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The Cochrane Database of Systematic... May 2024Acute heart failure (AHF) is new onset of, or a sudden worsening of, chronic heart failure characterised by congestion in about 95% of cases or end-organ hypoperfusion... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute heart failure (AHF) is new onset of, or a sudden worsening of, chronic heart failure characterised by congestion in about 95% of cases or end-organ hypoperfusion in 5% of cases. Treatment often requires urgent escalation of diuretic therapy, mainly through hospitalisation. This Cochrane review evaluated the efficacy of intravenous loop diuretics strategies in treating AHF in individuals with New York Heart Association (NYHA) classification III or IV and fluid overload.
OBJECTIVES
To assess the effects of intravenous continuous infusion versus bolus injection of loop diuretics for the initial treatment of acute heart failure in adults.
SEARCH METHODS
We identified trials through systematic searches of bibliographic databases and in clinical trials registers including CENTRAL, MEDLINE, Embase, CPCI-S on the Web of Science, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry platform (ICTRP), and the European Union Trials register. We conducted reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was performed on 29 February 2024.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) involving adults with AHF, NYHA classification III or IV, regardless of aetiology or ejection fraction, where trials compared intravenous continuous infusion of loop diuretics with intermittent bolus injection in AHF. We excluded trials with chronic stable heart failure, cardiogenic shock, renal artery stenosis, or end-stage renal disease. Additionally, we excluded studies combining loop diuretics with hypertonic saline, inotropes, vasoactive medications, or renal replacement therapy and trials where diuretic dosing was protocol-driven to achieve a target urine output, due to confounding factors.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened papers for inclusion and reviewed full-texts. Outcomes included weight loss, all-cause mortality, length of hospital stay, readmission following discharge, and occurrence of acute kidney injury. We performed risk of bias assessment and meta-analysis where data permitted and assessed certainty of the evidence.
MAIN RESULTS
The review included seven RCTs, spanning 32 hospitals in seven countries in North America, Europe, and Asia. Data collection ranged from eight months to six years. Following exclusion of participants in subgroups with confounding treatments and different clinical settings, 681 participants were eligible for review. These additional study characteristics, coupled with our strict inclusion and exclusion criteria, improve the applicability of the body of the evidence as they reflect real-world clinical practice. Meta-analysis was feasible for net weight loss, all-cause mortality, length of hospital stay, readmission, and acute kidney injury. Literature review and narrative analysis explored daily fluid balance; cardiovascular mortality; B-type natriuretic peptide (BNP) change; N-terminal-proBNP change; and adverse incidents such as ototoxicity, hypotension, and electrolyte imbalances. Risk of bias assessment revealed two studies with low overall risk, four with some concerns, and one with high risk. All sensitivity analyses excluded trials at high risk of bias. Only narrative analysis was conducted for 'daily fluid balance' due to diverse data presentation methods across two studies (169 participants, the evidence was very uncertain about the effect). Results of narrative analysis varied. For instance, one study reported higher daily fluid balance within the first 24 hours in the continuous infusion group compared to the bolus injection group, whereas there was no difference in fluid balance beyond this time point. Continuous intravenous infusion of loop diuretics may result in mean net weight loss of 0.86 kg more than bolus injection of loop diuretics, but the evidence is very uncertain (mean difference (MD) 0.86 kg, 95% confidence interval (CI) 0.44 to 1.28; 5 trials, 497 participants; P < 0.001, I = 21%; very low-certainty evidence). Importantly, sensitivity analysis excluding trials with high risk of bias showed there was insufficient evidence for a difference in bodyweight loss between groups (MD 0.70 kg, 95% CI -0.06 to 1.46; 3 trials, 378 participants; P = 0.07, I = 0%). There may be little to no difference in all-cause mortality between continuous infusion and bolus injection (risk ratio (RR) 1.53, 95% CI 0.81 to 2.90; 5 trials, 530 participants; P = 0.19, I = 4%; low-certainty evidence). Despite sensitivity analysis, the direction of the evidence remained unchanged. No trials measured cardiovascular mortality. There may be little to no difference in the length of hospital stay between continuous infusion and bolus injection of loop diuretics, but the evidence is very uncertain (MD -1.10 days, 95% CI -4.84 to 2.64; 4 trials, 211 participants; P = 0.57, I = 88%; very low-certainty evidence). Sensitivity analysis improved heterogeneity; however, the direction of the evidence remained unchanged. There may be little to no difference in the readmission to hospital between continuous infusion and bolus injection of loop diuretics (RR 0.85, 95% CI 0.63 to 1.16; 3 trials, 400 participants; P = 0.31, I = 0%; low-certainty evidence). Sensitivity analysis continued to show insufficient evidence for a difference in the readmission to hospital between groups. There may be little to no difference in the occurrence of acute kidney injury as an adverse event between continuous infusion and bolus injection of intravenous loop diuretics (RR 1.02, 95% CI 0.70 to 1.49; 3 trials, 491 participants; P = 0.92, I = 0%; low-certainty evidence). Sensitivity analysis continued to show that continuous infusion may make little to no difference on the occurrence of acute kidney injury as an adverse events compared to the bolus injection of intravenous loop diuretics.
AUTHORS' CONCLUSIONS
Analysis of available data comparing two delivery methods of diuretics in acute heart failure found that the current data are insufficient to show superiority of one strategy intervention over the other. Our findings were based on trials meeting stringent inclusion and exclusion criteria to ensure validity. Despite previous reviews suggesting advantages of continuous infusion over bolus injections, our review found insufficient evidence to support or refute this. However, our review, which excluded trials with clinical confounders and RCTs with high risk of bias, offers the most robust conclusion to date.
Topics: Adult; Aged; Humans; Acute Disease; Bias; Cause of Death; Heart Failure; Infusions, Intravenous; Injections, Intravenous; Length of Stay; Randomized Controlled Trials as Topic; Sodium Potassium Chloride Symporter Inhibitors
PubMed: 38775253
DOI: 10.1002/14651858.CD014811.pub2 -
Clinical Case Reports May 2024Acute neuromuscular paralysis is a relatively common condition in emergency rooms (ERs). They can be caused by several reasons, including adverse drug reactions....
Acute neuromuscular paralysis is a relatively common condition in emergency rooms (ERs). They can be caused by several reasons, including adverse drug reactions. Betamethasone is a glucocorticoid commonly used for various conditions, such as allergic conditions. One of the rare but known side effects of glucocorticoids is hypokalemia. Rare cases of hypokalemia following high- and low-dose glucocorticoid injections have been reported. This study presents the history of a young, healthy male without significant past medical history who presented with an inability to stand and walk due to four-limb paralysis (more prominent in the lower limbs) following an intramuscular injection of a 4 mg betamethasone, which was prescribed for the treatment of allergic rhinitis. The patient was stabilized with an intravascular injection of potassium chloride diluted in 1000 mL of normal saline and monitored for 24 h, ruling out any other endocrine condition. Hypokalemia and its severe form are defined as the serum level of lower than 3.5 and 2.5 mEq/Lit, respectively. One of the etiologies of drug-induced hypokalemic paralysis is systemic glucocorticoid administration. In severe cases, it can cause quadriplegia and other neuromuscular, respiratory, and cardiac complications. Therefore, it is an urgent condition that should be managed carefully. Pregnant women who are receiving these medications are a specific group at risk of hypokalemic paralysis. There are several safer treatments for seasonal allergic rhinitis compared to systemic glucocorticoids, which should be considered by physicians. Moreover, paralysis in patients receiving these medications should be approached attentively since it might be caused by hypokalemia, which can be life threatening if not treated. It is advisable that the blood level of electrolytes, especially potassium, be checked for patients who present with paralysis or weakness after glucocorticoid injections.
PubMed: 38770411
DOI: 10.1002/ccr3.8923 -
Scientific Reports May 2024Understanding the association between compliance to the Chronic Kidney Disease (CKD) guidelines in real-world clinical settings and renal outcomes remains a critical gap...
Understanding the association between compliance to the Chronic Kidney Disease (CKD) guidelines in real-world clinical settings and renal outcomes remains a critical gap in knowledge. A comprehensive analysis was conducted using data from a national, multicenter CKD registry. This study included 4,455 patients with an estimated glomerular filtration rate (eGFR) measurement on the index date and eight additional metrics recorded within six months. These metrics comprised serum electrolyte levels, low-density lipoprotein cholesterol, hemoglobin, and the use of renin-angiotensin system inhibitors. The primary outcome was a composite of renal events, defined by a decline in eGFR to < 15 mL/min/1.73 m or a reduction of ≥ 30% in eGFR, confirmed by follow-up tests. Over a median follow-up of 513 days, 838 renal events were observed. High serum potassium levels (> 5.4 mmol/L) were associated with increased event rates compared to lower levels. Similarly, low serum sodium-chloride levels (< 33) correlated with higher event rates. Usage of renin-angiotensin system inhibitors, low serum calcium (< 8.4 mg/dL), and high uric acid levels (> 7.0 mg/dL) were also linked to increased events. Conversely, higher hemoglobin levels (≥ 13 g/dL) were associated with lower event rates. Compliance to guidelines, categorized into quartiles based on the number of met metrics, revealed a significantly reduced risk of events in the highest compliance group (meeting 8 metrics) compared to the lowest (0-5 metrics). Compliance to CKD guidelines in clinical practice is significantly associated with improved renal outcomes, emphasizing the need for guideline-concordant care in the management of CKD.
Topics: Aged; Female; Humans; Male; Middle Aged; Glomerular Filtration Rate; Guideline Adherence; Practice Guidelines as Topic; Registries; Renal Insufficiency, Chronic
PubMed: 38769367
DOI: 10.1038/s41598-024-62152-6 -
European Review For Medical and... May 2024Cisplatin is a widely used and potent cytotoxic chemotherapy agent, but its nephrotoxicity is a significant limiting side effect. Various premedication approaches have...
OBJECTIVE
Cisplatin is a widely used and potent cytotoxic chemotherapy agent, but its nephrotoxicity is a significant limiting side effect. Various premedication approaches have been implemented to preserve renal function, including magnesium (Mg) preloading. However, the optimal Mg dosage is still unknown. Our study aimed to assess the protective effects of different Mg doses as premedication in cisplatin-based chemoradiotherapy for patients with local/locally advanced cervical and head-neck cancers.
PATIENTS AND METHODS
This retrospective, multicenter study involved premedication with saline infusion containing potassium chloride and magnesium sulfate (MgSO4) for all patients before cisplatin treatment. Patients were divided into two groups: 12 mEq MgSO4 (low-dose Mg preload group, low-Mg) and 24 mEq MgSO4 (high-dose Mg preload group, high-Mg). Renal function was evaluated using serum creatinine (sCr, mg/dl) and estimated glomerular filtration rate (eGFR, ml/min). Acute kidney injury (AKI) was defined per the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Renal outcomes and efficacy were compared between the groups.
RESULTS
In the low-Mg group (n = 159), sCr levels were significantly higher compared to baseline, various weeks during treatment, and at the 1st, 3rd, 6th, and 12th months post-treatment (p < 0.001). In the high-Mg group (n = 128), no significant changes were observed during treatment and at 1st, 3rd, and 12th months post-treatment (p > 0.05). A significant reduction in mean sCr level from baseline to 6 months was noted in the high-Mg group (p < 0.001). eGFR values are generally correlated with sCr levels. AKI occurred in 21 (13.2%) and 22 (17.7%) patients in the low-Mg and high-Mg groups, respectively (p = 0.292). There was no difference in progression-free or overall survival between the groups.
CONCLUSIONS
We clearly demonstrated that saline hydration with 24 mEql MgSO4 supplementation before cisplatin treatment has a better renal protective effect than 12 mEql MgSO4 without reducing efficacy, especially in patients with local/local advanced cervical and head-neck cancer receiving cisplatin with concurrent radiotherapy.
Topics: Cisplatin; Humans; Retrospective Studies; Acute Kidney Injury; Female; Middle Aged; Magnesium Sulfate; Male; Antineoplastic Agents; Glomerular Filtration Rate; Head and Neck Neoplasms; Adult; Magnesium; Dose-Response Relationship, Drug; Aged
PubMed: 38766796
DOI: 10.26355/eurrev_202405_36185 -
Revista Brasileira de Ginecologia E... 2024Potassium channels have an important role in the vascular adaptation during pregnancy and a reduction in the expression of adenosine triphosphate-sensitive potassium...
OBJECTIVE
Potassium channels have an important role in the vascular adaptation during pregnancy and a reduction in the expression of adenosine triphosphate-sensitive potassium channels (Katp) has been linked to preeclampsia. Activation of Katp induces vasodilation; however, no previous study has been conducted to evaluate the effects of the inhibition of these channels in the contractility of preeclamptic arteries. Glibenclamide is an oral antihyperglycemic agent that inhibits Katp and has been widely used in vascular studies.
METHODS
To investigate the effects of the inhibition of K, umbilical arteries of preeclamptic women and women with healthy pregnancies were assessed by vascular contractility experiments, in the presence or absence of glibenclamide. The umbilical arteries were challenged with cumulative concentrations of potassium chloride (KCl) and serotonin.
RESULTS
There were no differences between the groups concerning the maternal age and gestational age of the patients. The percentage of smokers, caucasians and primiparae per group was also similar. On the other hand, blood pressure parameters were elevated in the preeclamptic group. In addition, the preeclamptic group presented a significantly higher body mass index. The newborns of both groups presented similar APGAR scores and weights.
CONCLUSION
In the presence of glibenclamide, there was an increase in the KCl-induced contractions only in vessels from the PE group, showing a possible involvement of these channels in the disorder.
Topics: Humans; Female; Pregnancy; Pre-Eclampsia; Umbilical Arteries; Adult; Glyburide; Vasoconstriction; Young Adult; KATP Channels; Potassium Chloride
PubMed: 38765503
DOI: 10.61622/rbgo/2024AO02 -
Scientific Reports May 2024This study presents a thorough investigation into the concentration of heavy metals and mineral composition within four distinct coastal flora species: Cyperus...
This study presents a thorough investigation into the concentration of heavy metals and mineral composition within four distinct coastal flora species: Cyperus conglomeratus, Halopyrum mucronatum, Sericostem pauciflorum, and Salvadora persica. Employing rigorous statistical methodologies such as Pearson coefficient correlation, principal component analysis (PCA), analysis of variance (ANOVA), and interclass correlation (ICC), we aimed to elucidate the bioavailability of heavy metals, minerals, and relevant physical characteristics. The analysis focused on essential elements including copper (Cu), iron (Fe), manganese (Mn), zinc (Zn), magnesium (Mg), calcium (Ca), sodium (Na), potassium (K), and chloride (Cl), all of which are known to play pivotal roles in the ecological dynamics of coastal ecosystems. Through PCA, we discerned distinctive patterns within PC1 to PC4, collectively explaining an impressive 99.65% of the variance observed in heavy metal composition across the studied flora species. These results underscore the profound influence of environmental factors on the mineral composition of coastal flora, offering critical insights into the ecological processes shaping these vital ecosystems. Furthermore, significant correlations among mineral contents in H. mucronatum; K with content of Na (r = 0.989) and Mg (r = 0.984); as revealed by ICC analyses, contributed to a nuanced understanding of variations in electrical conductivity (EC), pH levels, and ash content among the diverse coastal flora species. By shedding light on heavy metal and mineral dynamics in coastal flora, this study not only advances our scientific understanding but also provides a foundation for the development of targeted environmental monitoring and management strategies aimed at promoting the ecological sustainability and resilience of coastal ecosystems in the face of ongoing environmental challenges.
Topics: Metals, Heavy; Minerals; Multivariate Analysis; Ecosystem; Biological Availability; Principal Component Analysis
PubMed: 38760440
DOI: 10.1038/s41598-024-62201-0 -
Analytical Methods : Advancing Methods... May 2024Microfluidic channels fabricated over fabrics or papers have the potential to find substantial application in the next generation of wearable healthcare monitoring...
Microfluidic channels fabricated over fabrics or papers have the potential to find substantial application in the next generation of wearable healthcare monitoring systems. The present work focuses on the fabrication procedures that can be used to obtain practically realizable fabric-based microfluidic channels (μFADs) utilizing patterning masks and wax, unlike conventional printing techniques. In this study, comparative analysis was used to differentiate channels obtained using different masking tools for channel patterning as well as different wax materials as hydrophobic barriers. Drawbacks of the conventional tape and candle wax technique were noted and a novel approach was used to create microfluidic channels through a facile and simple masking technique using PVC clear sheets as channel stencils and beeswax as the channel barriers. The resulting fabric based microfluidic channels with varying widths as well as complex microchannel, microwell, and micromixer designs were investigated and a minimum channel width resolution of 500 μm was successfully obtained over cotton based fabrics. Thereafter, the PVC clear sheet-beeswax based microwells were successfully tested to confine various organic and inorganic samples indicating vivid applicability of the technique. Finally, the microwells were used to make a simple and facile colorimetric assay for glucose detection and demonstrated effective detection of glucose levels from 10 mM to 50 mM with significant color variation using potassium iodide as the coloring agent. The above findings clearly suggest the potential of this alternative technique for making low-cost and practically realizable fabric based diagnostic devices (μFADs) in contrast to the other approaches that are currently in use.
Topics: Waxes; Polyvinyl Chloride; Textiles; Colorimetry; Microfluidic Analytical Techniques; Cost-Benefit Analysis; Glucose; Lab-On-A-Chip Devices; Humans; Equipment Design; Wearable Electronic Devices
PubMed: 38747244
DOI: 10.1039/d4ay00389f -
BioRxiv : the Preprint Server For... May 2024Despite the profound behavioral effects of the striatal dopamine (DA) activity and the inwardly rectifying potassium channel ( ) being a key determinant of striatal...
Despite the profound behavioral effects of the striatal dopamine (DA) activity and the inwardly rectifying potassium channel ( ) being a key determinant of striatal medium spiny neuron (MSN) activity that also profoundly affects behavior, previously reported DA regulations of Kir are conflicting and incompatible with MSN function in behavior. Here we show that in normal mice with an intact striatal DA system, the predominant effect of DA activation of D1Rs in D1-MSNs is to cause a modest depolarization and increase in input resistance by inhibiting Kir, thus moderately increasing the spike outputs from behavior-promoting D1-MSNs. In parkinsonian (DA-depleted) striatum, DA increases D1-MSN intrinsic excitability more strongly than in normal striatum, consequently strongly increasing D1-MSN spike firing that is behavior-promoting; this DA excitation of D1-MSNs is stronger when the DA depletion is more severe. The DA inhibition of Kir is occluded by the Kir blocker barium chloride (BaCl ). In behaving parkinsonian mice, BaCl microinjection into the dorsal striatum stimulates movement but occludes the motor stimulation of D1R agonism. Taken together, our results resolve the long-standing question about what D1R agonism does to D1-MSN excitability in normal and parkinsonian striatum and strongly indicate that D1R inhibition of Kir is a key ion channel mechanism that mediates D1R agonistic behavioral stimulation in normal and parkinsonian animals.
PubMed: 38746264
DOI: 10.1101/2024.04.29.590632 -
Journal of the American Board of Family... 2024Consider IV Acetazolamide in addition to standard IV loop diuretic therapy in patients hospitalized for acute decompensated heart failure..
Consider IV Acetazolamide in addition to standard IV loop diuretic therapy in patients hospitalized for acute decompensated heart failure..
Topics: Humans; Acetazolamide; Heart Failure; Acute Disease; Sodium Potassium Chloride Symporter Inhibitors; Diuretics; Carbonic Anhydrase Inhibitors
PubMed: 38740482
DOI: 10.3122/jabfm.2023.230379R0 -
Indian Journal of Critical Care... May 2024In a critically ill patient, when an arterial blood sample is processed on an arterial blood gas (ABG) analyzer, it also measures electrolytes apart from analyzing the...
BACKGROUND
In a critically ill patient, when an arterial blood sample is processed on an arterial blood gas (ABG) analyzer, it also measures electrolytes apart from analyzing the blood gases. The turnaround time for ABG analysis is way too less compared to the conventional electrolyte analysis with a serum sample.
OBJECTIVE
This study intends to investigate whether values of electrolytes estimated in arterial blood can substitute the routinely practiced method.
MATERIALS AND METHODS
This is a retrospective cross-sectional study. The source of data is patients' reports of serum electrolytes and ABG analysis from the Clinical Biochemistry laboratory, CIMS Teaching Hospital, Chamarajanagar between January and June 2021. The electrolytes report of 200 patients from whom both arterial and venous blood samples were sent to the Clinical Biochemistry laboratory on the same day and at the same time for analysis were selected. The data was compiled, compared, and correlated using a suitable statistical tool.
RESULTS
The mean and standard deviation of sodium (135.62 ± 5.20 in venous vs 134.08 ± 8.49 in arterial blood), potassium (4.20 ± 0.64 vs 3.80 ± 0.75), and chloride (102.28 ± 4.99 vs 96.33 ± 8.11) were observed. However, when the concordance correlation coefficient and Bland-Altman plot analysis were made there was no agreement between electrolytes analyzed on serum in an autoanalyzer with that of ABG analyzer.
CONCLUSION
We conclude that the electrolytes measured by a conventional autoanalyzer on a serum sample cannot be replaced by values analyzed on a blood gas analyzer.
HOW TO CITE THIS ARTICLE
Devaki RN, Kasargod P, Roopa Urs AN, Chandrika N. A Retrospective Database Analysis to Investigate if Electrolytes in Venous Blood are Equivalent to the Levels in Arterial Blood. Indian J Crit Care Med 2024;28(5):442-446.
PubMed: 38738198
DOI: 10.5005/jp-journals-10071-24702