Decongestive diuresis using combination intravenous loop diuretics plus chlorothiazide in type 1 acute cardiorenal syndrome and worsening acute kidney injury; a neglected paradigm in resource-poor settings

2019 ◽  
Vol 9 (2) ◽  
pp. e13-e13
Author(s):  
Macaulay Amechi Chukwukadibia Onuigbo
Keyword(s):  
Renal Failure ◽  
Elderly Patients ◽  
Medical Center ◽  
Cardiorenal Syndrome ◽  
Loop Diuretics ◽  
Recent Experience ◽  
Resource Poor ◽  
The University ◽  
University Of Vermont

Over the last decade or more, there has grown a body of evidence demonstrating that renal dysfunction in heart failure is a combination of forward failure from reduced cardiac output and therefore reduced glomerular filtration rate, as well as "congestive renal failure" secondary to renal venous hypertension. We had demonstrated the efficacy of combination intravenous loop diuretics used concurrently with intravenous chlorothiazide to achieve significant renal salvage in such patients at the Mayo Clinic Health System in Northwestern Wisconsin. We describe a similar recent experience with three consecutive elderly patients at the University of Vermont Medical Center, Burlington, VT, USA. We posit that this paradigm of care is underutilized. We argue that aggressive decongestive therapy with combination intravenous loop and thiazide diuretics is a neglected and underutilized mechanism and must be utilized more frequently in the treatment of worsening renal failure with type 1 cardiorenal syndrome. This imperative is even most compelling in resource-poor settings where mechanical ultrafiltration with dialysis or similar machines is not available or simply not affordable. Moreover, we had also demonstrated that accelerated rising Pro B natriuretic peptide (Pro-BNP) in such patients portends a good prognosticator for renal salvage. We present here three consecutive elderly patients recently so managed successfully at the University of Vermont Medical Center in Burlington, VT, USA.

scholarly journals Transition to Subspecialty Sign-Out at an Academic Institution and Its Advantages

2017 ◽  
Vol 4 ◽  
pp. 237428951771476 ◽  
Author(s):  
Joanna L. Conant ◽  
Pamela C. Gibson ◽  
Janice Bunn ◽  
Abiy B. Ambaye
Keyword(s):  
Quality Assurance ◽  
Medical Center ◽  
Turnaround Time ◽  
Support Staff ◽  
Surgical Pathology ◽  
Clinician Satisfaction ◽  
Multidisciplinary Conference ◽  
The University ◽  
University Of Vermont ◽  
General Sign

Many pathology departments are introducing subspecialty sign-out in surgical pathology. In 2014, the University of Vermont Medical Center transitioned from general sign-out to partial subspecialty sign-out to include gastrointestinal and breast/cervix subspecialty benches; other specimens remained on general benches. Our experiences with the transition are described, including attending pathologist, trainee, support staff, and clinician satisfaction. A survey was e-mailed to all University of Vermont Medical Center anatomic pathology attendings, pathology trainees, pathologist assistants and grossing technicians, and clinicians who send surgical pathology specimens, immediately before and 1 year after transitioning to partial subspecialty sign-out. Quality assurance metrics were obtained for the 18 months prior to and following the transition. Gastrointestinal and breast/cervix attendings were more satisfied with partial subspecialty sign-out compared to those on the general benches. Overall, trainees were more satisfied with general sign-out because of the rotation schedule but preferred partial subspecialty sign-out due to improved teaching and more focused learning while on subspecialty benches. Clinicians remained very satisfied with our department and our reports; no differences were observed. Turnaround time was unchanged. After switching to partial subspecialty sign-out, there were significantly fewer discrepancies following multidisciplinary conference review for gastrointestinal and breast/cervix cases but remained the same for general cases. Fewer formal internal consults were performed after transitioning to partial subspecialty sign-out across all areas, but more notable for gastrointestinal and breast/cervix cases. Our data show improved quality assurance metrics and trainee education in a subspecialty sign-out setting compared to general sign-out setting.

The Cardiac Rehabilitation Program of the University of Vermont Medical Center

1986 ◽  
Vol 6 (7) ◽  
pp. 265-277 ◽  
Author(s):  
Philip A. Ades ◽  
Cathy P. Meacham ◽  
Mary A. Handy ◽  
William E. Nedde ◽  
John S. Hanson
Keyword(s):  
Cardiac Rehabilitation ◽  
Medical Center ◽  
Rehabilitation Program ◽  
Cardiac Rehabilitation Program ◽  
The University ◽  
University Of Vermont

scholarly journals Comparison between ultrafiltration and loop diuretics to neurohormonal and kidney parameters in cardiorenal syndrome type 1: a meta-analysis of randomized controlled trials

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
BP Putra ◽  
FN Putra
Keyword(s):  
Randomized Controlled Trials ◽  
Cystatin C ◽  
Cardiorenal Syndrome ◽  
Loop Diuretics ◽  
Treatment Modalities ◽  
Cochrane Library ◽  
Controlled Trials ◽  
Randomized Controlled ◽  
Significant Difference

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Acute heart failure can affect the kidney, which is known as cardiorenal syndrome (CRS) type 1 that may worsen renal function and increase mortality. Ultrafiltration (UF) and loop diuretics are CRS type 1 treatment modalities mainly in improving congestion. Renin-angiotensin-aldosterone system (RAAS) is one of the key role mechanisms in type-1 CRS patients. Previous studies showed inconclusive neurohormonal and kidney parameters outcome comparisons between UF and loop diuretics in type-1 CRS patients. Purpose This study has the purpose to compare the effect of UF and loop diuretics to neurohormonal and renal parameters in type-1 CRS patients. Methods We did comprehensive searching using predefined keywords in online databases of Pubmed, ScienceDirect, EMBASE, and The Cochrane Library to screen all relevant literature until November 2020. We included all randomized controlled trials (RCTs) that compared the neurohormonal and renal parameters between UF and loop diuretics in type-1 CRS patients, not on chronic dialysis therapy and have serum creatinine (SCr) below 3 mg/dL. The neurohormonal parameters analysed in this study are changes of N-terminal pro-brain natriuretic peptide (NT-proBNP), plasma renin activity (PRA), and serum aldosterone, while the renal parameters analysed are changes of SCr, Cystatin-C, and dialysis dependency. We used Cochrane Risk-of-bias tools for accessing bias risk. We performed analysis to provide standard mean difference (SMD) for laboratory parameters and risk ratio (RR) for dialysis dependency with 95% confidence interval (CI) using fixed-effect heterogeneity test. Results We included 11 RCTs met our inclusion criteria. The UF groups showed more NT-proBNP decline compared with the diuretics groups although not statistically significant (SMD = -0.02, 95% CI -0.22 to 0.17, p = 0.80, I²=0%). The UF group showed RAAS activity increment, which are significantly difference in PRA (SMD = 0.38, 95% CI 0.12 to 0.63, p = 0.004, I²=54%) but no significance in aldosterone change (SMD = 0.09, 95% CI -0.17 to 0.34, p = 0.50, I²=0%). Surprisingly, the UF group tends to have incremental dialysis dependency risk although not statistically significant (pooled RR = 1.28, 95% CI 0.73 to 2.26, p = 0.39, I²=0%). The diuretics group shows more significant SCr improvement (SMD = 0.23, 95% CI 0.08 to 0.38, p = 0.003, I²=41%), yet no significance Cystatin-C improvement (SMD = 0.21, 95% CI -0.02 to 0.43, p = 0.07, I²=0%). Conclusions There is no significant difference between ultrafiltration and loop diuretics to neurohormonal and kidney parameters change in type-1 CRS patients although loop diuretics administration shows more benefits. However, further trials are needed to establish the comparison.

A blood-based polyamine signature associated with MEN1 duodenopancreatic neuroendocrine tumor progression

2021 ◽  
Author(s):  
Johannes F Fahrmann ◽  
Amanda R Wasylishen ◽  
Carolina R C Pieterman ◽  
Ehsan Irajizad ◽  
Jody Vykoukal ◽  
...  
Keyword(s):  
Disease Progression ◽  
Medical Center ◽  
National Institutes Of Health ◽  
Cancer Center ◽  
Test Time ◽  
Cancer Types ◽  
Md Anderson ◽  
The University ◽  
Related Mortality

Abstract Purpose Duodenopancreatic neuroendocrine tumors (dpNETs) frequently occur in patients with Multiple Endocrine Neoplasia Type 1 (MEN1), and metastatic dpNET is the primary cause of disease-related mortality. There is a need for biomarkers that can identify patients with MEN1-related dpNETs that are at high risk of developing distant metastasis. Polyamines have tumor promoting roles in several cancer types. We hypothesized that MEN1-dpNET-related disease progression is associated with elevated levels of circulating polyamines. Experimental Design Through an international collaboration between MD Anderson Cancer Center (MDACC), the National Institutes of Health (NIH), and the University Medical Center Utrecht (UMCU), plasma polyamine levels were assessed using mass spectrometry in a total of 84 patients with MEN1 (20 with distant metastatic dpNETs (cases) and 64 with either indolent dpNETs or no dpNETs (controls)). A mouse model of MEN1-pNET, Men1  fl/flPdx1-Cre  Tg, was used to test time-dependent changes in plasma polyamines associated with disease progression. Results A 3-marker plasma polyamine signature (3MP: n-acetylputrescine, acetylspermidine, and diacetylspermidine) distinguished patients with metastatic dpNETs from controls in an initial set of plasmas from the three participating centers. The fixed 3MP yielded an AUC of 0.84 (95% CI: 0.62-1.00) with 66.7% sensitivity at 95% specificity for distinguishing cases from controls in an independent test set from MDACC. In Men1  fl/flPdx1-Cre  Tg mice, the 3MP was elevated early and remained high during disease progression. Conclusions Our findings provide a basis for prospective testing of blood-based polyamines as a potential means for monitoring patients with MEN1 for harboring or developing aggressive disease.

scholarly journals All Hands-On Deck and All Decks on Hand: Surmounting Supply Chain Limitations During the COVID-19 Pandemic

2021 ◽  
Vol 8 ◽  
pp. 237428952110119
Author(s):  
Jill S. Warrington ◽  
Jessica W. Crothers ◽  
Andrew Goodwin ◽  
Linda Coulombe ◽  
Tania Hong ◽  
...  
Keyword(s):  
Supply Chain ◽  
Medical Center ◽  
Clinical Care ◽  
Disease Outbreaks ◽  
Full Time ◽  
Sample Collection ◽  
Full Time Equivalent ◽  
Laboratory Staff ◽  
The University ◽  
University Of Vermont

Testing during the COVID-19 pandemic has been crucial to public health surveillance and clinical care. Supply chain constraints—spanning limitations in testing kits, reagents, pipet tips, and swabs availability—have challenged the ability to scale COVID-19 testing. During the early months, sample collection kits shortages constrained planned testing expansions. In response, the University of Vermont Medical Center, University of Vermont College of Medicine, Vermont Department of Health Laboratory, Aspenti Health, and providers across Vermont including 16 area hospitals partnered to surmount these barriers. The primary objectives were to increase supply availability and manage utilization. Within the first month of Vermont’s stay-at-home order, the University of Vermont Medical Center laboratory partnered with College of Medicine to create in-house collection kits, producing 5000 per week. University of Vermont Medical Center reassigned 4 phlebotomists, laboratory educators, and other laboratory staff, who had reduced workloads, to participate (requiring a total of 5.3-7.6 full-time equivalent (FTE) during the period of study). By August, automation at a local commercial laboratory produced 22,000 vials of media in one week (reducing the required personnel by 1.2 FTE). A multisite, cross-institutional approach was used to manage specimen collection kit utilization across Vermont. Hospital laboratory directors, managers, and providers agreed to order only as needed to avoid supply stockpiles and supported operational constraints through ongoing validations and kit assembly. Throughout this pandemic, Vermont has ranked highly in number of tests per million people, demonstrating the value of local collaboration to surmount obstacles during disease outbreaks and the importance of creative allocation of resources to address statewide needs.

scholarly journals Undiagnosed Malignancy and Therapeutic Complications in Oncology Patients: A 10-Year Review of Autopsy Cases

2021 ◽  
Author(s):  
Noman Javed ◽  
Justin Rueckert ◽  
Sharon Mount
Keyword(s):  
Retrospective Study ◽  
Cancer Patients ◽  
Cause Of Death ◽  
Medical Therapy ◽  
Medical Errors ◽  
Incidental Finding ◽  
Medical Center ◽  
Postmortem Examination ◽  
The University ◽  
University Of Vermont

Context.— Despite technologic and medical advancements, autopsies are essential to uncover clinically unsuspected diagnoses, to advance our understanding of disease processes, and to help reduce medical errors. Objective.— To investigate the percentage of malignancy clinically diagnosed and undiagnosed in a series of hospital autopsies. Secondarily, to explore the therapeutic complications directly contributing to death in cancer patients. Design.— A 10-year retrospective study (2008–2018). All nonforensic autopsies performed at the University of Vermont Medical Center during this period were reviewed by 2 pathologists, and data, including antemortem diagnoses of malignancy, and autopsy findings, including therapeutic complications, were collected. Results.— A total of 246 cases documented a diagnosis of malignancy. In 34.5% (85 of 246) of cases a tissue diagnosis of malignancy was first documented following postmortem examination. In 41.2% (35 of 85) of cases there was clinical antemortem suspicion of malignancy, whereas in 58.8% (50 of 85) clinically unsuspected malignancy was first diagnosed after postmortem examination. In 16.0% (8 of 50) of cases the undiagnosed malignancy was the primary cause of death. The overall rate of therapeutic complication related to the treatment of oncologic disease in patients that resulted in death was 21.7% (35 of 161). Conclusions.— Our study shows the percentage of clinically unsuspected malignancies revealed by postmortem examination to be 5% (50 of 1003) of all autopsy cases. In 16% (8 of 50) of cases, the cause of death was due to the clinically undiagnosed malignancy, and hence not an incidental finding. Despite advances in medical therapy in the management of oncologic disease, in up to 21.7% (35 of 161) of cases therapeutic complications directly contributed to death.

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