Urine Volume Output Research Articles

Comparison of postoperative awakening between ciprofol and propofol in elderly patients undergoing hip replacement surgery: a single-blind, randomized, controlled trial.

The aim of this paper was to compare the impact of continuous infusion of ciprofol versus propofol on postoperative awakening in elderly patients following hip replacement surgery. Patients were randomized into two groups (N.=45 each): the ciprofol group and the propofol group. The ciprofol group received ciprofol for anesthesia induction and maintenance, while the propofol group underwent anesthesia induction and maintenance using propofol. The primary outcome was awakening time. Secondary outcomes included spontaneous breathing recovery time, extubation time, time to modified Aldrete Score ≥9, modified observer's assessment of alertness/sedation (MOAA/S) scores, anesthetic dosage, volume of fluid replacement, urine output and administration of vasoactive drugs. The Ciprofol group exhibited a significantly prolonged awakening time (11.0±6.4 min vs. 7.4±4.3 min, P=0.003), spontaneous breathing recovery time (9.9±6.3 min vs. 5.9±4.3 min, P=0.001), and extubation time (12.0 [8.0-16.0] min vs. 8.5 [6.0-11.0] min, P=0.005), and reduced requirement for intraoperative fluid replacement (728.9±254.2 mL vs. 908.3±287.5 mL, P=0.003), increased urine output (235.1±102.1 mL vs. 173.5±106.2 mL, P=0.007), decreased likelihood of vasoactive drug administration (15/30 vs. 28/14, P=0.002). No significant differences were observed between the two groups in terms of reaching a modified Aldrete Score ≥9, MOAA/S scores at 0, 5, 15, or 30 minutes post-extubation, or occurrence of adverse reactions (P>0.05). The dosage of remifentanil was significantly higher in the ciprofol group [5.4 (2.7-7.4) μg·kg-1·h-1 vs. 3.4 (1.9-4.3) μg·kg-1·h-1, P=0.004], with a mean maintenance dose of ciprofol at 0.8 mg·kg-1·h-1 (range: 0.5 to 1.2 mg·kg-1·h-1). Compared to propofol, the administration of ciprofol in elderly patients following hip replacement surgery is associated with prolonged awakening time, spontaneous breathing recovery time, and extubation. The average intravenous maintenance dosage of ciprofol in geriatric patients under general anesthesia was 0.8 mg·kg-1·h-1.

Natriuretic and Saluretic effects of Caesalpinia bonduc (Linn.) Roxb Seed Extracts in Rats

The study aimed to explore the diuretic effects of extracts of Caesalpinia bonduc (Linn.) Roxb seed, a member of the Caesalpiniaceae family, using an acute rat model. Dehydrated rats were administered single dose of the extracts, prepared in both aqueous and ethanol forms, at doses of 200 and 400 mg/kg orally. Additionally, rats were given 25 mg/kg of frusemide and hydrochlorothiazide as standard diuretic drugs orally, for comparative analysis. A control group received oral administration of normal saline at a dose of 25 ml/kg. The metabolic cages were used to house the rats in pairs and urine output was measured at intervals of 5 hours and 24 hours. The results showed that higher doses of both extracts substantially raised the volume of urine output. This diuretic effect was observed gradually within 5 hours and sustained throughout the 24 hour study period. Furthermore, the 400 mg/kg dose of ethanolic extract exhibited a diuretic effect comparable to that of frusemide. Analysis of urine samples revealed a significantly elevated Na+, K+ and Cl- with the ethanolic extract of C. bonduc seeds. However, neither dose of the extracts significantly altered the pH nor specific gravity of urine during routine urinalysis. The findings suggest that extracts from C. bonduc seeds possess diuretic properties, supporting their traditional use in managing urinary problems. Further exploration is necessary to pinpoint the active phytoconstituents accountable for these observed effects.

Herbal Diuresis: Investigating the Efficacy of <i>Wedelia chinensis</i> Leaf Extracts in Rats

Background: Herbal drugs are currently being explored for pharmacological efficacy. They are relatively safe and have fewer side effects. Objective: The objective of this research was to explore the diuretic effects of the extracts of the leaves of Wedelia chinensis (Osbeck) Merill, a member of the Asteraceae family, using an acute rat model. Methods: Dehydrated rats were administered single doses of the extracts, prepared in both aqueous and ethanol forms, at doses of 200 and 400 mg/kg orally. Additionally, rats were orally administered 25 mg/kg of frusemide and hydrochlorothiazide as standard diuretic drugs, for comparative analysis. A control group received oral administration of normal saline at a dose of 25 ml/kg. The metabolic cages were used to house the rats in pairs and urine output was measured at intervals of 5 and 24 hours. Results: Results indicated a significant increase in urine volume output with higher doses of both extracts. This diuretic effect was observed gradually within 5 hours and sustained throughout the 24-hour study period. Furthermore, the 400 mg/kg dose of aqueous extract exhibited a diuretic effect comparable to that of frusemide. Analysis of the urine samples revealed a significantly elevated Na+ and K+ with the aqueous extract of W. chinensis leaves. However, neither dose of the extracts significantly altered the pH nor specific gravity of urine during routine urinalysis. Conclusion: The findings suggest that extracts from W. chinensis leaves possess diuretic properties, supporting their traditional use in managing urinary problems. Further exploration is necessary to pinpoint the active phytoconstituents accountable for these observed effects.

Study on the Effects of Angiotensin Receptor/Neprilysin Inhibitors on Renal Haemodynamics in Healthy Dogs.

An angiotensin receptor/neprilysin inhibitor (ARNI), a heart failure treatment, is a combination drug made up of sacubitril, a neprilysin inhibitor, and valsartan, a vascular receptor blocker. No human or veterinary studies regarding the effect of ARNI on renal haemodynamics in the absence of cardiac or renal issues exist. Therefore, we investigated the effect of ARNI on renal haemodynamics in five healthy dogs. ARNI was administered to all five dogs at an oral dose of 20 mg/kg twice daily for 4 weeks. Renal haemodynamics were assessed on the day before ARNI administration (BL), on Day 7, and on Day 28. The glomerular filtration rate (GFR) significantly increased on Day 28 compared to BL and Day 7, whereas renal plasma flow increased on Day 7 and Day 28 compared to BL. Systolic blood pressure significantly decreased between BL and Day 28. Plasma atrial natriuretic peptide (ANP) concentrations increased on Day 7 compared to BL. Additionally, ANP concentrations increased on Day 28 in three of the five dogs. Different ANP concentrations were observed in the remaining two dogs. Both urine output volume and heart rate remained relatively stable and did not exhibit significant change. In conclusion, ARNI may enhance renal haemodynamics in healthy dogs. ARNI could be a valuable drug for treating both heart and kidney disease in dogs.

Троспия хлорид у детей: динамика симптома остаточной мочи при коррекции расстройств мочеиспускания

Background. A significant place among pediatric urination disorders is occupied by overactive bladder (OAB). Treatment involving the use of M-anticholinergics is aimed to suppress detrusor overactivity. The side effects of treatment include urination problems, incomplete bladder emptying (residual urine), and acute urinary retention. Methods. We monitored 20 children aged 5–15 years, among them 12 boys and 8 girls. The average age (М±δ) was 8.47 ± 3.46 years. The 2-day uroflow monitoring revealed residual urine (RU) in 9 patients (1–15 times per monitoring period). The urination volume and rate, as well as RU, were assessed by uroflow monitoring conducted at home using the SIGMA F uroflowmeter (RZN registration certificate No. 2020/11522 of 5.08.2020). One of the components of combination therapy was trospium chloride (Spasmex) in a dose of 10–15 mg per day, depending on the age and disorder. Statistical data processing was performed using the STATISTICA 10 (StatSoft, Inc., USA) and Excel (Microsoft Office 2016) software packages. The differences were considered significant at p<0.05. The descriptive statistics were presented as М±δ (where М was median, δ was standard deviation). Results. The average effective volume (AEV) of urination in the group was reduced by 10–86.5% relative to the age norm. Furthermore, incomplete bladder emptying was reported in 9 patients. After treatment, the minimum urine output volume and the maximum urine flow rate increased significantly, while the urination rate decreased. There were no significant changes in the urine output volume (average and maximum), however, an upward trend of the urine output volume was observed. No increase in the number of RU cases following prescription of trospium chloride was reported. In fact, the decrease in their number was recorded. Conclusion. Pediatric micturition cycle abnormalities also include the RU symptom. The M-anticholinergic drug, trospium chloride (Spasmex), in a daily dose of 10-15 mg represents a safe and effective medication option. Therapy lasting up to 2 months results in the significant increase in minimum bladder volume and maximum urine flow rate, the decrease in pollakiuria severity, but never changes the rate and amount of residual urine.

How Much Furosemide Should be Administered to Prevent Transfusion-Associated Circulatory Overload? Results of a Dose-Finding Study

BACKGROUND: Transfusion-associated circulatory overload (TACO) is a common but under-reported complication of transfusion therapy, and results in significant morbidity and mortality. Pre-transfusion furosemide has been proposed as a mitigating strategy but has not received widespread endorsement, in part due to uncertainty regarding safe and effective dosing. An observational study was therefore conducted with the goal of creating a reliable dose-response curve in patients at high risk of TACO, using the statistical technique of Multiple Comparisons Procedure with Modelling (MCP-MOD). METHODS: Eligible patients were identified by screening bolus intravenous (IV) furosemide orders at two large academic hospitals. Eligibility criteria were selected to mimic those of a planned randomized controlled trial (RCT) of pre-transfusion furosemide for the prevention of TACO. Inclusion criteria were inpatients 50 years of age or older. Exclusion criteria were active bleeding, hemodynamic instability, glomerular filtration rate (GFR) < 30mL/min or need for dialysis, diuretic therapy (other than furosemide) administered less than 24 hours, furosemide (either IV or PO) administered less than 12 hours, or exogenous albumin administered less than 8 hours prior to index furosemide therapy. The primary outcome measure was the total volume of urine output in the six hours following IV furosemide administration. MCP-MOD analysis was performed after every 50 patients and continued until a weight-adjusted dose-response curve could be established with 100 mL precision, using the following covariates: age, sex, mean arterial pressure (MAP), serum albumin, GFR and history of chronic furosemide use. RESULTS: A total of 149 participants (53 female and 96 male) were enrolled over 2 years. As too few patients received doses exceeding 0.6 mg/kg to allow for a precise dose-response curve, only 132 patients receiving weight-adjusted doses ranging from 0.1 to 0.6 mg/kg were included in the MCP-MOD analysis. The characteristics of these patients are shown in Table 1. The dose-response curve formula that was derived from these patients was: Urine Output at 6 hours (mL) = 717.21 + 191.33 ln(dose (mg)/weight (kg)) + 0.73 × Age (years) + 103.37 × Sex (M=1/F=0) + 1.63 × GFR (ml/min) + 5.45 × MAP (mmHg) - 9.56 × albumin (g/L) - 62.31 × chronic diuretic use (Y=1/N-0) The curve with accompanying 95% confidence intervals is shown in Figure 1 This formula suggests that in an 80 kg patient with a GFR of 75 mL/min, a MAP of 85 mmHg, albumin of 40 g/L and no history of chronic diuretic use, 10 mg of IV furosemide should produce a diuresis of approximately 600 mL, sufficient to prevent circulatory overload from the transfusion of 1 unit of RBCs. A dose of 20 mg would be required to achieve a similar diuresis in patients with either a MAP < 60 mmHg, or a combination of both a GFR < 45 mL/min and a history of chronic diuretic use. CONCLUSIONS: A statistically precise dose-response curve for IV furosemide is possible with the inclusion of relevant clinical covariates, and can be used to guide dosing decisions in patients at risk of transfusion-associated circulatory overload. This formula derived from this study will inform the dosing recommendations of a planned RCT: Transfusion-Associated Circulatory Overload: Best Eliminated by Lasix® (TACO-BEL).

Preoperative tamsulosin effect on postoperative urinary retention following spinal surgery: A randomized controlled trial

BackgroundCurrent study aims to investigate pre-surgical medical intervention on the reduction of POUR incidence in patients undergoing spine surgery. MethodThe study was a single center double-blind randomized placebo clinical trial. Participants were individuals over 18 years old who underwent spinal surgery at the Educational and Therapeutic Hospital between 2020 and 2023. Inclusion criteria included the ability to provide informed consent and follow the study schedule, while exclusion criteria included certain medical conditions, current medication use, and inability to take oral medication after surgery. ResultsThe study enrolled 100 patients. There was no significant difference in age or gender distribution between the tamsulosin and placebo groups, but the tamsulosin group had a lower prevalence of diabetes. The duration of surgery was shorter in the tamsulosin group, and there was no significant difference in the surgical site. The tamsulosin group had significantly less post-void residual volume on the eighth day of the study, but there were no significant differences in urine output volume during surgery or residual urine volume before or after surgery. ConclusionTamsulosin may be effective in preventing postoperative urinary retention (POUR), but its effectiveness in treating established POUR is uncertain. The Tamsulosin group had significantly lower post-void residual volume after spine surgery. Considering the low risk of adverse effects, Tamsulosin could be considered for high-risk patients. However, patients should be aware of potential risks and seek medical attention if they experience adverse effects. Further research is needed to determine the best dosage and duration of treatment.

Abstract P135: Effect Of A High Fat Western Diet On The Progression Of Diabetic Kidney Disease In Type 2 Diabetic Nephropathy (T2DN) Rats

Diet influences the growing rate of obesity, increasing the risk of developing metabolic syndrome, which leads to chronic illnesses such as diabetes. Diabetic Nephropathy (DN) is a complication of Type 2 Diabetes prevalent in about 1 in 3 diabetics and is the primary cause of End-Stage Renal Disease (ESRD). The aim of this study was to assess how a high-fat Western diet impacts diabetic severity and DN during ESRD. We used aged (38+ wks) T2DN rats, an established DN model which has chronic kidney disease at this age and placed them on a normal (NFD) or high fat (42%, HFD) diet for 12 weeks. Previous studies revealed that T2DN males have more severe kidney injury progression. Thus, male (N=5-6) and female (N=6) rats were used to test effects of HFD in both sexes. Total food intake did not vary between diets. Urine and glucose tolerance tests (GTT) were assessed at weeks 0, 3, 6, 9, and 12. Both male (404.0 ± 10.2 vs 431.0 ± 7.1 g, p=0.053) and female (305.0 ± 14.4 vs 334.5 ± 17.6 g, p=0.22) T2DN rats gained weight on the HFD; however, the total body weights were not significantly different by week 12. Throughout the study, there were no significant differences in GTT curves or fasting blood glucose levels in females on NFD or HFD (wk 12: 123.3 ± 10.7 vs 149.3 ± 12.3 mg/dL, p=0.14). In contrast, the HFD males’ fasting blood glucose levels increased progressively over the 12-week period and became significantly different between the two groups by week 9 (204.5 ± 10.8 vs 284.4 ± 15.8 mg/dL, p=0.003). Furthermore, at the 2 hr time point in the week 9 GTTs, male blood glucose concentrations were elevated compared to females (370.4 ± 25.1 vs 457.5 ± 10.4 mg/dL, p=0.01; and 222.7 ± 28.8 vs 205 ± 16.8 mg/dL, p=0.61, for male and female, respectively). The HFD did not affect urine volume output or kidney/total body weight ratios in males or females compared to their NFD counterparts. However, heart weight/total body weight ratios in females were significantly reduced on the HFD (3.7 ± 0.1 vs 3.4 ± 0.1, p=0.03). Ongoing studies will quantify renal fibrosis, glomerular damage, albuminuria, glucosuria, lipidemia, and liver damage resulting from the HFD. In conclusion, the HFD seems to have a more deleterious effect on glucose handling in males than females; however, further studies are warranted to validate this effect.

Early Postoperative Serum Sodium Level and Urine Output Volume Profile after Endoscopic Endonasal Transsphenoidal Surgery in Macroadenoma Pituitary Tumor

Introduction: Surgery is still the initial treatment of choice to for the majority of date with pituitary tumors. One of the most commonly performed minimally invasive neurosurgical procedures is transsphenoidal endoscopic endonasal surgery (ETS) and microscopic transsphenoidal surgery (MTS), used commonly for the resection of pituitary tumors. Neurosurgical operations for pituitary and suprasellar tumors may result in postoperative complications due to the crucial anatomical location of these tumors. The resulting postoperative complications can manifest as anterior or posterior pituitary dysfunction, particularly sodium disturbances, due to the changes in antidiuretic hormone (ADH) secretion, which remains one of the most frequent postoperative reasons for hospital readmission. Method: The aim of this study is to describe and determine the frequency distribution of patient characteristics who underwent endoscopic endonasal transsphenoidal resection of pituitary adenoma at Universitas Sumatera Utara Hospital between 2021 and 2022. Result: The findings of this study showed the frequency distribution of patient characteristics who underwent endoscopic endonasal transsphenoidal resection and postoperative sodium serum level profile as well as postoperative urine output profile. Discussion: The discussion section briefly discusses the findings and their implications. It mentions the high prevalence of headache and visual deficits among the patients, which aligns with previous studies. It also provides an overview of normal water balance and the pathophysiology of water balance disorders after pituitary surgery.

Digital Health Transformers and Opportunities for Artificial Intelligence-Enabled Nephrology.

Digital Health Transformers and Opportunities for Artificial Intelligence-Enabled Nephrology.

Risk factors for acute kidney injury after pancreatoduodenectomy, and association with postoperative complications and death

BackgroundAcute kidney injury (AKI) is associated with increased morbidity and mortality after general surgery, although little is known among patients undergoing pancreatoduodenectomy. The objective was to investigate the association between AKI and postoperative complications and death after pancreatoduodenectomy. MethodsAll patients ≥18 years who underwent a pancreatoduodenectomy 2008–2019 at the Karolinska University Hospital, Stockholm, Sweden, were included. Standardized criteria for AKI, including estimated glomerular filtration rate (eGFR) and urine volume measurements, were used to grade postoperative AKI. ResultsIn total, 970 patients were included with a median age of 68 years (IQR 61–74) of whom 517 (53.3%) were men. There were 137 (14.1%) patients who developed postoperative AKI. Risk factors for AKI included lower preoperative eGFR, cardiovascular disease and treatment with renin-angiotensin system inhibitors or diuretics. Those who developed AKI had a higher risk of severe postoperative complications, including Clavien-Dindo score ≥ IIIa (adjusted OR 3.35, 95% CI 2.24–5.01) and ICU admission (adjusted OR 7.83, 95% CI 4.39–13.99). In time-to-event analysis, AKI was associated with an increased risk for both 30-day mortality (adjusted HR 4.51, 95% CI 1.54–13.27) and 90-day mortality (adjusted HR 4.93, 95% CI 2.37–10.26). Patients with benign histology and AKI also had an increased 1-year mortality (HR 4.89, 95% CI 1.88–12.71). ConclusionsPostoperative AKI was associated with major postoperative complications and an increased risk of postoperative mortality. Monitoring changes in serum creatinine levels and urine volume output could be important in the immediate perioperative period to improve outcomes after pancreatoduodenectomy.

Development and validation of a nomogram to predict the 30-day mortality risk of patients with intracerebral hemorrhage

BackgroundIntracerebral hemorrhage (ICH) is a stroke syndrome with an unfavorable prognosis. Currently, there is no comprehensive clinical indicator for mortality prediction of ICH patients. The purpose of our study was to construct and evaluate a nomogram for predicting the 30-day mortality risk of ICH patients.MethodsICH patients were extracted from the MIMIC-III database according to the ICD-9 code and randomly divided into training and verification cohorts. The least absolute shrinkage and selection operator (LASSO) method and multivariate logistic regression were applied to determine independent risk factors. These risk factors were used to construct a nomogram model for predicting the 30-day mortality risk of ICH patients. The nomogram was verified by the area under the receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA).ResultsA total of 890 ICH patients were included in the study. Logistic regression analysis revealed that age (OR = 1.05, P < 0.001), Glasgow Coma Scale score (OR = 0.91, P < 0.001), creatinine (OR = 1.30, P < 0.001), white blood cell count (OR = 1.10, P < 0.001), temperature (OR = 1.73, P < 0.001), glucose (OR = 1.01, P < 0.001), urine output (OR = 1.00, P = 0.020), and bleeding volume (OR = 1.02, P < 0.001) were independent risk factors for 30-day mortality of ICH patients. The calibration curve indicated that the nomogram was well calibrated. When predicting the 30-day mortality risk, the nomogram exhibited good discrimination in the training and validation cohorts (C-index: 0.782 and 0.778, respectively). The AUCs were 0.778, 0.733, and 0.728 for the nomogram, Simplified Acute Physiology Score II (SAPSII), and Oxford Acute Severity of Illness Score (OASIS), respectively, in the validation cohort. The IDI and NRI calculations and DCA analysis revealed that the nomogram model had a greater net benefit than the SAPSII and OASIS scoring systems.ConclusionThis study identified independent risk factors for 30-day mortality of ICH patients and constructed a predictive nomogram model, which may help to improve the prognosis of ICH patients.

Optimization of the Chronic Kidney Disease-Peritoneal Dialysis App to Improve Care for Patients on Peritoneal Dialysis in Northeast Thailand: User-Centered Design Study.

BackgroundThe prevalence of peritoneal dialysis (PD) in Thailand is increasing rapidly in part because of Thailand’s Peritoneal Dialysis First policy. PD is a home-based renal replacement therapy in which patients with chronic kidney disease perform up to 4 exchanges of dialysate fluid per day in the peritoneal cavity. Overhydration is one of the most common complications in patients on PD and is associated with increased morbidity and mortality. To monitor hydration status, patients collect hydration metrics, including body weight, blood pressure, urine output, and ultrafiltration volume, from each dialysis cycle and enter this information into a PD logbook. This information is reviewed bimonthly at PD clinic appointments. The chronic kidney disease-PD (CKD-PD) app with near-field communication (NFC) and optical character recognition (OCR) was developed to automate hydration metric collection. The information was displayed in the app for self-monitoring and uploaded to a database for real-time monitoring by the PD clinic staff. Early detection and treatment of overhydration could potentially reduce the morbidity and mortality related to overhydration.ObjectiveThis study aims to identify usability issues and technology adoption barriers for the CKD-PD app with NFC and OCR and a monitoring system and to use this information to make rapid cycle improvements.MethodsA multidisciplinary team of nephrologists, PD clinic nurses, computer programmers, and engineers trained and observed 2 groups of 5 participants in the use of the CKD-PD app with NFC and OCR and a monitoring system. The participants were observed using technology in their homes in 3 phases. The data collected included the Unified Theory of Acceptance and Use of Technology questionnaire, think-aloud observation, user ratings, completion of hydration metrics, and upload of hydration metrics to the central database. These results were used by the team between phases to improve the functionality and usefulness of the app.ResultsThe CKD-PD app with NFC and OCR and a monitoring system underwent 3 rapid improvement cycles. Issues were identified regarding the usability of the NFC and OCR data collection, app stability, user interface, hydration metric calculation, and display. NFC and OCR improved hydration metric capture; however, issues remained with their usability. App stability and user interface issues were corrected, and hydration metrics were successfully uploaded by the end of phase 3. Participants’ scores on technology adoption decreased but were still high, and there was enthusiasm for the self-monitoring and clinical communication features.ConclusionsOur rapid cycle process improvement methodology identified and resolved key barriers and usability issues for the CKD-PD app with NFC and OCR and a monitoring system. We believe that this methodology can be accomplished with limited training in data collection, statistical analysis, and funding.

Formulation, Characterization, and the Diuretic Effects of a New Intravenous Metolazone Emulsion.

Acute decompensated heart failure is often treated with a combination of loop and thiazide-like diuretics. Of these thiazide-like diuretics, two common choices are intravenous chlorothiazide or oral metolazone. Metolazone is more potent and has a longer duration of action, but since it is an oral formulation, it has a longer on-set time as compared to chlorothiazide. In addition, metolazone is poorly water-soluble, thereby rendering intravenous formulation more challenging. To address these issues, we proposed the formulation of a solvent-free metolazone emulsion for intravenous administration. An oil-in-water emulsion containing 1 mg/mL of metolazone was formulated by homogenizing soybean oil and l-lecithin in water in the presence of optimized concentrations of glycerin with tween 80 or poloxamer 188 as surfactant. The emulsion was characterized on the basis of particle size, zeta potential, morphology and metolazone release kinetics. The diuretic effect of the metolazone emulsion was evaluated in rats. The 1 mg/mL metolazone emulsion prepared with 5% tween 80 displayed the best physical stability. The emulsion exhibited a hydrodynamic diameter of 157.13±1.52 nm. About 93% of metolazone was released from the formulation within 2 h. The 2 mg/kg and 4 mg/kg dose of the metolazone emulsion increased urine output in the rats by 68.9 and 134%, respectively, as compared to control rats. Furthermore, the 4 mg/kg dose exhibited a 168.8%, 25.8%, and 150.9% increase in sodium, potassium, and chloride, respectively. This metolazone emulsion was capable of increasing urine volume output and demonstrated both natriuretic and kaliuretic properties.

A nutraceutical formulation combined with sclerofoam-assisted laser treatment ameliorates chronic venous insufficiency

Chronic venous insufficiency has a high impact on the healthcare system due to its high incidence worldwide. We performed a study in 30 women with thigh and leg varices due to major saphenous vein valve incontinence with saphenous trunk reflux causing phlebo-lymphoedema to assess the efficacy of sclerofoam-assisted laser treatment combined with nutraceutical administration. The patients underwent endovascular combination sealing of the saphenous trunk with sclerofoam-assisted laser treatment technique into the major saphenous veins under low-volume tumescent anesthesia followed by intraoperative phlebectomies. Post-operatively, the patients received capsules containing Aesculus Hippocastanum, chondroitin sulphate, proanthocyanidins from Pinus pinaster Aiton, proanthocyanidins from Vitis vinifera L., hydrolysed marine collagen and carcinine dihydrochloride for 3 weeks. We evaluated the extracellular fluid volume of the lower limbs using bioimpedance spectroscopy pre- (T0) and post-surgery (T2) (impedance is a vector which is composed of two components, resistance [RES] and reactance [REA)]). In addition, we evaluated the following parameters pre- and post-surgery: pain, heaviness, paresthesia, itching, swelling, daily urine volume output and leg volume. Limb volume was significantly decreased at T2 compared to T0 (p < 0.01). RES and REA were significantly increased at T2 compared to T0 (p < 0.0001 and p < 0.01, respectively). A significant improvement in heaviness, paresthesia, pain, swelling and itch was also observed (all p < 0.0001) while no changes in terms of diuresis occurred. No adverse effects were observed. The present study shows a promising approach to the treatment of chronic venous insufficiency that warrants further clinical studies in larger cohorts of patients.

Double arterial cannulation versus right axillary artery cannulation for acute type A aortic dissection: a retrospective study

BackgroundCannulation strategy in surgery for acute type A aortic dissection (ATAAD) remains controversial. We aimed to retrospectively analyze the safety and efficacy of double arterial cannulation (DAC) compared with right axillary cannulation (RAC) for ATAAD.MethodsFrom January 2016 to December 2018, 431 ATAAD patients were enrolled in the study. Patients were divided into DAC group (n = 341) and RAC group (n = 90). Propensity score matching analysis was performed to compare the early and mid-term outcomes between these two groups. To confirm the organ protection effect by DAC, intraoperative blood gas results and cardiopulmonary bypass parameters were compared between the two groups.ResultsDemographics and preoperative comorbidities were comparable between two groups, while patients in DAC group were younger than RAC group (51.55 ± 13.21 vs. 56.07 ± 12.16 years, P < 0.001). DAC had a higher incidence of limb malperfusion (18.2% vs. 10.0%, P = 0.063) and lower incidence of coronary malperfusion (5.3% vs. 12.2%, P = 0.019). No significant difference in cardiopulmonary bypass and cross-clamp time was found between the two groups. The in-hospital mortality was 13.5% (58/431), while there was no difference between the two groups (13.5% vs. 13.3%; P = 0.969). Patients who underwent DAC had higher incidence of postoperative stroke (5.9% vs. 0%, P = 0.019) and lower incidence of postoperative acute kidney injury (AKI) (24.7% vs. 40.3%; P = 0.015). During a mean follow-up period of 31.8 (interquartile range, 25–45) months, the overall survival was 81.5% for DAC group and 78.0% for RAC group (P = 0.560). Intraoperative blood gas results and cardiopulmonary bypass parameters showed that DAC group had more intraoperative urine output volume than RAC group (P = 0.05), and the time of cooling (P = 0.04) and rewarming (P = 0.04) were shorter in DAC group.ConclusionsDAC will not increase the surgical risks compared to RAC, but could reduce the incidence of postoperative AKI which may be benefit for renal protection.

A Rare Case of Concurrent New-Onset Microscopic Polyangiitis and Thrombotic Thrombocytopenic Purpura in a 77-Year-Old Woman

Introduction:Microscopic polyangiits (MPA) is a rare ANCA-associated necrotizing vasculitis that affects the small vessels, often involving the lung or kidney. When presenting with diffuse alveolar hemorrhage, this disease warrants emergent treatment, often with plasma exchange. Here, we present a rare case of a patient presenting with alveolar hemorrhage in the setting of MPA and concurrent thrombotic thrombocytopenic purpura (TTP) with an extremely reduced ADAMTS13 activity.Case Report:A 77 y/o woman with HTN and PUD presented to outside facility with new onset anemia (Hb 6.3 g/dL). Positive Coombs test gave her a tentative diagnosis of hemolytic anemia, and she was transfused 2 U RBCs. Ten days later, she presented to our hospital with respiratory distress. Hb remained stable at 10.7 but had leukocytosis with WBC 22,000 with left shift, platelets 439. Vitals not consistent with sepsis though saturating 70-80% on room air. In the ED, she developed frank hemoptysis and was emergently intubated. CTA chest was negative for pulmonary embolus but demonstrated diffuse ground-glass opacities. COVID test negative. Bronchoscopy was consistent with diffuse alveolar hemorrhage (DAH), and she received tranexamic acid, crystalloids, 1 U RBCs. Suspicious for underlying vasculitic process, she was given pulse dose IV steroids (1 g methylprednisolone daily) and started plasma exchange. Creatinine on presentation was elevated at 1.77 but she continued to have adequate urine output and appropriate volume status. Her hospital course was marked by progressive thrombocytopenia with schistocytes appreciated on peripheral smear. ADAMTS13 activity <5% with inhibitor detected, consistent with TTP. Vasculitic workup revealed positive myeloperoxidase antibodies and p-ANCA consistent with MPA. Other rheumatologic workup ANA positive 1:640 and positive IgM cardiolipin antibodies; she had no personal autoimmune history but some family autoimmune disease including one daughter with systemic lupus erythematosus and another relative with Guillian-Barre. She remained intubated for 4 days and post-extubation experienced some short-lived ICU delirium but after made a remarkable recovery. She completed 12 total sessions of of plasma exchange and 3 of 4 planned doses of rituximab, to continue on oral steroids outpatient and prophylactic TMP-SMX. She was discharged to rehab facility on hospital day 20.Discussion:With diffuse alveolar hemorrhage on presentation, initial differential remained broad including delayed presentation of transfusion-related lung injury (TRALI) given recent history of transfusion. She had recently started hydralazine outpatient. Along with positive ANA, this could suggest drug-induced lupus. However, histone antibodies were negative, but results may have been compromised by steroids and plasma exchange. Both MPA and TTP can be deadly but are managed with similar treatment. Luckily, our patient was rapidly initiated on plasma exchange following hospitalization. Although further workup including ADAMTS13 and vasculitis labs were pending at the time, it is important to not delay treatment while awaiting results. Cased of concurrent TTP and ANCA-associated vasculitis have been described in the literature, but the full relationship between these two entities remains unclear. TTP may develop after starting glucocorticoids in the setting of ANCA vasculitis, so close monitoring is recommended. DisclosuresNo relevant conflicts of interest to declare.

Risk Factors and Outcomes of Acute Kidney Injury after Type A Aortic Dissection Surgery at A Tertiary Care Hospital

Objective: This study aimed to determine the risk factors predisposing to postoperative acute kidney injury (AKI) after type A aortic dissection repair; regarding patient-related, surgery-related and anesthesia-related factors.Material and Methods: A retrospective cohort study was conducted in patients who underwent type A aortic dissection repair under cardiopulmonary bypass (CPB), during the periods from January 2008 and December 2019. Patient-related, surgery-related and anesthesia-related factors were evaluated for association with AKI. AKI was defined by the Kidney Disease: Improving Global Outcomes criteria. The outcomes and mortality of AKI were also investigated.Results: Included were 95 patients, and the incidence of AKI was 65.3%. The 30-day mortality resulted only in the AKI group (14.9%). From multivariate logistic regression analysis, receiving intraoperative cryoprecipitate (odd ratio; OR 14.18; 95% confidence interval (CI), 3.27-61.5) and PRC transfusion (OR 1.001; 95% CI, 1.0005-1.002) in ICU were the risk factors for AKI. The protective factors were: higher preoperative serum bicarbonate levels (OR 0.83; 95% CI, 0.70- 0.99), higher volume of urine output during CPB (OR 0.71; 95% CI, 0.55-0.91) and higher immediate postoperative mean arterial pressure (OR 0.95; 95% CI, 0.92-0.98). Thirty-day mortality was significantly higher in the AKI group (14.5% vs 0%; p-value=0.025), and 15.0% of patients required renal replacement therapy.Conclusion: The higher level of three factors including preoperative serum bicarbonate levels (&gt;23 mmol/l), volume of urine output during CPB and immediate postoperative mean arterial pressure (&gt;81 mmHg) are likely to be the protective factors of AKI.

Oral Nifedipine Versus Intravenous Labetalol in the Management of Severe Pregnancy Induced Hypertension: A Randomized Control Trial

Background : Pregnancy-also known as gestation is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but can occur through assisted reproductive technology protedures. To assess the efficacy of oral Nifedipine and I/V Labetalol for lowering BP in severe PIH after 28 weeks of pregnancy.&#x0D; Materials and methods: In this study 100 subjects were selected with severe pregnancy induced hypertension as per inclusion criteria. After taking informed written consent they were randomly allocated into two groups, A &amp; B. Group A received initially tablet nifedipine 10 mg orally with repeated doses of 20 mg every 20 minutes upto five doses while Group B received intravenous labetalol 20 mg initially followed by escalating doses of 40, 80, 80 and 80 mg every 20 minutes until the therapeutic goal blood pressure Systolic £ 150 mmHg &amp; diastolic £ 100 mmHg was achieved. Primary outcomes were the time interval and the number of doses needed to achieve a blood pressure of £ 150/100 mmHg, Secondary outcomes were fetomaternal safety, efficacy and side effects of both drugs. The outcomes were recorded in a preformed data collection sheet. All the data were analyzed by computer based software SPSS version 19 (SPSS Inc, Chicago, IL, USA). P &lt;0.05 at 95% level was taken as statistically significant.&#x0D; Results: A total of 100 patients of different ages with mean age of 27.41 years were taken in the study. Primi patients were more in Group A the Group B and mode of delivery was commonly caesarian section (66% vs 78%) in both groups. Proportion of target BP achievement were 100% in Group A and it was 72% in Group B. Need of drug dose and time of reduction was found significantly less among Group A women. Change of mean ± SD, SBP was more rapid in Group A ( 174.90 ± 20.01 vs 158.40 ± 11.13) women who were on Group A oral nifedipine than Group B ( 179.80 ± 16.54 vs 167.40 ± 15.02) i/v labetalol group after first dose. It was same for DBP also. Need of mean dose were less in group A than Group B (1.72 vs 3.30) also total time needed to achieve target BP was less in Group A (34.40 vs 66.0 mins). There was no need of doses exceeding third dose who were on oral nifidipine than i/v labetolol. Both maternal and fetal heart rate was not influenced by both the drugs. Side effects of drugs were found more in Group B (8% vs 4%) and fetal death also more common in there (8% vs 16%). Value of APGAR scores was found higher both at 1 minute and at 5 minutes among Group A neonates than Group B. Significant urine output volume was found in Group A patients than Group B at first hour.&#x0D; Conclusion: Oral nifedipine and intravenous labetalol both the regimens are found to be effective in the management of severe PIH. But Nifidipine lowers blood pressure more rapidly with fewer doses with minimum fetomaternal side-effects.&#x0D; Chatt Maa Shi Hosp Med Coll J; Vol.20 (1); January 2021; Page 55-61

Nutritional status and volume control in adolescents on chronic hemodialysis.

Pediatric patients on maintenance hemodialysis (HD) are at risk of both malnutrition and fluid overload. This pilot study aimed to assess correlates of normalized protein catabolic rate (nPCR) in adolescents on chronic HD, in particular fluid status markers. All patients aged 10-18 years on chronic HD in our center between 2017 and 2019 were enrolled. For each patient, mean nPCR was calculated and correlations with the following parameters investigated: dry body weight change in subsequent 3 months in kg (∆BW) and percentage of BW (∆BW%), change in body mass index (∆BMI), preHD systolic and diastolic blood pressure (SBP, DBP), residual urine output, biochemistry, and blood volume monitoring-derived first hour refill index (RI), calculated as ratio between ultrafiltration rate and reduction in relative blood volume in first hour of dialysis. Seventy-nine nPCR determinations were collected in 23 patients, median age 14.8 years. nPCR significantly correlated with ∆BW, ∆BW%, ∆BMI, spKT/V, and preHD serum creatinine, and negatively correlated with age, DBP SDS (r=-0.466, p=0.025) and RI (r=-0.435, p=0.043). RI was significantly higher in patients with nPCR <1 than those with nPCR above this threshold: 3.2 (1.9-4.7) vs. 1.4 (0.7-1.8) ml/kg/h/% (p=0.021). At multivariable analysis, nPCR remained positively correlated with creatinine and spKt/V, and inversely correlated with RI. nPCR is a significant predictor of weight change in adolescents on maintenance HD, and seems associated with creatinine and dialysis adequacy. Inverse correlation with RI suggests possible associations between malnutrition and fluid overload, but larger prospective studies are needed to confirm this. A higher resolution version of the Graphical abstract is available as Supplementary information.