Evaluation of 1β-Hydroxylation of Deoxycholic Acid as a Non-Invasive Urinary Biomarker of CYP3A Activity in the Assessment of Inhibition-Based Drug-Drug Interaction in Healthy Volunteers

In this study, we aimed to evaluate the utility of endogenous 1β-hydroxy-deoxycholic acid/total deoxycholic acid ratio (1β-OH-DCA/ToDCA) in spot urine as a surrogate marker of cytochrome P450 3A (CYP3A) activity in the assessment inhibition-based drug-drug interactions in healthy volunteers. This was accomplished through an open-label, three-treatment parallel-arm study in healthy male volunteers from Zimbabwe. Each group received itraconazole (ITZ; 100 mg once daily; n = 10), fluconazole (FKZ; 50 mg once daily; n = 9), or alprazolam (APZ; 1 mg once daily; n = 8) orally. Midazolam (MDZ), dosed orally and intravenously, was used as a comparator to validate the exploratory measures of CYP3A activity and the effects of known inhibitors. Urinary metabolic ratios of 1β-OH-DCA/ToDCA before and after CYP3A inhibitor treatment showed a similar magnitude of inhibitory effects of the three treatments as that measured by oral MDZ clearance. The maximum inhibition effect of a 75% reduction in the 1β-OH-DCA/ToDCA ratio compared to the baseline was achieved in the ITZ group following six once-daily doses of 100 mg. The correlations of the two markers for CYP3A inhibitor treatment were significant (r_s = 0.53, p < 0.01). The half-life of urinary endogenous 1β-OH-DCA/ToDCA was estimated as four days. These results suggested that 1β-OH-DCA/ToDCA in spot urine is a promising convenient, non-invasive, sensitive, and relatively quickly responsive endogenous biomarker that can be used for CYP3A inhibition-based drug-drug interaction in clinical studies.

Disentanglement of Cape fur seals (Arctocephalus pusillus pusillus) with reversible medetomidine-midazolam-butorphanol

Anaesthesia in pinnipeds is considered a much higher risk than in most terrestrial mammals because of their frequent proximity to water and physiological and anatomical adaptations related to diving, which also influence their anaesthesia management. Anaesthetising and immobilising entangled seals does not allow for selection of animals that are at a safe distance from the water’s edge. Medetomidine-midazolam-butorphanol (MMB) sedation was trialled on eight entangled Cape fur seals (CFS) (Arctocephalus pusillus pusillus) to determine if it was safe to use on animals that entered the water post-darting. The MMB was given at an estimated dose of 0.03 mg/kg, 0.2 mg/kg and 0.2 mg/kg, respectively, via remote darting. Sedation was reversed with intramuscular atipamezole (0.15 mg/kg) and naltrexone (0.4 mg/kg) to antagonise the effects of medetomidine and butorphanol, respectively. Moderate sedation was achieved in six animals. Six of the animals entered the water after being darted. There was a single mortality and a single animal that was too lightly sedated for capture. The preliminary results indicate that MMB produces suitable sedation for disentanglement of CFS. Additionally, MMB might be suitable for application to field-based biological research.

Midazolam and dexmedetomidine sedation impair systolic heart function

BACKGROUND

Sedation is an essential part of clinical practice. Despite this fact, we still lack data describing the exact impact of sedation on heart function.

PURPOSE

To compare the changes in heart function, induced after sedation with either midazolam or dexmedetomidine, using cardiac magnetic resonance imaging (MRI).

METHODS

A total number of 30 volunteers were randomized into two groups: 15 participants in the midazolam group (MID) and 15 participants in the dexmedetomidine group (DEX). Every participant underwent a one-session cardiac MRI before and after sedation onset. The following parameters were recorded: left and right ventricle stroke volume (Ao-vol and Pul-vol resp.) and maximum flow velocity through the mitral valve during early (E-diast) and late diastole (L-diast). A monitor recorded values of mean blood pressure (MAP), pulse (P) and blood oxygen saturation (SpO2) in 5-minute intervals.

RESULTS

Dexmedetomidine led to a statistically significant decrease in Ao-vol (p = 0.006) and Pul-vol (p = 0.003), while midazolam decreased E-diast (p = 0.019) Ao-vol (p = 0.001) and Pul-vol (p = 0.01). The late diastolic filling was not influenced by the sedation technique.

CONCLUSION

Both sedation regimens worsened the systolic function of both ventricles. Midazolam moreover attenuated early diastolic filling of the left ventricle (Tab. 3, Fig. 4, Ref. 19).

Dexmedetomidine combined with midazolam infusion guided by bispectral index during bronchoscopy

BACKGROUND

Conscious sedation guided by bispectral index (BIS) during bronchoscopy has been proved to be a feasible approach. This study aimed to investigate the safety and efficacy of dexmedetomidine combined with midazolam for undergoing conscious sedation during bronchoscopy.

METHODS

The trial was registered prior to patient enrollment at the Chinese Clinical Trial Registry. Patients were randomized into DEX group (dexmedetomidine combined with midazolam) and FEN group (fentanyl combined with midazolam). Bronchoscopy was performed under awake sedation titrated to a BIS level of 60-80. The primary endpoint was the incidence of hypoxia, the secondary endpoint was the incidence of bradycardia and hypotension, effect of sedation including satisfaction degree (VAS) of the operators and patients and patients' willingness to undergo bronchoscopy again.

RESULTS

A total of 222 cases in DEX group and 211 cases in FEN group completed the study. The incidence of hypoxia and tachycardia in DEX group was lower than that in FEN group (8.1% vs 14.7%, 10.4% vs 19.0%, p < 0.05), and the incidence of hypotension and bradycardia in DEX group was higher than that in FEN group (6.8% vs 0, 15.3% vs 8.1%, p < 0.05). Midazolam dosage was significantly lower in the DEX group than in the FEN group, and the duration of surgery was significantly longer in the DEX group. The differences in intraoperative discomfort of VAS score, satisfaction VAS score, and willingness rate to undergo bronchoscopy again were not statistically significant between the two groups. In addition, the proportion of "procedural interference by patient movement" in DEX group was higher than that in FEN group.

CONCLUSIONS

The conscious sedation regimen of dexmedetomidine combined with midazolam monitored by BIS is considered to be safe and effective during bronchoscopy. The occurrence of hypoxia and tachycardia was less, and the fluctuation of blood pressure and heart rate was mild, but the proportion of bradycardia in dexmedetomidine group was higher than that in fentanyl combined with midazolam group.

Short-Acting Sedative-Analgesic Drugs Protect Against Development of Ventilator-Associated Events in Children: Secondary Analysis of the EUVAE Study

BACKGROUND

The U.S. Centers for Disease Control and Prevention proposed a shift in its surveillance paradigm from ventilator-associated pneumonia to ventilator-associated events (VAE) to broaden the focus of prevention and achieve a greater impact on outcomes. The main objective of the present study was to identify factors associated with pediatric VAEs in children undergoing mechanical ventilation ≥ 48 h.

METHODS

This was a secondary analysis of a pediatric cohort of a multicenter prospective study. Children who underwent mechanical ventilation ≥ 48 h were included. Exclusion criteria were previous ventilation, extracorporeal life support, and right-to-left shunt or pulmonary hypertension. In the subjects with multiple episodes of mechanical ventilation, only the first episode was considered. Remifentanil and propofol are classified as short-acting sedative and analgesic agents. Pediatric VAE is defined as an "increase in PEEP ≥ 2 cm of H₂O, an increase in [Formula: see text] of 0.20, or an increase in [Formula: see text] of 0.15 plus an increase in PEEP ≥ 1 cm of H₂O sustained for ≥1 d. Associations with pediatric VAE were estimated through multivariate Cox proportional hazards analysis. Hazard ratios and 95% CI were computed.

RESULTS

In a cohort of 90 children, 24 pediatric VAEs were documented in 906 ventilator-days. Pediatric VAEs developed after a median of 4.5 (interquartile range, 4-7.25) d. Surgical admissions, spontaneous breathing trials, early mobility, vasopressors, red blood cell units transfusion, type of sedation (continuous vs intermittent), benzodiazepine use for >3 d, and pharmacologic paralysis were not associated with pediatric VAE, whereas the use of continuous short-acting sedative-analgesic agents was identified as a strong protective factor against pediatric VAE (hazard ratio 0.06 [95% CI 0.007-0.5]).

CONCLUSIONS

Treatment with short-acting sedative-analgesic agents should be preferred for sedation of mechanically ventilated children in intensive care.

HEMATOLOGIC AND BIOCHEMICAL VALUES OF THE JUVENILE EASTERN GRAY SQUIRREL (SCIURUS CAROLINENSIS)

Venous blood samples were collected from 64 apparently healthy juvenile Eastern gray squirrels (Sciurus carolinensis) after sedation with midazolam at the Wildlife Center of Texas located in Houston, Texas, during 2012. Blood gas (pH, PCO2, PO2, base excess, bicarbonate, oxygen saturation), electrolyte (sodium, potassium), biochemical (total CO2, ionized calcium, glucose), and hematologic parameters (hematocrit, hemoglobin, complete blood count) were determined using the i-STAT point-of-care analyzer. Sex did not affect any analyte. All squirrels recovered uneventfully and were successfully rehabilitated and released. Most values were as expected based on comparison to other young rodent species. These analyte data for healthy juvenile Eastern gray squirrels may be useful in assessment of Eastern gray squirrel population health and management and treatment of individual squirrels presented in need of medical care.

Fixed dexmedetomidine infusion versus fixed-dose midazolam bolus as primary sedative for maintaining intra-procedural sedation during endobronchial ultrasound-guided transbronchial needle aspiration: a double blind randomized controlled trial

Objective: The utility and safety of fixed dexmedetomidine infusion was compared to fixed-dose midazolam bolus among patients undergoing EBUS-TBNA.Methods: In this randomized double-blind study, 197 patients were assigned to receive dexmedetomidine (Group D, 1 μg/kg before, and 0.6 μg/kg/hour during, procedure) or midazolam (Group M, 2 mg before procedure) sedation. The primary outcome was number of rescue midazolam boluses administered to achieve Ramsay Sedation Scale (RSS) score of two or more. We also studied sedation depth during procedure, adverse hemodynamic and hypoxemic events, bronchoscopist and patient satisfaction, and time-to-discharge from recovery room.Results: Rescue midazolam requirement was significantly lesser in 99 Group D (0.9 ± 1.2 boluses) than in 98 Group M (2.0 ± 2.4 boluses), subjects. Mean RSS score was significantly higher in Group D subjects (2.5 ± 0.7 vs. 2.3 ± 0.7). Significantly more subjects in Group D developed hypotension (46 vs. 27) or bradycardia (37 vs. 5), but none required specific intervention. Bronchoscopists reported significantly greater overall procedure satisfaction in Group D subjects.Conclusion: Fixed dexmedetomidine infusion reduced need for rescue sedation during EBUS-TBNA, and allowed slightly faster post-procedure recovery, as compared to fixed-dose midazolam bolus. However, it caused hypotension and bradycardia more frequently.Clinical trial registration: www.clinicaltrials.gov identifier is NCT02713191.

Emerging Approaches in Intravenous Moderate and Deep Sedation

Successful pharmacological innovations that have made a difference in daily practice are rare in the world of anesthesia and sedation. After many years of research, it seems that we finally have two new drug innovations that are likely to change the paradigm of moderate and deep sedation. These are oliceridine and remimazolam. Both have been in development for over a decade. Oliceridine was synthesized in a lab as an entirely new molecule. It is a biased μ- receptor agonist that acts preferentially on the G-protein pathway (which is responsible for analgesia). At least in lower doses, it has minimal effect on the beta-arrestin pathway, which is responsible for unwanted effects of μ-opioid receptor activation such as respiratory depression and gastrointestinal dysfunction. Like any other μ- receptor agonist, it produces appropriate dose-dependent analgesia. Remimazolam is structurally similar to midazolam; however, it has an additional ester linkage that delivers the kinetics of remifentanil. As a result, while pharmacodynamically identical to midazolam, remimazolam is metabolized by ester hydrolysis and subsequently its elimination is rapid and predictable. The present review discusses the two drugs in detail with a particular emphasis on their potential role in moderate and deep sedation.

Sedative and Behavioral Effects of Intranasal Midazolam in Comparison with Other Administrative Routes in Children Undergoing Dental Treatment - A Systematic Review

AIM

The aim of this study was to systematically identify and evaluate the available literature on the effectiveness of intranasal midazolam sedation compared with midazolam administered through other routes in the sedation and behavior management of children during dental treatment.

MATERIALS AND METHODS

The search was done using electronic databases such as PubMed Central, Cochrane Database of Systematic Reviews, LILACS, ScienceDirect, and SIGLE. All studies comparing the sedative effect and behavior management effectiveness of intranasal midazolam with midazolam administered through other routes in children were included.

RESULTS

Electronic database search identified 163 articles, out of which 143 were excluded after reading titles and removing duplication. The remaining 20 studies were evaluated in detail. A final of 13 studies were included based on the inclusion criteria. Among the 13 studies included in the present review, a high risk of bias was noted in all the 13 articles. There was no adequate blinding of personnel and participants in the study, allocation concealment was improper and presence of inadequate blinding of the outcome assessment. . Statistically, no significant difference was observed between intranasal midazolam and other midazolam routes on behavior and sedation level in the studies included in this review.

CONCLUSION

Limited studies are available pertaining to the sedative and behavioral effects of intranasal midazolam, and thus, this review recommends need for more research evaluating the sedative effect of intranasal midazolam in comparison with midazolam administered through other routes in the behavior management of children during dental treatment.

Effectiveness and adverse drug reactions of levetiracetam and midazolam in refractory neonatal seizure: A cross-sectional comparative study

BACKGROUND

Neonatal seizure (NS) reflects serious underlying brain injury, requiring immediate evaluation and early treatment. In neonates, phenobarbitone and phenytoin are used primarily to control the seizures. If uncontrolled, widespread off-label use of midazolam and levetiracetam was practiced. These drugs gained popularity though there are no such studies available on literature search comparing them. The present study was designed to explore these lacunae using these two drugs in refractory cases. To study the efficacy and adverse drug reactions (ADRs) of midazolam and levetiracetam not responding to usual line of therapy.

MATERIALS AND METHODS

This was a prospective cross-sectional study conducted on 69 neonates in the NICU and Department of Pharmacology in Burdwan Medical College and Hospital, West Bengal. Patients receiving midazolam or levetiracetam when uncontrolled with first line antiepileptics, namely, phenobarbitone and phenytoin, were considered eligible. The study variables were time to control seizure, seizure recurrence and frequency, and treatment-related adverse events. analysis used Mann-Whitney U-test were applied Comparison with respect to time to control and Chi-square test were applied to detect difference in proportion for ADRs. The SPSS Statistics 17.0 was used for analysis.

RESULTS

We compared the time periods to control neonatal seizure for effectiveness between levetiracetam and midazolam showing no significant difference (P = 0.190). Comparing the portion of recurrences in two groups gives statistically nonsignificant (P = 0.878) result. Only respiratory depression was seen in the levetiracetam group (12.90%) and midazolam group (18.42%). All adverse events were 'probable' as per the WHO-UMC criteria, and there was no statistically significant difference between the two drugs (P = 0.533).

CONCLUSIONS

Both midazolam and levetiracetam are equally effective and safe in NS not responding to usual line of treatment.

The Effectiveness of Intranasal Midazolam for the Treatment of Prehospital Pediatric Seizures: A Non-inferiority Study

Background: Intranasal (IN) midazolam allows for rapid, painless treatment of pediatric seizures in the prehospital setting and may be a preferred administration route if determined to be non-inferior to intravenous (IV) or intramuscular (IM) routes. We sought to evaluate the effectiveness of IN midazolam for terminating prehospital pediatric seizures compared to midazolam administered by alternate routes. Methods: We performed a retrospective, non-inferiority analysis using data from a regional Emergency Medical Services (EMS) database. We included pediatric patients ≤ 14 years treated with midazolam (0.1 mg/kg) by EMS for non-traumatic seizures. The primary outcome was the proportion of patients requiring redosing of midazolam after initial treatment with IN midazolam compared to those that received IV or IM midazolam. We established a priori a risk difference of 6.5% as the non-inferiority margin. Results: We evaluated outcomes from 2,034 patients (median age 6 years [interquartile range 3 - 10 years], 55% male). Initial administration routes were 461 (23%) IN, 547 (27%) IM, 1024 (50%) IV, and 2 (0.1%) intraosseous (IO). Midazolam redosing occurred in 116 patients (25%) who received IN midazolam versus 222 patients (14%) treated initially with midazolam via alternate routes (risk difference 11% [95%CI 7 - 15%]). The age-adjusted odds ratio for redosing midazolam after intranasal administration compared to alternate route administration was 2.0 (95% CI 1.6 - 2.6). Conclusion: Prehospital treatment of pediatric seizure with intranasal midazolam was associated with increased frequency of redosing compared to midazolam administered by other routes, suggesting that 0.1 mg/kg is a subtherapeutic dose for intranasal midazolam administration.

Effect of Pre-Treatment with a Combination of Fentanyl and Midazolam for Prevention of Etomidate-Induced Myoclonus

Objective

Pre-treatment with either fentanyl or midazolam has previously been used to prevent etomidate-induced myoclonus (EIM). The aim of the present study was to determine the effect of pre-treatment with a combination of midazolam and fentanyl in reducing the incidence and severity of EIM.

Methods

This prospective, randomised, double-blind study was conducted on 210 surgical patients allocated to three study groups. Group F patients received fentanyl 2 μg kg^-1 and 5 mL saline. Group M patients received midazolam 0.03 mg kg^-1 and 5 mL saline. Group FM patients received fentanyl 2 μg kg^-1 plus midazolam 0.03 mg kg^-1. The study drugs were administered intravenously over 30 s. Five minutes after study drug administration, etomidate 0.3 mg kg^-1 was administered over 60 s. Patients were observed for 1 min for occurrence and severity of EIM.

Results

The incidence of EIM was 34/70 (48.6%), 55/70 (78.6%) and 11/70 (15.7%) in groups F, M and FM, respectively (p=0.001). Myoclonus of moderate or severe grade occurred in 23/70 (32.9%), 45/70 (64.3%) and 6/70 (8.6%) in groups F, M and FM, respectively (p=0.001). Patients who experienced myoclonus exhibited a significantly higher percentage change in post-induction heart rate (p=0.02), systolic blood pressure (p=0.001) and mean blood pressure (p=0.001) from pre-induction values than those who did not.

Conclusion

Pre-treatment with a combination of fentanyl and midazolam is more effective than that with fentanyl or midazolam alone in reducing the incidence and severity of EIM. Myoclonus is associated with a higher post-induction haemodynamic variation.

Comparison of the effects of butorphanol-midazolam-medetomidine and butorphanol-azaperone-medetomidine in wild common palm civets (Paradoxurus musangus)

OBJECTIVE

To assess the efficacy of butorphanol-azaperone-medetomidine (BAM) and butorphanol-midazolam-medetomidine (BMM) protocols for immobilization of wild common palm civets (Paradoxurus musangus) with subsequent antagonization with atipamezole.

STUDY DESIGN

Prospective, randomized, blinded clinical trial.

ANIMALS

A total of 40 adult wild common palm civets, 24 female and 16 male, weighing 1.5-3.4 kg.

METHODS

The civets were randomly assigned for anesthesia with butorphanol, azaperone and medetomidine (0.6, 0.6 and 0.2 mg kg^-1, respectively; group BAM) or with butorphanol, midazolam and medetomidine (0.3, 0.4 and 0.1 mg kg^-1, respectively; group BMM) intramuscularly (IM) in a squeeze cage. When adequately relaxed, the trachea was intubated for oxygen administration. Physiological variables were recorded every 5 minutes after intubation. Following morphometric measurements, sampling, microchipping and parasite treatment, medetomidine was reversed with atipamezole at 1.0 or 0.5 mg kg^-1 IM to groups BAM and BMM, respectively. Physiological variables and times to reach the different stages of anesthesia were compared between groups.

RESULTS

Onset time of sedation and recumbency was similar in both groups; time to achieve complete relaxation and tracheal intubation was longer in group BAM. Supplementation with isoflurane was required to enable intubation in five civets in group BAM and one civet in group BMM. All civets in group BAM required topical lidocaine to facilitate intubation. End-tidal carbon dioxide partial pressure was lower in group BAM, but heart rate, respiratory rate, rectal temperature, peripheral hemoglobin oxygen saturation and mean arterial blood pressure were not different. All civets in both groups recovered well following administration of atipamezole.

CONCLUSIONS AND CLINICAL RELEVANCE

Both BAM and BMM combinations were effective for immobilizing wild common palm civets. The BMM combination had the advantage of producing complete relaxation that allowed intubation more rapidly.

The rs776746 variant of CYP3A5 is associated with intravenous midazolam plasma levels and higher clearance in critically ill Mexican paediatric patients

WHAT IS KNOWN AND OBJECTIVE

Midazolam is a drug that is metabolized by cytochrome P450 (CYP450) enzymes, particularly CYP3A4 and CYP3A5. The presence of single-nucleotide polymorphisms (SNPs) in the genes encoding these enzymes, such as CYP3A4*1B which is associated with low enzyme expression and activity and CYP3A5*3, has been associated with decrease in enzymatic activity and reduced drug clearance, with potential effects on drug levels and/or toxicity. The present study was conducted to determine the frequencies of the allelic variants of the CYP3A4 (rs2740574) and CYP3A5 (rs776746) genes and their effects on the plasma levels and clearance of intravenous midazolam in critically ill Mexican paediatric patients.

METHODS

Seventy-two DNA samples were genotyped by real-time PCR with TaqMan probes. Plasma midazolam levels were determined at 3 and 24 h post infusion by high-performance liquid chromatography.

RESULTS AND DISCUSSION

The allelic variant rs776746 (CYP3A5*3) was associated with high midazolam plasma levels; the median concentration in patients with the normal genotype (CC) <0.01 ng/ml (Q₂₅ 0.01-Q₇₅ 196.09), whereas patients with the allelic variant (TT+TC) had a median midazolam concentration of 320.3 ng/ml (Q₂₅ 37.51-Q₇₅ 529.51), p = 0.001. The median pharmacokinetic clearance rates were 0.10 L/kg/h (Q₂₅ 0.01-Q₇₅ 0.34) in patients with the allelic variant (TT+TC) and 0.03 L/kg/h (Q₂₅ 0.002-Q₇₅ 0.13) in patients with the normal genotype (CC), p = 0.042.

WHAT IS NEW AND CONCLUSION

This is the first study that reports the frequency of the rs776746 polymorphism in critically ill paediatric patients, which is relevant, since carriers of the *1 allele synthesizing a functional enzyme may need higher doses to achieve adequate sedation. Our results show that compared with carriers of the normal allele, patients with the CYP3A5*3 allelic variant (rs776746) had increased plasma midazolam levels at 3 h after infusion discontinuation (320.3 ng/ml) and greater clearance (0.10 L/kg/h) of the drug.

Oxidative Stress Reduction by Midazolam Premedication during Oocyte Retrieval Procedure: Pilot Study

Infertility is one of the major medical problems nowadays. Couples who opt for In Vitro Fertilization (IVF) face a great deal of stress which certainly affects the outcome of the procedure. Therefore, we aimed to reduce the stress during the oocyte retrieval procedure by applying midazolam. Total oxidant (TOC) and antioxidant (TAC) capacities of serum, as well as glutathione (GSH) content and catalase activity, were measured in both control and midazolam groups. Follicular fluid was also tested for oxidant capacity and IL1β. Results implied that the midazolam group increased TAC at the end of the procedure. At the same time, the control group decreased GSH at the beginning of the procedure, and both groups decreased catalase activity at the end of the procedure. The results imply that stress during the procedure affects oxidative and antioxidative parameters of the patients, but did not affect the frequency of the pregnancy at the end of this pilot study. Yet, the results imply that oxidative and antioxidative mechanisms during IVF should be investigated in detail as they could affect the outcome of IVF.

Novel Genetically Modified Mouse Model to Assess Soman-Induced Toxicity and Medical Countermeasure Efficacy: Human Acetylcholinesterase Knock-in Serum Carboxylesterase Knockout Mice

The identification of improved medical countermeasures against exposure to chemical warfare nerve agents (CWNAs), a class of organophosphorus compounds, is dependent on the choice of animal model used in preclinical studies. CWNAs bind to acetylcholinesterase and prevent the catalysis of acetylcholine, causing a plethora of peripheral and central physiologic manifestations, including seizure. Rodents are widely used to elucidate the effects of CWNA-induced seizure, albeit with a caveat: they express carboxylesterase activity in plasma. Carboxylesterase, an enzyme involved in the detoxification of some organophosphorus compounds, plays a scavenging role and decreases CWNA availability, thus exerting a protective effect. Furthermore, species-specific amino acid differences in acetylcholinesterase confound studies that use oximes or other compounds to restore its function after inhibition by CWNA. The creation of a human acetylcholinesterase knock-in/serum carboxylesterase knockout (C57BL/6-Ces1ctm1.1LocAChEtm1.1Loc/J; a.k.a KIKO) mouse may facilitate better modeling of CWNA toxicity in a small rodent species. The current studies characterize the effects of exposure to soman, a highly toxic CWNA, and evaluate the efficacy of anti-seizure drugs in this newly developed KIKO mouse model. Data demonstrate that a combination of midazolam and ketamine reduces seizure duration and severity, eliminates the development of spontaneous recurrent seizures, and protects certain brain regions from neuronal damage in a genetically modified model with human relevance to organophosphorus compound toxicity. This new animal model and the results of this study and future studies using it will enhance medical countermeasures development for both defense and homeland security purposes.

Patterns of benzodiazepine underdosing in the Established Status Epilepticus Treatment Trial

OBJECTIVE

This study was undertaken to describe patterns of benzodiazepine use as first-line treatment of status epilepticus (SE) and test the association of benzodiazepine doses with response to second-line agents in patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT).

METHODS

Patients refractory to an adequate dose of benzodiazepines for the treatment of SE were enrolled in ESETT. Choice of benzodiazepine, doses given prior to administration of second-line agent, route of administration, setting, and patient weight were characterized. These were compared with guideline-recommended dosing. Logistic regression was used to determine the association of the first dose of benzodiazepine and the cumulative benzodiazepine dose with the response to second-line agent.

RESULTS

Four hundred sixty patients were administered 1170 doses of benzodiazepines (669 lorazepam, 398 midazolam, 103 diazepam). Lorazepam was most frequently administered intravenously in the emergency department, midazolam intramuscularly or intravenously by the emergency medical services personnel, and diazepam rectally prior to ambulance arrival. The first dose of the first benzodiazepine (N = 460) was lower than guideline recommendations in 76% of midazolam administrations and 81% of lorazepam administrations. Among all administrations, >85% of midazolam and >76% of lorazepam administrations were lower than recommended. Higher first or cumulative benzodiazepine doses were not associated with better outcomes or clinical seizure cessation in response to second-line medications in these benzodiazepine-refractory seizures.

SIGNIFICANCE

Benzodiazepines as first-line treatment of SE, particularly midazolam and lorazepam, are frequently underdosed throughout the United States. This broad and generalizable cohort confirms prior single site reports that underdosing is both pervasive and difficult to remediate. (ESETT ClinicalTrials.gov identifier: NCT01960075.).

Effect of hand-holding and conversation alone or with midazolam premedication on preoperative anxiety in adult patients-A randomised controlled trial

Background and Aims:

Anxiety causing stress is most profound before surgery. Anxiolytics are used routinely to combat perioperative anxiety. Studies have shown that hand-holding and communication are useful in reducing anxiety levels intraoperatively. This study compares the effectiveness of the same with pharmacological interventions in allaying preoperative anxiety.

Material and Methods:

This is a three-arm parallel-group randomised controlled trial. A total of 90 adult patients aged <45 years and of American Society of Anesthesiologists (ASA) grade 1–2, undergoing laparoscopic surgery were enroled in this study. Patients received either intravenous (IV) midazolam (group M) or hand-holding and conversation (group HC), or a combination of IV midazolam and holding and conversation (group HCM) in the preoperative room. Anxiety, heart rate (HR) and mean blood pressure (MBP) were recorded before and 20 minutes after the intervention. Anxiety was measured using the Amsterdam preoperative anxiety and information scale. The analysis of covariance (ANCOVA) test was done to analyse the difference between the groups.

Results:

The mean anxiety scores were significantly different in the three groups (p = 0.04) after intervention, with the lowest score in group HCM, followed by group HC and the highest score in group M. The mean heart rates were also significantly different in the three groups after intervention but MBP was not significantly different in the three groups.

Conclusion:

A combination of hand-holding and conversation and midazolam is best for allaying preoperative anxiety in patients undergoing laparoscopic surgeries than either method alone.

Stability and Compatibility of Ramosetron with Midazolam in 0.9% Sodium Chloride Injection for Postoperative Nausea and Vomiting Administration

Background

Combination antiemetic therapy has become a common practice for the prevention of postoperative nausea and vomiting (PONV). The aim of the present study was to evaluate the stability and compatibility of ramosetron hydrochloride and midazolam in 0.9% sodium chloride injection when stored at 4°C and 25°C for up to 14 days.

Methods

Admixtures were assessed initially and for 14 days after preparation in polyolefin bags and glass bottles using 0.9% sodium chloride injection as the diluent and stored at 4°C or 25°C. The initial concentrations were 0.3 mg/100 mL ramosetron hydrochloride and 0.5 mg/100 mL midazolam hydrochloride. For all samples, the compatibility parameters (including precipitation, cloudiness, discoloration and pH values) were evaluated. Chemical stability was also determined using high-performance liquid chromatography (HPLC) analysis.

Results

After a 14-day period of storage at 4°C or 25°C, the percent of the initial concentration of ramosetron hydrochloride and midazolam hydrochloride in the various solutions were maintained at a minimum of 97%. All of the mixtures remained clear and colourless throughout the observation period, and no colour change or precipitation was observed.

Conclusion

The results indicate that admixtures of 0.3 mg/100 mL ramosetron hydrochloride and 0.5 mg/100 mL midazolam hydrochloride in normal saline were stable for 14 days at 4°C or 25°C when packaged in polyolefin bags or glass bottles and protected from light.

Propofol versus midazolam for sedation during radiofrequency ablation in patients with hepatocellular carcinoma

Background and Aim

Standardization of the sedation protocol during radiofrequency ablation (RFA) in patients with hepatocellular carcinoma (HCC) is needed. This randomized, single‐blind, investigator‐initiated trial compared clinical outcomes during and after RFA using propofol and midazolam, respectively, in patients with HCC.

Methods

Few‐ and small‐nodule HCC patients (≤3 nodules and ≤3 cm) were randomly assigned to either propofol or midazolam. Patient satisfaction was assessed using a 100‐mm visual analog scale (VAS) (1 mm = not at all satisfied, 100 mm = completely satisfied). Sedation recovery rates 1, 2, 3, and 4 h after RFA were evaluated based on Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores; full recovery was defined as a MOAA/S score of 5.

Results

Between July 2013 and September 2017, 143 patients with HCC were enrolled, and 135 patients were randomly assigned to the treatment group. Compared with midazolam, propofol exhibited similar median procedural satisfaction (propofol: 73.1 mm, midazolam: 76.9 mm, P = 0.574). Recovery rates 1 and 2 h after RFA were higher in the propofol group than in the midazolam group. Meanwhile, recovery rates observed 3 and 4 h after RFA were similar in the two groups. The safety profiles during and after RFA were almost identical in the two groups.

Conclusion

Patient satisfaction was almost identical in patients receiving propofol and midazolam sedation during RFA. Propofol sedation resulted in reduced recovery time compared with midazolam sedation in patients with HCC. The safety profiles of both propofol and midazolam sedation during and after RFA were acceptable.

Effects of Premedication With Midazolam on Recovery and Discharge Times After Tonsillectomy and Adenoidectomy

Background

Midazolam is commonly used preoperatively for anxiety. Adverse effects data in pediatric patients with obstructive sleep apnea (OSA) undergoing tonsillectomy and adenoidectomy (T&A) is limited.

Aims

We hypothesized that preoperative midazolam increases the time to emergence from anesthesia and postoperative discharge. Secondary objectives assessed if patients receiving midazolam experienced increased side effects or complications from treatment.

Methods

This study was a retrospective chart review of patients undergoing T&A from July 2014 to December 2015. Midazolam receiving patients (midazolam group: MG) were compared to patients who did not (non-midazolam group: NMG). Multivariable analyses were performed and adjusted for predefined potential cofounder variables.

Results

Emergence and discharge times were 5.2 minutes (95% CI [-7.1, 17.4]; p=0.41) and 10.1 minutes (95% CI [-6.7, 26.8]; p=0.24) longer in MG. These results were not statistically significant. Comparing by OSA status, there was no statistical difference in emergence and discharge times between mild, moderate and severe OSA groups or between MG and NMG within each OSA group. Emergence and discharge times in moderate OSA was 6.1 minutes (95% CI [-17.6, 29.8]; p=0.61) and 18.8 minutes (95% CI [-16.4, 53.9]; p=0.29) longer than mild OSA, and in the severe OSA group, 2.6 minutes (95% CI [-19.9, 25.1]; p=0.82) shorter and 2.8 minutes (95% CI [-30.3, 35.9]; p=0.87) longer. The incidence of postoperative complications was comparable between MG and NMG groups.

Conclusions

Premedication with midazolam was not associated with prolonged emergence or discharge time or higher incidence of complications after anesthesia for T&A in patients with OSA.

A Randomized Controlled Study Comparing Dexmedetomidine-Midazolam with Fentanyl-Midazolam for Sedation during awake Fiberoptic Intubation in Anticipated Difficult Airway

Background:

Awake fibreoptic nasotracheal intubation is an effective technique for the management of patients with difficult airways. Adequate sedation with effective topicalization of the airway is important to overcome discomfort and achieve intubation successfully.

Aim and Objectives:

Our aim was to compare the effectiveness of dexmedetomidine-midazolam with fentanyl-midazolam infusion for providing conscious sedation during fibreoptic intubation in patients with anticipated difficult airway under topical anaesthesia.

Materials and Methods:

Thirty adult patients of ASA physical status classification I and II with anticipated difficult airway and planned for elective awake nasal fibreoptic intubation under conscious sedation were randomly allocated into two groups. Dexmedetomidine 1 μg.kg-1 diluted in 50 ml saline was infused in Group DM over 10 min and Fentanyl 2 μg.kg-1 diluted in 50 ml saline was infused in Group FM over 10 min. Topicalization of the airway was done in all patients. All patients were assessed for sedation score, ease of endotracheal tube placement, patient comfort and cooperation, tolerance to endotracheal tube, any adverse events and recall of procedure.

Results:

The score of the modified OAA/S was comparable between the groups (P > 0.05). Quality of AFOI was comparable in both groups (P > 0.05). The intubation time and first EtCO2 were significantly lower in dexmedetomidine group (P <0.05). Group DM also showed better hemodynamics and less episodes of desaturation than Group FM.

Conclusion:

Fentanyl-midazolam and dexmedetomidine-midazolam are both effective for awake fiberoptic intubation under topical anesthesia. Dexmedetomidine allows better endurance and more stable hemodynamics.

A Comparative Study of Dexamethasone versus Midazolam as Adjuvant to 0.5% Bupivacaine in Ultrasound-Guided Supraclavicular Brachial Plexus Block for Upper-Limb Surgeries

Background:

Ultrasound has been effective in using low volume of local anesthetics for supraclavicular block. Steroids have been shown to increase the duration of local anesthetics.

Aims and Objectives:

In this study, we compare the efficacy of dexamethasone versus midazolam when added to bupivacaine in supraclavicular brachial plexus block for upper-limb surgeries with regard to the time of onset and duration of sensory and motor blockades, duration of analgesia, sedation, and hemodynamic parameters.

Setting and Design:

This is a prospective, randomized, double-blind study conducted on 60 patients belonging to the American Society of Anesthesiologists physical status classes 1 and 2, undergoing upper-limb surgeries under ultrasound-guided supraclavicular brachial plexus block.

Materials and Methods:

Sixty patients were divided into two groups of 30 each. Group dexamethasone (Group D) received bupivacaine 0.5% 18 mL + dexamethasone 4 mg + 1 mL normal saline. Group midazolam (Group M) received bupivacaine 0.5% 18 mL + 2 mg midazolam. We compared the onset and duration of sensory and motor blocks, hemodynamic variables, pain and sedation scores, and duration of analgesia.

Statistical Analysis:

The statistical software, namely SPSS 18.0 and R environment ver. 3.2.2, were used for the analysis of the data. P < 0.05 was considered statistically significant.

Results:

The onset of sensory and motor blocks was significantly faster in Group D compared to Group M. The duration of sensory and motor blockades and duration of analgesia showed a significant increase in Group D in comparison with Group M.

Conclusion:

Dexamethasone as an adjuvant hastens the onset and prolongs the duration of both sensory and motor blocks and reduces postoperative analgesic requirement when compared to midazolam.

Validation of a HPLC method for quantification of midazolam in rat plasma: Application during a Maytenus ilicifolia-drug interaction study

Midazolam (MDZ) is routinely employed as a marker compound of cytochrome P450 3A (CYP3A) activity. Despite the many HPLC-UV methods described to quantify MDZ in plasma, all of them use acetonitrile (ACN) or a mixture of methanol-isopropanol as organic solvent of the mobile phase. Since the ACN shortage in 2008, efforts have been made to replace this solvent during HPLC analysis. A simple, sensitive, accurate and repeatable HPLC-UV method (220 nm) was developed and validated to quantify MDZ in rat plasma using methanol instead. The method was applied during a herb-drug interaction study involving Maytenus ilicifolia, a Brazilian folk medicine used to treat gastric disorders. Plasma samples were alkalinized and MDZ plus alprazolam (internal standard) were extracted with diethyl ether. After solvent removal, the residue was reconstituted with methanol-water (1:1). The analyte was eluted throughout a C₁₈ column using sodium acetate buffer (10 mm, pH 7.4)-methanol (40:60, v/v). The precision at the lower limit of quantification never exceeded 19.40%, and 13.86% at the higher levels of quality control standards, whereas the accuracy ranged from -19.81 to 14.33%. The analytical curve was linear from 50 to 2,000 ng/ml. The activity of the hepatic CYP3A enzymes was not affected by the extract.

Evaluation of the antifungal activity in vitro of midazolam against fluconazole-resistant Candida spp. isolates

Aim: The purpose of this study was to evaluate the antifungal activity of midazolam, alone and in association with azoles, against isolates of clinical Candida spp. in planktonic and biofilm form. Materials & methods: The antifungal activity was observed using the broth microdilution technique. Flow cytometry tests were performed to investigate the probable mechanism of action and the comet test and cytotoxicity test were applied to evaluate DNA damage. Results: Midazolam (MIDAZ) showed antifungal activity against planktonic cells (125-250 μg/ml) and reduced the viability of Candida spp. biofilms (125 a 2500 μg/ml). The interaction of MIDAZ against Candida spp. biofilms was observed through scanning electron microscopy, causing alteration of their appearance. Therefore, MIDAZ has antifungal potential against Candida spp.