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Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose–Response Curves in Worsening Refractory Congestive Heart Failure

IntroductionDiuretic responsiveness in patients with chronic heart failure (CHF) is better assessed by urine production per unit diuretic dose than by the absolute urine output or diuretic dose. Diuretic resistance arises over time when the plateau rate of sodium and water excretion is reached prior to optimal fluid elimination and may be overcome when hypertonic saline solution (HSS) is added to high doses of furosemide.MethodsForty-two consecutively hospitalized patients with refractory CHF were randomized in a 1:1:1 ratio to furosemide doses (125xa0mg, 250xa0mg, 500xa0mg) so that all patients received intravenous furosemide diluted in 150xa0ml of normal saline (0.9%) in the first step (0–24xa0h) and the same furosemide dose diluted in 150xa0ml of HSS (1.4%) in the next step (24–48xa0h) as to obtain 3 groups as follows: Fourteen patients receiving 125xa0mg (groupxa01), fourteen patients receiving 250xa0mg (groupxa02), and fourteen patients receiving 500xa0mg (groupxa03) of furosemide. Urine samples of all patients were collected at 30, 60, and 90xa0min, and 3, 4, 5, 6, 8, and 24xa0h after infusion. Diuresis, sodium excretion, osmolality, and furosemide concentration were evaluated for each urine sample.ResultsAfter randomization, 40 patients completed the study. Two patients, one in groupxa02 and one in groupxa03 dropped out. Patients in groupxa01 (125xa0mg furosemide) had a mean age of 77xa0±xa017xa0years, 43% were male, 6 (43%) had heart failure with a preserved ejection fraction (HFpEF), and 64% were in New York Heart Association (NYHA) class IV; the mean age of patients in groupxa02 (250xa0mg furosemide) was 80xa0±xa08.1xa0years, 15% were male, 5 (38%) had HFpEF, and 84% were in NYHA class IV; and the mean age of patients in groupxa03 (500xa0mg furosemide) was 73xa0±xa012xa0years, 54% were male, 6 (46%) had HFpEF, and 69% were in NYHA class IV. HSS added to furosemide increased total urine output, sodium excretion, urinary osmolality, and furosemide urine delivery in all patients and at all time points. The percentage increase was 18,14, and 14% for urine output; 29, 24, and 16% for total sodium excretion; 45, 34, and 20% for urinary osmolarity; and 27, 36, and 32% for total furosemide excretion in groups 1, 2, and 3, respectively. These findings were translated in an improvement in the furosemide dose–response curves in these patients.ConclusionThese results may serve as new pathophysiological basis for HSS use in the treatment of refractory CHF.

Label Style and Color Contribution to Explain Market Price Difference in Italian Red Wines Sold in the Chinese Wine Market

ABSTRACT This study employs a hedonic price methodology to investigate the implicit price of individual labelling characteristics of Italian red wines sold in the Chinese market. Our results highlight the most important quality attributes (extrinsic and intrinsic) given in the label capable to explain price difference. In particular, reveal significant premium price for wine origin, identified in particular through the DOC/DOCG appellation given in the label, and for clean labels or labels with particular designs. On the contrary, a price discount has been revealed for Italian wines produced with local grape varieties and with a label characterised by warm colors. These results, partly in disagreement with other empirical evidence, contribute to enrich the existing literature in this field by providing useful suggestions both to the producers and other stakeholders operating in the wine industry.