RESUMO
Rice bean [Vigna umbellata (Thunb.) Ohwi and Ohashi], an annual legume in the genus Vigna, is a promising crop suitable for cultivation in a changing climate to ensure food security. It is also a medicinal plant widely used in traditional Chinese medicine; however, little is known about the medicinal compounds in rice bean. In this study, we assessed the diuretic effect of rice bean extracts on mice as well as its relationship with the contents of eight secondary metabolites in seeds. Mice gavaged with rice bean extracts from yellow and black seeds had higher urinary output (5.44-5.47 g) and water intake (5.8-6.3 g) values than mice gavaged with rice bean extracts from red seeds. Correlation analyses revealed significant negative correlations between urine output and gallic acid (R = -0.70) and genistein (R = -0.75) concentrations, suggesting that these two polyphenols negatively regulate diuresis. There were no obvious relationships between mice diuresis-related indices (urine output, water intake, and weight loss) and rutin or catechin contents, although the concentrations of both of these polyphenols in rice bean seeds were higher than the concentrations of the other six secondary metabolites. Our study findings may be useful for future research on the diuretic effects of rice bean, but they should be confirmed on the basis of systematic medical trials.
Assuntos
Diuréticos , Polifenóis , Sementes , Animais , Camundongos , Diuréticos/farmacologia , Sementes/química , Polifenóis/farmacologia , Polifenóis/análise , Masculino , Extratos Vegetais/farmacologia , Vigna/química , Ácido Gálico/farmacologia , Genisteína/farmacologia , Catequina/farmacologia , Catequina/análise , Rutina/farmacologia , Rutina/análise , Diurese/efeitos dos fármacosRESUMO
BACKGROUND: Recent advances in heart failure (HF) care have sought to shift management from inpatient to outpatient and observation settings. We evaluated the association among HF treatment in the (1) inpatient; (2) observation; (3) emergency department (ED); and (4) outpatient settings with 30-day mortality, hospitalizations and cost. METHODS: Using 100% Medicare inpatient, outpatient and Part B files from 2011-2018, 1,534,708 unique patient encounters in which intravenous (IV) diuretics were received for a primary diagnosis of HF were identified. Encounters were sorted into mutually exclusive settings: (1) inpatient; (2) observation; (3) ED; or (4) outpatient IV diuretic clinic. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 30-day hospitalization and total 30-day costs. Multivariable logistic and linear regression were used to examine the association between treatment location and the primary and secondary outcomes. RESULTS: Patients treated in observation and outpatient settings had lower 30-day mortality rates (observation OR 0.67, 95% CI 0.66-0.69; P < 0.001; outpatient OR 0.53, 95% CI 0.51-0.55; P < 0.001) compared to those treated in inpatient settings. Observation and outpatient treatment were also associated with decreased 30-day total cost compared to inpatient treatment. Observation relative cost -$5528.77, 95% CI -$5613.63 to -$5443.92; outpatient relative cost -$7005.95; 95% CI -$7103.94 to -$6907.96). Patients treated in the emergency department and discharged had increased mortality rates (OR 1.15, 95% CI 1.13-1.17; P < 0.001) and increased rates of hospitalization (OR 1.72, 95% CI 1.70-1.73; P < 0.001) compared to patients treated as inpatients. CONCLUSIONS: Medicare beneficiaries who received IV diuresis for acute HF in the outpatient and observation settings had lower mortality rates and decreased costs of care compared to patients treated as inpatients. Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.
Assuntos
Insuficiência Cardíaca , Medicare , Humanos , Idoso , Estados Unidos/epidemiologia , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/diagnóstico , Hospitalização , Alta do Paciente , Diuréticos , DiureseRESUMO
Aim: Compare heart failure (HF) costs of Furoscix use at home compared with inpatient intravenous (IV) diuresis. Patients & methods: Prospective, case control study of chronic HF patients presenting to emergency department (ED) with worsening congestion discharged to receive Furoscix 80 mg/10 ml 5-h subcutaneous infusion for ≤7 days. 30-day HF-related costs in Furoscix group derived from commercial claims database compared with matched historical patients hospitalized for <72 h. Results: Of 24 Furoscix patients, 1 (4.2%) was hospitalized in 30-day period. 66 control patients identified and were well-matched for age, sex, ejection fraction (EF), renal function and other comorbidities. Furoscix patients had reduced mean per patient HF-related healthcare cost of $16,995 (p < 0.001). Conclusion: Furoscix use was associated with significant reductions in 30-day HF-related healthcare costs versus matched hospitalized controls.
What is this article about? In heart failure (HF), the heart cannot pump as well as it should. This causes blood to back up in the vessels that return blood to the heart. Fluid leaks from these vessels and collects in vital organs such as the lungs. This fluid build-up is called congestion. Congestion causes symptoms such as shortness of breath, tiredness and leg swelling. Furoscix is a prescription medicine, a diuretic, that treats congestion. Diuretics help get rid of extra fluid by increasing urination. Congestion is usually managed with oral diuretics, but sometimes congestion cannot be controlled by oral diuretics and patients may have to spend several days at a clinic or hospital to receive diuretics given through a vein (intravenous or iv.). Furoscix is a new formulation of furosemide, a common diuretic, and is delivered into the skin (subcutaneous) by a self-administered pump instead of through an iv. Our investigation aimed to answer two questions Can Furoscix be given to patients at home instead of in the hospital with iv. diuretics? Is there a cost savings to using Furoscix? Instead of being admitted to the hospital for iv. diuretics, HF patients with worsening congestion who came to the emergency department were sent home to receive Furoscix 80 mg/10 ml 5-h subcutaneous infusion for ≤7 days. 30-day costs related to HF in these patients were compared with costs from similar group of patients previously hospitalized for iv. diuretics. What were the results & what do they mean? In patients who needed to be admitted to the hospital for iv. diuretics, Furoscix given at home instead reduced congestion and resulted in significant cost savings. Patients with heart failure, who are not getting relief with oral diuretics, can be treated with Furoscix at home without having to be admitted to the hospital for iv. diuretics. Use of Furoscix instead of iv. furosemide can save money to the healthcare system.
Assuntos
Custos de Cuidados de Saúde , Insuficiência Cardíaca , Humanos , Estudos de Casos e Controles , Estudos Prospectivos , Diurese , Insuficiência Cardíaca/tratamento farmacológico , HospitaisRESUMO
BACKGROUND: Neutrophil gelatinase-associated lipocalin (NGAL) is a recognised biomarker for acute kidney injury (AKI).This study investigated the impact of balanced forced-diuresis using RenalGuard® system (RG), in reducing acute kidney injury (AKI) rates and the associated NGAL levels (6-h post-CPB plasma level) post adult cardiac surgery with cardiopulmonary bypass (CPB). METHODS: Patients included in the study were at high-risk for AKI post cardiac surgery, namely history of diabetes and/or anaemia, e-GFR 20-60 ml/min/1.73 m2, Logistic EuroScore > 5, anticipated CPB time > 120 min. Patients were randomized to either RG (n = 110) or managed as per current practice (control = 110). RIFLE-defined AKI rate (based on serum creatinine level increase) within first 3 days of surgery and 6-h post CPB NGAL levels were the primary and secondary end-points. RESULTS: Pre and intra-operative characteristics between the two groups were similar (p > 0.05) including the pre-op NGAL levels, the oxygen delivery (ecDO2i) and the carbon dioxide production (ecVCO2i) during CPB. Patients in the RG group had a significantly lower post-operative RIFLE-defined AKI rate compared to control (10% (11/110) v/s 20.9% (23/110), p = 0.03). Overall, median 6-h post CPB NGAL levels in patients with AKI were significantly higher than those who did not develop AKI (211 vs 150 ng/ml, p < 0.001). Patients managed by balanced forced-diuresis had lower post-operative NGAL levels (146 vs 178 ng/ml, p = 0.09). Using previously reported NGAL cut-off level for AKI (142 ng/ml), binary logistic regression analysis confirmed a beneficial effect of the RG system, with an increased risk of AKI of 2.2 times in the control group (OR 2.2, 95% CI 1.14-4.27, p = 0.02). CONCLUSIONS: Overall, the 6-h post-CPB plasma NGAL levels were significantly higher in patients who developed AKI. Patients managed with the novel approach of balanced forced-diuresis, provided by the RenalGuard® system, had a lower AKI rate and lower NGAL levels indicating a lesser degree of renal tissue injury. Trial registration ClinicalTrials.gov website, NCT02974946, https://clinicaltrials.gov/ct2/show/NCT02974946 .
Assuntos
Injúria Renal Aguda , Procedimentos Cirúrgicos Cardíacos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/prevenção & controle , Proteínas de Fase Aguda , Adulto , Biomarcadores , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Creatinina , Diurese , Humanos , Lipocalina-2 , Lipocalinas , Valor Preditivo dos Testes , Proteínas Proto-OncogênicasRESUMO
BACKGROUND: Recurrent congestion in cardiac amyloidosis (CA) remains a management challenge, often requiring high dose diuretics and frequent hospitalizations. Innovative outpatient strategies are needed to effectively manage heart failure (HF) in patients with CA. Ambulatory diuresis has not been well studied in restrictive cardiomyopathy. Therefore, we aimed to examine the outcomes of an ambulatory diuresis clinic in the management of congestion related to CA. METHODS AND RESULTS: We retrospectively studied patients with CA seen in an outpatient HF disease management clinic for (1) safety outcomes of ambulatory intravenous (IV) diuresis and (2) health care utilization. Forty-four patients with CA were seen in the clinic a total of 203 times over 6 months. Oral diuretics were titrated at 96 (47%) visits. IV diuretics were administered at 56 (28%) visits to 17 patients. There were no episodes of severe acute kidney injury or symptomatic hypotension. There was a significant decrease in emergency department and inpatient visits and associated charges after index visit to the clinic. The proportion of days hospitalized per 1000 patient days of follow-up decreased as early as 30 days (147.3 vs 18.1/1000 patient days of follow-up, P< .001) and persisted through 180 days (33.6 vs 22.9/1000 patient days of follow-up, P< .001) pre- vs post-index visit to the clinic. CONCLUSIONS: We demonstrate the feasibility of ambulatory IV diuresis in patients with CA. Our findings also suggest that use of a HF disease management clinic may reduce acute care utilization in patients with CA. Leveraging multidisciplinary outpatient HF clinics may be an effective alternative to hospitalization in patients with HF due to CA, a population who otherwise carries a poor prognosis and contributes to high health care burden.
Assuntos
Instituições de Assistência Ambulatorial , Amiloidose/complicações , Cardiomiopatias/complicações , Diuréticos/uso terapêutico , Insuficiência Cardíaca/terapia , Idoso , Instituições de Assistência Ambulatorial/economia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Diurese , Diuréticos/administração & dosagem , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Custos de Cuidados de Saúde , Necessidades e Demandas de Serviços de Saúde , Insuficiência Cardíaca/etiologia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos RetrospectivosRESUMO
Various dose regimens of imipenem have been prescribed in critically ill patients undergoing continuous renal replacement therapy (CRRT) but there are limited information on its pharmacokinetics (PK) and treatment efficacy. The aim of this study was to describe the population PK of imipenem in patients receiving CRRT, and utilize this model to inform optimal dosing regimens using pharmacokinetics/pharmacodynamics (PK/PD) target as a surrogate marker for treatment efficacy. Population PK modelling was undertaken in 20 patients receiving CRRT to characterize variabilities and identify influential covariates. Monte Carlo simulations were performed to evaluate differences in probability of target attainment (PTA) between empirically used dosing regimens (0.5 g q6h, 1 g q8h, and 1 g q6h), and to explore the impact of CRRT intensity and identified covariates on target attainment. Imipenem concentration data were adequately described using a one-compartment model. Residual diuresis and burn injury were identified modifiers for imipenem endogenous clearance. The simulations showed that the impact of CRRT intensity on target attainment is clinically irrelevant, whereas urine output and burn injury influence PTA for pathogens with an MIC ≥ 4 mg/L. At an MIC ≤ 2 mg/L, satisfactory PTAs (>80%) were achieved for all three investigated dose regimens regardless of urine output, burn injury, and CRRT intensity. Our results indicate that from a safety perspective, 0.5 g q6h imipenem is optimal in these patients for pathogens with an MIC ≤ 2 mg/L, and 1 g q6h is recommended for non-burn patients with anuria against MIC 4-16 mg/L.
Assuntos
Antibacterianos/farmacocinética , Imipenem/farmacocinética , Terapia de Substituição Renal , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/administração & dosagem , Estado Terminal , Diurese , Feminino , Humanos , Imipenem/administração & dosagem , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Método de Monte CarloRESUMO
A recent study showed that a significant fall in mean arterial pressure (MAP) occurred following intravenous injection of two novel superparamagnetic iron oxide nanoparticles (SPIONs), MF66 and OD15. To assess if this was caused by excessive glomerular clearance, the effect of both particles on renal function was studied. Experiments were performed on sodium pentobarbital anaesthetised male Wistar rats (250-350 g). Twenty-minute urine clearances were taken followed by an i.v. bolus of MF66, OD15 (2 mg·kg-1), or dH2O (0.4 mL·kg-1). MF6 or OD15 injection resulted in a significant transient drop in MAP and renal blood flow by approximately 33% and 50% (P < 0.05). The absolute excretion of sodium was significantly increased (P < 0.05) by almost 80% and 70% following OD15 and MF66, respectively. Similarly, fractional excretion of sodium was increased by almost 80% and 60% following OD15 and MF66, respectively. The glomerular filtration rate was not significantly affected, but urine flow increased nonsignificantly by approximately 50% and 66% following i.v. injection of OD15 and MF66, respectively. SPIONs produce a decrease in blood pressure and a natriuresis; however, the rate of fluid filtration in the kidney was not significantly affected.
Assuntos
Sistemas de Liberação de Medicamentos/efeitos adversos , Compostos Férricos/efeitos adversos , Taxa de Filtração Glomerular/efeitos dos fármacos , Hipotensão/induzido quimicamente , Nanopartículas de Magnetita/efeitos adversos , Natriurese/efeitos dos fármacos , Circulação Renal/efeitos dos fármacos , Anestesia Intravenosa , Animais , Diurese/efeitos dos fármacos , Compostos Férricos/administração & dosagem , Compostos Férricos/farmacocinética , Injeções Intravenosas , Imageamento por Ressonância Magnética/métodos , Nanopartículas de Magnetita/administração & dosagem , Nanopartículas de Magnetita/química , Masculino , Taxa de Depuração Metabólica , Modelos Animais , Pentobarbital/administração & dosagem , Ratos , Ratos WistarRESUMO
INTRODUCTION: The relationship between hypertension and fluid overload in pre-dialysis CKD patients need to be elucidated. Current study aimed to find relationship between fluid overload and hypertension along with prescribed diuretic therapy using bioimpedance spectroscopy (BIS). METHODOLOGY: A prospective observational study was conducted by inviting pre-dialysis CKD patients. Fluid overload was assessed by BIS. RESULTS: A total of 312 CKD patients with mean eGFR 24.5 ± 11.2 ml/min/1.73 m2 were enrolled. Based on OH value ≥7 %, 135 (43.3 %) patients were hypervolemic while euvolemia was observed in 177 (56.7 %) patients. Patients were categorized in different regions of hydration reference plot (HRP) generated by BIS i.e., 5.1 % in region-N (normal BP and fluid status), 20.5 % in region I (hypertensive with severe fluid overload), 29.5 % in region I-II (hypertensive with mild fluid overload), 22 % in region II (hypertensive with normohydration), 10.2 % in region III (underhydration with normal/low BP) and 12.5 % in region IV (normal BP with severe fluid overload). A total of 144 (46 %) patients received diuretics on basis of physician assessment of BP and edema. Maximum diuretics 100 (69.4 %) were prescribed in patients belonging to regions I and I-II of HRP. Interestingly, a similar number of diuretic prescriptions were observed in region II (13 %) and region IV (12 %). Surprisingly, 7 (4.9 %) of patients in region III who were neither hypervolemic nor hypertensive were also prescribed with diuretics. CONCLUSION: BIS can aid clinicians to categorize CKD patients on basis of their fluid status and provide individualized pharmacotherapy to manage hypertensive CKD patients.
Assuntos
Pressão Sanguínea/efeitos dos fármacos , Composição Corporal/efeitos dos fármacos , Diurese/efeitos dos fármacos , Diuréticos/uso terapêutico , Hipertensão/tratamento farmacológico , Padrões de Prática Médica , Insuficiência Renal Crônica/tratamento farmacológico , Equilíbrio Hidroeletrolítico/efeitos dos fármacos , Desequilíbrio Hidroeletrolítico/tratamento farmacológico , Idoso , Espectroscopia Dielétrica , Diuréticos/efeitos adversos , Prescrições de Medicamentos , Impedância Elétrica , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Rim/efeitos dos fármacos , Rim/fisiopatologia , Malásia/epidemiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Estudos Prospectivos , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/fisiopatologia , Resultado do Tratamento , Desequilíbrio Hidroeletrolítico/diagnóstico , Desequilíbrio Hidroeletrolítico/epidemiologia , Desequilíbrio Hidroeletrolítico/fisiopatologiaRESUMO
OBJECTIVE: To compare bladder sensitivity between patients with pelvic pain and patients who were pain free, undergoing noninvasive, controlled bladder distension via diuresis. We also sought to measure potential mechanisms underlying bladder sensitivity. DESIGN: Prospective observational study. SETTING: Community teaching hospital. POPULATION: Reproductive-age women with non-bladder chronic pelvic pain (CPP, n = 23), painful bladder syndrome (PBS, n = 23), and pelvic pain-free controls (n = 42) METHODS: Participants were compared on cystometric capacity, pelvic floor pressure-pain thresholds (PPTs), pelvic muscle function, O'Leary-Sant bladder questionnaire, and psychosocial instruments using Wilcoxon rank-sum tests. Multivariate regression was used to identify factors underlying bladder pain phenotypes. MAIN OUTCOME MEASURES: Pelvic floor pain thresholds; self-reported bladder distension pain. RESULTS: Participants with PBS exhibited higher bladder distension pain than those with CPP, with both groups reporting higher pain levels than controls (P < 0.05). No significant associations were found between bladder distension pain and pelvic muscle structure or pain sensitivity measures; however, bladder distension pain positively correlates with both vaginal PPTs adjacent to the bladder (r = 0.46) and pain with transvaginal bladder palpation (r = 0.56). Pain at maximal distension was less influenced by somatic sensitivity than bladder symptoms (r = 0.35 versus r = 0.59; P < 0.05). Multivariate regression identified three independent components of bladder symptoms in PBS: bladder distension pain, bladder sensation, and somatic symptoms. CONCLUSIONS: Diuresis-induced bladder pain differentiates CPP from PBS. Experimental bladder pain is not predicted by pelvic floor sensitivity. Compared with patient-reported outcomes it appears less influenced by psychological factors. Further study is needed to determine whether screening for experimental bladder pain sensitivity could predict future risk of PBS. TWEETABLE ABSTRACT: Controlled, water ingestion-provoked bladder pain can objectively identify visceral pain sensitivity.
Assuntos
Dor Crônica/diagnóstico , Cistite Intersticial/diagnóstico , Medição da Dor/métodos , Dor Pélvica/diagnóstico , Adulto , Diurese/fisiologia , Feminino , Humanos , Análise Multivariada , Limiar da Dor , Diafragma da Pelve/fisiopatologia , Pressão , Estudos Prospectivos , Análise de Regressão , Estatísticas não Paramétricas , Inquéritos e Questionários , Bexiga Urinária/fisiopatologia , Adulto JovemRESUMO
OBJECTIVE: Urinary radiotracer excretion of 68Ga-Labelled prostate-specific membrane antigen (PSMA) ligands may complicate the assessment of the prostate region and differentiation of lymph nodes from ureteral activity. The aim of this study was to assess the value of delayed imaging after forced diuresis. MATERIALS AND METHODS: Sixty-six patients underwent 68Ga-PSMA I&T PET/CT for evaluation of prostate cancer at 60 min post-injection. In subgroups of patients, this was amended by delayed imaging after 180 min post-injection, preceded by furosemide and oral hydration early, at the time of tracer injection, or delayed, at 100 min post-injection. Urinary tracer activity within the bladder and focal ureteral activity was analyzed. RESULTS: After forced diuresis, linear and focal visualization of ureters was significantly reduced. After delayed furosemide, mean and peak bladder activity decreased (p < 0.001), and image quality of the prostate region improved on delayed images (p < 0.001). Early furosemide co-injection with tracer resulted in increased mean and peak bladder activity (p < 0.001) and in deteriorated image quality of the prostate region on delayed images (p = 0.008). CONCLUSION: Ga-PSMA I&T PET/CT delayed imaging after forced diuresis can improve the assessment of prostate region and pelvic lymph nodes by removing excreted tracer from the lower urinary tract. KEY POINTS: ⢠Forced diuresis can improve image quality in 68 Ga-PSMA I&T. ⢠After forced diuresis, linear and focal visualization of ureters was reduced. ⢠Timing of diuresis relative to 68 Ga-PSMA I&T injection is important. ⢠Early furosemide co-injection with tracer resulted in deteriorated image quality on delayed images. ⢠After delayed furosemide, image quality improved on delayed images.
Assuntos
Antígenos de Superfície , Glutamato Carboxipeptidase II , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Neoplasias da Próstata/diagnóstico por imagem , Compostos Radiofarmacêuticos , Idoso , Idoso de 80 Anos ou mais , Diurese/fisiologia , Feminino , Humanos , Linfonodos/patologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Pelve/patologia , Neoplasias da Próstata/patologia , Neoplasias da Próstata/fisiopatologiaRESUMO
BACKGROUND: In this study we have looked at the reliability of a multi-sugar test in a pediatric patient population and its accuracy at small urine volumes to evaluate intestinal permeability. METHODS: Out of 117 subjects enrolled, 31 were healthy and 86 were sick. A solution containing lactulose, rhamnose, sucrose, and sucralose was administered to subjects who were on fasting; the urine excreted during 5 h was collected and measured. Samples were analyzed by gas chromatography-tandem mass spectrometry and results were expressed as percentage of sugar recoveries and lactulose/rhamnose (L/R) ratio. RESULTS: The analyses showed a clear effect of low urinary volumes (≤240 mL) particularly affecting rhamnose excretion in healthy subjects and sucrose and sucralose recovery in diseased children. Despite the low rhamnose recovery, as lactulose is not similarly affected, the diagnostic reliability of L/R ratio is well preserved at low diuresis conditions. However, this ratio can be useful to discriminate acute conditions vs. clinical remissions only at high urine volumes. Data also suggest potential diagnostic applicability of sucrose and sucralose in children at high urine volumes. CONCLUSIONS: In conclusion, the multi-sugar test has a good predictivity in pediatric subjects but results must be carefully interpreted in the face of reduced diuresis.
Assuntos
Carboidratos/urina , Gastroenteropatias , Mucosa Intestinal/metabolismo , Pré-Escolar , Diurese , Feminino , Cromatografia Gasosa-Espectrometria de Massas , Gastroenteropatias/patologia , Gastroenteropatias/urina , Humanos , Lactente , Lactulose/urina , Masculino , Permeabilidade , Ramnose/urina , Sacarose/análogos & derivados , Sacarose/urinaRESUMO
INTRODUCTION: Circulatory failure is frequent in intensive care unit (ICU) patients and is associated with a high mortality and morbidity. There is no current consensus on which parameters best evaluate circulatory failure, and clinical practice regarding haemodynamic assessment is unknown. This study describes current clinical practice regarding circulatory assessment in ICU patients with shock. MATERIAL AND METHODS: This was a prospective, observational cohort study conducted in a university hospital ICU over a four-month period. Doctors working in the ICU were divided into two groups: trainees and specialists. They registered their circulatory assessments of consecutive patients with shock. The parameters included type of shock, kind of parameters used (markers of hypoperfusion, hypovolaemia and flow), which parameter was considered to be most important and the clinical action taken. RESULTS: A total of 23 doctors performed 210 patient assessments, which was equivalent to a median of eight (interquartile range: 5-14) per doctor. Trainees used six (5-8) parameters compared with five (3-6) parameters per assessment among specialists (p < 0.01). Mean arterial pressure (MAP) was the most frequently assessed parameter (n = 178) and both specialist (in 23% of assessments) and trainees (30%) considered MAP to be the most important parameter. Hypoperfusion markers were assessed in 99% of the cases, and a marker of hypovolaemia was also assessed in 83% (95% confidence interval (CI) 78-88) of these cases. Fluid was the most frequent clinical action taken, and was given after 150 assessments, but a marker of hypovolaemia was not assessed in 13% (95% CI 9-20) of these situations. Trainees assessed heart rate (76% versus 54%; p < 0.01), diastolic (45% versus 28%, p < 0.01) and systolic blood pressure (70% versus 46%; p < 0.01) and central venous oxygen saturation (63% versus 35%; p < 0.01) more frequently than specialists. CONCLUSION: MAP was the most frequently used parameter and fluid the most frequently given treatment by ICU doctors assessing patients with shock. The study indicates that assessment of hypoperfusion leads to the use of a marker of hypovolaemia, but in some cases fluid was given without this assessment. The haemodynamic assessment differed between ICU specialists and trainees. FUNDING: Righospitalet's Research Council supported the study. TRIAL REGISTRATION: not relevant.
Assuntos
Competência Clínica , Cuidados Críticos , Hemodinâmica , Padrões de Prática Médica , Choque/diagnóstico , Choque/fisiopatologia , Pressão Arterial , Débito Cardíaco , Diurese , Hidratação , Frequência Cardíaca , Hemoglobinas/metabolismo , Hospitais Universitários , Humanos , Hipovolemia/diagnóstico , Hipovolemia/terapia , Ácido Láctico/sangue , Oxigênio/sangue , Estudos Prospectivos , Choque/terapiaRESUMO
AIM: The impact of cardiac dysfunction on the liver is known as cardiac hepatopathy. In certain instances this can result in significant hepatic fibrosis or cirrhosis. The validity of non-invasive tools to assess hepatic fibrosis, such as FibroScan(®) which measures liver stiffness (LSM), has not been established in this setting. We examined the impact of cardiac dysfunction on LSM using FibroScan(®) and the influence of volume changes on LSM. METHODS AND RESULTS: A prospective, cross-sectional study examined the use of FibroScan(®) in subjects with left-sided heart failure (LHF, n = 32), right-sided heart failure (RHF, n = 9), and acute decompensated heart failure (ADHF, n = 8). The impact of volume changes upon LSM was further examined in the ADHF group (pre- and post-diuresis) and in a haemodialysis group (HD, n = 12), pre- and post-ultrafiltration on dialysis. Compared with healthy controls [n = 55, LSM = median 4.4 (25th percentile 3.6, 75th percentile 5.1) kPa], LSM was increased in all the cardiac dysfunction subgroups [LHF, 4.7 (4.0, 8.7) kPa, P = 0.04; RHF, 9.7 (5.0, 10.8) kPa, P < 0.001; ADHF, 11.2 (6.7, 14.3) kPa, P < 0.001]. Alteration in volume status via diuresis did not change the baseline LSM in ADHF [11.2 (6.7, 14.3) to 9.5 (7.3, 21.6) kPa, P > 0.05] with mean diuresis 5051 ± 1585 mL, or ultrafiltration in HD [6.0 (3.6, 5.1) vs. 5.7 (4.8, 7.0) kPa, P > 0.05] with mean diuresis 1962 ± 233 mL. CONCLUSION: Our findings support the concept of increased LSM in the cardiac failure population. LSM was not altered to a statistically significant level with acute volume changes.
Assuntos
Insuficiência Cardíaca/complicações , Cirrose Hepática/patologia , Fígado/patologia , Idoso , Distribuição de Qui-Quadrado , Estudos Transversais , Diurese , Técnicas de Imagem por Elasticidade/instrumentação , Feminino , Insuficiência Cardíaca/patologia , Hemodinâmica , Humanos , Cirrose Hepática/diagnóstico , Hepatopatias/diagnóstico , Hepatopatias/patologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estatística como Assunto , Estatísticas não Paramétricas , Volume Sistólico , Função Ventricular EsquerdaRESUMO
BACKGROUND: Associations of proteinuria with low-level urinary cadmium (Cd) are currently interpreted as the sign of renal dysfunction induced by Cd. Few studies have considered the possibility that these associations might be non causal and arise from confounding by factors influencing the renal excretion of Cd and proteins. METHODS: We examined 184 healthy male workers (mean age, 39.5 years) from a zinc smelter (n = 132) or a blanket factory (n = 52). We measured the concentrations of Cd in blood (B-Cd) and the urinary excretion of Cd (U-Cd), retinol-binding protein (RBP), protein HC and albumin. Associations between biomarkers of metal exposure and urinary proteins were assessed by simple and multiple regression analyses. RESULTS: The medians (interquartile range) of B-Cd (µg/l) and U-Cd (µg/g creatinine) were 0.80 (0.45-1.16) and 0.70 (0.40-1.3) in smelter workers and 0.66 (0.47-0.87) and 0.55 (0.40-0.90) in blanket factory workers, respectively. Occupation had no influence on these values, which varied mainly with smoking habits. In univariate analysis, concentrations of RBP and protein HC in urine were significantly correlated with both U-Cd and B-Cd but these associations were substantially weakened by the adjustment for current smoking and the residual influence of diuresis after correction for urinary creatinine. Albumin in urine did not correlate with B-Cd but was consistently associated with U-Cd through a relationship, which was unaffected by smoking or diuresis. Further analyses showed that RBP and albumin in urine mutually distort their associations with U-Cd and that the relationship between RBP and Cd in urine was almost the replicate of that linking RBP to albumin CONCLUSIONS: Associations between proteinuria and low-level urinary Cd should be interpreted with caution as they appear to be largely driven by diuresis, current smoking and probably also the co-excretion of Cd with plasma proteins.
Assuntos
Biomarcadores/urina , Metalurgia , Exposição Ocupacional , Proteinúria/epidemiologia , Indústria Têxtil , Zinco/toxicidade , Adulto , Albuminúria , Argélia , alfa-Globulinas/urina , Cádmio/sangue , Cádmio/urina , Fatores de Confusão Epidemiológicos , Diurese , Humanos , Masculino , Pessoa de Meia-Idade , Proteinúria/induzido quimicamente , Proteinúria/urina , Proteínas de Ligação ao Retinol/urina , Fumar/urinaRESUMO
α(1D)-adrenoceptors are involved in the genesis/maintenance of hypertension in spontaneously hypertensive rats (SHR). This study aims to investigate the role of α(1D)-adrenoceptors in the antinatriuretic and antidiuretic responses in SHR subjected to high sodium (SHRHNa) and normal sodium (SHRNNa) intake for six weeks. Renal inulin clearance study was performed in which the antinatriuretic and antidiuretic responses to phenylephrine were examined in the presence and absence of α(1D)-adrenoceptors blocker BMY7378. Data, mean±S.E.M. were subjected to ANOVA with significance at p<0.05. Results show that feeding SHR for six weeks with high salt did not cause any change in blood pressure. SHRHNa had higher (all p<0.05) urine flow rate (UFR), fractional and absolute excretion of sodium (FE(Na) and U(Na)V) compared to SHRNNa. Phenylephrine infusion produced significant reduction in UFR, FE(Na) and U(Na)V in both SHRHNa and SHRNNa. The antidiuretic and antinatriuretic responses to phenylephrine in both groups were attenuated in the presence of BMY7378. Moreover, the antidiuretic and antinatriuretic responses to phenylephrine and BMY7378 were independent on any significant changes in renal and glomerular hemodynamics in both groups. Thus we conclude that high sodium intake did not bring any further increase in blood pressure of SHR, however, it results in exaggerated natriuresis and diuresis in SHRHNa. Irrespective of dietary sodium changes, α1-adrenoceptors are involved in mediating the antinatriuretic and antidiuretic responses to phenylephrine in SHR. Further, high sodium intake did not significantly influence the functionality of α(1D)-adrenoceptors in mediating the adrenergically induced antinatriuresis and antidiuresis.
Assuntos
Diurese , Túbulos Renais/metabolismo , Natriurese , Receptores Adrenérgicos alfa 1/fisiologia , Sódio na Dieta/administração & dosagem , Sódio/metabolismo , Animais , Pressão Sanguínea , Diurese/efeitos dos fármacos , Natriurese/efeitos dos fármacos , Fenilefrina/farmacologia , Ratos , Ratos Endogâmicos SHRRESUMO
BACKGROUND: As the accuracy of the "Sugar Test" is currently debated, this study was conducted to focus on how urine volumes may impact the test results. METHODS: Fifty-five subjects, 23 healthy and 32 with Irritable Bowel Syndrome (IBS), were enrolled. Lactulose and D-mannitol dissolved in water were administered to all the participating subjects; the urine excreted was collected and the total urine volume was measured. The urine samples were analyzed by High Performance Liquid Chromatography (HPLC). The results were expressed as percentage of urine recovery of lactulose and D-mannitol and lactulose/D-mannitol ratio (LMR). RESULTS: All subjects were divided into two groups: subjects with urine volume < 500 mL and subjects with urine volume > or = 500 mL. Urine analysis showed that the mean LMR was significantly lower in subjects with urine volume > or = 500 mL than in subjects with urine volume < 500 mL (0.02 +/- 0.02 vs 0.04 +/- 0.04; p < 0.05). A significant increase in D-mannitol recovery was found to be associated with greater urine volumes (p < 0.001). CONCLUSIONS: The urine volume may influence urinary excretion of sugar probes. Intake of liquids should therefore be carefully monitored before and during the test and the volume of urine produced over the period of collection should be precisely measured.
Assuntos
Diurese , Absorção Intestinal , Síndrome do Intestino Irritável/fisiopatologia , Lactulose , Manitol , Adulto , Cromatografia Líquida de Alta Pressão , Fatores de Confusão Epidemiológicos , Difusão , Feminino , Humanos , Mucosa Intestinal/metabolismo , Mucosa Intestinal/ultraestrutura , Síndrome do Intestino Irritável/urina , Lactulose/farmacocinética , Lactulose/urina , Masculino , Manitol/farmacocinética , Manitol/urina , Microvilosidades/metabolismo , Pessoa de Meia-Idade , Peso Molecular , PermeabilidadeRESUMO
BACKGROUND AND AIMS: The Acute Kidney Injury Network (AKIN) criteria assert a new definition for acute kidney injury (AKI). We investigated the incidence of hospital-acquired AKI, along with the clinical characteristics and outcomes in hospitalized patients according to AKIN stage. METHODS: We performed a prospective, observational, single-center study. We monitored serum creatinine everyday for all patients using a hospital data survey system during the study period from September 2007 to February 2008. RESULTS: Hospital-acquired AKI occurred in 1.2% of all hospitalized patients during the study period. Among patients with AKI, 29.2% were in stage 1, 36.5% were in stage 2 and 34.4% were in stage 3. A significantly higher rate of renal recovery was observed in patients with lower-stage injuries (71.4, 60.0, and 21.2% for stages 1, 2, and 3, respectively). Mortality for patients with stage 3 AKI (51.5%) was significantly higher than that for patients with stages 1 or 2 (p < 0.013). Independent risk factors for mortality in patients with AKI included malignancy, stage 3 AKI, diuretic use, and intensive care unit admission prior to AKI. CONCLUSIONS: Our findings support the utility of the AKIN criteria for hospital-acquired AKI, and demonstrate that stage 3 AKI poses a significant risk for poor patient and renal outcomes.
Assuntos
Injúria Renal Aguda/diagnóstico , Índice de Gravidade de Doença , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Comorbidade , Creatinina/sangue , Diurese , Feminino , Gastroenteropatias/epidemiologia , Humanos , Incidência , Pacientes Internados/estatística & dados numéricos , Falência Renal Crônica/terapia , Testes de Função Renal , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Prognóstico , Estudos Prospectivos , Terapia de Substituição Renal , República da Coreia/epidemiologia , Fatores de Risco , Resultado do TratamentoRESUMO
Optimizing responses to intravenous furosemide (ivF) in acute pulmonary edema is limited by current insensitive noninvasive means of volume assessment. We conducted a pilot study to assess the feasibility of performing repeated measures of echocardiographic and bioimpedance analysis (BIA) parameters and test their response as noninvasive markers of volume response to ivF. We also aimed to identify the most potentially sensitive markers of this response. Patients receiving ivF for a clinical diagnosis of acute cardiogenic pulmonary edema were studied. Echocardiographic and BIA parameters were measured at 0, 0.5, 1, 2, and 3 h after ivF. Intraobserver variability for each parameter was determined. Thirty-one patients were enrolled who were receiving 40-100 mg of ivF. Transmitral (MV) early peak velocity following Valsalva maneuver and transtricuspid (TV) early peak velocity reduced significantly (P= 0.012 and 0.010, respectively), whereas MV deceleration time increased significantly (P= 0.006) in response to ivF. Short-axis inferior vena cava diameter (SIVC) in expiration and inspiration and SIVC corrected for body surface area in expiration and inspiration reduced significantly following ivF (P= 0.039, 0.020, 0.032, and 0.016, respectively). BIA estimates of extracellular water decreased significantly (P= 0.001), whereas impedance (Z) at currents of 5, 50, 100, and 200 kHz increased following ivF; the changes were significant with all but the last parameter (P < 0.0001, 0.006, 0.010, and 0.051, respectively). Maximal change from baseline for each parameter was greater than its respective intraobserver variability. Performing repeated measures of echocardiographic and BIA parameters is feasible in this unstable group of patients. The above panel of parameters could potentially be used to track volume response to ivF and, thus, to optimize treatment in acute pulmonary edema.
Assuntos
Diurese/efeitos dos fármacos , Diuréticos/administração & dosagem , Monitoramento de Medicamentos/métodos , Ecocardiografia Doppler , Impedância Elétrica , Furosemida/administração & dosagem , Hemodinâmica/efeitos dos fármacos , Sistemas Automatizados de Assistência Junto ao Leito , Edema Pulmonar/tratamento farmacológico , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Composição Corporal , Estudos de Viabilidade , Feminino , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Projetos Piloto , Valor Preditivo dos Testes , Edema Pulmonar/diagnóstico por imagem , Edema Pulmonar/fisiopatologia , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do TratamentoRESUMO
The Gamble phenomenon (initially described over 70 years ago as "an economy of water in renal function referable to urea") suggested that urea plays a special role in the urinary concentrating mechanism and that the concentrating mechanism depends in some complex way on an interaction between NaCl and urea. In this study, the role of collecting duct urea transporters in the Gamble phenomenon was investigated in wild-type mice and mice in which the inner medulla collecting duct (IMCD) facilitative urea transporters, UT-A1 and UT-A3, had been deleted (UT-A1/3-/- mice). The general features of the Gamble phenomenon were confirmed in wild-type mice, namely 1) the water requirement for the excretion of urea is less than for the excretion of an osmotically equivalent amount of NaCl; and 2) when fed various mixtures of urea and salt in the diet, less water is required for the excretion of the two substances together than the amount of water needed for the excretion of the two substances separately. In UT-A1/3-/- mice both of these elements of the phenomenon were absent, indicating that IMCD urea transporters play a central role in the Gamble phenomenon. A titration study in which wild-type mice were given progressively increasing amounts of urea showed that the ability of the kidney to reabsorb urea was saturable, resulting in osmotic diuresis above excretion rates of approximately 6,000 microosmol/day. In the same titration experiments, when increasing amounts of NaCl were added to the diet, mice were unable to increase urinary NaCl concentrations to >420 mM, resulting in osmotic diuresis at NaCl excretion rates of approximately 3,500 microosmol/day. Thus both urea and NaCl can induce osmotic diuresis when large amounts are given, supporting the conclusion that the decrease in water excretion with mixtures of urea and NaCl added to the diet (compared with pure NaCl or urea) is due to the separate abilities of urea and NaCl to induce osmotic diuresis, rather than to any specific interaction of urea transport and NaCl transport at an epithelial level.
Assuntos
Túbulos Renais Coletores/fisiologia , Proteínas de Membrana Transportadoras/fisiologia , Ureia/metabolismo , Água/metabolismo , Animais , Transporte Biológico/fisiologia , Diurese/fisiologia , Regulação da Expressão Gênica/fisiologia , Túbulos Renais Coletores/química , Masculino , Proteínas de Membrana Transportadoras/análise , Proteínas de Membrana Transportadoras/genética , Camundongos , Camundongos Knockout , Sódio/urina , Cloreto de Sódio/metabolismo , Ureia/urina , Transportadores de UreiaRESUMO
Objetivo: Evaluar el manejo del paciente quemado, durante las primeras 48 horas. Se realizó un estudio en 36 pacientes que presentaron quemaduras, en el Servicio de Emergencia del Hospital Nacional Arzobispo Loayza de Lima-Perú en un período de 12 meses durante el año 2001, todos sometidos a Tratamiento Médico de Reanimación Hidroelectrolítica. Estos pacientes, luego fueron clínicamente evaluados por: edad, género, extensión de quemadura, profundidad, localización, agente causal, infusión de cristaloides y control de diuresis horaria; establecidos por la Asociación Americana de Quemaduras, conocidos como parámetros del Soporte Vital Avanzado de Quemaduras. Para efectos del procesamiento de datos, se distribuyeron a los pacientes por intervalos, según las diversas variables para ambos días post quemadura, respectivamente. Los resultados al terminar el presente estudio fueron: el promedio de edad fue de 34.7 años + 18.2; varones 58.3 por ciento y mujeres 41.3 por ciento. La localización más frecuente fue en miembros inferiores (69.4 por ciento). La profundidad de la quemadura fue de 86 por ciento en II y III. El agente etiológico más frecuente fue Líquido Caliente (25.0 por ciento). El volumen promedio de cristaloides administrados, en general, fue de 3222.2cc + 421.8 de 1916.7cc + 174.2 para el primer y segundo día, respectivamente y a través de la Fórmula de Parkland fue de 3388.9cc + 443.6 para las 8 primeras horas de ocurrido el accidente. El volumen urinario se usó como control en la monitorización en la administración de fluidos, siendo el volumen promedio de 42.5cc/h + 21.3 y de 54.2cc/h + 19.2, para el primer y segundo día, respectivamente. Los analgésicos usados fueron antiinflamatorios no Esteroideos (81.8 por ciento) y opiáceos (18.2 por ciento). La cobertura de la quemadura fue semioclusiva en 86.3 por ciento y abierta 13.7 por ciento. Se concluye que: la monitorización de los cristaloides en el Servicio de Emergencia...
Purpose: To evaluate handling of the burnt patient during the first 48 hours. A study on 36 patients with BURNS was carried out in the Emergency Room of Arzobispo Loayza National Hospital in Lima - Peru. This study was performed in a 12 month period during 2001, and all patients underwent medical treatment of hydroelectrolytical resuscitation. Afterwards, the patients were clinically evaluated for: age, gender, burn extension, depth, location, causal agent, infusion of crystalloids and control of hourly diuresis, established by the American Burn Association, known as the Advance Burn Life Support parameters. In order to process data, the patients were distributed by intervals, according to diverse variables for both days post burn respectively. The results by the end of this study were that: the mean age was of 34.7 + years old + 18.2, men 58.3% and women 41.3%. The most common location was in the lower limbs (69.4%). Burns were of 86% in second and third degree. The most frequent etiological agent was Hot Liquids (25.0%). The average volume of crystalloids administered was 3222.2 cc + 421.8 and 1916.7 cc + 174.2 during the first and second day, respectively and through the Parkland Formula was of 3388.9 cc + 443.6 for the first eight hours after the accident. The urinary volume was used as a control for monitoring during fluid administration, the average volume being 42.5 cc/h + 21.3 and 54.2 cc/h + 19.2 the first and second day after the burn, respectively. Analgesics used were non-steroidal anti-inflammatory drugs (81.8%) and the Opiaceous (18.2%). The dressing of the burn was semiocclusive in 86.3% and open in 13.7%. As a conclusion it can be said that, monitoring of the crystalloids in the Emergency Room of the Arzobispo Loayza National Hospital comply with the parameters of the American Burn Association in one trurd of total patients. The type of coverage that prevails in the Emergency Room...