Impact of early initiation of renin-angiotensin blockade on renal function and clinical outcomes in patients with hypertensive emergency: a retrospective cohort study.

BACKGROUND: Hypertensive emergency is a critical disease that causes multifaceted sequelae, including end-stage kidney disease and cardiovascular disease. Although the renin-angiotensin-aldosterone (RAA) system is enormously activated in this disease, there are few reports that attempt to characterize the effect of early use of RAA inhibitors (RASi) on the temporal course of kidney function. METHODS: This retrospective cohort study was conducted to clarify whether the early use of RASi during hospitalization offered more favorable benefits on short-term renal function and long-term renal outcomes in patients with hypertensive emergencies. We enrolled a total of 49 patients who visited our medical center with acute severe hypertension and multiple organ dysfunction between April 2012 and August 2020. Upon admission, the patients were treated with intravenous followed by oral antihypertensive drugs, including RASi and Ca channel blockers (CCB). Kidney function as well as other laboratory and clinical parameters were compared between RASi-treated and CCB- treated group over 2 years. RESULTS: Antihypertensive treatment effectively reduced blood pressure from 222 ± 28/142 ± 21 to 141 ± 18/87 ± 14 mmHg at 2 weeks and eGFR was gradually restored from 33.2 ± 23.3 to 40.4 ± 22.5 mL/min/1.73m2 at 1 year. The renal effect of antihypertensive drugs was particularly conspicuous when RASi was started in combination with other conventional antihypertensive drugs at the early period of hospitalization (2nd day [IQR: 1-5.5]) and even in patients with moderately to severely diminished eGFR (< 30 mL/min/1.73 m2) on admission. In contrast, CCB modestly restored eGFR during the observation period. Furthermore, renal survival probabilities were progressively deteriorated in patients who had manifested reduced eGFR (< 15 mL/min/1.73 m2) or massive proteinuria (urine protein/creatinine ≥ 3.5 g/gCr) on admission. Early use of RASi was associated with a favorable 2-year renal survival probability (0.90 [95%CI: 0.77-1.0] vs. 0.63 [95%CI: 0.34-0.92] for RASi ( +) and RASi (-), respectively, p = 0.036) whereas no apparent difference in renal survival was noted for CCB. CONCLUSIONS: Early use of RASi contributes to the renal functional recovery from acute reduction in eGFR among patients with hypertensive emergencies. Furthermore, RASi offers more favorable effect on 2-year renal survival, compared with CCB.

Importance of a Collaboration Agreement in the Management of Physician-Staffed Helicopters.

OBJECTIVE: The purpose of this study was to present the management of 3 physician-staffed helicopters (helicopter emergency medical service [HEMS]) in 3 different requests in eastern Shizuoka based on a collaboration agreement and to investigate the current state of dispatches based on the agreement. METHODS: We investigated 3 incidents managed simultaneously by HEMS based on the collaboration agreement by inquiry to the bases, which were located in eastern Shizuoka, Yamanashi, and Kanagawa. We also investigated all records on the management of HEMS based on the collaboration agreement since the contract was made in 2014 by inquiry to the Shizuoka prefectural government. RESULTS: Three simultaneous flight requests were successfully completed. The total number of dispatches based on the collaboration agreement was 112 flights for 7 years from 2014 to 2020. The most frequent reason for request was overlapping request (n = 71). The prefecture with the highest number of requests was Shizuoka (n = 79), where medical resources were limited and the most frequent disease was trauma (n = 93). CONCLUSION: The present study reports how 3 HEMS were operated simultaneously for 3 different requests. To use medical resources effectively, including HEMS, the collaboration agreement among neighboring prefectures was very important, especially for areas in which medical resources are limited.

Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise caused by rapid resumption after prolonged detraining.

BACKGROUND: We report a case of acute renal failure with loin pain and patchy renal ischemia after anaerobic exercise (ALPE) caused by sudden training resumption. CASE PRESENTATION: A 19-year-old Asian man who was a college American football player presented with severe back pain, headache, and malaise. He developed acute kidney injury without myoglobinuria. Based on the typical medical history and symptoms, we made a diagnosis of ALPE. Symptoms improved within a few days, and serum creatinine levels simproved after discharge. He resumed training, adjusting his load step by step. CONCLUSION: During the coronavirus disease 2019 pandemic, many athletes were unable to undergo adequate training. Long-term de-training leads to decreased various organ function and reduces the anaerobic threshold. Rapid resumption after prolonged de-training may put individuals at risk of developing ALPE.

Remarkable diastereomeric effect on thermoresponsive behavior of polyurethane based on lysine and tartrate ester derivatives.

This study describes the long-distance diastereomeric effect on thermoresponsive properties in water-soluble diastereomeric polyurethanes (PUs) composed of an l-lysine ethyl ester diisocyanate and a trimethylene glycol l-/d-tartrate ester, which have differences in spatial arrangements of the ethyl esters in the mirror image. The PUs based on l-lysine and l-/d-tartrate ester, named l-PU and d-PU, were synthesized with various number average molecular weights from 4700 to 13 100. In turbidimetry, l-PU showed a steep phase transition from 100%T to 0%T within about 10 °C at 4 g L-1, whereas d-PU did not change completely to 0%T transmittance even at 80 °C at 4 g L-1. In addition, the thermoresponsive properties of l-PU were less affected by concentration than those of d-PU. This long-distance diastereomeric effect on thermoresponsive behavior between l-PU and d-PU appeared in common among 6 samples with 4700 to 13 100 number average molecular weight. In the dynamic light scattering experiments at each transmittance, the hydrodynamic diameter (D h) of l-PU increased up to 1000 nm, while the D h of d-PU remained almost at 200-300 nm. The C[double bond, length as m-dash]O stretching vibration of FT-IR spectra showed that d-PU has more hydrogen-bonded ester groups than L-PU. Thus, we speculated that the difference in the retention of polymer chains in the micelle to promote intermicellar bridging generates the long-distance diastereomeric effect.