Treatment of the syndrome of inappropriate secretion of antidiuretic hormone by urea

Recent data have shown the role of urea in the urinary concentrating mechanism. We studied the effects of exogenous urea administration in hyponatremia associated with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). In 20 patients with SIADH, we observed a positive correlation between serum sodium and blood urea levels (r = 0.65; p < 0.01). In one patient with an oat cell carcinoma and SIADH-induced hyponatremia, we observed the same positive correlation (r = 0.80; p < 0.01) but also a negative one between the excreted fraction of filtered sodium and urinary urea (r = -0.67; p < 0.001). The short-term administration of low doses of urea (4 to 10 g) resulted in correcting the “salt-losing” tendency of this patient. Longer term administration of high doses of urea (30 g/day) was attempted with the same patient as well as with a healthy volunteer subject with Pitressin^®-induced SIADH. In both patients, urea treatment lowered urinary sodium excretion as long as hyponatremia was significant (< 130 meq/liter). Urea treatment also induced a persistent osmotic diuresis, allowing a normal daily intake of water despite SIADH. This was clearly shown during the long-term treatment of a third patient with SIADH who was taking 30 g urea/day during 11 weeks.It is concluded that urea is a good alternative in the treatment of patients with SIADH who present with persistent hyponatremia despite the restriction of water intake.     

Atrial flutter. Electrocardiographic,vectorcardiographic and echocardiographic correlation

The duration, contour, and amplitude of atrial flutter wave (f) was studied by electrocardiogram (ECG) and vectorcardiogram (VCG) in 32 patients and was related to the size of the left atrium (LA) measured by the echocardiogram (E). The following ECG parameters were analyzed: (1) the duration of left atrial depolarization, i.e., LA wave; (2) the amplitude of LA wave; (3) the surface area of LA wave; (4) maximum amplitude (A) of f in Leads 2 and V₁. There was good correlation between LA size and the duration of depolarization and surface area (p < 0.01), but the maximum amplitude of the f wave in Leads 2 and V₁ failed to predict LA size.The post-conversion sinus P wave showed abnormal LA depolarization time (P > 0.12 sec.) in 62 per cent of patients with enlarged left atrium (ELA) and in 43 per cent of patients with normal size LA (NLA).The VCG of the flutter wave revealed two patterns, (1) an eliptical smooth fsÊ loop in 63 per cent of patients with NLA, and (2) distorted fsÊ loop in 67 per cent of patients with ELA.Both VCG patterns were subdivided in two subgroups according to the number and location of conduction delays. The VCG of post-conversion P wave confirmed conduction delays in both groups.We conclude that both the size of the left atrium and conduction delays play a basic role in the duration and contour of left atrial wave.     

Quantitative evaluation of vitamin E in the treatment of angina pectoris.

Because of previous reports of the beneficial effect of vitamin E in angina pectoris patients, 48 patients, with both stable angina and positive (chest pain plus ishemic ST depression) maximal exercise treadmill tests, participated in a double-blind cross-over study of 6 months of vitamin E and 6 months of placebo therapy, separated by a 2 month no treatment period. All 48 patients had positive selective coronary arteriograms (75 per cent obstruction of at least a major coronary artery) and/or Q wave ECG evidence of previous myocardial infarction (Minnesota criteria). Evaluation of drug effectiveness was based on performance of serial maximal exercise treadmill tests, serial systolic time interval measurements, and daily angina diaries. No statistically significant differences between the two treatment studied. It is concluded that a large dose of vitamin E (1,600 I.U. of d-alpha-tocopherol succinate daily) for 6 months in patients with stable angina pectoris fails to increase the exercise capacity, improve left ventricular function, or reduce the frequency of chest pain.     

Myocardial infarction in young adults: Risk factors and natural history

The risk factors and clinical course of 165 patients under 40 years of age (mean age 35) having an initial myocardial infarction (MI) (Group I) were compared to 100 patients over 40 (mean age 50) (Group II). Six risk factors were analyzed: smoking 20 pack-years, hyperlipidemia, hypertension, family history of ischemic disease, diabetes mellitus, and obesity. Only two patients in Group I and six patients in Group II had no risk factors, but the mean number of risk factors in Group I (3) differed from Group II (2) (p< 0.05). Group I had only 18% of patients without either obesity, hyperlipidemia, hypertension, or diabetes mellitus as risk factors while Group II had 41 patients with similar findings (p< 0.001). Group I had hyperlipidemia, obesity, and family history more commonly than did Group II while hypertension was more frequent in the older patients. A prior history of angina was present in nearly half of Group I and II but physical exertion just prior to MI was more common in Group I (32%) than in Group II (20%) (p < 0.05). Death at the time of MI was more frequent in Group II (p < 0.001) but congestive failure occurred in 17% of both groups. On follow-up, 45% of both groups had no complications, and the rates of subsequent MI and angina pectoris were similar in both groups. However, late death was less frequent in Group I than in Group II. Patients under 40 with myocardial infarction have more risk factors than those over 40 which may play some role in pathophysiology of young myocardial infarction. Physical exertion at the time of myocardial infarction is more common in younger patients. The complication rate is similar in both young and older myocardial infarction patients but the mortality rate, both early and late, is lower in young myocardial infarction patients.     

Disassociation of the plasma insulin response from the blood glucose concentration during glucose infusions in normal dogs

Twenty-two anesthetized dogs were given a constant glucose infusion (14 mg/kg/min) for 360 min, while blood glucose concentration was continuously monitored. Plasma insulin concentration was measured every 30 min. The blood glucose peaked at 60 min and then steadily fell (mean fall, $\text{56}\text{mg}\text{100}\text{ml}$), while plasma insulin continuously rose (mean rise, 65 μU/ml). This suggests that blood glucose concentratiion was not the primary stimulus for insulin secretion. In a second series of experiments, five dogs received glucose infusions as described above. One week later, each dog was reinfused with a larger total glucose load, regulated by continuous blood glucose monitoring to exactly reproduce the blood glucose response observed during the first infusion. Plasma insulin concentrations during the high load infusions were significantly higher than during the low load infusions. Thus, changes in glucose load produced changes in plasma insulin concentration, even though blood glucose levels were held constant. Thus, using two different approaches, we have demonstrated that plasma insulin levels can be dissociated from the coexisting blood glucose concentration. These results suggest that the level of blood glucose may not be the primary determinant of the insulin response to glucose during the chronic phase of insulin secretion.     

Emergency Department Visits after Kidney Transplantation

Background and objectives

In 2011, there were approximately 131 million visits to an emergency department in the United States. Emergency department visits have increased over time, far outpacing growth of the general population. There is a paucity of data evaluating emergency department visits among kidney transplant recipients. We sought to evaluate the incidence and risk factors for emergency department visits after initial hospital discharge after transplantation in the United States.

Design, setting, participants, & measurements

We identified 10,533 kidney transplant recipients from California, New York, and Florida between 2009 and 2012 using the State Inpatient and Emergency Department Databases included in the Healthcare Cost and Utilization Project. We used multivariable Poisson and Cox proportional hazard models to evaluate adjusted incidence rates and time to emergency department visits after transplantation.

Results

There were 17,575 emergency department visits over 13,845 follow-up years (overall rate =126.9/100 patient-years; 95% confidence interval, 125.1 to 128.8). The cumulative incidences of emergency department visits at 1, 12, and 24 months were 12%, 40%, and 57%, respectively, with median time =19 months; 48% of emergency department visits led to hospital admission. Risk factors for higher emergency department rates included younger age, women, black and Hispanic race/ethnicity, public insurance, depression, diabetes, peripheral vascular disease, and emergency department use before transplant. There was wide variation in emergency department visits by individual transplant center (10th percentile =70.0/100 patient-years; median =124.6/100 patient-years; and 90th percentile =187.4/100 patient-years).

Conclusions

The majority of kidney transplant recipients will visit an emergency department in the first 2 years post-transplantation, with significant variation by patient characteristics and individual centers. As such, coordination of care through the emergency department is a critical component of post-transplant management, and specific acumen of transplant-related care is needed among emergency department providers. Additional research assessing best processes of care for post-transplant management and health care expenditures and outcomes associated with emergency department visits for transplant recipients are warranted.     

Improving Access to Noninstitutional Long‐Term Care for American Indian Veterans

Home‐based primary care (HBPC) is an effective model of noninstitutional long‐term care developed in the Department of Veterans Affairs (VA) to provide ongoing care to homebound persons. Significant rural populations of American Indians have limited access to services designed for frail older adults. Fourteen Veterans Affairs Medical Centers (VAMCs) initiated efforts to expand access to HBPC in concert with local tribes and Indian Health Service (IHS) facilities. This study characterizes the resulting emerging models of HBPC and co‐management. Using an observational design, key respondent telephone interviews (n = 37) were conducted with stakeholders representing the 14 VAMCs to describe these HBPC programs, and HBPC models were evaluated in relation to VAMC organizational culture as revealed on the annual VA All Employee Survey. Twelve VAMCs independently developed HBPC expansion programs for American Indian veterans, and six different program models were implemented. Two models were unique to collaborations between VAMCs and tribes; in these collaborations, the tribes retained primary care responsibilities. VAMC used the other four models for delivery of care in remote rural areas to all veteran populations, American Indians and non‐Indians alike. Strategies to improve access by reducing geographic barriers occur in all models. Comparing mean VAMC organizational culture ratings, as defined in the Competing Values Framework, revealed significant group differences for one of these six models. Findings from this study illustrate the flexibility of the HBPC program and opportunities for co‐management and expansion of healthcare access for American Indians and non‐Indians, particularly in rural areas.     

泌尿外科实施医护联合查房的效果评价

目的：探讨医护联合查房新型服务模式在泌尿外科的实施效果。方法选择2014年1—12月在泌尿外科住院的650例手术患者作为实验组,在患者入院当天、手术前第1天、手术当天、术后第1天、出院当天实施医护联合查房模式,选择同期在泌尿外科住院的500例手术患者作为对照组,实施传统的医护分开查房模式,对两组病人进行出院满意度及护士工作满意度问卷调查,对照两种工作模式的患者满意度、护士对专业提升效果及满意度、护理成效。结果实验组护理工作质量高,调查护士工作满意度95．45％,出院患者满意度98．46％,差异有统计学意义P＜0．05。结论实施医护联合查房,能提高整体护理水平,建立和谐的医护关系,更重要的是为患者提供了优质、安全、高效的医疗护理服务,大大提高了病人满意度,赢得了社会效益。     

The Heart Failure Association Atlas: rationale,objectives, and methods

Heart failure (HF) constitutes the growing cardiovascular burden and the major public health issue, but comprehensive statistics on HF epidemiology and related management in Europe are missing. The Heart Failure Association (HFA) Atlas has been initiated in 2016 in order to close this gap, representing the continuity directly rooted in the European Society of Cardiology (ESC) Atlas of Cardiology. The major aim of the HFA Atlas is to establish a contemporary dataset on HF epidemiology, resources and reimbursement policies for HF management, organization of the National Heart Failure Societies (NHFS) and their major activities, including education and HF awareness. These data are gathered in collaboration with the network of NHFS of the ESC member and ESC affiliated countries. The dataset will be continuously improved and advanced based on the experience and enhanced understanding of data collection in the forthcoming years. This will enable revealing trends, disparities and gaps in knowledge on epidemiology and management of HF. Such data are highly needed by the clinicians of different specialties (aside from cardiologists and cardiac surgeons), researchers, healthcare policy makers, as well as HF patients and their caregivers. It will also allow to map the snapshot of realities in HF care, as well as to provide insights for evidence‐based health care policy in contemporary management of HF. Such data will support the ESC/HFA efforts to improve HF management ant outcomes through stronger recommendations and calls for action. This will likely influence the allocation of funds for the prevention, treatment, education and research in HF.