Hourly Kinetics of Critical Organ Dysfunction in Extremely Preterm Infants

Rationale: Use of severity of illness scores to classify patients for clinical care and research is common outside of the neonatal ICU. Extremely premature (<29 weeks' gestation) infants with extremely low birth weight (<1,000 g) experience significant mortality and develop severe pathology during the protracted birth hospitalization. Objectives: To measure at high resolution the changes in organ dysfunction that occur from birth to death or discharge home by gestational age and time, and among extremely preterm infants with and without clinically meaningful outcomes using the neonatal sequential organ failure assessment score. Methods: A single-center, retrospective, observational cohort study of inborn, extremely preterm infants with extremely low birth weight admitted between January 2012 and January 2020. Neonatal sequential organ failure assessment scores were calculated every hour for every patient from admission until death or discharge. Measurements and Main Results: Longitudinal, granular scores from 436 infants demonstrated early and sustained discrimination of those who died versus those who survived to discharge. The discrimination for mortality by the maximum score was excellent (area under curve, 0.91; 95% confidence intervals, 0.88-0.94). Among survivors with and without adverse outcomes, most score variation occurred at the patient level. The weekly average score over the first 28 days was associated with the sum of adverse outcomes at discharge. Conclusions: The neonatal sequential organ failure assessment score discriminates between survival and nonsurvival on the first day of life. The major contributor to score variation occurred at the patient level. There was a direct association between scores and major adverse outcomes, including death.

Maximum vasoactive-inotropic score and mortality in extremely premature, extremely low birth weight infants

OBJECTIVE

To determine the relationship between maximum vasoactive-inotropic (VIS^max) and mortality in extremely premature (<29 weeks completed gestation), extremely low birth weight (ELBW, <1000 g) infants.

STUDY DESIGN

Single center, retrospective, and observational cohort study.

RESULTS

We identified 436 ELBW, <29 week, inborn infants cared for during the study period. Compared to infants with VIS^max of 0, the frequency of mortality based on VIS^max ranged from 3.3-fold to 46.1-fold. VIS^max > 30 was associated with universal mortality. Multivariable modeling that included gestational age, birth weight, and VIS^max revealed significant utility to predict mortality with negative predictive value of 87.0% and positive predictive value of 84.8% [adjusted AUROC: 0.90, (0.86-0.94)] among patients that received vasoactive-inotropic treatment.

CONCLUSION

VIS^max is an objective measure of hemodynamic/cardiovascular support that was directly associated with mortality in extremely premature ELBW infants. The VIS^max represents an important step towards neonatal precision medicine and risk stratification of extremely premature ELBW infants.

Prescription of hormone replacement therapy in postmenopausal women with renal failure

Prescription of hormone replacement therapy in postmenopausal women with renal failure.

BACKGROUND

Although patients with end-stage renal disease (ESRD) are at increased risk for early menopause, osteoporosis, cognitive dysfunction, and cardiovascular disease, few postmenopausal women are prescribed hormone replacement therapy (HRT). The reasons for the low prescription rate are not known. This study uses data from the United States Renal Data System (USRDS) to assess the prevalence and predictors of HRT use in postmenopausal women with ESRD.

METHODS

Data were obtained from the USRDS Dialysis Morbidity and Mortality Study Wave 2. All women who were at least 45 years of age were considered postmenopausal and were selected for our analysis. Demographics, behavior and medical characteristics were abstracted from the database. Logistic regression was used to estimate the independent contribution of population characteristics in predicting the use of HRT. Linear regression models were used to estimate the relationship between HRT use and both triglycerides and total cholesterol.

RESULTS

The overall prevalence of HRT prescription was 10.8%. Important predictors of HRT use included age (aOR = 0.74, 95% CI 0.13 to 0.88, P < 0.001), black ethnicity (aOR = 0.50, 95% CI, 0.31 to 0.78, P < 0.002), college education (aOR = 3. 00, 95% CI, 1.70 to 5.24, P < 0.001), and the ability to ambulate (aOR = 1.99, 95% CI, 1.01 to 3.91, P = 0.05). Serum triglyceride and total cholesterol levels were higher among women treated with HRT than among those not treated with HRT (264 +/- 155 vs. 217 +/- 159 mg/dl, P = 0.001 and 220 +/- 62 vs. 209 +/- 55 mg/dl, P = 0.02, respectively).

CONCLUSIONS

HRT is prescribed less frequently in postmenopausal ESRD patients than in the general population. Younger age, higher education levels, white race, and the ability to ambulate were important predictors of HRT use. Targeting populations of patients who are likely to benefit from but less likely to be prescribed HRT may increase the prescription of HRT.

Principles of dialysis: special issues in women

Nephrologists are frequently responsible for the primary care of their female patients. As such, they must be aware of medical issues that are unique to women. Although many of the medical considerations are similar to those in women without renal disease, there are a number of special considerations unique to end-stage renal disease (ESRD) patients. Women comprise a smaller proportion of the dialysis population and have better survival rates than men do. The improved survival is less marked than seen in the general population and may be function of differential susceptibility to disease processes, socio-cultural factors, or gender differences in acceptance or transplantation rates. A variety of factors are important in choosing dialysis modality including lifestyle issues and previous abdominal surgery. Women with ESRD are at high risk of both sexual and gonadal dysfunction, for which the latter may be treated with replacement hormones. Pregnancy is rare and requires an increase in the dose of dialysis and the care of a team of experienced physicians. Finally, awareness and implementation of routine health maintenance recommendations is essential in the care of female dialysis patients.

Cardiac angiotensin II receptor populations during aortocaval fistulae, AII and beta adrenergic receptor blockade

Cardiac angiotensin (AII) receptor subtype expression that occurs during volume overload and beta adrenergic blockade was assessed in male rats pretreated with saline (S) or saralasin (Sar) for 2 weeks. Following pre-treatment, an arteriovenous fistula was produced and some animals were then infused with metoprolol or propranolol for 28 days after which AII binding studies were done. In sham-operated animals, there was more of the AT1 receptor subtype that exhibited more monophasic binding. With fistula, there was biphasic binding, with the AT2 population being the predominate type. Metoprolol or propranolol partially reversed the receptor population shift back to AT1, indicating that the AT2 receptor subtype may play a role in the heart enlargement induced by volume overload and suggesting a functional interrelationship between the beta adrenergic receptors and AII receptors.

A comparison of the effects of buspirone and diazepam on plasma corticosterone levels in rat

The effect of the anxiolytic agents, buspirone and diazepam, on the hypothalamic-pituitary-adrenal axis (HPAA), indicated by changes in the concentration of corticosterone (CS) in plasma, were studied 1/2, 1, 2, 4, 6, 8 and 24 hr after administration of the drug (i.p.). Samples of plasma were collected in the mid-morning (0930-1130 hr) when activity in the hypothalamic-pituitary-adrenal axis in the rat and control levels of corticosterone were low and were repeated in the afternoon (1400-1600 hr) when activity in the hypothalamic-pituitary-arenal axis and levels of corticosterone were higher. At small doses (1 mg/kg) buspirone had a greater facilitating effect on the hypothalamic-pituitary-adrenal axis than did diazepam. In addition, buspirone had a greater maximum facilitatory effect (477%) on levels of corticosterone than diazepam (345%). However, buspirone (ED50 = 8.6 mumol/kg) and diazepam (ED50 = 8.7 mumol/kg) were equipotent. Administration of 1 mg/kg of buspirone in the morning increased the combined 1/2 and 1 hr circulating levels of corticosterone 75% above control levels. Diazepam, at 1 mg/kg, did not produce any significant changes in levels of corticosterone. Large doses (10 mg/kg) of buspirone increased morning levels of corticosterone by 328% and diazepam increased levels of corticosterone by 265%. During the afternoon small doses of buspirone or diazepam did not significantly alter levels of corticosterone.(ABSTRACT TRUNCATED AT 250 WORDS)