Microalbuminuria, renal function and development of sustained hypertension: a longitudinal study in the early stage of hypertension

OBJECTIVE: Microalbuminuria (MA) is a marker of adverse outcome in hypertension. The aim of this study was to investigate the association of MA with cardiovascular risk factors and glomerular hyperfiltration in the early stage of hypertension and to assess its predictive value for the development of sustained hypertension requiring antihypertensive treatment. DESIGN AND PARTICIPANTS: We studied 1041 young stage 1 hypertensive subjects. Study variables were 24-h ambulatory blood pressure and heart rate, anthropometric measures, metabolic variables, creatinine clearance and lifestyle factors analyzed as a function of ascending urinary albumin measured from 24-h collections. Subjects were followed until they developed sustained hypertension and were eligible for antihypertensive medication according to current guidelines. SETTING: Seventeen outpatient clinics in Italy. RESULTS: Eighty-five percent of the subjects were normoalbuminuric, 9% had borderline MA, and 6% had overt MA. No between-group differences were found for age, body mass index, heart rate, lifestyle factors and biochemistry in both genders. Creatinine clearance was greater in the subjects with overt MA and borderline MA than in the normoalbuminuric subjects (P = 0.003 and 0.011, respectively). In a two-way ANCOVA, microalbuminuric subjects both with hyperfiltration (P < 0.001) and with normal filtration (P = 0.04) had higher 24-h systolic blood pressure than subjects with normoalbuminuria and normal filtration. In a Cox analysis, neither MA nor hyperfiltration were significant predictors of development of sustained hypertension. CONCLUSION: MA is not associated with an adverse metabolic risk profile in the early stage of hypertension. MA is associated with greater hemodynamic load and with glomerular hyperfiltration in this clinical setting, but does not help in predicting those subjects destined to develop sustained hypertension requiring antihypertensive therapy.     

Obesity: Risk Factor for Increased Resource Utilization at Bidirectional Glenn

Background

Underweight infants with single‐ventricle cardiac physiology have been shown to have increased morbidity, mortality, and resource utilization. The purpose of this study was to determine whether patients who were overweight, as defined by weight‐for‐length z score >90th percentile, were similarly at risk for increased resource utilization, as defined by mechanical ventilation hours (VHs) and intensive care unit length of stay (ICU LOS).

Methods

We evaluated resource utilization for 109 patients from our institution who underwent bidirectional Glenn surgery from January 2010 to June 2015 and met prespecified inclusion criteria. Patients were divided into 3 groups: underweight (z score, <5th percentile), normal weight (z score, 5th–90th percentile), and overweight (z score, >90th percentile).

Results

ICU LOS was longer in the overweight group (median, 18.5 days) when compared with the under‐ and normal‐weight groups (median LOS, 11 and 9 days, respectively) but did not reach statistical significance. VHs were also increased in the overweight group (median, 72 hours) when compared with the underweight (median, 27 hours) and normal weight (median, 25 hours) groups. This increase in VHs was statistically significant (P = .03).

Conclusions

This study suggests that patients with single‐ventricle physiology who are overweight at the time of their bidirectional Glenn surgery may be at risk for increased resource utilization as compared with those who meet or fail to meet their caloric recommendations. These findings represent an underappreciated risk factor in this already‐vulnerable patient population, providing potential opportunity for intervention and improved outcomes.     

Impact of Early Initiation of Enteral Nutrition on Survival During Pediatric Extracorporeal Membrane Oxygenation

Introduction: Pediatric data related to safety, tolerance, and outcomes of enteral nutrition (EN) for patients requiring extracorporeal membrane oxygenation (ECMO) are lacking. The objectives of this study were to evaluate early nutrition status and timing of EN initiation on survival during pediatric ECMO. Methods: A single center institutional review board–approved retrospective chart review was performed on all pediatric patients requiring ECMO from October 2008 through December 2013. Demographics, ECMO variables, laboratory values, vasoactive inotropic score (VIS), and nutrition data on day 5 (d5) were collected. Patients receiving parenteral nutrition (PN) were compared with those receiving any EN on d5. Analyses were conducted to identify factors influencing survival to completion of ECMO and to discharge. Results: Forty‐nine patients aged 53 ± 76 months met inclusion criteria. Kaplan‐Meier curves demonstrated greater survival to discharge in patients receiving any EN, compared with only receiving PN (P = .031). EN on d5 of ECMO support (P = .040) and a higher percentage of daily energy intake achieved (P = .013) were protective, whereas a higher VIS was associated with increased mortality (P = .010). Multivariable analysis demonstrated EN was no longer associated with survival to discharge (P = .139), whereas energy intake (P = .021) and VIS (P = .013) remained significant. Conclusions: Pediatric patients who received nutrition that was closer to goal energy intake, as well as those who received any EN early during ECMO, had improved survival to hospital discharge.     

Angiotensin‐converting enzyme inhibition increases glucose‐induced insulin secretion in response to acute restraint

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Effects of St John's wort and its active constituents,hypericin and hyperforin,on isolated rat urinary bladder

Objectives To investigate the effect of St John's wort (SJW) and its active constituents hypericin and hyperforin on detrusor smooth muscle contractility and their possible neuroprotective role against ischaemic‐like conditions, which could arise during overactive bladder disease. Methods In whole bladders, intrinsic nerves underwent electrical field stimulation (EFS). The effect of drugs on the contractile response and its recovery in reperfusion phase (R) was monitored at different concentrations during 1 or 2 h of anoxia‐glucopenia (A‐G) and the first 30 min of R. The effects of the drugs were also investigated on rat detrusor muscle strips contracted with carbachol, KCl and electrically. Key Findings SJW has spasmolytic activity, which increases with increasing concentration and it worsens the damage induced by A‐G/R on rat urinary bladder. Hypericin and hyperforin had no effect during ischemic‐like conditions but they both exert a dual modulation of rat detrusor strips contraction. At high micromolar concentrations they showed a relaxing effect, but at submicromolar range hypericin increased the plasma membrane depolarisation and hyperforin showed a stimulatory effect on the cholinergic system. Conclusions The results of our study showed that SJW and its constituents could modulate urinary bladder contractility and even worsen A‐G/R injury.     

Use of Temporary Enteral Access Devices in Hospitalized Neonatal and Pediatric Patients in the United States

Background: Temporary enteral access devices (EADs), such as nasogastric (NG), orogastric (OG), and postpyloric (PP), are used in pediatric and neonatal patients to administer nutrition, fluids, and medications. While the use of these temporary EADs is common in pediatric care, it is not known how often these devices are used, what inpatient locations have the highest usage, what size tube is used for a given weight or age of patient, and how placement is verified per hospital policy. Materials and Methods: This was a multicenter 1‐day prevalence study. Participating hospitals counted the number of NG, OG, and PP tubes present in their pediatric and neonatal inpatient population. Additional data collected included age, weight and location of the patient, type of hospital, census for that day, and the method(s) used to verify initial tube placement. Results: Of the 63 participating hospitals, there was an overall prevalence of 1991 temporary EADs in a total pediatric and neonatal inpatient census of 8333 children (24% prevalence). There were 1316 NG (66%), 414 were OG (21%), and 261 PP (17%) EADs. The neonatal intensive care unit (NICU) had the highest prevalence (61%), followed by a medical/surgical unit (21%) and pediatric intensive care unit (18%). Verification of EAD placement was reported to be aspiration from the tube (n = 21), auscultation (n = 18), measurement (n = 8), pH (n = 10), and X‐ray (n = 6). Conclusion: The use of temporary EADs is common in pediatric care. There is wide variation in how placement of these tubes is verified.     

Predictors of cancer mortality in elderly subjects

Cancer mortality was analysed in 3282 elderly subjects aged 65 years from 2 cohorts of general population having different life-style patterns. They took part in the CASTEL (CArdiovascular STudy in the ELderly), a 12-year lasting prospective Italian study. The aim of the present analysis was to identify the items able to influence cancer mortality. A biochemical profile and a questionnaire on lifestyle were collected. Continuous items were averaged and compared with analysis of variance, frequencies with the Pearson's ² test. Mortality was recorded yearly for 12 years from the Registrar's Office and causes of death double-checked by consulting medical case sheets and family doctors' files. The influence of items on mortality was evaluated with the Cox multivariate analysis. Relative risk (RR) of each item was adjusted for confounders. Age, gender, tobacco smoking, the presence of respiratory symptoms, low body mass index in males, serum alanine transaminase (ALT) and alkaline phosphatase (ALP), as well as the town of residence, were powerful predictors of cancer mortality. In the entire population, 12-year overall mortality was 49.4%, cardiovascular 22.8%, and neoplastic 11%; the latter was higher in males than in females (15.7% vs. 7.9%, p < 0.00001). In subjects with respiratory symptoms neoplastic mortality was 11.6% (RR: 1.47) vs. 9.7% in those without symptoms (p < 0.01). Subjects with very low cholesterol ( 178 mg/dl), those with high uric acid ( 8.7 mg/dl) and males with low body mass index ( 22.7 kg/m²) has an increased risk of cancer mortality. RR of cancer mortality increased with increasing ALT or ALP. It was 1 in those having ALT and ALP between 9 and 41.2U/I, 1.41 in those exceeding this latter level and < 1 in those below 9U/I. RR of ALP had a similar trend, the best protective cut-off value being <106 and the worst one > 177U/I. When both serum enzymes were simultaneously raised, RR of cancer mortality increased to 2.84.