Supplemental Hydration Research Articles

Investigating the benefits and harms of hypodermoclysis of patients in palliative care: A consecutive cohort study

Background: Palliative populations are at risk for dehydration which can cause discomfort, distress and cognitive symptoms. Subcutaneous hydration (‘hypodermoclysis’) has been used as an alternative administration route to the more invasive intravenous route, but research is lacking on its net clinical effects (harms and benefits) for palliative populations, particularly in real world settings. Aim: To quantify prospectively the net clinical effects of hypodermoclysis in palliative patients with advanced disease who required supplementary fluids. Design: Multisite, multinational consecutive cohort study. Setting/participants: Patients receiving hypodermoclysis in an inpatient palliative care setting. Results: Twenty sites contributed data for 99 patients, of which 88 had complete benefits and harms data. The most common primary target symptom for infusion was generalised weakness (18.2%), and the most common non-symptom indication was supplemental hydration (31.8%). Benefits were experienced in 33% of patients in their primary target symptom, and in any symptom in 56.8%. Harms were experienced in 38.7% of patients (42% at Grade 1). Benefits increased with higher performance status, while harms were more frequent in patients with lower performance status (Australia-modified Karnofsky performance status ⩽40). Patients in the terminal phase of their illness experienced the least benefit (15.4% in any indication only) and had more frequent harms (38%). Conclusions: Hypodermoclysis may improve certain symptoms in patients in palliative care but frequency of harms and benefits may differ at certain timepoints in the illness trajectory. Further research is needed to better delineate which patients will derive the most net clinical benefit from hypodermoclysis.

Impact of a Head and Neck Cancer Chemoradiation (HNC CRT) Nurse Practitioner (NP) on Patient Outcomes

<h3>Purpose/Objective(s)</h3> In addition to chemotherapy toxicities, most HNC patients receiving CRT experience moderate to severe radiation-induced pharyngitis. Management includes escalating analgesics, dietary modification, supplemental hydration, and feeding tubes for nutritional support as needed. Uncontrolled symptoms can interrupt or truncate curative intent treatment, impacting both quality of life and cancer outcomes. In 2014, a fulltime NP role dedicated to symptom management during and immediately post-CRT was initiated at our center. We assessed the impact on patient Emergency Department (ER) visits, hospitalizations and deaths. <h3>Materials/Methods</h3> Patients receiving definitive primary CRT with curative intent were identified during 12 month periods prior to (April 2012-March 2013) and three years after (April 2017-March 2018) initiation of the NP from records of H&N MDT case conferences. We hypothesized that ER visits and hospitalizations would be reduced with NP care. Effects on treatment delivery were secondary outcomes. Patient demographic, tumor, treatment, ER visit, hospital admission, and mortality data were extracted retrospectively from the electronic medical record. Unadjusted comparisons were done using the chi-square test for categorical variables and t-test for continuous variables with p<0.05 considered of significance. This project was approved by the institutional REB. <h3>Results</h3> 105 and 120 patients were identified in the pre-NP and post-NP cohorts, respectively. Post-NP patients were younger (mean age 63.2 vs 67.3 years), more often had oropharyngeal cancer (81.5% vs 56.2%), did not receive weekly carboplatin (0.0% vs 8.6%), and received cisplatin scheduled q3weekly less often (45.0% vs 71.4%) and weekly more often (48.3% vs 16.2%). Patients received a mean of 3.6 visits and 4.3 phone calls with the NP. There was no difference in ER visits within 42 days of treatment between cohorts (55.2% vs 55.8%). However, hospital admissions were reduced (60.0% vs 45.8%, p=0.034). Length of stay was similar, and there was no difference in 90-day mortality (2.9% vs 2.5%). <h3>Conclusion</h3> This before-and-after study showed a 23.7% reduction in hospitalizations after introduction of the NP role, consistent with the findings of others (Terzo 2017). Over 50% of patients visited the ER at least once and 1 in 40 died in both cohorts. Time trends included a 14.3% increase in the number of patients receiving CRT; and shifts in patient age, cancer type and cisplatin schedule consistent with an increasing incidence of HPV-related oropharyngeal cancer. We cannot rule out effects of these trends or other interventions on our results. Additional limitations include inability to harmonize staging between cohorts and lack of quality of life and cost effectiveness data. Nevertheless, these data support the value of a NP role focused on HNC patients receiving CRT to optimize outcomes.

Uncoupling Sickle Hematopoiesis Induced Angiotensin Receptor Signaling in Sickle Nephropathy

Angiotensin II (Ang-II) is a major bioactive peptide of the renin-angiotensin system. We recently reported hyperangiotensinemia in mice and patients with sickle cell disease (SCD), likely mediated by SCD-associated vascular damage (Chang, et al Nat Commun 2015). Herein, we explored whether the hyperangiotensinemia was driven by sickle hematopoiesis and its role in sickle nephropathy. We transplanted bone marrow from Berkeley sickle mice (SS) into C57Bl/6 WT mice (WT) and followed mice fully chimeric for sickle hematopoiesis for 6-9 months. Control WT mice were transplanted with bone marrow from WT mice. We observed that the SS/WT sickle hematopoietic chimeras developed elevated plasma Ang-II levels while the control chimeras did not, suggesting that sickle hematopoietic cells instigate hyperangiotensinemia. We then placed SS/WT chimeric mice or untransplanted Berk-SS mice on captopril, an angiotensin converting enzyme inhibitor (ACE-inhibitor) that would lower plasma Ang-II levels, and as expected Ang-II levels returned to baseline levels found in control mice. Additionally, an improvement in albuminuria and focal segmental glomerulo-necrosis (FSGN) was also noted, implying that sickle glomerulopathy is dependent on sickle hematopoiesis driven hyperangiotensinemia, and blocking this signaling can reverse the glomerular pathology. Similar results were also seen with the use of losartan, an Ang-II receptor 1 blocker (AT1R blocker) in SS/WT chimeras and untransplanted Berk-SS mice. This finding was confirmed by transplanting Berk-SS bone marrow in AT1R knockout mice (SS/AT1R-/- chimeras). Ang-II-AT1R signaling resulted in increased Smad1/2 phosphorylation, nitrotyrosine and TGFβ1 production in SS/WT glomeruli, resulting in FSGS that was absent in SS/AT1R-/- mice. While AT1R blockade improved glomerular pathology and albuminuria, the urine concentration defect (hyposthenuria), present in SCD, worsened with AT1R blockade with losartan. Hyposthenuria was even more severe in captropril treated Berk-SS mice, resulting in high mortality, which was averted only if they received supplemental hydration. Hence, while increased Ang-II signaling caused sickle glomerulopathy, Ang-II protected against severe hyposthenuria instigated by SCD, by signaling through AT1R and likely through a second receptor, conceivably AT2R. AT2R is known to have renoprotective functions, and AT2R-/- mice develop worse experimentally induced acute tubular necrosis. We investigated the mechanism of induction of hyposthenuria further using mice deficient in both Ang-II receptors and generating SS/AT1R-/- and SS/AT2R-/- chimeras along with the appropriate controls (WT/AT1R-/-, WT/AT2R-/-, WT/WT and SS/WT chimeric mice), by transplanting bone marrow from Berk-SS or WT mice into WT, AT1R-/- and AT2R-/- mice. Dual AT1R and AT2R deficiency is embryonic lethal. WT/WT mice had no hyposthenuria, while SS/WT chimeras developed the classic hyposthenuria associated with SCD. In AT1R chimeras: Both WT/AT1R-/- and SS/AT1R-/- chimeras developed hyposthenuria compared to WT/WT mice, demonstrating that Ang-II-AT1R signaling helps concentrate urine both in normal and sickle mice. In AT2R chimeras: WT/AT2R-/- chimeras had no hyposthenuria as WT/WT chimeras, suggesting that AT2R plays little role in concentrating urine in normal situations. However, SS/AT2R-/- chimeras developed significantly worse hyposthenuria than SS/WT chimeras, suggesting that under the stress of sickle cell disease, Ang-II-AT2R signaling improves hyposthenuria caused by SCD. Hence, while increased Ang-II signaling causes glomerulopathy via AT1R, it improves urine concentration in SCD both via AT1R and AT2R signaling. Indeed, a combination of AT1R inhibition with losartan, and an AT2R agonism via C21 (kindly provided by Vicore Pharma) improved both albuminuria and hyposthenuria in sickle mice. In summary, we show the molecular basis of sickle nephropathy and demonstrates that sickle hematopoiesis induces pathologic hyperangiotensinemia; increased Ang-II-AT1R signaling leads to glomerulopathy and end stage renal disease, despite its protective role in urine concentration; Ang-II-AT2R signaling improves hyposthenuria. Therefore, clinically, reduced AT1R signaling can improve sickle nephropathy, and dual AT1R blockade with AT2R agonism can be explored as a preferred therapeutic target. DisclosuresNo relevant conflicts of interest to declare.

Enhancing the mechanical and durability properties of subzero-cured one-part alkali-activated blast furnace slag mortar by using submicron metallurgical residue as an additive

Cold weather (<0 °C) is known for its detrimental impacts on concrete, and thus expensive and energy-consuming heating and insulation systems are used in cold-weather concreting to prevent frost damage. Supplementary cementitious materials are not recommended for use in cold-weather concreting because they slow down the setting time of concrete. In this study, one-part alkali-activated slag (AAS) was presented as an alternative environment-friendly binder for winter construction. The impacts of iron-containing submicron metallurgical residue on the reactivity, hardened properties, and durability of subzero-cured one-part AAS pastes and mortars were comprehensively studied. The incorporation of submicron particles (SMPs) enhanced the reactivity of AAS pastes by increasing the amount of precipitated hydrate phases and developing supplemental hydration products like calcium ferrosilicate hydrate. The positive effects of SMPs were highlighted via the denser microstructure, higher ultrasonic pulse velocity, increased compressive strength, and better durability properties of the AAS mortars. These improvements were attributed to the nucleation and filling behaviors of the added SMPs. On the contrary, decreased subzero curing temperature hindered the reaction progress, which adversely affected the hardened and durability properties of the mortars and limited the SMPs efficiency. With additional above-zero curing, higher compressive strength and lower water absorption and permeable porosity were measured in the AAS mortar cured initially at −5 °C compared to that cured at +20 °C.

13 Evaluating Potential Overuse of Intravenous Hydration in Patients Hospitalized with Bronchiolitis

Abstract Background Bronchiolitis is the primary cause of hospitalization in children during the first year of life. Respiratory support and hydration are the two pillars of management. Practice guidelines for bronchiolitis (NICE and CPS) recommend nasogastric (NG) hydration before intravenous (IV) fluids if oral hydration cannot be maintained. However, IV hydration remains the primary mode of hydration at our tertiary care pediatric centre. Objectives This is a resource stewardship project aiming to evaluate the baseline use of IV versus NG hydration in children 0-15 months hospitalized for bronchiolitis and requiring supplemental hydration. The secondary objective is to evaluate potential barriers to NG hydration for these children. Design/Methods Data was collected retrospectively for the 2017-2018 bronchiolitis season. A survey was sent to all the pediatric emergency (ED) physicians and nurses, pediatric hospitalists, ED fellows, pediatric residents and ward nurses. Results Among eligible patients (n=95), IV hydration was prescribed 52% of the time, compared to 48% NG hydration. Ninety-six percent (47/49) of IV hydration was initiated in the ED, while only 4% (2/49) was initiated on the ward. Among patients who began receiving hydration in the ED (80/95, or 84%), 41% (33/80) were hydrated via NG and 59% (47/80) by IV. In the survey, while 92% (57/62) of responding physicians claimed to be aware of national guidelines for bronchiolitis, only 67% (42/62) said that NG was the recommended mode of hydration. Among ED practitioners, 56% (19/34) were up-to-date on the recommendation. Two-thirds of all respondents (physicians and nurses) felt that NG hydration would be more acceptable to parents. Among nurses, 84% (38/45) felt that IV installation was a longer procedure to complete. Despite the existence of a local order set indicating NG hydration as the preferred hydration method, only 64% (40/62) of physicians were aware of its existence, and only 23% of these (9/40) actually use the guideline. Main reasons of disuse included forgetting the guideline exists and it not being easily available. In contrast, 93% of nurses were aware of the local guideline. Conclusion Intravenous hydration is overused among patients hospitalized with bronchiolitis at our centre, and the ED is the main setting where this occurs. There is a discrepancy between physicians’ theoretical knowledge of hydration guidelines and the application of these in reality. Barriers to the use of NG hydration can be amenable to a quality improvement (QI) intervention targeting improved knowledge and use of our local guideline, and this will be our focus going forward.

Epidemiology of Endemic Nephropathy of Unknown Etiology in Latin America: A Review on Morbidity and Mortality

Endemic nephropathy disease unexplained by diabetes or hypertension is highly prevalent on countries of Latin America. The purpose of this review is to present a brief summary to analyze de epidemiologic data on morbidity and mortality as well as the etiology unexplained by diabetes and hypertension, with emphasis in studies from areas of sugarcane, heat stress or cotton plantation, to understand the contributing social and work factors. From our review we conclude that clinical trials are needed to elucidate the nephropathy unexplained by conventional risk factors in Guatemala, Honduras, Panama, and Mexico, and some other countries, from areas of sugarcane, heat stress or cotton plantation work. Regular monitoring assessment of heat stress during harvesting season needs to be implemented by labor ministries authorities in a way to regulate the compliance of each employer on measures they should take to prevent worker illnesses and death caused by heat stress. Although there is some evidence about hydration preventing nephropathy, large clinical trials are needed to determine the extent of supplemental hydration solutions and time interval to slow the loss of kidney function in areas of sugarcane, heat stress or cotton plantation work. Employers should take steps that help workers become acclimatized, gradually build up exposure to heat, especially workers who are new to working in the heat or have been away from work.

Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis.

Intravenous (IV) hydration is used primarily in children with bronchiolitis at our institution. Because nasogastric (NG) hydration can provide better nutrition, the goal of our quality improvement (QI) initiative was to increase the rate of NG hydration in eligible children 1 to 23 months old with bronchiolitis by 20% over 6 months. We used Plan-Do-Study-Act cycles to increase the use of NG hydration in eligible children. Interventions included educational and system-based changes and sharing parental feedback with providers. Chart reviews were performed to identify the rates of NG hydration, which were plotted over time in a statistical process control p chart. The balancing measure was the rate of complications in children with NG versus IV hydration. Two hundred and ninety-three children who were hospitalized with bronchiolitis needed supplemental hydration during the QI initiative (January 2016-April 2016). Ninety-one children were candidates for NG hydration, and 53 (58%) received NG hydration. The rates of NG hydration increased from a baseline of 0% pre-QI bronchiolitis season (January 2015-April 2015) to 58% during the initiative. There was no aspiration and no accidental placement of the NG tube into a child's airway. Nine patients (17%) in the NG group had a progression of disease requiring nil per os status, and 6 of these were transferred to the PICU whereas none of those in the IV group were transferred to the PICU. Post-QI initiative, the majority of nurses (63%) and physicians (95%) stated that they are more likely to consider NG hydration in children with bronchiolitis. We successfully increased the rates of NG hydration in eligible children with bronchiolitis by using educational and system-based interventions.

Efficacy of oral supplemental hydration for the prevention of contrast-induced nephropathy in rats.

To compare oral rehydration solution (ORS) with saline infusion for preventing contrast-induced nephropathy (CIN) in a rat model. Adult male Sprague-Dawley rats (310-360g) received intravenous indomethacin (10mg/kg), N G-nitro-L-arginine methyl ester (10mg/kg), and iohexol (10mL/kg) to induce acute contrast-induced renal injury (CIN group); control rats received saline only. For hydration, rats received either continuous infusion (20mL/kg/h) of saline or three oral doses (20mL/kg each) of ORS. Acute renal injury was evaluated by assaying urine collected for 24h beginning 2h before the contrast injection, evaluating blood taken 22h after the contrast injection, and examining the kidneys histopathologically. Hydration with saline prevented only the contrast-induced increase in plasma creatinine, whereas ORS prevented deleterious changes in plasma creatinine, blood urea nitrogen, and creatinine clearance as well as in urinary protein, albumin, and N-acetyl-D-glucosaminidase concentrations. Histopathologic changes noted in the CIN group were diminished in both saline and ORS groups. Both intravenous saline administration and oral hydration with ORS decreased the severity of CIN. Hydration with ORS was comparable to intravenous saline infusion in preventing CIN-associated abnormalities.

No drought about it: Effects of supplemental hydration on the ecology, behavior, and physiology of free-ranging rattlesnakes

Hydration is a critical element for many physiological processes in vertebrates. While it seems intuitive that drought is stressful to animals, studies examining drought are typically observational and do not explicitly assess how the hydration state of study subjects influences their physiology and behavior. We examined how hydration affects several physiological and behavioral variables in free-ranging Northern Pacific rattlesnakes (Crotalus oreganus oreganus) by experimentally manipulating their hydration levels in the field. Our results suggest that supplemental water has a significant effect on reproduction, as all hydrated females gave birth during the experiment, while no control females did. We saw no effect of hydration on movement parameters; males moved a larger total distance and had larger home ranges than females, regardless of hydration status. Interestingly, body condition at the end of the study was significantly higher in hydrated snakes, suggesting that hydrated individuals might have been acquiring more food than control snakes. We saw no effect on baseline stress hormone concentrations or their increase in response to an acute stressor. Additional experimental studies are needed to better understand the pivotal roles of hydration in the physiology and behavior of reptiles.

Activities for engaging schools in health promotion

Purpose – The purpose of this paper is to describe activities used to initiate health promotion in the school setting. Design/methodology/approach – Description of successful pilot Health Promoting School (HPS) initiatives in Canada and Uganda and the validated measures central to each program. Evaluation methodologies: quantitative data from the tools used complimented by descriptive/qualitative methods. Findings – Previously validated tools/methodologies used include: The World Health Organization (WHO) growth charts for comparison of children ' s height, weight, head circumference, and BMI against multi-ethnic standards; a 24-h dietary recall instrument to assess dietary diversity as a proxy measure of nutritional adequacy; urine analysis to evaluate baseline renal function and the effect of supplemental hydration; “photo-voice” to aid discussion of personal and community issues of concern; “role play” to promote dialogue and promote social competence; and fitness training. Each activity can combine th...

Supplemental Intravenous Crystalloid Administration Does Not Reduce the Risk of Surgical Wound Infection

Wound perfusion and oxygenation are important determinants of the development of postoperative wound infections. Supplemental fluid administration significantly increases tissue oxygenation in surrogate wounds in the subcutaneous tissue of the upper arm in perioperative surgical patients. We tested the hypothesis that supplemental fluid administration during and after elective colon resections decreases the incidence of postoperative wound infections. Patients undergoing open colon resection were randomly assigned to small-volume (n = 124, 8 mL.kg(-1).h(-1)) or large-volume (n = 129, 16-18 mL.kg(-1).h(-1)) fluid management. Our major outcomes were two distinct criteria for diagnosis of surgical wound infections: 1) purulent exudate combined with a culture positive for pathogenic bacteria, and 2) Center for Disease Control criteria for diagnosis of surgical wound infections. All wound infections diagnosed using either criterion by a blinded observer in the 15 days after surgery were considered in the analysis. Wound healing was evaluated with the ASEPSIS scoring system. Of the patients given small fluid administration, 14 had surgical wound infections; 11 given large fluid therapy had infections, P = 0.46. ASEPSIS wound-healing scores were similar in both groups: 7 +/- 16 (small volume) versus 8 +/- 14 (large volume), P = 0.70. Our results suggest that supplemental hydration in the range tested does not impact wound infection rate.

A case of gain-of-function mutation in calcium-sensing receptor: supplemental hydration is required for renal protection

The calcium-sensing receptor (CaSR) regulates the extracellular calcium level, mainly by controlling parathyroid hormon secretion and renal calcium reabsorption. In gain-of-function CaSR mutations, the genetic abnormalities increase CaSR activity leading to the development of such clinical manifestations as hypercalciuric hypocalcemia and hypoparathyroidism. We report a Japanese case of CaSR gain-of-function mutation and represent a therapeutic intervention based on the functional characteristics of CaSR in renal tubule. DNA sequence analysis revealed a heterozygous G to T mutation identified in a 12-year-old Japanese girl presenting with sporadic onset of hypercalciuric hypocalcemia and hypoparathyroidism. The mutation is located in the N-terminal extracellular domain of the CaSR gene, one of the most important parts for the three-dimensional construction of the receptor, resulting in the substitution of phenylalanine for cysteine at amino acid 131 (C131F) in exon 3. Based on the diagnosis of the gain-of-function mutation in the CaSR, oral hydrochlorothiazide administration and supplemental hydration were started in addition to calcium supplementation. The combination therapy of thiazide and supplemental hydration markedly reduced both renal calcium excretion and urinary calcium concentration from 0.4-0.7 to less than 0.1 mg/mg (urinary calcium/creatinine ratio) and from 10-15 to 3-5 mg/dl (urinary calcium concentration), respectively. This therapy stopped the progression of renal calcification during the follow-up period. Supplemental hydration should be considered essential for the following reasons: (1) calcium supplementation activates the CaSR in the kidney and suppresses renal urinary concentrating ability, (2) the thiazide has a diuretic effect, (3) as calcium supplementation increases renal calcium excretion, the supplemental hydration decreases urinary calcium concentration by increasing urinary volume, thereby diminishing the risk of intratubular crystallization of calcium ion.

Head and Neck Manifestations of Erythema Multiforme in Children

Erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis are related disorders of skin and mucous membranes, which are typically associated with antecedent medication use or infection. We review 108 cases of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis from Texas Children's Hospital, Houston, Texas, from 1981 to 1991, and illustrate the characteristic skin and mucosal lesions. In addition, we describe in detail two unusual cases requiring intensive airway management. Head and neck manifestations were present in 4 of 79 patients (5%) with erythema multiforme and 26 of 28 patients (93%) with Stevens-Johnson syndrome. In Stevens-Johnson syndrome, mucosal involvement of the lip (93%), conjunctiva (82%), oral cavity (79%), and nose (36%) were most common. Antecedent medication use was identified in 59% of erythema multiforme patients and 68% of Stevens-Johnson syndrome patients. We note a striking increase in the number of cases in our series caused by cephalosporins. Fifty percent of Stevens-Johnson syndrome patients required supplemental hydration or alimentation because of the severity of the oral cavity involvement. The head and neck mucosal manifestations largely respond to local care, and the routine use of prophylactic antibiotics or systemic steroids is not recommended.

The small intestine and gastric secretion in the rat. The effects of intestinal bypass, resection, and supplemental hydration on interdigestive gastric secretion.

Resection of the distal 40% of small intestine increased the total acid output in female Holtzman rats when compared to that of controls. This effect was not seen in animals with the same intestinal segment bypassed. The administration of saline either subcutaneously or intraluminally in animals with bypassed intestinal segments caused similar elevations of total acid output above those of controls and suggest that dehydration contributed to the previous lack of response. We have also shown that distention of the intestine, per se, did not influence the gastric secretion in this preparation. Further investigation of hydration differences is necessary in order to separate the secretory responses: that due to resection or bypass from that due to the fluid state alone.