-452, 2016.

Discordance Between Hemoconcentration and Clinical Assessment of Decongestion in Acute Heart Failure

IntroductionHemoconcentration has been proposed as a surrogate for successful decongestion in acute heart failure (AHF). The aim of the present study was to evaluate the relationship between hemoconcentration and clinical measures of congestion. Methods and ResultsWe studied 704 patients with AHF and volume overload. A composite congestion score was calculated at admission and discharge, with a score >1 denoting persistent congestion. Hemoconcentration was defined as any increase in hematocrit and hemoglobin levels between baseline and discharge. Of 276 patient with hemoconcentration, 66 (23.9%) had persistent congestion. Conversely, of 428 patients without hemoconcentration, 304 (71.0%) had no clinical evidence of congestion. Mean hematocrit changes were similar with and without persistent congestion (0.18 ± 3.4% and −0.19 ± 3.6%, respectively; P = .17). There was no correlation between the decline in congestion score and the change in hematocrit (P = .93). Hemoconcentration predicted lower mortality (hazard ratio 0.70, 95% confidence interval 0.54–0.90; P = .006). Persistent congestion was associated with increased mortality independent of hemoconcentration (Ptrend = .0003 for increasing levels of congestion score). ConclusionsHemoconcentration is weakly related to congestion as assessed clinically. Persistent congestion at discharge is associated with increased mortality regardless of hemoconcentration. Hemoconcentration is associated with better outcome but cannot substitute for clinically derived estimates of congestion to determine whether decongestion has been achieved.

Chronic nasal dysfunction in children: Allergic rhinitis? Infectious? What to do if neither?

To review challenges in the diagnosis, work-up, and management of healthy children who present to the otolaryngologist with nasal dysfunction. Common symptoms include chronic nasal congestion, with or without rhinorrhea, with or without previous empirically treated 'allergic rhinitis' and/or 'sinus' infection. Symptoms are often unresolved despite chronic use of intranasal steroid, antihistamine, and/or leukotriene receptor antagonists. There are no published studies addressing nasal symptoms in children who test negative for allergies yet report persistent nasal obstruction, congestion, and/or rhinorrhea. Recent publications continue to address efficacy of medical and/or surgical treatment for allergic rhinitis or acute/chronic rhinosinusitis. Best practice for children who 'fail' medical therapy but have impaired quality of life because of nasal dysfunction remains unknown. Chronic nasal symptoms are common in childhood despite daily treatment using intranasal steroid, antihistamines, and/or leukotriene receptor antagonist therapies. Diet and dietary habit history should be included during evaluation and differential diagnosis as excessive dairy and sugar may contribute to chronic symptoms. Children who fail medical therapy for persistent nasal symptoms, allergic or not, should be referred and considered for outfracture of inferior turbinates and inferior turbinoplasty. Turbinate reduction procedures have demonstrated significant improvement in all domains of SinoNasal Quality of Life as measured by 'SN-5' survey.

Current Approach to Decongestive Therapy in Acute Heart Failure.

Congestion, defined by elevated cardiac filling pressures, is the major driver of hospitalization in acute decompensated heart failure. Careful clinical assessment should allow to determine whether volume overload or volume misdistribution is the predominating mechanism of congestion. Differentiation is imperative because therapy differs. If volume overloads prevails, loop diuretics are considered the mainstay therapy. However, early use of combinational therapy with diuretics acting more proximal or distal in the nephron could allow for a more profound natriuresis and diuresis. A stepped guided pharmacological treatment should focus on achieving complete decongestion, because persistent congestion is a major driver of readmission. If diuretic strategies remain unsuccessful, ultrafiltration should be considered. Ultrafiltration should be used with caution in the setting of worsening of renal function. When volume misdistribution and impaired venous capacitance predominate the picture of congestion, unloading-more than diuretics-with arteriolar and venous vasodilators might mitigate the clinical picture of congestion. This review offers a thorough overview and practical insight in the use of current and potential decongestive therapies.

Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study.

BackgroundB-lines evaluated by lung ultrasound (LUS) are the sonographic sign of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure (HF). Our aim was to assess the prognostic value of B-lines at discharge to predict rehospitalization at 6 months in patients with acute HF (AHF).MethodsA prospective cohort of 100 patients admitted to a Cardiology Department for dyspnea and/or clinical suspicion of AHF were enrolled (mean age 70 ± 11 years). B-lines were evaluated at admission and before discharge. Subjects were followed-up for 6-months after discharge.ResultsMean B-lines at admission was 48 ± 48 with a statistically significant reduction before discharge (20 ± 23, p < .0001). During follow-up, 14 patients were rehospitalized for decompensated HF. The 6-month event-free survival was highest in patients with less B-lines (≤ 15) and lowest in patients with more B-lines (> 15) (log rank χ2 20.5, p < .0001). On multivariable analysis, B-lines > 15 before discharge (hazard ratio [HR] 11.74; 95 % confidence interval [CI] 1.30–106.16) was an independent predictor of events at 6 months.ConclusionsPersistent pulmonary congestion before discharge evaluated by ultrasound strongly predicts rehospitalization for HF at 6-months. Absence or a mild degree of B-lines identify a subgroup at extremely low risk to be readmitted for HF decompensation.

Tolvaptan in Patients Hospitalized With Acute Heart Failure: Rationale and Design of the TACTICS and the SECRET of CHF Trials.

Congestion is a primary reason for hospitalization in patients with acute heart failure (AHF). Despite inpatient diuretics and vasodilators targeting decongestion, persistent congestion is present in many AHF patients at discharge and more severe congestion is associated with increased morbidity and mortality. Moreover, hospitalized AHF patients may have renal insufficiency, hyponatremia, or an inadequate response to traditional diuretic therapy despite dose escalation. Current alternative treatment strategies to relieve congestion, such as ultrafiltration, may also result in renal dysfunction to a greater extent than medical therapy in certain AHF populations. Truly novel approaches to volume management would be advantageous to improve dyspnea and clinical outcomes while minimizing the risks of worsening renal function and electrolyte abnormalities. One effective new strategy may be utilization of aquaretic vasopressin antagonists. A member of this class, the oral vasopressin-2 receptor antagonist tolvaptan, provides benefits related to decongestion and symptom relief in AHF patients. Tolvaptan may allow for less intensification of loop diuretic therapy and a lower incidence of worsening renal function during decongestion. In this article, we summarize evidence for decongestion benefits with tolvaptan in AHF and describe the design of the Targeting Acute Congestion With Tolvaptan in Congestive Heart Failure Study (TACTICS) and Study to Evaluate Challenging Responses to Therapy in Congestive Heart Failure (SECRET of CHF) trials.

Interaction Between Worsening Renal Function and Persistent Congestion in Acute Decompensated Heart Failure

Worsening renal function (WRF) and congestion are inextricably related pathophysiologically, suggesting that WRF occurring in conjunction with persistent congestion would be associated with worse clinical outcome. We studied the interdependence between WRF and persistent congestion in 762 patients with acute decompensated heart failure (HF). WRF was defined as ≥0.3 mg/dl increase in serum creatinine above baseline at any time during hospitalization and persistent congestion as ≥1 sign of congestion at discharge. The primary end point was all-cause mortality with mean follow-up of 15 ± 9 months. Readmission for HF was a secondary end point. Persistent congestion was more common in patients with WRF than in patients with stable renal function (51.0% vs 26.6%, p <0.0001). Both persistent congestion and persistent WRF were significantly associated with mortality (both p <0.0001). There was a strong interaction (p = 0.003) between persistent WRF and congestion, such that the increased risk for mortality occurred predominantly with both WRF and persistent congestion. The adjusted hazard ratio for mortality in patients with persistent congestion as compared with those without was 4.16 (95% confidence interval [CI] 2.20 to 7.86) in patients with WRF and 1.50 (95% CI 1.16 to 1.93) in patients without WRF. In conclusion, persisted congestion is frequently associated with WRF. We have identified a substantial interaction between persistent congestion and WRF such that congestion portends increased mortality particularly when associated with WRF.

Inferior Vena Cava and Hemodynamic Congestion.

Background:Among the indices able to replace invasive central venous pressure (CVP) measurement for patients with acute decompensated heart failure (ADHF) the diameters of the inferior vena cava (IVC) and their respiratory fluctuations, so-called IVC collapsibility index (IVCCI), measured by echocardiography, have recently gained ground as a quite reliable proxy of CVP.Objectives:The aims of our study were to compare three different ways of evaluating cardiac overload by using the IVC diameters and/or respiratory fluctuations and by calculating the inter-method agreementPatients and Methods:Medical records of patients hospitalized for right or bi-ventricular acute decompensated heart failure from January to December 2013 were retrospectively evaluated. The predictive significance of the IVC expiratory diameter and IVC collapsibility index (IVCCI) was analyzed using three different methods, namely a) the criteria for the indirect estimate of right atrial pressure by Rudski et al. (J Am Soc Echocardiogr. 2010); b) the categorization into three IVCCI classes by Stawicki et al. (J Am Coll Surg. 2009); and c) the subdivision based on the value of the maximum IVC diameter by Pellicori et al. (JACC Cardiovasc Imaging. 2013).Results:Among forty-seven enrolled patients, those classified as affected by persistent congestion were 22 (46.8%) using Rudski’s criteria, or 16 (34%) using Stawicki’s criteria, or 13 (27.6%) using Pellicori’s criteria. The inter-rater agreement was rather poor by comparing Rudski’s criteria with those of Stawicki (Cohen’s kappa = 0.369; 95% CI 0.197 to 0.54), as well as by comparing Rudski’s criteria with those of Pellicori (Cohen’s kappa = 0.299; 95% CI 0.135 to 0.462). Further, a substantially unsatisfactory concordance was also found for Stawicki’s criteria compared to those of Pellicori (Cohen’s kappa= 0.468; 95% CI 0.187 to 0.75).Conclusions:The abovementioned IVC ultrasonographic criteria for hemodynamic congestion appear clearly inconsistent. Alternatively, a sequential or simultaneous combination of clinical scores of congestion, IVC ultrasonographic indices, and circulating levels of natriuretic peptides could be warranted.

Fluid removal in acute heart failure: diuretics versus devices.

Fluid removal and relief of congestion are central to treatment of acute heart failure. Diuretics have been the decongestive mainstay but their known limitations have led to the exploration of alternative strategies. This review compares diuretics with ultrafiltration and examines the recent evidence evaluating their use. Relevant recent studies are the Diuretic Optimization Strategies Evaluation trial (of diuretics) and the Cardiorenal Rescue Study in Acute Decompensated Heart Failure (of ultrafiltration). The Diuretic Optimization Strategies Evaluation study evaluated strategies of loop diuretic use during acute heart failure (continuous infusion versus intermittent bolus and high dose versus low dose). After 72 h, there was no significant difference with either comparison for the coprimary end points. Patients treated with a high-dose strategy tended to have greater diuresis and more decongestion compared with low-dose therapy, at the cost of transient changes in renal function. The Cardiorenal Rescue Study in Acute Decompensated Heart Failure study showed that in acute heart failure patients with persistent congestion and worsening renal function, ultrafiltration, as compared with a medical therapy, was associated with similar weight loss but greater increase in serum creatinine and more adverse events. Decongestion remains a major challenge in acute heart failure. Although recent studies provide useful data to guide practice, the relatively poor outcomes point to the continued need to identify better strategies for safe and effective decongestion.

Incidence des troubles digestifs sur l’état respiratoire des enfants porteurs de handicap

Gastrointestinal manifestations are common in children with disability and concern more than 60% of them. They are involved in many complications, especially in respiratory disorders (persistent congestion, aspiration pneumonia). It is mainly the oromotor dysfunction (OMD) and the gastroesophageal reflux disease (GERD) sometimes associated to delayed gastric emptying, since they are source of oropharyngeal aspirations or pneumonia in case of massive GERD. The OMD is diagnosed during clinical examination and may require in some cases an exploration of swallowing. Its management mainly includes the modification of food texture. In severe forms prohibiting oral feeding, a gastrostomy is indicated. In case of DOM associated to severe GERD, antireflux surgery such as Nissen fundoplicature is coupled with gastrostomy. GERD is explored by 24h pH monitoring if non-externalized. The upper digestive tract endoscopy is only indicated in case of suspected esophagitis. Only proton pump inhibitors had demonstrated efficacy in GERD and should be prescribed in combination with other measures such as right lateral decubitus positioning in some patients. Antireflux surgery is indicated in case of severe complicated GERD resistant to medical treatment. Due to their central role in respiratory complications, digestive disorders should be systematically investigated and managed to improve the quality of life of children with disabilities.

Decongestive therapy and renal function in acute heart failure: time for a new approach?

Outcomes after admission for acute heart failure (AHF) remain extremely poor, especially for patients with decreased renal function or those in whom worsening renal function (WRF) develops during treatment. The Table shows the baseline estimated glomerular filtration rate (GFR) with 30- and 60-day mortality from the Dose Optimization Strategies Evaluation trial in acute Heart Failure (DOSE HF), the CArdioRenal REScue Study in acute Heart Failure (CARRESS HF), and the Renal Optimization Strategies Evaluation trial in acute Heart Failure (ROSE HF).1–3 GFR at randomization in each of these trials was significantly decreased, and the 60-day mortality of 14.7% in CARRESS HF (the only study to date requiring documentation of WRF before randomization) is one of the highest yet reported. View this table: Table. Baseline Estimated Glomerular Filtration Rate and 30- and 60-Day Mortality Rates From the DOSE Trial, the ROSE Trial, and the CARRESS in Acute Heart Failure Trial Recently Conducted by the National Heart, Lung, and Blood Institute Heart Failure Network WRF may have many causes in the setting of AHF.4 These include underdiuresis (which may lead to persistent increases in central venous pressure, thereby adversely affecting GFR), direct renal damage from the effects of drugs or procedures, progression of underlying disease, and overdiuresis leading to volume depletion with the subsequent engagement of baroreflex mechanisms and, as a result, a reduction in renal blood flow, GFR, and a fall in cardiac output. WRF may also be caused by a transient reduction in intravascular volume such that the rate at which intravascular volume is replenished from the extravascular space (the so-called plasma refill rate) is exceeded. This can occur despite persistent systemic congestion, as suggested by the results from CARRESS HF in which serum creatinine increased further during treatment with ultrafiltration, despite clinical evidence of ongoing congestion. Regardless of cause, outcomes …