Volume Excess Research Articles

ОКАЗАНИЕ МЕДИЦИНСКОЙ ПОМОЩИ СВЕРХ УСТАНОВЛЕННОГО ОБЪЕМА: ВЫПОЛНЕНИЕ ОБЯЗАТЕЛЬСТВ ПО ДОГОВОРУ ОБЯЗАТЕЛЬНОГО МЕДИЦИНСКОГО СТРАХОВАНИЯ ИЛИ С ПАЦИЕНТОМ

Significance. The issue of medical care delivery in excess of the established volume, including by private health sector operating under compulsory health insurance remains a challenge to the medical community. The subject of the study, on the one hand, was the overview of the current situation regarding medical organizations that submit registers of bills and invoices for medical services provided to the insured under the territorial program and insurance medical organizations that refuse to reimburse services in excess of the established volumes. On the other hand, the inability of a medical organization to refuse to provide medical care to citizens who have applied for care. The purpose of the study was to analyze the normative and legal acts that regulate legal relations between participants and subjects of the compulsory health insurance, indicating impossibility or difficulties for the parties to fulfill their obligations to ensure care delivery to the insured under the compulsory health insurance program. Material and methods. Material and methods of the study included an analytical review aimed at studying and analyzing the legal policy, current legal practice, current situation regarding place in the medical service market, including the private health sector, in order to answer the research question. Results. The conducted analysis shows that the main function of medical organizations is to provide medical care to the insured. At the same time, territorial funds are responsible for providing medical care to the insured under the federal compulsory health insurance program, and are to create all conditions to ensure availability of services. The federal legislation does not make the provision of free medical care to a citizen under the compulsory health insurance program dependable upon the planned total volume of services and guarantees the provision of free medical care to the insured in the compulsory health insurance system. When the planned volumes of medical care under the program of compulsory health insurance do not correspond to the actual demand, the excess of these volumes provided by a medical organization cannot be attributed to the financial results of its performance. Conclusion. The foregoing confirms the conclusions that medical services provided in excess of the established volumes are to be considered as insured events and are subject to reimbursement in the stated amount. Accordingly, they cannot be a restriction to realizing the powers to provide medical care to citizens under the program of state guarantees in cases where the volume of medical services provided exceeds the planned one, envisaged by the compulsory health insurance contract. This position will help avoid risks, including reputational ones, and prevent the organizations from filing a lawsuit.

Health care delivery above the established level: obligatory medical insurance contract performance or to the patient

The imperfection of the normative legal acts regulating legal relations between participants and subjects of compulsory medical insurance inevitably leads to the impossibility or difficulties for the parties to fulfill their obligations to ensure the provision of medical assistance to insured persons under compulsory medical insurance programs. Medical organizations included in the unified register of medical organizations operating in the field of CHI are limited in exercising their powers to provide medical care to citizens under the state guarantees program in the event that the volume of medical services provided exceeds the planned services provided for in the CHI agreement. The "forced" provision of medical care "in excess of the volume", in the first place, is aimed at meeting the actual needs of patients in this service. And ignoring this circumstance by medical organizations contradicts the basic principles of protecting the health of citizens, namely, the priority of its provision in the field of health protection.The inadmissibility of refusal to provide medical care and the revision of legal instruments for its provision in order to avoid a negative impact on patients, and on the performer represented by a medical organization, is the topic of this discussion.Presentation by the contractor in the person of a medical organization for payment of medical services in excess of the distributed volume and (or) financial security established by the medical organization in accordance with the legislation on CHI should not be a reason for refusing to provide medical services at the time of the consumer's request and when planning treatment. At the same time, based on the results of examinations conducted by insurance medical organizations for monitoring the volume of medical care for identified cases of medical care in excess of the distributed volume established by the decision of the commission for the development of the territorial program, acts of medical and economic control were drawn up.Non-payment by the insurance medical organizations of the subject of bills for the rendered medical services, motivated by the excess of the volumes and financial support established by the territorial CHI program, served as the basis for the medical organization to file a lawsuit.

Thiazide diuretics are back in CKD: the case of chlorthalidone.

Sodium and volume excess is the fundamental risk factor underlying hypertension in chronic kidney disease (CKD) patients, who represent the prototypical population characterized by salt-sensitive hypertension. Low salt diets and diuretics constitute the centrepiece for blood pressure control in CKD. In patients with CKD stage 4, loop diuretics are generally preferred to thiazides. Furthermore, thiazide diuretics have long been held as being of limited efficacy in this population. In this review, by systematically appraising published randomized trials of thiazides in CKD, we show that this class of drugs may be useful even among people with advanced CKD. Thiazides cause a negative sodium balance and reduce body fluids by 1-2l within the first 2-4weeks and these effects go along with improvement in hypertension control. The recent CLICK trial has documented the antihypertensive efficacy of chlorthalidone, a long-acting thiazide-like diuretic, in stage 4 CKD patients with poorly controlled hypertension. Overall, chlorthalidone use could be considered in patients with treatment-resistant hypertension when spironolactone cannot be administered or must be withdrawn due to side effects. Hyponatremia, hypokalaemia, volume depletion and acute kidney injury are side effects that demand a vigilant attitude by physicians prescribing these drugs. Well-powered randomized trials assessing hard outcomes are still necessary to more confidently recommend the use of these drugs in advanced CKD.

Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury.

Critical illness is often complicated by acute kidney injury (AKI). In patients with severe AKI, renal replacement therapy (RRT) is deployed to address metabolic dysfunction and volume excess until kidney function recovers. This review is intended to provide a comprehensive update on key aspects of RRT prescription and delivery to critically ill patients. Recently completed trials have enhanced the evidence base regarding several RRT practices, most notably the timing of RRT initiation and anticoagulation for continuous therapies. Better evidence is still needed to clarify several aspects of care including optimal targets for ultrafiltration and effective strategies for RRT weaning and discontinuation.

Iatrogenic blood loss in critical care: A prospective observational study conducted at Universitas Academic Hospital in the Free State Province, South Africa.

Background Prevention of iatrogenic blood loss is an essential component of patient blood management (PBM) in intensive care units (ICUs). The amount of iatrogenic blood loss from diagnostic phlebotomy in the ICUs at Universitas Academic Hospital, Free State Province, South Africa, is unknown. Objectives To quantify diagnostic phlebotomy volumes, and volumes submitted in excess for diagnostic testing in the ICU. Methods We conducted a prospective descriptive observational study on adults who were admitted to ICUs at a single centre over a period of 14 days. The weight of each filled phlebotomy tube was calculated using the specific gravity of blood and averages of empty phlebotomy tubes, establishing the total volume. ResultsData from 59 participants with a median length of stay at the ICU of 3 days were analysed. The median phlebotomy volume was 7.0 mL day and 13.6 mL/ICU admission. The volume of blood required for analysis daily and ICU admission was 0.7 mL and 2.2 mL, respectively. The median phlebotomy volume in excess of the amount required for analysis daily and ICU admission was 5.05 mL and 12.11 mL, respectively. Conclusion While the median excess daily phlebotomy volume in this present study may seem insignificant and underestimating the true excess of phlebotomy volume, interventions to reduce phlebotomy volumes and development of a PBM guideline for appropriate phlebotomy volumes and preventing wastage of patients’ blood in the ICU is required. Contributions of the study We determined blood volume requirements for laboratory instrumentation, which allows phlebotomists to be cognisant of the true requirements for diagnostic tests to be undertaken accurately. We established diagnostic blood loss volumes in critical care units at a tertiary hospital in South Africa and we advocate for the introduction of patient blood management practice guidelines at local institutions.

Natriuretic peptides, extracellular volume, and subclinical cardiovascular changes in chronic kidney disease stages 1–3: a pilot study

Natriuretic peptide levels are elevated in persons with chronic kidney disease (CKD) stages 1–3, but it remains unclear whether this is associated with extracellular volume excess or early cardiovascular changes....

Color Doppler Sonography Assisted Subcutaneous Mastectomy with Inferior Pedicled Nipple-Areola Complex in Female-to-Male Transsexuals: A Retrospective Cohort Analysis.

The surgical goals of gender reassignment surgery of the breast in female-to male transsexuals (FMT) is the aesthetic shaping of a male thoracic wall with minimal scarring, while preserving the sensitivity of the nipple-areola complex (NAC). For large and ptotic breasts, we perform a mastectomy over an inframammary access with inferior pedicled NAC under color Doppler visualization of the perforators. This paper presents the technique, including complications and assessment of quality of life, as part of a unicentric analysis. This was a retrospective analysis of 23 patients (46 mastectomies) performed between September 2014 and September 2020. The complication rate and the number of corrective surgeries were recorded for quality assessment. A semiquantitative score was used to evaluate aesthetic outcome, nipple sensitivity, quality of life, and sexuality. A total of 46 mastectomies were performed in 23 patients. The patient survey showed high patient satisfaction. Loss of nipple sensitivity was observed after one mastectomy (2.17%). In 91.67% of cases, patients reported that their appearance reflected how they feel on the inside. In 75% of cases, patients reported feeling equal to other men. The overall complication rate was 10.87%. Shape correction due to persistent excess of volume was rare (2.17%, equivalent to one mastectomy). Subcutaneous mastectomy with inferior nipple pedicle can be performed with a high degree of safety and satisfaction in FMT. Color Doppler-guided visualization of the perforator vessels is helpful in allowing a thin pedicle preparation, thus reducing the need for secondary surgeries to optimize the shape. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

MO651: The Blood to Extracellular Volume Relationship is Stable and in the Physiologic Range in Chronic Haemodialysis Patients

Abstract BACKGROUND AND AIMS Blood volume (BV) is tightly controlled by the kidneys and the interstitial space plays an important role in this control. The interstitial space serves as a volume buffer in case of volume excess or volume depletion. It is the purpose of this buffer to maintain adequate circulatory and diastolic filling pressures, and thereby to maintain a functional circulation of the blood. BV is approximately one-third of the extracellular volume (ECV) under physiologic conditions. In haemodialysis patients without renal function, ECV is expanded because fluid is accumulated in the interdialytic period. This volume excess has to be removed during dialysis by ultrafiltration (UF) of blood. The question therefore arises, i) how is this volume excess distributed between intra-and extravascular compartments in dialysis patients and ii) how is this distribution affected by UF? METHOD Blood and extracellular volumes were measured in 79 stable chronic haemodialysis patients with moderate volume overload (1.85 ± 1.22 L). Immediately before treatment, ECV and volume overload were evaluated by bioimpedance spectroscopy using the body composition monitor [BCM, Fresenius Medical Care (FMC), Bad Homburg, Germany]. ECV at the end of treatment was calculated by subtracting the intra-dialytic weight loss from pre-dialysis ECV. The actual BV at the beginning of dialysis was determined by indicator dilution, using an online infusate bolus of 240 mL which was administered immediately after the beginning of the dialysis session and subsequent calculation using the data of the relative BV monitor integrated into the haemodiafiltration machine 5008 [Fresenius Medical Care (FMC), Bad Homburg, Germany]. BV at the end of the dialysis session was calculated from the measurement of BV at the beginning and the relative BV at the end of dialysis. RESULTS The relationship of BV (5.76 ± 1.54 L) to ECV (17.91 ± 3.90 L) was 0.321 ± 0.039 at dialysis start and 0.319 ± 0.040 at the end (BV 5.20 ± 1.41 L, ECV 16.22 ± 3.57 L). The mean deviation between pre- and post-dialysis was −0.002 ± 0.018. There were strong correlations (P < .001) between BV and ECV both at the beginning (r = 0.88) and at the end (r = 0.88) of dialysis. CONCLUSION These data show that i) the blood to extracellular volume ratio in haemodialysis patients is close to one-third assumed under physiologic conditions and that ii) this ratio remains unchanged in spite of UF. The constant relationship between the two compartments is maintained under conditions of haemodialysis with the rapid volume removal by UF. This confirms previous findings that the vascular refilling volume is only about 70% of UF volume during dialysis. Despite the lack of kidney function, the mechanisms to adequately distribute volume excess between intra- and extravascular appear to be maintained. The volume shift between plasma and interstitial volume prevents both an inter-dialytic cardio-vascular burden and intra-dialytic hypotension. Therefore, haemodialysis patients with moderate volume overload are likely to be adequately protected from volume-related complications. To the best of our knowledge, this is the first time that these relationships are reported in dialysis patients.

The Common Phenotype Of Polycythemia And Hypervolemia In Hospitalized Heart Failure Patients

<h3>Background</h3> : Heart failure patients have wide variations in intravascular volumes which form the basis for disease initiation and progression and contribute to confusion in treatment strategies. Blood volume analysis (BVA) is a bedside blood test that measures with 98% accuracy intravascular volumes of a HF patient, including plasma and red blood cell volume (RBCV). Extremes in excess of red blood cell volume (polycythemia (P)) in HF patients have been associated with poorer outcomes including mortality. A not uncommon BVA phenotype is that of secondary P, with or without hypervolemia(P/Hypervol). We sought to further clarify the clinical correlates and outcomes associated with this phenotype in a mixed LVEF cohort of hospitalized HF patients and whether this phenotype would be detectable utilizing pHct or Hgb measures. <h3>Methods/Results</h3> : In a cohort of 245 consecutively admitted HF patients (142 men/103 women) with mixed EFs who underwent BVA guided care, 25 patients (10.2%) had P/Hypervol and 3 patients (1.2%) had P with normal or low total blood volume. The presence of this phenotype was equal in patients with HFrEF and HFpEF (52%/48%). P/Hypervol was observed less frequently in patients over 75 (p=0.03), and among patients with BMI>35 (p=0.07). Despite P, the peripheral Hct (pHct) was either normal (57.1%), or >10% below normal (39.3%), indicating that in a majority of patients excess red cells were accompanied by an excess of plasma and that pHct would not indicate P. The BVA-provided RBCV showed that in 93% of patients with P that diuresis alone would not be able to achieve euvolemia without extreme hemoconcentration. Patients with P or P/Hypervol were treated with therapeutic phlebotomy or sent for hematology consults to achieve euvolemia. In terms of outcomes at 30 days post-discharge, 12% of the phenotype were readmitted, similar to those with other phenotypes; no deaths occurred in the P/Hypervol phenotype within 30 days or 365 days. 30-day readmissions did occur (56%) in the phenotype similar to other phenotypes (62.3%). <h3>Conclusions</h3> : The P/Hypervol phenotype is common and worrisome for several reasons. Neither the pHct, the BMI or age is sufficient to identify this phenotype. The plasma and red blood cell volume (RBCV) expansion may hasten disease progression accounting for underrepresentation of older patients in this cohort. Further, the discrepancy in the pHct might lead clinicians to suspect that the patient has a dilutionally low pHct, when, in fact, they have an increased RBCV and a diuretic strategy alone will only hemoconcentrate the patient, increasing viscosity and risk of thrombotic events while not achieving euvolemia. BVA-guided assessment demonstrated the specificity to identify this phenotype. and raise the value of therapeutic phlebotomy to optimize volume and RBCV; this cohort merits improved BVA-guided evaluation to better discern the impact of this phenotype on HF outcomes.

Multimodality Approach to Lymphedema Surgery Achieves and Maintains Normal Limb Volumes: A Treatment Algorithm to Optimize Outcomes.

Surgical treatment of advanced lymphedema is challenging and outcomes are suboptimal. Physiologic procedures including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) improve lymphatic flow but cannot reverse fibrofatty tissue deposition, whereas liposuction removes fibrofatty tissue but cannot prevent disease progression. The adjunctive use of nanofibrillar collagen scaffolds (BioBridgeTM) can promote lymphangiogenesis. We report a treatment algorithm utilizing a multimodality approach to achieve sustained normal limb volumes in patients with stage II-III lymphedema. A retrospective review of late stage II-III lymphedema patients treated with liposuction, physiologic procedures, and BioBridgeTM from 2016 through 2019 was conducted. Treatment outcome in the form of excess volume reduction is reported. Total of 14 patients underwent surgical treatment of late stage II and III lymphedema according to our triple therapy algorithm. Patients had a baseline median volume excess of 29% (19.8, 43.3%). The median volume excess was improved to 0.5% (−4.3, 3.8%) at 14.4 months from the first stage surgery (p < 0.05) and further improved to −1.0% (−3.3, 1.3%) after triple therapy with BB placement at 24.6 months. A triple therapy surgical treatment algorithm can optimize outcomes and achieve sustained normalization of limb volume in late stage II-III lymphedema. The incorporation of nanofibrillar collagen scaffold technology allows for improved and sustained volume reduction.

Outcomes and technical modifications of vascularized lymph node transplantation from the lateral thoracic region for treatment of lymphedema.

This study evaluates clinical outcomes of vascularized lymph node transplantation (VLNT) from the lateral thoracic region and technical modifications. Consecutive patients that underwent lateral thoracic VLNT to treat extremity lymphedema were included. Demographic and treatment data were recorded, and outcomes data including limb volume, LDex score, and Lymphedema Life Impact Scale (LLIS), QuickDASH, and LEFS questionnaires, were collected prospectively. Consecutive patients that underwent single-photon emission computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (RLM) were analyzed to characterize the physiological drainage of the normal upper extremity. A consecutive series of 32 flaps were included. At 24 months postoperatively mean reduction in limb volume excess was 47.2% (±11.6; p = 0.0085), LDex score was 63.1% (±8.5; p < 0.001), and LLIS score was 65.1% (±7.4; p < 0.001). Preoperatively 14/31 patients (45.2%) reported cellulitis, and postoperatively there were no episodes at up to 24 months (p < 0.001). No patient developed donor extremity lymphedema at mean 18.6 (±8.3) months follow-up. SPECT/CT-RLM of 182 normal axillae demonstrated that the sentinel lymph node(s) of the upper extremity was consistently anatomically located in the upper outer quadrant of the axilla (97%). VLNT from the lateral thoracic region is effective and versatile for the treatment of lymphedema with a low donor site complication rate.

Analysis of the deep drilling technology in unstable formations at the Semyrenky gas condensate field

The paper presents a general overview of deep drilling in unstable formations at the Semyrenky gas condensate field of the Dnipro-Donetsk Trough, including well design, bottom hole assemblies (BHA), drilling conditions, and drilling muds. Problems encountered during drilling for production casing of Wells 72- and 75-Semyrenky using high-speed drilling methods are analyzed. The relationships between the rate of penetration and disturbed rock stability, volume excess and depth, as well as consistent empirical patterns in changes in mud properties and depth are established. With these technical and economic performance indicators for well drilling are given, elements of a borehole stability management strategy were defined, the principles of mud selection for drilling through problem zones are validated. The paper discusses the requirements to a mud hydraulics program to reduce the erosion of borehole walls, specific borehole preparation techniques, such as reaming and gauging, for drilling in problem zones, and alternative options to ensure borehole stability. Keywords: borehole stability; statistical models; hole gauging; hole geometry; drilling mud; BHA.

Experimental and Modeling Comparison of the Dynamics of Capped and Freestanding Poly(2-chlorostyrene) Films.

Proximity to a nonrepulsive wall is commonly considered to cause slower dynamics, which should lead to greater relaxation times for capped thin polymer films than for bulk melts. To the contrary, here we demonstrate that Al-capped films of poly(2-chlorostyrene) exhibit enhanced dynamics with respect to the bulk, similar to analogous freestanding films. To quantitatively resolve the impact of interfaces on whole film dynamics, we analyzed the experimental data via the Cooperative Free Volume rate model. We found that the interfacial region adjacent to a cap contains an excess of free volume (relative to the bulk) about half of that proximate to a free surface. Employing a useful analogy between confinement and pressure effects, we estimated that the effect of capping an 18 nm freestanding film would be equivalent to applying a pressure increase of 19 MPa.

Estimated plasma volume status is a modest predictor of true plasma volume excess in compensated chronic heart failure patients

Plasma volume and especially plasma volume excess is a relevant predictor for the clinical outcome of heart failure patients. In recent years, estimated plasma volume based on anthropometric characteristics and blood parameters has been used whilst direct measurement of plasma volume has not entered clinical routine. It is unclear whether the estimation of plasma volume can predict a true plasma volume excess. Plasma volume was measured in 47 heart failure patients (CHF, 10 female) using an abbreviated carbon monoxide rebreathing method. Plasma volume and plasma volume status were also estimated based on two prediction formulas (Hakim, Kaplan). The predictive properties of the estimated plasma volume status to detect true plasma volume excess > 10% were analysed based on logistic regression and receiver operator characteristics. The area under the curve (AUC) to detect plasma volume excess based on calculation of plasma volume by the Hakim formula is 0.65 (with a positive predictive value (PPV) of 0.62 at a threshold of − 16.5%) whilst the AUC for the Kaplan formula is 0.72 (PPV = 0.67 at a threshold of − 6.3%). Only the estimated plasma volume status based on prediction of plasma volume by the Kaplan formula formally appears as an acceptable predictor of true plasma volume excess, whereas calculation based on the Hakim formula does not sufficiently predict a true plasma volume excess. The low positive predictive values for both methods suggest that plasma volume status estimation based on these formulas is not suitable for clinical decision making.

Case Report on Cirrhosis of Liver

Liver is the second largest organ in human body, more than 5,000 separate bodily functions .including helping blood to clot, cleansing the blood of toxins to converting food into nutrients to control hormone levels, fighting infections and illness, regenerating back after injury and metabolizing cholesterol, glucose, iron and controlling their levels. A 56- years old patient was admitted in AVBRH on date 9/12/2020 in ICU with the chief complaint of abdominal distension, breathlessness on exertion, pedal edema, fever since 8 days. After admitted in hospital all investigation was done including blood test, ECG, fluid cytology, peripheral smear, ultrasonography, etc. All investigation conducted and then final diagnosis confirmed as cirrhosis of liver. Patient was not having any history of communicable disease or any hereditary disease but he has history of hypertension and type II Diabetes mellitus for 12 years. Patient was COVID-19 negative and admitted in intensive care unit. Patient had been undergone with various investigations like physical examination, blood test, CSF fluid examination, ascitic fluid examination, fluid cytology, peripheral smear, ultrasonography, RT-PCR etc. Patient was treated with tab. farobact ER 300 mg BD, tab. Lasix 40 mg OD, tab. Udilive 300 mg BD, tab. Rifagut 300 mg BD, tab. Metformin 500 mg OD, tab. Amlo 5mg OD, syp. Duphalac 30ml HS. Monitor vital signs, maintain input output, Monitoring and managing potential complications like, bleeding and haemorrhage, hepatic encephalopathy, fluid volume excess, monitor laboratory tests as indicated, Identify and assess for pedal edema.&#x0D; Conclusion: Cirrhosis of the liver is one of the final stages of liver disease. It is a serious condition, causing scarring and permanent damage to the liver. Life expectancy depends on the stage and type of cirrhosis of liver. Cirrhosis progresses, more and more scar tissue forms, making it difficult for the liver to function (decompensated cirrhosis). Advanced cirrhosis is life-threatening. If liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and, rarely, reversed.

Grain and processed grain products market: topical issues and ways of their solution

The goal is to assess the current state of the market for grain and its processed products, to determine the features of its functioning and prospects for further development. Methods - economic, statistical and analytical, which made it possible to identify main trends taking place in grain products subcomplex of the country, draw up a balance of resources, as well as the use of grain and grain products. Results - in the process of studying this problem, it was indicated that as a result of reduction in the own products volume, the resource part of the balance of grain and its use for the analyzed period decreased. It was determined that grain market in Kazakhstan is exportoriented. The analysis indicates a high level of self-sufficiency in grain crops and products of their processing in the republic. It has been determined that grain industry fully meets the needs of the domestic market, thereby contributing to the increase in the level of food security of the country. The negative tendency of reducing production volume and export of flour has been clarified. The presence and relevant use of grain processing facilities are analyzed. The authors note a significant excess of the potential possible processing volume over the actual indicators. Information on the export of flour in the context of exporting countries is presented. The assessment of the export potential of grain market has been carried out. The emphasis is made on the fact that Kazakhstan has a significant reserve of grain and flour exports. Conclusions - measures of State regulation of problems in logistics system, transportation of raw materials and flour, as well as directions of effective support for the development of milling industry, market infrastructure are proposed, including based on the principles of public-private partnership.

Use of Ultrasound to Assess Hemodynamics in Acutely Ill Patients.

Early diagnosis of AKI and preventive measures can likely decrease the severity of the injury and improve patient outcomes. Current hemodynamic monitoring variables, including BP, heart and respiratory rates, temperature, and oxygenation status, have been used to identify patients at high risk for AKI. Despite the widespread use of such variables, their ability to accurately and timely detect patients who are high risk has been questioned. Therefore, there is a critical need to develop and validate tools that can measure new and more kidney-specific hemodynamic and laboratory variables, potentially assisting with AKI risk stratification, implementing appropriate and timely preventive measures, and hopefully improved outcomes. The new ultrasonography techniques provide novel insights into kidney hemodynamics and potential management and/or therapeutic targets. Contrast-enhanced ultrasonography; Doppler flow patterns of hepatic veins, portal vein, and intrakidney veins; and ultrasound elastography are among approaches that may provide such information, particularly related to vascular changes in AKI, venous volume excess or congestion, and fluid tolerance. This review summarizes the current state of these techniques and their relevance to kidney hemodynamic management.

Prognostic implications of echocardiographic measures of left and right atrial pressures on survival in patients with end stage renal disease

Background Volume excess is common in patients with end stage renal disease (ESRD). We examined the prognostic value of clinical and echocardiographic measures of left (LA) and right atrial (RA) hypertension in this population. Method We prospectively collected demographic, clinical, pharmacological, echocardiographic data on 575 consecutive ESRD patients on hemodialysis undergoing cardiac evaluation before renal transplantation in a dedicated cardiac clinic. Survival was analyzed as a function of clinical and echocardiographic measures of LA and (RA) hypertension. Result Elevated LA pressure was seen in 48% of the patients based on E/e’ velocity ratio of ≥ 15, and 28% had elevated RA pressure based on inferior vena caval size. Physical examination grossly underestimated the prevalence of both LA and RA hypertension. Atrial pressures were normal in 46% and both atrial pressures were elevated in 20% of the patients. Elevated LA pressure in the presence of normal RA pressure was found in 30%. Over a period of 20 ± 8 months, there were 43 deaths. There was a graded increase in mortality with increases in LA and bi-atrial hypertension (p = .009). The 2-year mortality rate was 6% in those with normal atrial pressures, 13% in those with isolated LA hypertension and 28% in those with bi-atrial hypertension. Conclusion Mitral E/e’ ratio and inferior vena caval size are vastly more sensitive than physical examination for recognition of elevated atrial pressures and are strong predictors of survival in ESRD patients. Limited echocardiographic examination may have a role in ESRD patients undergoing dialysis to help achieve euvolemic status.

УПРАВЛЕНИЕ ЗАТРАТАМИ, ПРИБЫЛЬЮ И БЕЗУБЫТОЧНОСТЬЮ ТРАНСПОРТНОЙ КОМПАНИИ

To manage the financial stability of the company, working capital, current activities, business risk and solvency, CVP analysis, the value of the break-even point plays an important role, as well as the degree of excess of sales volumes over the critical point, which determines the company's stability margin. The article analyzes the income and expenses of the company, the analysis of the volume of production, cost and profit, the analysis of break-even and the relationship between the income and the number of flight hours of the studied company of Air Astana JSC, which revealed a strong relationship between the indicators based on the calculated correlation coefficient (0.9527), as well as a direct dependence of the income (90.75%) of the company on the flight hours based on the coefficient of determination. The analysis of the influence of various factors on the critical sales volume and break-even points is carried out.

Not all fluid overloads are the same: some practical considerations for better decongestion

Not all fluid overloads are the same: some practical considerations for better decongestion