Intravenous levosimendan-norepinephrine combination during off-pump coronary artery bypass grafting in a hemodialysis patient with severe myocardial dysfunction

This the case of a 63 year-old man with end-stage renal disease (on chronic hemodialysis), unstable angina and significantly impaired myocardial contractility with low left ventricular ejection fraction, who underwent off-pump one vessel coronary bypass surgery. Combined continuous levosimendan and norepinephrine infusion (at 0.07 μg/kg/min and 0.05 μg/kg/min respectively) started immediately after anesthesia induction and continued for 24 hours. The levosimendan/norepinephrine combination helped maintain an appropriate hemodynamic profile, thereby contributing to uneventful completion of surgery and postoperative hemodynamic stability. Although levosimendan is considered contraindicated in ESRD patients, this case report suggests that combined perioperative levosimendan/norepinephrine administration can be useful in carefully selected hemodialysis patients with impaired myocardial contractility and ongoing myocardial ischemia, who undergo off-pump myocardial revascularization surgery

Time to Diagnosis in Cushing's Syndrome: A Meta-Analysis Based on 5367 Patients.

This is a pre-copyedited, author-produced version of an article accepted for publication in The Journal of Clinical Endocrinology & Metabolism, following peer review. The version of record: German Rubinstein, Andrea Osswald, Eva Hoster, Marco Losa, Atanaska Elenkova, Sabina Zacharieva, Márcio Carlos Machado, Felicia Alexandra Hanzu, Stephanie Zopp, Katrin Ritzel, Anna Riester, Leah Theresa Braun, Ilonka Kreitschmann-Andermahr, Helen L Storr, Prachi Bansal, María-José Barahona, Elisa Cosaro, Sema Ciftci Dogansen, Philip C Johnston, Ricardo Santos de Oliveira, Christian Raftopoulos, Carla Scaroni, Elena Valassi, Steven J A van der Werff, Jochen Schopohl, Felix Beuschlein, Martin Reincke, Time to diagnosis in Cushing’s syndrome: A meta-analysis based on 5367 patients, The Journal of Clinical Endocrinology & Metabolism, dgz136, https://doi.org/10.1210/clinem/dgz136 is available online at: https://doi.org/10.1210/clinem/dgz136.CONTEXT: Signs and symptoms of Cushing's syndrome (CS) overlap with common diseases, such as the metabolic syndrome, obesity, osteoporosis, and depression. Therefore, it can take years to finally diagnose CS, although early diagnosis is important for prevention of complications. OBJECTIVE: The aim of this study was to assess the time span between first symptoms and diagnosis of CS in different populations to identify factors associated with an early diagnosis. DATA SOURCES: A systematic literature search via PubMed was performed to identify studies reporting on time to diagnosis in CS. In addition, unpublished data from patients of our tertiary care center and 4 other centers were included. STUDY SELECTION: Clinical studies reporting on the time to diagnosis of CS were eligible. Corresponding authors were contacted to obtain additional information relevant to the research question. DATA EXTRACTION: Data were extracted from the text of the retrieved articles and from additional information provided by authors contacted successfully. From initially 3326 screened studies 44 were included. DATA SYNTHESIS: Mean time to diagnosis for patients with CS was 34 months (ectopic CS: 14 months; adrenal CS: 30 months; and pituitary CS: 38 months; P < .001). No difference was found for gender, age (<18 and ≥18 years), and year of diagnosis (before and after 2000). Patients with pituitary CS had a longer time to diagnosis in Germany than elsewhere. CONCLUSIONS: Time to diagnosis differs for subtypes of CS but not for gender and age. Time to diagnosis remains to be long and requires to be improved