Safety and Feasibility of Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy With Calcium-Containing Solutions: A Randomized Controlled Trial

BACKGROUND

Calcium-free (Ca-free) solutions are theoretically the most ideal for regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT). However, the majority of medical centers in China had to make a compromise of using commercially available calcium-containing (Ca-containing) solutions instead of Ca-free ones due to their scarcity. This study was designed to probe into the potential of Ca-containing solution as a secure and efficient substitution for Ca-free solutions.

METHODS

In this prospective, randomized single-center trial, 99 patients scheduled for CRRT were randomly assigned in a 1:1:1 ratio to one of three treatment groups: continuous veno-venous hemodialysis Ca-free dialysate (CVVHD Ca-free) group, continuous veno-venous hemodiafiltration calcium-free dialysate (CVVHDF Ca-free) group, and continuous veno-venous hemodiafiltration Ca-containing dialysate (CVVHDF Ca-containing) group at cardiac intensive care unit (CICU). The primary endpoint was the incidence of metabolic complications. The secondary endpoints included premature termination of treatment, thrombus of filter, and bubble trap after the process.

RESULTS

The incidence of citrate accumulation (18.2% vs. 12.1% vs. 21.2%) and metabolic alkalosis (12.1% vs. 0% vs. 9.1%) did not significantly differ among three groups (p > 0.05 for both). The incidence of premature termination was comparable among the groups (18.2% vs. 9.1% vs. 9.1%, p = 0.582). The thrombus level of the filter and bubble trap was similar in the three groups (p > 0.05 for all).

CONCLUSIONS

In RCA-CRRT for CICU population, RCA-CVVHDF with Ca-containing solutions and traditional RCA with Ca-free solutions had a comparable safety and feasibility.

TRIAL REGISTRATION

ChiCTR2100048238 in the Chinese Clinical Trial Registry.

Ionic homeostasis, acid-base balance and the risk of citrate accumulation in patients after cardiovascular surgery treated with continuous veno-venous haemofiltration with post-dilution regional citrate anticoagulation - An observational case-control study

BACKGROUND

Patients after cardiovascular surgery, requiring renal replacement therapy, can benefit from adequate non-heparin circuit anticoagulation. Simplified regional citrate anticoagulation (RCA) protocol proposes the use of citric acid dextrose formula A (ACD-A) during post-dilutional continuous veno-venous hemofiltration (CVVH) with standard bicarbonate buffered calcium containing replacement solution. Citrate accumulation diagnosed upon total to ionized calcium ratio (tCa/iCa) and low ionized calcium (iCa) are considered as the biggest risks related to regional citrate accumulation.

METHODS

This prospective observational case-control study evaluated electrolyte and acid-base homeostasis in cardiovascular surgery patients treated with post-dilution CVVH with a simplified RCA protocol with ACD-A. In total, 50 consecutive cardiovascular surgery patients were evaluated. Base excess, pH, bicarbonate, lactate, Na+, Cl-, Mg++, and inorganic phosphate concentrations, the total to ionized calcium ratio (tCa/iCa), and high anion gap metabolic acidosis were assessed during haemofiltration treatment in survivors and non-survivors.

RESULTS

Thirty-three (66%) patients died. The therapies were very well balanced in sodium and chloride homeostasis. The lactate concentration and anion gap decreased during CVVH sessions lasting longer than 72 hours, but no inter-group difference was observed. The tCa/iCa ratio exceeded 4.5% and was significantly higher in non-survivors (p=0.037). Initial lactate concentration did not correlate with tCa/iCa ratio during haemofiltration. Magnesium and phosphate concentrations decreased and additional supplementation with magnesium was necessary. The magnesium concentration was lower in the non-survivors.

CONCLUSIONS

The incidence of citrate accumulation exceeded 4% and was significantly higher in non-survivors. Supplementation with magnesium and phosphate ions is needed in CVVH with RCA.

Physiology-based toxicokinetic modelling of aluminium in rat and man

A sufficient quantitative understanding of aluminium (Al) toxicokinetics (TK) in man is still lacking, although highly desirable for risk assessment of Al exposure. Baseline exposure and the risk of contamination severely limit the feasibility of TK studies administering the naturally occurring isotope 27Al, both in animals and man. These limitations are absent in studies with 26Al as a tracer, but tissue data are limited to animal studies. A TK model capable of inter-species translation to make valid predictions of Al levels in humans-especially in toxicological relevant tissues like bone and brain-is urgently needed. Here, we present: (i) a curated dataset which comprises all eligible studies with single doses of 26Al tracer administered as citrate or chloride salts orally and/or intravenously to rats and humans, including ultra-long-term kinetic profiles for plasma, blood, liver, spleen, muscle, bone, brain, kidney, and urine up to 150 weeks; and (ii) the development of a physiology-based (PB) model for Al TK after intravenous and oral administration of aqueous Al citrate and Al chloride solutions in rats and humans. Based on the comprehensive curated 26Al dataset, we estimated substance-dependent parameters within a non-linear mixed-effect modelling context. The model fitted the heterogeneous 26Al data very well and was successfully validated against datasets in rats and humans. The presented PBTK model for Al, based on the most extensive and diverse dataset of Al exposure to date, constitutes a major advancement in the field, thereby paving the way towards a more quantitative risk assessment in humans.

Regional citrate anticoagulation "non-shock" protocol with pre-calculated flow settings for patients with at least 6 L/hour liver citrate clearance

BACKGROUND

Regional citrate anticoagulation (RCA) for the prevention of clotting of the extracorporeal blood circuit during continuous kidney replacement therapy (CKRT) has been employed in limited fashion because of the complexity and complications associated with certain protocols. Hypertonic citrate infusion to achieve circuit anticoagulation results in variable systemic citrate- and sodium load and increases the risk of citrate accumulation and hypernatremia. The practice of "single starting calcium infusion rate for all patients" puts patients at risk for clinically significant hypocalcemia if filter effluent calcium losses exceed replacement. A fixed citrate to blood flow ratio, personalized effluent and pre-calculated calcium infusion dosing based on tables derived through kinetic analysis enable providers to use continuous veno-venous hemo-diafiltration (CVVHDF)-RCA in patients with liver citrate clearance of at least 6 L/h.

METHODS

This was a single-center prospective observational study conducted in intensive care unit patients triaged to be treated with the novel pre-calculated CVVHDF-RCA "Non-shock" protocol. RCA efficacy outcomes were time to first hemofilter loss and circuit ionized calcium (iCa) levels. Safety outcomes were surrogate of citrate accumulation (TCa/iCa ratio) and the incidence of acid-base and electrolyte complications.

RESULTS

Of 53 patients included in the study, 31 (59%) had acute kidney injury and 12 (22.6%) had the diagnosis of cirrhosis at the start of CVVHDF-RCA. The median first hemofilter life censored for causes other than clotting exceeded 70 h. The cumulative incidence of hypernatremia (Na > 148 mM), metabolic alkalosis (HCO3- > 30 mM), hypocalcemia (iCa < 0.9 mM) and hypercalcemia (iCa > 1.5 mM) were 1/47 (1%), 0/50 (0%), 1/53 (2%), 1/53 (2%) respectively and were not clinically significant. The median (25th-75th percentile) of the highest TCa/iCa ratio for every 24-h interval on CKRT was 1.99 (1.91-2.13).

CONCLUSIONS

The fixed citrate to blood flow ratio, as opposed to a titration approach, achieves adequate circuit iCa (< 0.4 mm/L) for any hematocrit level and plasma flow. The personalized dosing approach for calcium supplementation based on pre-calculated effluent calcium losses as opposed to the practice of "one starting dose for all" reduces the risk of clinically significant hypocalcemia. The fixed flow settings achieve clinically desirable steady state systemic electrolyte levels.

A simplified protocol for individualized regional citrate anticoagulation for hemodialysis: A single-center, randomized clinical study

INTRODUCTION

The lack of individualized treatment protocols and complicated procedures are important factors limiting the use of regional citrate anticoagulation (RCA) technology in hemodialysis. This study aims to validate the safety and efficacy of a simplified individualized RCA protocol for hemodialysis.

MATERIALS AND METHODS

From June 2019 to August 2019, 45 patients with active bleeding or bleeding tendency undergoing maintenance hemodialysis in the Nephrology Department of the First Affiliated Hospital of Nanchang University were randomly divided into a modified conventional RCA protocol group with a low-flux dialyzer, a simplified individualized RCA protocol group with a high-flux dialyzer, and a simplified individualized RCA protocol group with a low-flux dialyzer.

RESULTS

A total of 45 patients were included in this study. The mean age of the patients was 57.38 ± 19.05 years, and 78% were men. Forty-three patients completed 4 hours of hemodialysis, and the median total clotting scores in the 3 groups were 11, 12, and 12. Compared with the modified conventional RCA protocol group with a low-flux dialyzer, the 2 simplified individualized RCA protocol groups had better clotting scores for the dialyzer, arterial bubble trap, and single-pool urea clearance index (spKt/VBUN) and lower costs. Moreover, these parameters did not differ between the 2 simplified individualized RCA protocol groups. No electrolyte or acid-base imbalances or citrate poisoning was observed in any of the 3 groups. Adverse events did not differ significantly among the 3 groups.

CONCLUSIONS

The simplified individualized RCA protocol is safe, effective, and easy to implement. Therefore, this protocol can be promoted for clinical practice.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Study Registry under registration number ChiCTR1900023801.

Transient Vasodilation in Mouse 4T1 Tumors after Intragastric and Intravenous Administration of Gold Nanoparticles

Gold nanoparticles (AuNPs) are foreseen as a promising tool in nanomedicine, both as drug carriers and radiosensitizers. They have been also proposed as a potential anticancer drug due to the anti-angiogenic effect in tumor tissue. In this work we investigated the effect of citrate-coated AuNPs of nominal diameter 20 nm on the growth and metastatic potential of 4T1 cells originated from a mouse mammary gland tumor inoculated into the mammary fat pad of Balb/ccmdb mice. To evaluate whether AuNPs can prevent the tumor growth, one group of inoculated mice was intragastrically (i.g.) administered with 1 mg/kg of AuNPs daily from day 1 to day 14 after cancer cell implantation. To evaluate whether AuNPs can attenuate the tumor growth, the second group was intravenously (i.v.) administered with 1 or 5 mg/kg of AuNPs, twice on day 5 and day 14 after inoculation. We did not observe any anticancer activity of i.v. nor i.g. administered AuNPs, as they did not affect neither the primary tumor growth rate nor the number of lung metastases. Unexpectedly, both AuNP treatment regimens caused a marked vasodilating effect in the tumor tissue. As no change of potential angiogenic genes (Fgf2, Vegfa) nor inducible nitric oxygenase (Nos2) was observed, we proposed that the vasodilation was caused by AuNP-dependent decomposition of nitrosothiols and direct release of nitric oxide in the tumor tissue.

Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy

BACKGROUND

Acute kidney injury (AKI) is a major comorbidity in hospitalised patients. Patients with severe AKI require continuous renal replacement therapy (CRRT) when they are haemodynamically unstable. CRRT is prescribed assuming it is delivered over 24 hours. However, it is interrupted when the extracorporeal circuits clot and the replacement is required. The interruption may impair the solute clearance as it causes under dosing of CRRT. To prevent the circuit clotting, anticoagulation drugs are frequently used.

OBJECTIVES

To assess the benefits and harms of pharmacological interventions for preventing clotting in the extracorporeal circuits during CRRT.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs or cluster RCTs) and quasi-RCTs of pharmacological interventions to prevent clotting of extracorporeal circuits during CRRT.

DATA COLLECTION AND ANALYSIS

Data were abstracted and assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) with 95% confidence intervals (CI). The primary review outcomes were major bleeding, successful prevention of clotting (no need of circuit change in the first 24 hours for any reason), and death. Evidence certainty was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

MAIN RESULTS

A total of 34 completed studies (1960 participants) were included in this review. We identified seven ongoing studies which we plan to assess in a future update of this review. No included studies were free from risk of bias. We rated 30 studies for performance bias and detection bias as high risk of bias. We rated 18 studies for random sequence generation,ààsix studies for the allocation concealment, three studies for performance bias, three studies for detection bias,à nine studies for attrition bias,à14 studies for selective reporting and nine studies for the other potential source of bias, as having low risk of bias. We identified eight studies (581 participants) that compared citrate with unfractionated heparin (UFH). Compared to UFH, citrate probably reduces major bleeding (RR 0.22, 95% CI 0.08 to 0.62; moderate certainty evidence) and probably increases successful prevention of clotting (RR 1.44, 95% CI 1.10 to 1.87; moderate certainty evidence). Citrate may have little or no effect on death at 28 days (RR 1.06, 95% CI 0.86 to 1.30, moderate certainty evidence). Citrate versus UFH may reduce the number of participants who drop out of treatment due to adverse events (RR 0.47, 95% CI 0.15 to 1.49; low certainty evidence). Compared to UFH, citrate may make little or no difference to the recovery of kidney function (RR 1.04, 95% CI 0.89 to 1.21; low certainty evidence). Compared to UFH, citrate may reduceàthrombocytopenia (RR 0.39, 95% CI 0.14 to 1.03; low certainty evidence). It was uncertain whether citrate reduces a cost to health care services because of inadequate data. For low molecular weight heparin (LMWH) versus UFH, six studies (250 participants) were identified. Compared to LMWH, UFH may reduce major bleeding (0.58, 95% CI 0.13 to 2.58; low certainty evidence). It is uncertain whether UFH versus LMWH reduces death at 28 days or leads to successful prevention of clotting. Compared to LMWH, UFH may reduce the number of patient dropouts from adverse events (RR 0.29, 95% CI 0.02 to 3.53; low certainty evidence). It was uncertain whether UFH versus LMWH leads to the recovery of kidney function because no included studies reported this outcome. It was uncertain whether UFH versus LMWH leads to thrombocytopenia. It was uncertain whether UFH reduces a cost to health care services because of inadequate data. For the comparison of UFH to no anticoagulation, one study (10 participants) was identified. It is uncertain whether UFH compare to no anticoagulation leads to more major bleeding. It is uncertain whether UFH improves successful prevention of clotting in the first 24 hours, death at 28 days, the number of patient dropouts due to adverse events, recovery of kidney function, thrombocytopenia, or cost to health care services because no study reported these outcomes. For the comparison ofàcitrate to no anticoagulation,àno completed study was identified.

AUTHORS' CONCLUSIONS

Currently,àavailable evidence does not support the overall superiority of any anticoagulant to another. Compared to UFH, citrate probably reduces major bleeding and prevents clotting and probably has little or no effect on death at 28 days. For other pharmacological anticoagulation methods, there is no available data showing overall superiority to citrate or no pharmacological anticoagulation. Further studies are needed to identify patient populations in which CRRT should commence with no pharmacological anticoagulation or with citrate.

Citrate Supplementation Restores the Impaired Mineralisation Resulting from the Acidic Microenvironment: An In Vitro Study

Chronic metabolic acidosis leads to bone-remodelling disorders based on excessive mineral matrix resorption and inhibition of bone formation, but also affects the homeostasis of citrate, which is an essential player in maintaining the acid-base balance and in driving the mineralisation process. This study aimed to investigate the impact of acidosis on the osteogenic properties of bone-forming cells and the effects of citrate supplementation in restoring the osteogenic features impaired by the acidic milieu. For this purpose, human mesenchymal stromal cells were cultured in an osteogenic medium and the extracellular matrix mineralisation was analysed at the micro- and nano-level, both in neutral and acidic conditions and after treatment with calcium citrate and potassium citrate. The acidic milieu significantly decreased the citrate release and hindered the organisation of the extracellular matrix, but the citrate supplementation increased collagen production and, particularly calcium citrate, promoted the mineralisation process. Moreover, the positive effect of citrate supplementation was observed also in the physiological microenvironment. This in vitro study proves that the mineral matrix organisation is influenced by citrate availability in the microenvironment surrounding bone-forming cells, thus providing a biological basis for using citrate-based supplements in the management of bone-remodelling disorders related to chronic low-grade acidosis.

Effects of increasing dietary level of organic acids and nature-identical compounds on growth, intestinal cytokine gene expression and gut microbiota of rainbow trout (Oncorhynchus mykiss) reared at normal and high temperature

Organic acids (OA) and nature-identical compounds (NIC) such as monoterpenes and aldehydes are well-known growth and health promoters in terrestrial livestock while their application for fish production is recent and their mechanisms of action require further study. Hence, this study tested the increasing dietary level (D0, D250, D500, D1000; 0, 250, 500 and 1000 mg kg feed^-1 respectively) of a microencapsulated blend containing citric and sorbic acid, thymol and vanillin over 82 days on rainbow trout to assess the effects on growth, feed utilization, intestine cytokine gene expression and gut microbiota (GM). Furthermore, the effects on intestinal cytokine gene expression and GM were also explored after one week at high water temperature (23 °C). OA and NIC improved specific growth rate (SGR) and feed conversion rate (FCR) during the second half (day 40-82) of the feeding trial, while at the end of the trial protein (PER) and lipid efficiency (LER) increased with increasing dietary level. GM diversity and composition and cytokine gene expression analysis showed no significant differences in fish fed with increasing doses of OA and NIC (82 days) demonstrating the absence of inflammatory activity in the intestinal mucosa. Although there were no statistical differences, GM structure showed a tendency in clustering D0 group separately from the other dietary groups and a trend towards reduction of Streptococcus spp. was observed in the D250 and D1000 groups. After exposure to high water temperature, lower GM diversity and increased gene expression of inflammatory intestinal cytokines were observed for both inclusions (D0 vs. D1000) compared to groups in standard condition. However, the gene up-regulation involved a limited number of cytokines showing the absence of a substantial inflammation process able to compromise the functional activity of the intestine. Despite further study should be conducted to fully clarify this mechanism, cytokines up-regulation seems to be concomitant to the reduction of the GM diversity and, particularly, to the reduction of specific lactic acid bacteria such as Leuconostoc. The application of the microencapsulate blend tested can be a useful strategy to improve growth and feed utilization in rainbow trout under normal temperature conditions. According to the results organic acids and nature-identical compounds did not revert the effects triggered by the increased temperature of water.

Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

BACKGROUND

Critically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH).

METHODS

Retrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT.

RESULTS

In patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively.

CONCLUSIONS

UFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.

Effect of Regional Citrate Anticoagulation vs Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney Injury: A Randomized Clinical Trial

IMPORTANCE

Although current guidelines suggest the use of regional citrate anticoagulation (which involves the addition of a citrate solution to the blood before the filter of the extracorporeal dialysis circuit) as first-line treatment for continuous kidney replacement therapy in critically ill patients, the evidence for this recommendation is based on few clinical trials and meta-analyses.

OBJECTIVE

To determine the effect of regional citrate anticoagulation, compared with systemic heparin anticoagulation, on filter life span and mortality.

DESIGN, SETTING, AND PARTICIPANTS

A parallel-group, randomized multicenter clinical trial in 26 centers across Germany was conducted between March 2016 and December 2018 (final date of follow-up, January 21, 2020). The trial was terminated early after 596 critically ill patients with severe acute kidney injury or clinical indications for initiation of kidney replacement therapy had been enrolled.

INTERVENTIONS

Patients were randomized to receive either regional citrate anticoagulation (n = 300), which consisted of a target ionized calcium level of 1.0 to 1.40 mg/dL, or systemic heparin anticoagulation (n = 296), which consisted of a target activated partial thromboplastin time of 45 to 60 seconds, for continuous kidney replacement therapy.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes were filter life span and 90-day mortality. Secondary end points included bleeding complications and new infections.

RESULTS

Among 638 patients randomized, 596 (93.4%) (mean age, 67.5 years; 183 [30.7%] women) completed the trial. In the regional citrate group vs systemic heparin group, median filter life span was 47 hours (interquartile range [IQR], 19-70 hours) vs 26 hours (IQR, 12-51 hours) (difference, 15 hours [95% CI, 11 to 20 hours]; P < .001). Ninety-day all-cause mortality occurred in 150 of 300 patients vs 156 of 296 patients (Kaplan-Meier estimator percentages, 51.2% vs 53.6%; unadjusted difference, -2.4% [95% CI, -10.5% to 5.8%]; unadjusted hazard ratio, 0.91 [95% CI, 0.72 to 1.13]; unadjusted P = .38; adjusted difference, -6.1% [95% CI, -12.6% to 0.4%]; primary adjusted hazard ratio, 0.79 [95% CI, 0.63 to 1.004]; primary adjusted P = .054). Of 38 prespecified secondary end points, 34 showed no significant difference. Compared with the systemic heparin group, the regional citrate group had significantly fewer bleeding complications (15/300 [5.1%] vs 49/296 [16.9%]; difference, -11.8% [95% CI, -16.8% to -6.8%]; P < .001) and significantly more new infections (204/300 [68.0%] vs 164/296 [55.4%]; difference, 12.6% [95% CI, 4.9% to 20.3%]; P = .002).

CONCLUSIONS AND RELEVANCE

Among critically ill patients with acute kidney injury receiving continuous kidney replacement therapy, anticoagulation with regional citrate, compared with systemic heparin anticoagulation, resulted in significantly longer filter life span. The trial was terminated early and was therefore underpowered to reach conclusions about the effect of anticoagulation strategy on mortality.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02669589.

Application of regional citrate anticoagulation in membrane therapeutic plasma exchange

BACKGROUND

Both regional citrate anticoagulation (RCA) and heparin are used as anticoagulants during membrane therapeutic plasma exchange (mTPE). However, there are few reports of comparisons of the two methods. The aim of this study was to compare different anticoagulants in mTPE and observe the effectiveness, safety, and advantages of RCA.

METHODS

We retrospectively included 85 patients who underwent mTPE in the past 1 year, and divided them into three groups. Patients with no bleeding tendency were administered heparin anticoagulation; patients with bleeding tendency/with liver dysfunction/who had undergone an operation were treated with RCA, or did not receive anticoagulation. In the heparin group, low-dose heparin anticoagulation was administered; in the RCA group, 4% sodium citrate solution was administered, and 10% calcium gluconate solution was pumped from the venous circuit tube. The peripheral blood platelet count, prothrombin time (PT), activated partial thromboplastin time (APTT), and electrolytes were detected before and after treatment in all patients.

RESULTS

A total of 255 sessions of mTPE were performed in 85 patients (2-7 times/case) with 120 sessions of heparin anticoagulation, 93 sessions of RCA, and 42 sessions of no anticoagulation. Compared with pretreatment values, the platelet count decreased by 53.7% and the PT and APTT increased (p < 0.05) in the heparin group after treatment. There were no differences in platelet count and PT before and after treatment in the RCA group. In the RCA group, the patients did not experience hypocalcemia or hypercalcemia, and no separator clotting occurred.

CONCLUSION

RCA is safe, feasible, and effective in mTPE, especially for patients with bleeding tendency and frequent monitoring is needed. It is worth widely developing and applying it in clinical practice.

Acute and Subacute Oral Toxicity of Mumefural, Bioactive Compound Derived from Processed Fruit of Prunus mume Sieb. et Zucc., in ICR Mice

Mumefural is a bioactive compound derived from the processed fruit of Prunus mume Sieb. et Zucc., a traditional health food; however, its safety has not been evaluated. We investigated the toxicity of mumefural through single and repeated oral administration at doses of 1250, 2500, and 5000 mg/kg in Institute of Cancer Research (ICR) mice. The acute toxicity assessment was not associated with adverse effects or death. Similarly, the subacute (four weeks) toxicity assessment did not reveal any mumefural-associated mortality, abnormal organ damage, or altered clinical signs, body weight, food consumption, or hematological parameters. However, albumin/globulin ratio and chloride ion levels were significantly increased in male mice treated with mumefural at ≥2500 mg/kg. Female mice exhibited significantly higher levels of chloride, sodium, and potassium ions, at a dose of 5000 mg/kg. Furthermore, the administration of 2500 and 5000 mg/kg mumefural decreased the absolute weight of spleen in male mice. These findings indicated that the approximate lethal dose of mumefural in ICR mice was >5000 mg/kg. No significant mumefural toxicity was observed at ≤5000 mg/kg. Our findings provide a basis for conducting future detailed studies to evaluate reproductive, neurological, genetic, and chronic toxicity of mumefural.

Regional citrate anticoagulation versus no-anticoagulation for continuous venovenous hemofiltration in patients with liver failure and increased bleeding risk: A retrospective case-control study

Objective

There are controversial opinions on anticoagulation for continuous venovenous hemofiltration (CVVH) in patients with liver failure (LF) and increased bleeding risk. Therefore, we conducted a retrospective study to evaluate the efficacy and safety of regional citrate anticoagulation (RCA) versus no-anticoagulation for CVVH in these patients.

Methods

The included patients were divided into RCA and no-anticoagulation group according to the CVVH anticoagulation strategy they accepted for CVVH. Filter lifespan, bleeding, citrate accumulation, catheter occlusion, and totCa/ionCa ratio were evaluated as outcomes.

Results

In the original cohort, the filter lifespan of the RCA group (41 patients, 79 filters) was significantly longer than the no-anticoagulation group (62 patients, 162 filters) (> 72 hours vs 39.5 hours (IQR 31.2–47.8), P = 0.002). The adjusted results demonstrated that RCA could significantly reduce the risk of filter failure (HR = 0.459, 95%CI 0.26–0.82, P = 0.008). Four episodes of totCa/ionCa > 2.5 were observed in the RCA group and continuously accepted RCA-CVVH after the reduction of citrate dose and blood flow. No obvious citrate accumulation was observed in these patients. In the matched cohort, the filter lifespan of the RCA group was significantly longer than the no-anticoagulation group (P = 0.013) as well. No significant difference in the episodes of totCa/ionCa > 2.5 was observed between the two matched groups (P = 0.074). Both in the original cohort and the matched cohort, the bleeding, acidosis, alkalosis, and catheter occlusion incidences were not significantly different between the two groups.

Conclusions

In LF patients with increased bleeding risk who underwent CVVH, RCA could prolong the filter lifespan and be safely used with careful blood gas monitoring and citrate dose adjusting. Further prospective, randomized, control studies are warranted to obtain robust evidences.

Routine coagulation testing in Vacutainer® Citrate Plus tubes filled at minimum or optimal volume

Background Filling of citrate tubes with appropriate amount of blood is essential for obtaining reliable results of coagulation testing. This study aimed to verify whether results of routine coagulation tests are comparable when the new Becton Dickinson Vacutainer® Citrate Plus tubes are filled at minimum or optimal volume. Methods The study population consisted of 133 patients (40 on oral anticoagulant therapy), who had blood collected for routine coagulation testing. Two sequential Vacutainer® Citrate Plus tubes of the same type and lot were drawn. The first tube was collected after a butterfly needle was inserted into the vein, so that the air in the tubing was aspirated into the tube before blood (minimum fill volume), whilst the second was drawn at optimal fill volume. Experiments were repeated using 2.7-mL (n = 86) and 1.8-mL (n = 47) tubes. Results Prothrombin time (PT) and fibrinogen values were slightly but significantly decreased in tubes with minimum than in those with optimal fill volume. The activated partial thromboplastin time (APTT) was slightly prolonged in tubes with minimum than in those with optimal fill volume, but the difference was not statistically significant. An identical trend was noted in separate analyses for the 2.7-mL and 1.8-mL tubes. Spearman's correlations between the two fill volumes were always >0.94 and bias was always within the quality specifications. Conclusions Blood drawing into Vacutainer® Citrate Plus tubes at minimum fill volume does not clinically bias routine coagulation testing.

Oral magnesium supplementation for leg cramps in pregnancy-An observational controlled trial

BACKGROUND

Oral magnesium for leg cramps treatment in pregnancy is a controversial issue according to recent Cochrane systematic review. This study aims to evaluate the efficacy of Mg++ supplementation in leg cramps treatment in pregnancy.

METHODS

This observational clinical trial studied 132 pregnant women with leg cramps in the first trimester of pregnancy. At baseline, 74 (56.3%) had two leg cramps episodes per week, 28 (21.1%) three episodes, 13 (9.8%) four episodes and 9 (6.8%) five or more episodes. They were randomized 1:1 to 300 mg/day of oral Mg++ citrate (n = 66) or placebo (n = 66). The primary outcome was the frequency of leg cramps episodes per week reported by pregnant women. Secondary outcomes were the ocurrence of leg cramps and oral magnesium side effects.

RESULTS

130 pregnant women completed the study and the two groups were comparable according to some sociodemographic and clinical characteristics. After 4 weeks of intervention it was observed a 28.4% (39/132) (CI 95%: 20.9-37.0) reduction of leg cramps in all participants and no difference between the two groups was found; reduction of 27.2% (18/66) (CI 95%: 17.0-39.6) in Mg++ group and 32.8% (21/66) (CI 95%: 21.6-45.7) in the placebo group. The OR of leg cramps was 1.3 (CI 95%: 0.6-2.9), p = 0.527, taking the placebo group as reference. Among pregnant women who remained with leg cramps the mean of leg cramps episodes per week showed no significance difference between the Mg++ and placebo groups; t-student test: p = 0.408. Four pregnant women showed gastrointestinal side effects; 2 in each group had nauseas and diarrhoea.

CONCLUSION

Oral magnesium supplementation during pregnancy did not reduce the ocurrence and frequency of episodes of leg cramps.

Regional citrate anticoagulation with a substitute containing calcium for continuous hemofiltration in children

Regional citrate anticoagulation (RCA) was recommended as the first treatment option for adults by the Kidney Disease Improving Global Outcomes Kidney Foundation in 2012, for the characteristic of sufficient anticoagulation in vitro, but almost no anticoagulation in vivo. Traditionally, the substitute for RCA is calcium-free. This study investigated a simplified protocol of RCA for continuous hemofiltration (CHF) in children using a commercially available substitute containing calcium.An analytical, observational, retrospective study assessed 59 pediatric patients with 106 sessions and 3580 hours of CHF. Values before and after treatment were compared, including Na, ionic calcium (iCa) and HCO3 concentrations, pH, and the ratio of total calcium to iCa (T/iCa). In addition, in vivo and in vitro iCa, treatment time, sessions with continuous transmembrane pressure >200 mm Hg, and sessions with clotting and bleeding were recorded.The average treatment time was 33.8 ± 10.1 hours. In vitro, 88.5% of iCa achieved the target (0.25-0.35 mmol/L), and in vivo, 95.4% of iCa achieved the target (1.0-1.35 mmol/L). There were 8 sessions with a transmembrane pressure >200 mm Hg and 3 sessions with filters clotted. After treatment, there were 2, 1, and 2 sessions with T/iCa > 2.5 (implying citrate accumulation), iCa < 0.9 mmol/L, and iCa > 1.35 mmol/L. No sodium disorders were recorded. There were fewer cases of acidemia and more cases of alkalemia after treatment compared to before.RCA-CHF with a substitute containing calcium and close monitoring could be a safe and effective treatment for children. In addition, the calcium test site in vitro and the adjustment of citrate should be given strict attention.

Citric acid mitigates soybean meal induced inflammatory response and tight junction disruption by altering TLR signal transduction in the intestine of turbot, Scophthalmus maximus L

A 12-week feeding trial was conducted to investigate the effect of citric acid on the involvement of TLRs in the soybean meal induced inflammatory response and tight junction disruption in the distal intestine of juvenile turbot (Scophthalmus maximus L.). Four isonitrogenous and isolipidic practical diets were formulated: fish meal-based diet (FM); 40% fish meal protein in FM replaced with soybean meal protein (SBM); SBM + 1.5% citric acid and SBM + 3% citric acid. Compared to the FM, diet SBM significantly increased the gene expression of TLRs (TLR2, TLR3, TLR5b, TLR9, TLR21, TLR22) and MyD88, as well as TLR related molecules (NF-κB, IRF-3, p38 and JNK), which were remarkably reduced by dietary citric acid. Similarly, citric acid supplementation in SBM markedly depressed gene expression of pro-inflammatory cytokines (TNF-α and IFN-γ) and pore-forming tight junction protein Claudin-7, and enhanced gene expression of the anti-inflammatory cytokine TGF-β1 and TJ proteins related to the decrease in paracellular permeability (Claudin-3, Claudin-4, Occludin, Tricellulin and ZO-1). Compared to the SBM, the concentration of IgM and C4 in serum was significantly reduced by dietary citric acid. In brief, dietary citric acid could synchronously inhibit TLRs-dependent inflammatory response regulated by NF-κB and IRF3, as well as cause TLRs-dependent tight junction disruption modulated by p38 and JNK. Therefore, citric acid could function on mitigating soybean meal induced enteropathy in the distal intestine of juvenile turbot.

Complementary techniques (spICP-MS, TEM, and HPLC-ICP-MS) reveal the degradation of 40 nm citrate-stabilized Au nanoparticles in rat liver after intraperitoneal injection

BACKGROUND

Due to the increased use of engineered nanoparticles (NPs), their tracing in environmental and biological systems is of utmost importance. Besides their accumulation within a biological specimen, little is known about their degradation and transformation into corresponding low-molecular species that might influence any toxicological impact.

ANALYTICAL METHODS

Wistar rats underwent intraperitoneal injections of 40 nm citrate-stabilized gold nanoparticles. Different liver samples were analysed for the occurrence of nanoparticles and potential degradation products by means of spICP-MS, TEM and HPLC-ICP-MS.

MAIN FINDINGS

Studies using spICP-MS revealed the presence of the originally administrated Au NPs (40 nm diameter) and some evidences of other Au-containing species due to the increased background signal. Images obtained by transmission electron microscopy (TEM) showed the predominant presence of particles of significantly smaller diameter (6 ± 2 nm). As complementary method, HPLC-ICP-MS confirmed the presence of both particle types indicating a degradation of the Au NPs accompanied by detection of low-molecular Au species.

CONCLUSIONS

This study underlines that degradation of gold nanoparticles to low-molecular gold species might have to be taken into account in future for studies on their toxicological behaviour and their potential use in clinical applications.

Impact of citrate- and chitosan-capped gold nanoparticles on the liver of Swiss albino mice: Histological and cyto-genotoxic study

The present study aimed to disclose the histological alterations and cyto-genotoxic potential induced by citrate- and chitosan-capped AuNPs on liver of adult Swiss albino mice. Animals were randomly divided into 8 groups. The first two groups were intraperitoneally (i.p) injected with physiological saline once and left for 10 days and every other day for 21 days, respectively, and kept as negative control groups. While the third and fourth groups were injected i.p with a single dose of 2 mg/kg of citrate- and chitosan-capped AuNPs, respectively, and left for 10 days. The fifth and sixth groups were injected i.p every other day for 21 days with 200 µg/kg of citrate- and chitosan-capped AuNPs, respectively. Animals of the seventh and eighth groups were injected i.p with 50 mg/kg cyclophosphamide once and left for 10 days and with 20 mg/kg cyclophosphamide every other day for 21 days, respectively. The livers of mice were dissected and processed for microscopic examination and for analyzing the expression of inflammation-related genes using RT-PCR. In addition, bone marrow samples were taken to investigate the mitotic index and the chromosomal aberrations. The present study showed various degrees of structural changes in the liver of animals received AuNPs. Such changes were more prominent in animals treated with a single dose of AuNPs, particularly with citrate-capped AuNPs as compared to chitosan-capped AuNPs. Furthermore, genotoxic analysis did not reveal any genotoxicity for AuNPs with both coats. Therefore, chitosan-capped AuNPs were less hepatotoxic than citrate-capped ones. However, it has not been proven that AuNPs are genotoxic by both coats.

An advanced recording and analysis system for the differentiation of guinea pig cough responses to citric acid and prostaglandin E2 in real time

Cough number and/or sound have been used to assess cough sensitivity/intensity and to discriminate cough patterns in clinical settings. However, to date, only manual counting of cough number in an offline manner is applied in animal cough studies, which diminishes the efficiency of cough identification and hinders the diagnostic discrimination of cough patterns, especially in animals with pulmonary diseases. This study aims to validate a novel recording/analysis system by which cough numbers are automatically counted and cough patterns are comprehensively differentiated in real time. The experiment was carried out in conscious guinea pigs exposed to aerosolized citric acid (CA, 150 mM) and prostaglandin E2 (PGE2, 0.43 mM). Animal body posture (video), respiratory flow, and cough acoustics (audio) were simultaneously monitored and recorded. Cough number was counted automatically, and cough sound parameters including waveform, duration, power spectral density, spectrogram, and intensity, were analyzed in real time. Our results showed that CA- and PGE2-evoked coughs had the same cough numbers but completely different patterns [individual coughs vs. bout(s) of coughs]. Compared to CA-evoked coughs, PGE2-evoked coughs possess a longer latency, higher cough rate (coughs/min), shorter cough sound duration, lower cough sound intensity, and distinct cough waveforms and spectrograms. A few mucus- and wheeze-like coughs were noted in response to CA but not to PGE2. In conclusion, our recording/analysis system is capable of automatically counting the cough number and successfully differentiating the cough pattern by using valuable cough sound indexes in real time. Our system enhances the objectivity, accuracy, and efficiency of cough identification and count, improves the intensity evaluation, and offers ability for pattern discrimination compared to traditional types of cough identification. Importantly, this approach is beneficial for assessing the efficacy of putative antitussive drugs in animals without or with pulmonary diseases, particularly in cases without significant change in cough number.

[Choice and management of anticoagulation during CRRT]

Continuous renal replacement therapies (CRRT) are widely used in the treatment of acute kidney injury. Several causes, related to the treatment itself or to the patient's condition, determine the coagulation of the extracorporeal circuit. These interruptions (or down-time) have a negative impact on the effectiveness of the treatment in terms of solute clearance and fluid balance. Historically, the choice of anticoagulant has fallen on unfractionated heparin because it is cheap and easy to use. Today, the use of citrate is recommended in most instances because of its high efficacy and safety. Several studies demonstrate the superiority of citrate in terms of filter survival. The reduction of down-time results in a reduction of the delta between the prescribed dialysis dose and the dose that is actually administered (ml/Kg/hour of collected effluent). The literature also agrees that there is a reduction in the incidence of major bleeding events when citrate is used instead of heparin, although there is no impact on mortality rates. Some technical and clinical complexities, secondary to citrate action both as anticoagulant and buffer, still exist in the use of regional citrate anticoagulation. However, complications due to citrate use, such as acid-base balance disorders and hypocalcaemia, are rare and easily reversible. There is not much data about the costs and benefits of using citrate instead of heparin; according to the experience within our own Unit, we have observed a reduction in costs when the data is normalized for 35 ml of effluent administered. Appropriate protocols, accurate surveillance and the automated management of regional citrate anticoagulation thanks to dedicated software make this technique safe and effective.

Regional citrate versus systemic heparin anticoagulation for continuous renal replacement therapy in critically ill patients with acute kidney injury (RICH) trial: study protocol for a multicentre, randomised controlled trial

INTRODUCTION

Acute kidney injury (AKI) is a well-recognised complication of critical illness which is of crucial importance for morbidity, mortality and health resource utilisation. Renal replacement therapy (RRT) inevitably entails an escalation of treatment complexity and increases costs for those patients with severe AKI. However, it is still not clear whether regional citrate anticoagulation or systemic heparin anticoagulation for continuous RRT (CRRT) is most appropriate. We hypothesise that, in contrast to systemic heparin anticoagulation, regional citrate anticoagulation for CRRT prolongs filter life span and improves overall survival in a 90-day follow-up period (coprimary endpoints).

METHODS AND ANALYSIS

We will conduct a prospective, randomised, multicentre, clinical trial including up to 1450 critically ill patients with AKI requiring CRRT. We suggest to investigate the effect of regional citrate anticoagulation for CRRT as compared with systemic heparin anticoagulation. The two coprimary outcomes are filter life span and overall survival in a 90-day follow-up period. Secondary outcomes are length of stay in the intensive care unit; length of hospitalisation; duration of CRRT; recovery of renal function at days 28, 60, 90 and 1 year; requirement for RRT after days 28, 60, 90 and 1 year; 28 days, 60 days, 90 days and 1-year all-cause mortality; major adverse kidney events at days 28, 60, 90 and 1 year; bleeding complications; transfusion requirements; infection rate and costs of RRT. Additionally, in an add-on study involving several of the participating centres, blood samples from recruited patients will be collected at different time points to analyse whether the anticoagulation strategy has an impact on immune response as evidenced by leucocyte recruitment and function.

ETHICS AND DISSEMINATION

The RICH trial has been approved by the Federal Institute for Drugs and Medical Devices, the leading Ethics Committee of the University of Münster and the corresponding Ethics Committee at each participating site.

TRIAL REGISTRATION NUMBER

NCT02669589.

Gustatory responses in macaque monkeys revealed with fMRI: Comments on taste, taste preference, and internal state

Studies of the neural mechanisms underlying value-based decision making typically employ food or fluid rewards to motivate subjects to perform cognitive tasks. Rewards are often treated as interchangeable, but it is well known that the specific tastes of foods and fluids and the values associated with their taste sensations influence choices and contribute to overall levels of food consumption. Accordingly, we characterized the gustatory system in three macaque monkeys (Macaca mulatta) and examined whether gustatory responses were modulated by preferences and hydration status. To identify taste-responsive cortex, we delivered small quantities (0.1 ml) of sucrose (sweet), citric acid (sour), or distilled water in random order without any predictive cues while scanning monkeys using event-related fMRI. Neural effects were evaluated by using each session in each monkey as a data point in a second-level analysis. By contrasting BOLD responses to sweet and sour tastes with those from distilled water in a group level analysis, we identified taste responses in primary gustatory cortex area G, an adjacent portion of the anterior insular cortex, and prefrontal cortex area 12o. Choice tests administered outside the scanner revealed that all three monkeys strongly preferred sucrose to citric acid or water. BOLD responses in the ventral striatum, ventral pallidum, and amygdala reflected monkeys' preferences, with greater BOLD responses to sucrose than citric acid. Finally, we examined the influence of hydration level by contrasting BOLD responses to receipt of fluids when monkeys were thirsty and after ad libitum water consumption. BOLD responses in area G and area 12o in the left hemisphere were greater following full hydration. By contrast, BOLD responses in portions of medial frontal cortex were reduced after ad libitum water consumption. These findings highlight brain regions involved in representing taste, taste preference and internal state.

Central adenosine A1 receptors inhibit cough via suppression of excitatory glutamatergic and tachykininergic neurotransmission

BACKGROUND AND PURPOSE

The adenosine A1 receptor is reported to mediate several excitatory effects in the airways and has inhibitory effects in the CNS. In this study, we investigated the role of peripheral and central A1 receptors in regulating cough and airway obstruction.

EXPERIMENTAL APPROACH

Drugs were administered to guinea pigs via inhalation or i.c.v. infusion. Following the administration of different drugs, cough was induced by exposing guinea pigs to aerosolized 0.4 M citric acid. An automated analyser recorded both cough and airway obstruction simultaneously using whole-body plethysmography.

KEY RESULTS

The A1 receptor agonist, cyclopentyladenosine (CPA, administered by inhalation), dose-dependently inhibited cough and also inhibited airway obstruction. Similarly, CPA, administered i.c.v., inhibited both the citric acid-induced cough and airway obstruction; this was prevented by pretreatment with the A1 receptor antagonist DPCPX (i.c.v.). Treatment with DPCPX alone dose-dependently enhanced the citric acid-induced cough and airway obstruction. This effect was reversed following treatment with either the glutamate GluN1 receptor antagonist D-AP5 or the neurokinin NK1 receptor antagonist FK-888.

CONCLUSIONS AND IMPLICATIONS

These findings suggest that activation of either peripheral or central adenosine A1 receptors inhibits citric acid-induced cough and airway obstruction. The data also suggest that tonic activation of central adenosine A1 receptors serves as a negative regulator of cough and airway obstruction, secondary to inhibition of excitatory glutamatergic and tachykininergic neurotransmission.

Impact of Potassium Citrate vs Citric Acid on Urinary Stone Risk in Calcium Phosphate Stone Formers

PURPOSE

To our knowledge no medication has been shown to be effective for preventing recurrent calcium phosphate urinary stones. Potassium citrate may protect against calcium phosphate stones by enhancing urine citrate excretion and lowering urine calcium but it raises urine pH, which increases calcium phosphate saturation and may negate the beneficial effects. Citric acid can potentially raise urine citrate but not pH and, thus, it may be a useful countermeasure against calcium phosphate stones. We assessed whether these 2 agents could significantly alter urine composition and reduce calcium phosphate saturation.

MATERIALS AND METHODS

In a crossover metabolic study 13 recurrent calcium phosphate stone formers without hypercalciuria were evaluated at the end of 3, 1-week study phases during which they consumed a fixed metabolic diet and received assigned study medications, including citric acid 30 mEq twice daily, potassium citrate 20 mEq twice daily or matching placebo. We collected 24-hour urine specimens to perform urine chemistry studies and calculate calcium phosphate saturation indexes.

RESULTS

Urine parameters did not significantly differ between the citric acid and placebo phases. Potassium citrate significantly increased urine pH, potassium and citrate compared to citric acid and placebo (p <0.01) with a trend toward lower urine calcium (p = 0.062). Brushite saturation was increased by potassium citrate when calculated by the relative supersaturation ratio but not by the saturation index.

CONCLUSIONS

Citric acid at a dose of 60 mEq per day did not significantly alter urine composition in calcium phosphate stone formers. The long-term impact of potassium citrate on calcium phosphate stone recurrence needs to be studied further.

Haemodialysis with Tinzaparin Versus Dialysate Citrate as Anticoagulation

Anticoagulation with citrate-containing haemodialysate (cHD) is an alternative to tinzaparin haemodialysate (tHD). The study investigated whether cHD would differ when changed from tHD. The same 18 patients were their own controls followed up with cHD for 5 months. LDL-cholesterol decreased at the end of a cHD session (p = 0.01). Neutrophils (p = 0.013) and monocytes (p = 0.007) dropped more during a cHD session. During the follow-up period of cHD, approximately 50% needed additional tinzaparin. Before the cHD session could start, there was a lower total cholesterol at 2 weeks (p = 0.014) and LDL-cholesterol at 1 month (p = 0.011) versus an increase of LDL at 5 months (p = 0.02). Only patients without additional tinzaparin had a reduction of -C-reactive protein (CRP) at 2 months of cHD (p < 0.05) but not later. Solely cHD seems possible only in half of the patients. A greater reduction in granulocytes and monocytes during cHD indicates a more extensive blood membrane interaction, while CRP may be lower.

Management of tannery wastewater for improving growth attributes and reducing chromium uptake in spinach through citric acid application

The use of chromium (Cr)-contaminated tannery wastewater for irrigation is a common practice, especially in developing countries like Pakistan. This practice is due to the shortage of good quality irrigation water for crop growth as well as the issue of tannery wastewater disposal. The current study was done to evaluate the effect of citric acid (CA) (0, 1.0, and 2.0 mM) on the growth and Cr uptake by spinach irrigated with different mixtures of tap water and tannery wastewater (100:0, 50:50, and 0:100 tap water to wastewater ratio). Plants were grown for 8 weeks under ambient conditions. Results showed that 50:50% tap water and wastewater increased plant height, dry weights of shoots and roots, total chlorophyll contents, and gas exchange attributes than the plants treated with only tap water or only wastewater. Increasing wastewater ratio increased electrolyte leakage (EL) in plants and enhanced the leaf key antioxidant enzyme activities as well as increased Cr contents. Foliar application of CA increased the plant dry weights, photosynthesis, and enzyme activities, whereas reduced the EL and Cr concentrations in plants than respective treatments without CA application. It can be concluded that 50:50 tap water and wastewater irrigation along with foliar CA application might be an effective strategy for increasing vegetable growth with reduced metal concentrations.

Effectiveness and Cost of Weekly Recombinant Tissue Plasminogen Activator Hemodialysis Catheter Locking Solution

BACKGROUND AND OBJECTIVES

Evidence to guide hemodialysis catheter locking solutions is limited. We aimed to assess effectiveness and cost of recombinant tissue plasminogen activator (rt-PA) once per week as a locking solution, compared with thrice weekly citrate or heparin, in patients at high risk of complications.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used a prospective design and pre-post comparison in three sites across Canada. Pre-post comparisons were conducted using multilevel mixed effects regression models accounting for cluster with site and potential enrollment of patients more than once. In the pre period, catheter malfunction was managed as per site-specific standard of care. The intervention in the post period was once weekly rt-PA as a locking solution (with citrate or heparin used for other sessions). The primary outcome was rate of rt-PA use for treatment of catheter malfunction. Secondary outcomes included rates of bacteremia, management of catheter malfunction, and cost.

RESULTS

There were 374 patients (mean age 68 years; 52% men) corresponding to 506 enrollments. Mean length of enrollment was 200 days (SD 119) in the pre period and 187 days (SD 101) in the post period. There was a significant decline in rate of rt-PA use for treatment of catheter malfunction in the post compared with pre period (adjusted incidence rate ratio, 0.39; 95% confidence interval, 0.30 to 0.52); however, there was no difference in the rate of bacteremia, or catheter stripping or removal/replacement. The increase in mean total health care cost in the post period was CAD$962 per enrollment, largely related to costs of rt-PA as a locking solution.

CONCLUSIONS

Once weekly rt-PA as a catheter locking solution was associated with a reduction in rt-PA use for treatment of catheter malfunction. Our results showing a reduction in rescue rt-PA use are consistent with a prior randomized trial, although we did not observe a reduction in bacteremia or catheter stripping/removal and did observe an increased incremental cost of this strategy primarily accounted for by the cost of the rt-PA.

Safety of Citrate Based Hemofiltration in Critically Ill Patients at High Risk for Bleeding: A Comparison with Nadroparin

Purpose

To study the incidence and severity of bleeding in high risk critically ill patients during high volume, citrate based continuous veno-venous hemofiltration (CVVH).

Design

A prospective 1-year observational cohort study comparing citrate based CVVH with nadroparin based CVVH.

Procedures

Critically ill patients with multiple organ dysfunction and in need of CVVH were observed for bleeding complications during their CVVH sessions. Pre-defined criteria determined that patients were treated with citrate based CVVH in case of active bleeding or increased risk for bleeding. Otherwise nadroparin was used as anticoagulant.

Statistical and Outcome Methods

The incidence of bleeding complications, the number of transfused blood cell concentrates and the filter-run-time were recorded. Analyses were made by non-parametric tests.

Main Findings

Fifty-five patients received 272 CVVH sessions. In the citrate group 14.8% experienced a bleeding complication compared to 25% in the nadroparin group (p=0.04). The number of transfused red blood cell concentrates was not different between groups. The nadroparin group had a longer filter run time (median 31.5 hours versus 22.5 hours, p=0.0001).

Conclusions

In high risk critically ill patients citrate based anticoagulation for CVVH is safe in terms of bleeding complications and transfusion requirements.

Citrate Anticoagulation during CVVH in High Risk Bleeding Patients

Background

Regional citrate anticoagulation (RCA) is an effective form of anticoagulation for continuous renal replacement therapy (CRRT) in patients with contraindications to heparin. Its use has been very limited, possibly because of the need for special infusion solutions and difficult monitoring of the metabolic effects.

Objective

To investigate the safety and the feasibility of an RCA method for continuous veno-venous hemofiltration (CVVH) using commercially available replacement fluid.

Methods

We evaluated 11 patients at high risk of bleeding, requiring CVVH. RCA was performed using commercially available replacement fluid solutions to maintain adequate acid-base balance. We adjusted the rate of citrate infusion to achieve a post-filter ionized calcium concentration [iCa] <0.4 mmol/L when blood flow was <250 ml/min, or <0.6 mmol/L when blood flow was >250 ml/min. When needed, we infused calcium gluconate to maintain systemic plasma [iCa] within the normal range.

Results

Twenty-nine filters ran for a total of 965.5 h. Average filter life was 33.6±20.5 h. Asymptomatic hypocalcemia was detected in 6.9% of all samples. No [iCa] values <0.9 mmol/L were observed. Hypercalcemia (1.39±0.05 mmol/L) occurred in 2.5% of all samples. We observed hypernatremia (threshold 153 mmol/L) and alkalosis (threshold 7.51) in only 9.3% and 9.4% respectively of all samples, mostly concomitantly. No patient showed any signs of citrate toxicity. Conclusions: We developed a protocol for RCA during CVVH using commercially available replacement fluid that proved safe, flexible and applicable in an Intensive Care Unit (ICU) setting.

Comparison of pre-filter and post-filter ionised calcium monitoring in continuous veno-venous hemodiafiltration (CVVHD-F) with citrate anti-coagulation

Background

It is widespread practice during citrate anticoagulated renal replacement therapy to monitor circuit ionised calcium (iCa²⁺) to evaluate the effectiveness of anticoagulation. Whether the optimal site to sample the blood path is before or after the haemofilter is a common question.

Methods

Using a prospectively collected observational dataset from intensive care patients receiving pre-dilution continuous veno-venous haemodiafiltration (CVVHD-F) with integrated citrate anticoagulation we compared paired samples of pre and post filter iCa²⁺ where the target range was 0.3–0.5 mmol.L^-1 as well as concurrently collected arterial iCa²⁺. Two nested mixed methods linear models were fitted to the data describing post vs pre filter iCa²⁺, and the relationship of pre, post and arterial samples.

Setting

An 11 bed general intensive care unit.

Participants

450 grouped samples from 152 time periods in seven patients on CRRT with citrate anticoagulation.

Results

The relationship of post to pre-filter iCa²⁺ was not 1:1 with post = 0.082 + 0.751 x pre-filter iCa²⁺ (95% CI intercept: 0.015–0.152, slope 0.558–0.942). Variation was greatest between patients rather than between circuits within the same patient or citrate dose. Compared to arterial iCa²⁺ there was no significant difference between pre and post-filter sampling sites (F-value 0.047, p = 0.827)

Conclusion

These results demonstrate that there is minimal difference between pre and post filter samples for iCa²⁺ monitoring of circuit anticoagulation in citrate patients relative to the arterial iCa²⁺ in CVVHD-F however compared to pre-filter sampling, post filter sampling has a flatter response and greater variation.

Effects of organic acids and essential oils blend on growth, gut microbiota, immune response and disease resistance of Pacific white shrimp (Litopenaeus vannamei) against Vibrio parahaemolyticus

An 8-week feeding trial was undertaken to evaluate supplemental effects of AviPlus^® (AP), a blend of organic acids [citric acid, 25%; sorbic acid, 16.7%] and essential oils [thymol, 1.7%; vanillin, 1.0%], on growth, gut microbiota, innate immunity and disease resistance of Pacific white shrimp (Litopenaeus vannamei) against Vibrio parahaemolyticus. A basal experimental diet was formulated and supplemented with 0, 0.3, 0.6, 0.9 and 1.2 g kg^-1 AP to produce five test diets (Con, AP0.3, AP0.6, AP0.9 and AP1.2). Each diet was fed to triplicate groups of shrimp (0.2 ± 0.01 g, mean ± SE) to apparent satiation three times daily. Growth performance and survival rate were not significantly influenced by AP supplementation (P > 0.05). Significantly (P < 0.05) higher serum total protein was found in groups fed ≥ 0.6 g kg^-1 AP compared to control. Serum alkaline phosphatase and phenoloxidase activities were significantly increased in AP0.9 and AP1.2 groups. Also, the group received AP0.6 diet showed significantly higher glutathione peroxidase activity than control. Expression of gut pro-inflammatory genes including TNF-α, LITAF and RAB6A were down-regulated by AP administration. Gut microbiota analysis showed the significant enhancement of the operational taxonomic unit (OTU) diversity and richness indices by AP application. AP supplementation led to increased abundance of Firmicutes and a reduction in abundance of Proteobacteria. Also, dietary inclusion of 1.2 g kg^-1 AP led to a significant increase in the abundance of Lactobacillus in shrimp gut. The group offered AP0.3 diet showed significantly higher disease resistance than control group. Furthermore, AP application significantly enhanced relative expression of immune related genes including lysozyme, penaeidin and catalase at 48 h post challenge. In conclusion, these findings show that the tested organic acids and essential oils mixture beneficially affects intestinal microflora and improves immune response and disease resistance of L. vannamei.

Anaplerotic therapy in propionic acidemia

BACKGROUND

Propionic acidemia is a rare metabolic disorder caused by a deficiency of propionyl- CoA carboxylase, the enzyme converting propionyl-CoA to methylmalonyl-CoA that subsequently enters the citric acid cycle as succinyl-CoA. Patients with propionic acidemia cannot metabolize propionic acid, which combines with oxaloacetate to form methylcitric acid. This, with the defective supply of succinyl-CoA, may lead to a deficiency in citric acid cycle intermediates.

PURPOSE

The objective of this study was to determine whether supplements with glutamine (400mg/kg per day), citrate (7.5mEq/kg per day), or ornithine α-ketoglutarate (400mg/kg per day) (anaplerotic agents that could fill up the citric acid cycle) would affect plasma levels of glutamine and ammonia, the urinary excretion of Krebs cycle intermediates, and the clinical outcome in 3 patients with propionic acidemia.

METHODS

Each supplement was administered daily for four weeks with a two week washout period between supplements. The supplement that produced the most favorable changes was supplemented for 30 weeks following the initial study period and then for a 2 year extension.

RESULTS

The urinary excretion of the Krebs cycle intermediates, α-ketoglutarate, succinate, and fumarate increased significantly compared to baseline during citrate supplementation, but not with the other two supplements. For this reason, citrate supplements were continued in the second part of the study. The urinary excretion of methylcitric acid and 3-hydroxypropionic acid did not change with any intervention. No significant changes in ammonia or glutamine levels were observed with any supplement. However, supplementation with any anaplerotic agents normalized the physiological buffering of ammonia by glutamate, with plasma glutamate and alanine levels significantly increasing, rather than decreasing with increasing ammonia levels. No significant side effects were observed with any therapy and safety labs (blood counts, chemistry and thyroid profile) remained unchanged. Motor and cognitive development was severely delayed before the trial and did not change significantly with therapy. Hospitalizations per year did not change during the trial period, but decreased significantly (p<0.05) in the 2years following the study (when citrate was continued) compared to the 2years before and during the study.

CONCLUSIONS

These results indicate that citrate entered the Krebs cycle providing successful anaplerotic therapy by increasing levels of the downstream intermediates of the Krebs cycle: α-ketoglutarate, succinate and fumarate. Citrate supplements were safe and might have contributed to reduce hospitalizations in patients with propionic acidemia.

Renal replacement therapy and anticoagulation

Today, up to 20% of all intensive care unit patients require renal replacement therapy (RRT), and continuous renal replacement therapies (CRRT) are the preferred technique. In CRRT, effective anticoagulation of the extracorporeal circuit is mandatory to prevent clotting of the circuit or filter and to maintain filter performance. At present, a variety of systemic and regional anticoagulation modes for CRRT are available. Worldwide, unfractionated heparin is the most widely used anticoagulant. All systemic techniques are associated with significant adverse effects. Most important are bleeding complications and heparin-induced thrombocytopenia (HIT-II). Regional citrate anticoagulation (RCA) is a safe and effective technique. Compared to systemic anticoagulation, RCA prolongs filter running times, reduces bleeding complications, allows effective control of acid-base status, and reduces adverse events like HIT-II. In this review, we will discuss systemic and regional anticoagulation techniques for CRRT including anticoagulation for patients with HIT-II. Today, RCA can be recommended as the therapy of choice for the majority of critically ill patients requiring CRRT.

Study to determine guidelines for pediatric colonoscopy

AIM

To investigated characteristics, diagnosis, bowel-cleansing preparation, sedation, and colonoscope length and diameter in Japanese pediatric patients receiving total colonoscopy.

METHODS

The present study evaluated consecutive patients aged ≤ 15 years who had undergone their first colonoscopy in Kurume University between January 2007 and February 2015. Data were retrospectively analyzed. We identified 110 pediatric patients who had undergone colonoscopy that had reached the cecum, allowing the observation of the total colon.

RESULTS

Hematochezia, abdominal pain, and diarrhea were the most common symptoms. For bowel-cleansing preparation, pediatric patients aged ≤ 12 years were treated with magnesium citrate, and patients aged 13-15 years were treated with polyethylene glycol 4000. For sedation, thiamylal with pentazocine, which has an analgesic effect, was used in patients aged ≤ 6 years, and midazolam with pentazocine was used in patients aged ≥ 7 years. Regarding the choice of endoscope, short and thin endoscopes were selected for younger patients, particularly patients aged ≤ 3 years. Positive diagnoses were made in 78 patients (70.9%). Inflammatory bowel disease (n = 49, 44.5%), including ulcerative colitis (n = 37, 33.6%) and Crohn’s disease (n = 12, 10.9%), was the most common diagnosis.

CONCLUSION

Colonoscopy offers a high diagnostic capability for pediatric patients with gastrointestinal symptoms. The selection of appropriate management the performance of colonoscopy is important in pediatric patients.

Preparation regimen is more important than patient-related factors: a randomized trial comparing a standard bowel preparation before colonoscopy with an individualized approach

BACKGROUND

Optimal bowel preparation is one of the most important factors affecting the quality of colonoscopy. Several patient-related factors are known to influence the quality of bowel cleansing but randomized trials in this area are lacking. We aimed to compare an individualized bowel prep strategy based on patient characteristics to a standard preparation regimen.

MATERIAL AND METHODS

We conducted an endoscopist-blinded multicenter randomized control-trial. The Boston Bowel Prep Score (BBPS) was used to assess quality of bowel preparation and a 10 point visual analogue scale to assess patient comfort during bowel prep. Patients were randomised to either the standard regimens of split-dose 4L polyethylene-glycol (group A), split-dose sodium picosulphate/magnesium citrate (group B) or to either of the two depending on their responses to a 3-item questionnaire (individualized preparation, group C).

RESULTS

185 patients were randomized during the study period and 143 patients were included in the final analysis. Patients in the individualized group had a median BBPS of 7 compared to a median of 6 in the standard group (p = 0.7). Also, there was no significant difference in patients' comfort scores, irrespective of study group or laxative regimen. However, on multivariable analysis, a split-dose 4L polyethylene-glycol was an independent predictor for achieving a BBPS>6 (OR 3.7, 95% CI 1.4-9.8), regardless of patient-related factors.

CONCLUSION

The choice of laxative seems to be more important than patient-related factors in predicting bowel cleansing. Comfort during bowel prep is not influenced by the type of strategy used.

Investigation of in-feed organic acids as a low cost strategy to combat Salmonella in grower pigs

Salmonella carriage in pigs is a significant food safety issue. Dietary supplementation with organic acids has previously been shown to reduce shedding and transmission of Salmonella. Therefore, this study aimed to examine the effect of three commercially available organic acid-based products on Salmonella levels in grower pigs, using a model of experimental infection that closely mimics natural exposure to the organism. Seven week old trial pigs (n=40) with a mean weight of 14.7kg were placed in one of four pens with 10 pigs/pen. Pens had previously been contaminated with Salmonella Typhimurium 4,[5],12;i;- via seeder pigs. Trial pigs received one of four diets for 28days: 1, control diet; 2, sodium butyrate supplemented diet; 3, benzoic acid supplemented diet and 4, formic-citric acid supplemented diet. A further 10 pigs were placed in a Salmonella-free pen receiving the control diet. Pigs were weighed and blood sampled on days 0 and 28. Faeces was collected on day 0, 2, 3, 5, 7, 14, 21 and 28 and examined for Salmonella. On day 28, 5 pigs/group were euthanised and ileocaecal lymph nodes (ILN) and caecal contents sampled for culture. The remaining 5 pigs/pen were then fed the control diet and faeces were collected on days 35 and 42. On day 42 pigs were euthanised and ILN and caecal contents tested for Salmonella levels. The trial was repeated once. Within the first two days of exposure to the contaminated environment, 96% (77/80) of pigs became infected. Most pigs shed Salmonella at levels of between 10⁰-10³ CFU/g faeces for at least 7days post-exposure. A significant reduction in Salmonella faecal concentration was observed after supplementation with sodium butyrate (p=0.001) and a formic citric acid blend (p<0.0001). Average daily weight gain (ADWG) was significantly increased in all groups fed the supplemented feed when compared to the positive control group. The use of sodium butyrate or a blend of formic and citric acid in feed could be considered a cost-effective control measure to reduce Salmonella faecal shedding and improve ADWG in Salmonella infected herds.

Click chemistry improved wet adhesion strength of mussel-inspired citrate-based antimicrobial bioadhesives

For the first time, a convenient copper-catalyzed azide-alkyne cycloaddition (CuAAC, click chemistry) was successfully introduced into injectable citrate-based mussel-inspired bioadhesives (iCMBAs, iCs) to improve both cohesive and wet adhesive strengths and elongate the degradation time, providing numerous advantages in surgical applications. The major challenge in developing such adhesives was the mutual inhibition effect between the oxidant used for crosslinking catechol groups and the Cu(II) reductant used for CuAAC, which was successfully minimized by adding a biocompatible buffering agent typically used in cell culture, 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (HEPES), as a copper chelating agent. Among the investigated formulations, the highest adhesion strength achieved (223.11 ± 15.94 kPa) was around 13 times higher than that of a commercially available fibrin glue (15.4 ± 2.8 kPa). In addition, dual-crosslinked (i.e. click crosslinking and mussel-inspired crosslinking) iCMBAs still preserved considerable antibacterial and antifungal capabilities that are beneficial for the bioadhesives used as hemostatic adhesives or sealants for wound management.

Anti-plaque and antimicrobial efficiency of different oral rinses in a 3-day plaque accumulation model

The idea of incorporating a mouthrinse with normal tooth brushing could be a useful adjunct to oral hygiene. Despite the principle nature of the toothpaste vehicle, most alcohol-based chemical plaque-control agents have been evaluated and later formulated in the mouthrinse vehicle. The current study was aimed to investigate the persistence of antimicrobial action and plaque inhibitory properties of a new alcohol-free mouthrinse when compared with positive control, chlorhexidine 0.12% and placebo control, physiologic saline solution mouthrinses. The evaluation of the antimicrobial activity was performed by saliva samples collected during the 3 days of usage. The results of this study indicate that this new oral rinse has an equivalent plaque inhibitory action to chlorhexidine, and the plaque inhibitory action of the rinse appears to be derived from a persistence of antimicrobial action in the mouth. Furthermore, no side effects were reported during the study, and the additional benefit of no alcohol presence in the rinse solution.

Alterations in taste perception as a result of hyperbaric oxygen therapy

The present study evaluates the effect of hyperbaric oxygen therapy on taste sensitivity, hedonic perception of taste, and food preferences. The studied groups included 197 people in total (79 in the study group; 118 in the control group). All patients from the study group were treated with hyperbaric oxygen therapy due to chronic non-healing wounds. The control group consisted of healthy people, who did not receive hyperbaric oxygen therapy. The taste intensity, recognition thresholds, and hedonic perception were examined using gustatory tests. The aqueous solutions of sucrose for sweet, sodium chloride for salty, citric acid for sour, quinine hydrochloride for bitter, and monosodium glutamate for umami taste were used. The participants fulfilled the questionnaire to examine pleasure derived from eating certain types of dishes. Gustatory tests and analyses of the pleasure derived from eating in the study group were carried out before the first exposure to hyperbaric oxygen and then at the end of therapy, after at least 25 sessions of treatment. In the control group, examination of perception of taste sensations was conducted only once. The results of comparing patients with non-healing wounds with healthy people are characterized by reduced taste sensitivity. After participation in hyperbaric oxygen therapy, the improvement in perception of taste sensations and changes in hedonic evaluation have occurred among patients with non-healing wounds. In terms of food preference, a decreased desire for eating sweet desserts, chocolate, and crisps was observed in those patients who received hyperbaric oxygen therapy.

[Litholytic therapy for urate nephrolithiasis]

AIM

To evaluate the effectiveness of ESWL combined with litholytic therapy in patients with uric acid kidney stones.

MATERIALS AND METHODS

A total of 59 patients with urate nephrolithiasis were observed at the Department of Urology, First Pavlov SMU of St. Peterburg. The patients were divided into two groups according to the treatment regimen. The study group comprised 30 patients who were administered litholytic therapy before ESWL. The comparison group included 29 patients with nephrolithiasis who underwent ESWL without prior litholytic therapy.

RESULTS

After 4 weeks of treatment with Blemaren, in 60% of patients of the study group a decrease in the calculus size was noted; in 83.3% of patients according to MSCT there was a decrease in calculus density. Disintegration of kidney stones after a single ESWL session was achieved in 86.7% of patients of the study group and in 65.5% of patients of the control group.

CONCLUSION

The results of this study allow us to recommend a 4-week course of Blemaren to treat patients with urate nephrolithiasis to prepare for ESWL.

[Modern diagnostic and management aspects of citrate therapy for uric acid nephrolithiasis]

INTRODUCTION

Iso-aciduria - long-term existence of urine pH within a narrow range (pH <0.8-1.2 units.) - activates certain enzymes for which these pH levels are favorable. Then, this activation induces precipitation of crystals corresponding to these enzymes.

OBJECTIVE

To enable citrate therapy without a risk of altering the stone chemical composition and to identify indicators reflecting the degree of metabolic disorders in patients with uric acid nephrolithiasis.

MATERIAL AND METHODS

Citrate therapy was provided with a mixture comprising "Potassium citrate monohydrate" and "Tri-sodium citrate di-hydrate" in a ratio of 2: 1. The study group included 64 patients, who had ultrasound-detected calyx stones and hyperechoic inclusions from 2 to 4 mm without acoustic shadow, located in the papillary region of the renal pyramids. Statistical analysis was performed by cross tabulations (pairing).

RESULTS

The results of the statistical analysis have proven the legitimacy and feasibility of the proposed method of classifying patients into homogeneous groups according to the disease severity.

CONCLUSION

Long-term citrate therapy should be carried out in such a way as to achieve maximum range of urine pH (from 5.4 to 7.8 units), which will allow to avoid deposition of other crystals upon the existing stone and identify indicators reflecting the degree of metabolic disorders in patients with uric acid nephrolithiasis.

CONCLUSION

Long-term citrate therapy should be carried out in such a way as to achieve maximum range of urine pH (from 5.4 to 7.8 units), thus avoiding deposition of other crystals upon the existing stone.

CT colonography after incomplete optical colonoscopy: bowel preparation quality at same-day vs. deferred examination

PURPOSE

To objectively compare the volume, density, and distribution of luminal fluid for same-day oral-contrast-enhanced CTC following incomplete optical colonoscopy (OC) vs. deferred CTC on a separate day utilizing a dedicated CTC bowel preparation.

METHODS

HIPAA-compliant, IRB-approved retrospective study compared 103 same-day CTC studies after incomplete OC (utilizing 30 mL oral diatrizoate) against 151 CTC examinations performed on a separate day after failed OC using a dedicated CTC bowel preparation (oral magnesium citrate/dilute barium/diatrizoate the evening before). A subgroup of 15 patients who had both same-day CTC and separate-day routine CTC was also identified and underwent separate analysis. CTC exams were analyzed for opacified fluid distribution within the GI tract, as well as density and volume. Data were analyzed utilizing Kruskal-Wallis and Wilcoxon Signed Rank tests.

RESULTS

Opacified luminal fluid extended to the rectum in 56% (58/103) of same-day CTC vs. 100% (151/151) of deferred separate-day CTC (p < 0.0001). For same-day CTC, contrast failed to reach the colon in 11% (11/103) and failed to reach the left colon in 26% (27/103). Volumetric colonic fluid segmentation for fluid analysis (successful in 80 same-day and 147 separate-day cases) showed significantly more fluid in the same-day cohort (mean, 227 vs. 166 mL; p < 0.0001); the actual difference is underestimated due to excluded cases. Mean colonic fluid attenuation was significantly lower in the same-day cohort (545 vs. 735 HU; p < 0.0001). Similar findings were identified in the smaller cohort with direct intra-patient CTC comparison.

CONCLUSIONS

Dedicated CTC bowel preparation on a separate day following incomplete OC results in a much higher quality examination compared with same-day CTC.

Insights about serum sodium behavior after 24 hours of continuous renal replacement therapy

Objective

Methods

Results

Conclusions

Effect of high-dose phytase and citric acid, alone or in combination, on growth performance of broilers given diets severely limited in available phosphorus

1. Two trials were conducted to evaluate the effect of high-dose phytase alone or in combination with citric acid (CA) in the diet severely limited in available phosphorus (P) on performance, plasma P and plasma Ca of broilers from 22 to 42 d of age. 2. In Trial 1, 297 21-d-old female chicks were placed into 27 pens and allocated to 9 maize-soybean meal-based dietary treatments, which were a positive control [PC, 4.23 g/kg non-phytate P (NPP)] and 8 negative control (NC, 1.35 g/kg NPP) groups consisting of two concentrations of CA (0 and 20 g/kg) and 4 concentrations of phytase (0, 1000, 2000 and 4000 U/kg) in a 2 × 4 factorial arrangement. In Trial 2, 192 21-d-old male chicks were placed into 24 pens and allocated to 6 wheat-canola meal-based dietary treatments, which were a PC (4.2 g/kg NPP), a NC (1.68 g/kg NPP) and 4 NC groups consisting of two concentrations of CA (0 and 20 g/kg) and two concentrations of phytase (2000 and 4000 U/kg) in a 2 × 2 factorial arrangement. 3. In both trials, birds fed on the PC had significantly higher average daily gain (ADG), average daily feed intake (ADFI), plasma P and lower feed conversion ratio (FCR) and plasma Ca than those of birds fed on the NC. CA supplementation significantly increased ADG and ADFI. There was a significant interaction between CA and phytase on plasma P where CA improved the effect of phytase on plasma P. In Trial 1, phytase addition improved ADG, ADFI, FCR and plasma Ca linearly. 4. Briefly, this research showed the interaction effect between CA and phytase on plasma P when broilers were fed on diets based on maize-soybean meal or wheat-canola meal. The results showed that CA supplementation lowered the concentration of phytase that is needed in low NPP diets to increase plasma P.

An Evaluation of Efficacy and Tolerability of Novel Enzyme Exfoliation Versus Glycolic Acid in Photodamage Treatment

BACKGROUND

Glycolic acid acts by chemical destruction of adhesions between skin cells to exfoliate superficial skin layers and excess pigmentation. It is well known to improve the appearance of photoaged skin, but is associated with varying degrees of skin irritation. Hydrolyzed salmon roe proteins destroy cell adhesions enzymatically with potentially less irritation than acid treatments. This double-blind prospective study assesses the efficacy and tolerability of hydrolyzed roe versus glycolic acid, and glycolic acid with citric acid.

METHODS

75 female subjects with mild to moderate photodamage, all skin types, and ages 31-70 years, were enrolled. In this 12 week study of twice daily self-treatments, patients were assigned to one of 3 groups; Group 1 (n-19) was assigned hydrolyzed roe cream, Group 2 (n=17), 4% glycolic acid, or Group 3 (n-16), 8% glycolic acid plus 2% citric acid. All patients used the same mild face wash and SPF 30 sunscreen throughout the study. Patients were evaluated at weeks 0, 8 and 12 for objective and subjective tolerability, improvement in photodamage by VISIA Complexion Analysis, modified Packman and Gans method, Visual Analog Scale (VAS), and answered an opinion questionnaire.

RESULTS

Group 1 improved in skin clarity from a VAS 44.1 to 55.7 (P=0.0317) at week 12. VISIA mean scores correlated with office evaluation showing improvement in brown spots from 453 to 417 (P = 0.0115) at 12 weeks. Group 2 improved in superficial fine lines at week 8 (-5.9, P=0.0428) and week 12 (-9.1, P=0.0019). Group 3 improved at week 12 in skin clarity (11.5, P = 0.0469) and skin roughness (-13.3, P = 0.0426), and in hyperpigmentation at week 8 (-9.4, P = 0.0462) and week 12 (-14.6, P= 0.0019).

CONCLUSION

Topical hydrolyzed roe protein used twice daily improves skin clarity. It has good tolerability with fewer instances of stinging and burning than the other glycolic acid containing creams. Patient's opinions of the 3 products were similar.