Benzodiazepine augmented γ-amino-butyric acid signaling increases mortality from pneumonia in mice

Benzodiazepines compromise the outcome of cancer immunotherapy

Acyl CoA binding protein (ACBP, which is encoded by diazepam binding inhibitor, DBI) acts on the gamma-amino butyric acid (GABA) receptor type A via a specific binding site that is shared by diazepam and other benzodiazepines. Both ACBP/DBI and benzodiazepines act as positive allosteric modulators, hence increasing GABA effects on this receptor. Recently, we found that ACBP/DBI acts as an endogenous immunosuppressor, meaning that its antibody-mediated neutralization has immunostimulatory effects and enhances the efficacy of immunotherapy and chemoimmunotherapy in mouse models. Driven by these considerations, we investigated whether diazepam administration in mice would reverse the beneficial effects of ACBP/DBI neutralization on cancer chemoimmunotherapy. Indeed, diazepam abolished the therapeutic of anti-ACBP/DBI antibodies, supporting the idea that diazepam exerts immunosuppressive properties. Of note, treatment with benzodiazepines was associated with poor clinical responses to chemoimmunotherapy in patients with non-small cell lung cancer (NSCLC) as compared to individuals not receiving any psychotropic drugs. Medication with other psychotropic drugs than benzodiazepines did not compromise the outcome of chemoimmunotherapy, indicating that this immunosuppressive effect was benzodiazepine specific. We conclude that benzodiazepines may confer systemic immunosuppression. This hypothesis requires further epidemiological and clinical confirmation.

Increased Pneumonia Risk Associated with Concomitant Use of Inhaled Corticosteroids and Benzodiazepines: A Pharmacovigilance Analysis

BACKGROUND

Inhaled corticosteroids (ICS) are effective in managing asthma and chronic obstructive pulmonary disease (COPD) but increase the risk of pneumonia. Benzodiazepines (BZD), commonly prescribed for comorbid psychiatric disorders in asthma or COPD patients, are also associated with pneumonia. This study investigates the risk of pneumonia associated with the concomitant use of ICS and BZD.

METHODS

Data from the FDA Adverse Event Reporting System from Q4 2013 to Q3 2023 were extracted. Reports involving asthma or COPD patients were included. Disproportionality analysis and logistic regression analysis were performed to assess the risk of pneumonia associated with the combined use of ICS and BZD. Additive and multiplicative models were used to further confirm the results. Additionally, subgroup analyses were conducted based on gender, age, and disease type.

RESULTS

A total of 238,411 reports were included. The combined use of ICS and BZD was associated with a higher reporting of pneumonia (ROR: 2.41, 95% CI 2.25-2.58). Using additive and multiplicative methods, the results remained significant. The strongest risk signals were observed in specific drug combinations, such as mometasone with clonazepam, budesonide with temazepam, and mometasone with zopiclone. Subgroup analyses showed higher pneumonia risks in females, patients over 60 years old, and those with asthma.

CONCLUSION

Our findings identified a significantly elevated pneumonia risk with the combined use of ICS and BZD. These results highlighted the necessity for cautious co-prescription of ICS and BZD and suggested the need for more comprehensive clinical studies to assess this interaction.

Impact of NMDA receptors block versus GABA-A receptors modulation on synaptic plasticity and brain electrical activity in metabolic syndrome

PURPOSE

Metabolic syndrome (MetS) is a common disorder associated with disturbed neurotransmitter homeostasis. Memantine, an N-methyl-d-aspartate receptor (NMDAR) antagonist, was first used in Alzheimer's disease. Allopregnanolone (Allo), a potent positive allosteric modulator of the Gamma-Amino-Butyric Acid (GABA)-A receptors, decreases in neurodegenerative diseases. The study investigated the impact of Memantine versus Allo administration on the animal model of MetS to clarify whether the mechanism of abnormalities is related more to excitatory or inhibitory neurotransmitter dysfunction.

MATERIALS AND METHODS

Fifty-six male rats were allocated into 7 groups: 4 control groups, 1 MetS group, and 2 treated MetS groups. They underwent assessment of cognition-related behavior by open field and forced swimming tests, electroencephalogram (EEG) recording, serum markers confirming the establishment of MetS model and hippocampal Glial Fibrillary Acidic Protein (GFAP) and Brain-Derived Neurotrophic Factor (BDNF).

RESULTS

Allo improved anxiety-like behavior and decreased grooming frequency compared to Memantine. Both drugs increased GFAP and BDNF expression, improving synaptic plasticity and cognition-related behaviors. The therapeutic effect of Allo was more beneficial regarding lipid profile and anxiety. We reported progressive slowing of EEG waves in the MetS group with Memantine and Allo treatment with increased relative theta and decreased relative delta rhythms.

CONCLUSIONS

Both Allo and Memantine boosted the outcome parameters in the animal model of MetS. Allo markedly improved the anxiety-like behavior in the form of significantly decreased grooming frequency compared to the Memantine-treated groups. Both drugs were associated with increased hippocampal GFAP and BDNF expression, indicating an improvement in synaptic plasticity and so, cognition-related behaviors.

Estimating the incidence rate ratio of common cold among patients with non-apnea sleep disorders: a retrospective cohort study

The purpose was to explore the potential effects of nonapnea sleep disorders (NSDs) and hypnotic use on the incidence of common cold. This study adapted population-based retrospective cohort study designed. We used the data from the Taiwan National Health Insurance Research Database between 1998 and 2011. In total, 59,476 patients with NSDs were included in the study cohort, and the reference cohort comprised 59,476 propensity score-matched patients. We conducted a Poisson regression analysis to assess the incidence of common cold. The overall incidence of common cold was significantly higher than that in the reference cohort. Compared with the patients of the reference cohort without hypnotic use, those of the NSDs cohort with benzodiazepines and zolpidem use had higher incidence of common cold. In conclusion, study cohort had a higher incidence of developing common cold, and particularly pronounced in NSDs with hypnotic use.

Phenobarbital versus benzodiazepines in alcohol withdrawal syndrome

AIM

Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment for alcohol withdrawal syndrome (AWS). Currently, existing research offers only modest guidance on the safety and effectiveness of phenobarbital in managing AWS in hospital settings. The study objective was to assess if a phenobarbital protocol for the treatment of AWS reduces respiratory complications when compared to a more traditionally used benzodiazepine protocol.

METHODS

A retrospective cohort study analyzing adults who received either phenobarbital or benzodiazepine-based treatment for AWS over a 4-year period, 2015-2019, in a community teaching hospital in a large academic medical system.

RESULTS

A total of 147 patient encounters were included (76 phenobarbital and 71 benzodiazepine). Phenobarbital was associated with a significantly decreased risk of respiratory complications, defined by the occurrence of intubation (15/76 phenobarbital [20%] vs. 36/71 benzodiazepine [51%]) and decreased incidence of the requirement of six or greater liters of oxygen when compared with benzodiazepines (10/76 [13%] vs. 28/71 [39%]). There was a significantly higher incidence of pneumonia in benzodiazepine patients (15/76 [20%] vs. 33/71 [47%]). Mode Richmond Agitation Sedation Scale (RASS) scores were more frequently at goal (0 to -1) between 9 and 48 h after the loading dose of study medication for phenobarbital patients. Median hospital and ICU length of stay were significantly shorter for phenobarbital patients when compared with benzodiazepine patients (5 vs. 10 days and 2 vs. 4 days, respectively).

CONCLUSION

Parenteral phenobarbital loading doses with an oral phenobarbital tapered protocol for AWS resulted in decreased risk of respiratory complications when compared to standard treatment with benzodiazepines.

Role of neurotransmitters in immune-mediated inflammatory disorders: a crosstalk between the nervous and immune systems

Immune-mediated inflammatory diseases (IMIDs) are a group of common heterogeneous disorders, characterized by an alteration of cellular homeostasis. Primarily, it has been shown that the release and diffusion of neurotransmitters from nervous tissue could result in signaling through lymphocyte cell-surface receptors and the modulation of immune function. This finding led to the idea that the neurotransmitters could serve as immunomodulators. It is now manifested that neurotransmitters can also be released from leukocytes and act as autocrine or paracrine modulators. Increasing data indicate that there is a crosstalk between inflammation and alterations in neurotransmission. The primary goal of this review is to demonstrate how these two pathways may converge at the level of the neuron and glia to involve in IMID. We review the role of neurotransmitters in IMID. The different effects that these compounds exert on a variety of immune cells are also reviewed. Current and future developments in understanding the cross-talk between the immune and nervous systems will undoubtedly identify new ways for treating immune-mediated diseases utilizing agonists or antagonists of neurotransmitter receptors.

Sex differences in factors influencing hospital-acquired pneumonia in schizophrenia patients receiving modified electroconvulsive therapy

BACKGROUND

Sex differences may be presented in the clinical features or symptoms of schizophrenia patients but also affect the occurrence of hospital-acquired pneumonia (HAP). Modified electroconvulsive therapy (mECT) is a common treatment method for schizophrenia, used in combination with antipsychotics. This retrospective research explores the sex difference in HAP affecting patients with schizophrenia who have received mECT treatment during hospitalization.

METHODS

We included schizophrenia inpatients treated with mECT and antipsychotics between January 2015 and April 2022. Blood-related and demographic data collected on admission were analyzed. Influencing factors of HAP in male and female groups were assessed separately.

RESULTS

A total of 951 schizophrenia patients treated with mECT were enrolled in the study, including 375 males and 576 females, of which 62 patients experienced HAP during hospitalization. The risk period of HAP in these patients was found to be the first day after each mECT treatment and the first three sessions of mECT treatment. Statistically significant differences in the incidence of HAP were identified in male vs. female groups, with an incidence in men about 2.3 times higher than that in women (P < 0.001). Lower total cholesterol (Z = -2.147, P = 0.032) and the use of anti-parkinsonian drugs (χ² = 17.973, P < 0.001) were found to be independent risk factors of HAP in male patients, while lower lymphocyte count (Z = -2.408, P = 0.016), hypertension (χ² = 9.096, P = 0.003), and use of sedative-hypnotic drugs (χ² = 13.636, P < 0.001) were identified in female patients.

CONCLUSION

Influencing factors of HAP in schizophrenia patients treated with mECT have gender differences. The first day after each mECT treatment and the first three sessions of mECT treatment were identified to have the greatest risk for HAP development. Therefore, it would be imperative to monitor clinical management and medications during this period according to these gender differences.

A nationwide cohort study of the association of benzodiazepines with SARS-CoV-2 infection and clinical outcomes

The evidence for the impact of benzodiazepine (BZD) use on infection or clinical outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is limited. We evaluated the association of BZD use with SARS-CoV-2 infection and the clinical outcomes of coronavirus disease 2019 (COVID-19) using a nationwide COVID-19 database from South Korea. This nationwide cohort study was performed using the COVID-19 database from the Health Insurance Review and Assessment Service of Korea, and SARS-CoV-2 positivity was investigated according to BZD use. SARS-CoV-2-positive adult patients were assessed in three groups, those who needed hospitalization, those with severe symptoms requiring intensive care, and those who died. A multivariate logistic regression model was used for all the analyses. After adjusting for potential confounding factors, there was no association between BZD use and SARS-CoV-2 positivity. SARS-CoV-2-positive patients with BZD use showed an increased risk of need for hospitalization from COVID-19 compared to those without BZD use (odds ratio [OR]: 1.33, 95% confidence interval [CI] 1.07-1.65). In addition, there was a higher risk for long-term users (OR: 2.64, 95% CI 1.08-6.47). Chronic BZD use contributed to a higher risk of the need for hospitalization among COVID-19 patients, whereas BZD use did not increase the risk of SARS-CoV-2 test positivity, severe outcomes, or mortality.

Effects of propofol on macrophage activation and function in diseases

Macrophages work with monocytes and dendritic cells to form a monocyte immune system, which constitutes a powerful cornerstone of the immune system with their powerful antigen presentation and phagocytosis. Macrophages play an essential role in infection, inflammation, tumors and other pathological conditions, but these cells also have non-immune functions, such as regulating lipid metabolism and maintaining homeostasis. Propofol is a commonly used intravenous anesthetic in the clinic. Propofol has sedative, hypnotic, anti-inflammatory and anti-oxidation effects, and it participates in the body’s immunity. The regulation of propofol on immune cells, especially macrophages, has a profound effect on the occurrence and development of human diseases. We summarized the effects of propofol on macrophage migration, recruitment, differentiation, polarization, and pyroptosis, and the regulation of these propofol-regulated macrophage functions in inflammation, infection, tumor, and organ reperfusion injury. The influence of propofol on pathology and prognosis via macrophage regulation is also discussed. A better understanding of the effects of propofol on macrophage activation and function in human diseases will provide a new strategy for the application of clinical narcotic drugs and the treatment of diseases.

Pathogenesis of ventilator-induced lung injury: metabolomics analysis of the lung and plasma

INTRODUCTION

Nowadays,the mechanical ventilation (MV) aims to rest the respiratory muscles while providing adequate gas exchange, and it has been a part of basic life support during general anesthesia as well as in critically ill patients with and without respiratory failure. However, MV itself has the potential to cause or worsen lung injury, which is also known as ventilator-induced lung injury (VILI). Thus, the early diagnosis of VILI is of great importance for the prevention and treatment of VILI.

OBJECTIVE

This study aimed to investigate the metabolomes in the lung and plasma of mice receiving mechanical ventilation (MV).

METHODS

Healthy mice were randomly assigned into control group; (2) high volume tidal (HV) group (30 ml/kg); (3) low volume tidal (LV) group (6 ml/kg). After ventilation for 4 h, mice were sacrificed and the lung tissue and plasma were collected. The lung and plasma were processed for the metabolomics analysis. We also performed histopathological examination on the lung tissue.

RESULTS

We detected moderate inflammatory damage with alveolar septal thickening in the HV group compared with the normal and LV groups.The metabolomics analysis results showed MV altered the metabolism which was characterized by the dysregulation of γ-amino butyric acid (GABA) system and urea cycle (desregulations in plasma and lung guanidinosuccinic acid, argininosuccinic acid, succinic acid semialdehyde and lung GABA ), Disturbance of citric acid cycle (CAC) (increased plasma glutamine and lung phosphoenol pyruvate) and redox imbalance (desregulations in plasma and/or lung ascorbic acid, chenodeoxycholic acid, uric acid, oleic acid, stearidonic acid, palmitoleic acid and docosahexaenoic acid). Moreover, the lung and plasma metabolomes were also significantly different between LV and HV groups.

CONCLUSIONS

Some lung and plasma metabolites related to the GABA system and urea cycle, citric acid cycle and redox balance were significantly altered, and they may be employed for the evaluation of VILI and serve as targets in the treatment of VILI.

Asthma Therapies on Pulmonary Tuberculosis Pneumonia in Predominant Bronchiectasis-Asthma Combination

Background: It is sometimes difficult to distinguish between asthma and bronchiectasis as their symptoms overlap, and these two diseases are associated with pulmonary tuberculosis (PTB) or pneumonia.

Objective: The purpose of this study is to determine the effects of bronchodilator drugs, steroids, antidepressants drugs, and antianxiety drugs on the risks of PTB or pneumonia in patients with bronchiectasis–asthma combination or bronchiectasis–asthma–chronic obstructive pulmonary disease combination—BCAS cohort.

Methods: After propensity score matching, we retrospectively studied patients with BCAS (N = 620) and without BCAS (N = 2,314) through an analysis. The cumulative incidence of PTB or pneumonia was analyzed through Cox proportional regression. After adjustment for sex, age, comorbidities, and medications [including long-acting beta2 agonist/muscarinic antagonists (LABAs/LAMAs), short-acting beta2 agonist/muscarinic antagonists (SABAs/SAMAs), leukotriene receptor antagonist, montelukast, steroids (inhaled corticosteroids, ICSs; oral steroids, OSs), anti-depressants (fluoxetine), and anti-anxiety drugs (benzodiazepines, BZDs)], we calculated the adjusted hazard ratios (aHR) and their 95% confidence intervals (95% CI) for these risks. Similar to OSs, ICSs are associated with an increased risk of PTB or pneumonia, lumping these two as steroids (ICSs/OSs).

Results: For the aHR (95% CI), with non-LABAs/non-OSs as the reference 1, the use of LABAs [0.70 (0.52–0.94)]/OSs [0.35 (0.29–0.44)] was associated with a lower risk of PTB or pneumonia. However, the current use of LABAs [2.39 (1.31–4.34)]/SABAs [1.61 (1.31–1.96)], steroids [ICSs 3.23 (1.96–5.29)]/OSs 1.76 (1.45–2.14)], and BZDs [alprazolam 1.73 (1.08–2.75)/fludiazepam 7.48 (1.93–28.9)] was associated with these risks. The current use of LAMAs [0.52 (0.14–1.84)]/SAMAs [1.45 (0.99–2.11)] was not associated with these risks.

Conclusion: The current use of LAMAs/SAMAs is relatively safe with respect to PTB or pneumonia risks, but LABAs/SABAs, steroids, and BZDs could be used after evaluation of the benefit for the BCAS cohort. However, we must take the possible protopathic bias into account.

Association between benzodiazepine premedication and 30-day mortality rate: A propensity-score weighted analysis of the Peri-interventional Outcome Study in the Elderly (POSE)

BACKGROUND

Recent guidelines suggest that benzodiazepine premedication should be avoided in elderly patients, though with limited supporting evidence.

OBJECTIVE

We conducted a secondary analysis of the POSE data to explore the association of premedication in patients aged 80 years or older with 30-day mortality.

DESIGN

We used propensity score methods to perform a confounder-adjusted time-to-event analysis of the association between benzodiazepine premedication and 30-day mortality of the POSE study.

SETTING

POSE was conducted as a European multicentre prospective cohort study.

PATIENTS

Adults aged 80 years or older scheduled for surgical or nonsurgical intervention under anaesthesia.

RESULTS

A total of 9497 patients were analysed. One thousand five hundred and twenty-one patients received benzodiazepine premedication, 7936 patients received no benzodiazepine premedication, 30 received clonidine and 10 had missing premedication data. Inverse propensity-score-weighted log-rank analysis did not provide unambiguous evidence for an association between benzodiazepine premedication and 30-day mortality; median [range] P = 0.048 [0.044 to 0.078], estimated 30-day mortality rates 3.21% and 4.45% in benzodiazepine-premedicated and nonbenzodiazepine-premedicated patients, respectively. Inverse propensity-score-weighted Cox regression resulted in a hazard ratio of 0.71 (95% CI 0.49 to 1.04), pointing at a possible reduction of 30-day mortality in the benzodiazepine premedication group. Sensitivity analyses, which constituted subgroup, matched-pairs, and subclassification analyses, resulted in similar findings.

CONCLUSION

This secondary analysis of the POSE data did not find evidence for an unambiguous association between benzodiazepine premedication and 30-day mortality. Point estimates indicated a reduction of 30-day mortality in benzodiazepine-premedicated patients. The results presented here might be affected by unmeasured confounding factors, which could be addressed in a randomised trial.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03152734.

Use of anxiolytics and hypnotic drugs during COVID-19 pandemic: The literature review

Anxiolytics and hypnotics are widely used drugs. First-line psychiatric indications for benzodiazepines (BZD) are alcohol/sedative-hypnotic withdrawal and catatonia, while panic disorder, general anxiety disorder, social anxiety disorder and insomnia are indications after failing of first/second-line treatments, and its use is recommended only for a short time. The spread of the SARS-CoV-2 virus influenced regular daily living, psychological, social, and economic stability. The COVID-19 pandemic has a multifactorial effect on people's mental health and has directly and indirectly influenced changing trends in the prescription, use and misuse of anxiolytics and hypnotics during the pandemic. This article will show use of anxiolytics and hypnotics in inpatients with SARS-CoV-2 infection with or without delirium, will present recommendation for BZD utilization in the infected individuals and will review interactions between BZD and antiviral drugs. Moreover, it will summarize available data on the frequency and reasons for use and abuse of BZD in the general population during the pandemic.

Non-antipsychotic medicines and modified electroconvulsive therapy are risk factors for hospital-acquired pneumonia in schizophrenia patients

BACKGROUND

Hospital-acquired pneumonia (HAP) has a significant and detrimental impact on schizophrenia patients. Non-antipsychotic medicines and modified electroconvulsive therapy (MECT) are frequently used in conjunction with antipsychotics to treat schizophrenia. Whether non-antipsychotic medicines or MECT are risk factors for HAP in schizophrenia treated with antipsychotics is still unknown.

METHODS

Patients with schizophrenia who were admitted to the Fourth People's Hospital of Chengdu between January 2015 and April 2022 were included in this retrospective cohort study. Individuals with HAP were 1:1 matched to individuals without HAP (non-HAP) using propensity score matching (PSM). The risk factors for HAP were analyzed by comparing the two groups.

RESULTS

A total of 7,085 schizophrenia patients were included in this study, with a mean age of 39.77 ± 14.45 years. 193 patients developed HAP on an average of 22.26 ± 21.68 days after admission with an incidence of 2.73%. After 1:1 PSM, 192 patients from each group (HAP and non-HAP) were included. The HAP group had significantly more patients with MECT and taking benzodiazepines, antidepressants, mood stabilizers, and anti-parkinsonians both before and after PSM by Bonferroni correction (P < 0.001). Multivariate logistic regression analysis showed that, combined with antipsychotics, non-antipsychotic medicines including benzodiazepines (OR = 3.13, 95%CI = 1.95-5.03, P < 0.001), mood stabilizers (OR =3.33, 95%CI =1.79-6.20, P < 0.001) and MECT (OR =2.58, 95%CI =1.49-4.46, P = 0.001) were associated with a significantly increased incidence of HAP.

CONCLUSION

The incidence of HAP in schizophrenia patients in our cohort was 2.73%. MECT and non-antipsychotic medicines, including benzodiazepines and mood stabilizers were risk factors for HAP in schizophrenia patients treated with antipsychotics.

Prior benzodiazepine use and mortality among adult patients with sepsis: A retrospective population-based cohort study in South Korea

OBJECTIVES

This study investigated whether long-term benzodiazepine use is associated with increased 90-day mortality among patients with sepsis.

METHODS

A retrospective population-based cohort study based on health records obtained from the National Health Insurance Service database in South Korea was conducted. All adult patients (≥18 years) admitted to the hospital with a primary diagnosis of sepsis or septic shock during 2010-2018 were included in the study. Sepsis and septic shock were diagnosed based on the International Classification of Diseases (10th revision: A40, A41 and R65.2). Benzodiazepine users were defined as individuals who were prescribed regular benzodiazepine continuously for over 6 months before admission.

RESULTS

A total of 251 837 patients with sepsis were included in this study, 16 686 of which (6.6%) were benzodiazepine users, and 235 151 (93.4%) were non-users. After propensity score (PS) matching, 33 370 patients (16 685 in both groups) were ultimately included. Moreover, following PS matching, the 90-day mortality among benzodiazepine users and non-users was 60.9% (10 167) and 41.4% (6916), respectively. Cox regression analysis further revealed the hazard ratio (HR) for 90-day mortality in benzodiazepine users to be 1.75, compared with non-users [95% confidence interval (CI): 1.70-1.81; P < .001]. Sensitivity analyses showed that, compared with non-users, HRs for 90-day mortality in benzodiazepine users without and with other psychiatric illnesses were 1.43 (95% CI: 1.38-1.49; P < .001) and 1.89 (95% CI: 1.84-1.94; P < .001), respectively.

CONCLUSION

Long-term benzodiazepine use is associated with increased 90-day mortality among adult patients with sepsis compared with non-users. This association was more evident in benzodiazepine users with other psychiatric diseases, such as depression or anxiety disorder.

Ischemic stroke and infection: A brief update on mechanisms and potential therapies

Ischemic stroke triggers a multifaceted inflammatory response in the brain that contributes to secondary brain injury and infarct expansion. In parallel with brain inflammation, ischemic stroke also leads to post-stroke immunosuppression. Stroke-induced leukopenia then predisposes patients to opportunistic infections potentially leading to pneumonia or unrinary tract infections and a worsened stroke outcome. There is evidence that the hypothalamic-pituitaryadrenal axis plays an important role in the etiology of post-stroke immunosuppression, by which prolonged glucocorticoid signalling leads to changes in immune responses. While opportunistic microbes in hospitals have been thought to be the source of infection, recent studies have reported that gut flora may also be a cause of post-stroke infection as a consequence of compromised integrity of the gut barrier after stroke. While antimicrobial drugs would appear to be a rational form of treatment for bacterial infections in stroke patients, the rise in drug-resistant bacteria and possible adverse effects of disrupting beneficial gut flora represent major challenges with these drugs. Considering the prominent role of gut microbiota in modulating immune responses, protecting and restoring the post-stroke gut bacteriome may provide significant benefit in the context of post-stroke infection. With such broad aspects of post-stroke infection occurring together with an extensive inflammatory response in the brain, a carefully considered administration of therapies for ischemic stroke is warranted.

Pneumonia Risk Associated with the Use of Individual Benzodiazepines and Benzodiazepine Related Drugs among the Elderly with Parkinson's Disease

Most patients with Parkinson's disease (PD) gradually develop oropharyngeal dysphagia which is often associated with pneumonia risk. The possible association of benzodiazepine (BZD) and benzodiazepine related drugs (BZRD) use with pneumonia risk has received increasing attention but remains controversial. We investigated pneumonia risk associated with the use of BZDs and BZRDs in older adult patients with PD. This case-control study analyzed data of 551,975 older adult patients with PD between 2001 and 2018 in Taiwan. To minimize potential confounding, we used 1:4 propensity score matching to include older adult patients without pneumonia as controls. Incident pneumonia risk was significantly higher in current (adjusted odds ratio (aOR) = 1.25, 95% CI = 1.23-1.27) and past (aOR = 1.13, 95% CI = 1.11-1.15) users of BZDs. Regarding BZRDs, recent (aOR = 1.08, 95% CI = 1.06-1.11) and past (aOR = 0.89, 95% CI = 0.88-0.91) users had higher and lower risks of incident pneumonia, respectively. Pneumonia risk varied based on their use of BZDs and BZRDs. In these individuals, incident pneumonia risk was high in users of BZDs, such as midazolam, lorazepam, flunitrazepam, estazolam, and clonazepam. Regarding the use of BZRDs, zopiclone increased incident pneumonia risk.

Chlorinated disinfection byproducts of diazepam perturb cell metabolism and induce behavioral toxicity in zebrafish larvae

Numerous byproducts resulting from chlorinated disinfection are constantly being generated during water treatment processes. The potential risks of these new emerging pollutions remain largely unknown. Here, we determined the risks of chlorinated disinfection byproducts of diazepam (DZP) in the cellular and zebrafish exposure experiments. The cytotoxicity of disinfection byproducts (MACB and MBCC) was greater than DZP in macrophage raw 264.7 cells at 10 mg/L. We further found that the effects of MBCC on the metabolism of glycine, serine, threonine and riboflavin were far greater than DZP by the targeted metabolomics methods. Moreover, MBCC significantly decreased the peak amplitude of neuronal action potential in primary embryonic rat (Spragu-Dawley SD) hippocampal neurons. We finally determined behavioral toxicity of DZP and byproducts in zebrafish larvae. MBCC significantly decreased the maximal swim-activity and peak duration of zebrafish after 72 h exposure. Altogether, these findings indicate the MBCC pose serious pressures on public health.

Propofol Ameliorates Exaggerated Human Neutrophil Activation in a LPS Sepsis Model

Background

Sepsis is a leading cause of morbidity and mortality worldwide. Many patients suffering from sepsis are treated on intensive care units and many of them require mechanical ventilation under sedation or general anesthesia. Propofol, a drug used for these purposes, is known to interact with polymorphonuclear granulocytes (PMNs). Therefore, the aim of this study was to investigate the influence of propofol on PMN functions after experimental Gram-negative induced sepsis using lipopolysaccharide (LPS) stimulation.

Methods

A total of 34 granulocyte-enriched samples were collected from healthy subjects. PMNs were isolated by density gradient centrifugation and incubated simultaneously with either 6 µg/mL or 60 µg/mL propofol, or none (control). Additionally, the experimental sepsis samples were incubated with either 40 pg/mL or 400 pg/mL LPS. Live cell imaging was conducted in order to observe granulocyte chemotactic migration, ROS production, and NETosis. Flow cytometry was used to analyze viability and antigen expression.

Results

Propofol led to significantly reduced PMN track length (p < 0.001) and track speed (p < 0.014) after LPS-induced sepsis in a dose-dependent manner. NETosis (p = 0.018) and ROS production (p = 0.039) were accelerated by propofol without LPS incubation, indicating improved immune function. Propofol also ameliorated LPS-induced increased NETosis and ROS-production. Antigen expression for CD11b, CD62l and CD66b was unaffected by propofol.

Conclusion

Propofol improves LPS-induced exaggerated PMN activation in an ex vivo model. Beneficial effects due to restored immune function in septic patients might be possible, but needs further investigation.

Benzodiazepines increase the likelihood of both infectious and thrombotic complications

INTRODUCTION

Benzodiazepines (BZDs) modulate peripheral γ-amino-butyric acid type A on macrophages causing immunomodulation. They inhibit proinflammatory cytokines increasing infections. Prior studies have also shown that infections can increase thrombotic complications. We sought to examine this relationship in trauma patients. We hypothesized that the presence of BZDs on admission urine drug screen (UDS) would increase rates of both complications.

METHODS

All patients submitted to the Pennsylvania Trauma Outcome Study database from 2003 to 2018 were queried. Those with a positive UDS for BZDs were analyzed. Infectious complications were defined as pneumonia, urinary tract infection, sepsis, wound, and soft tissue infection, and thrombotic complications were defined as presence of pulmonary embolism or deep vein thrombosis. Logistic regressions controlling for demographic and injury covariates assessed the adjusted impact of BZDs on infectious and thrombotic complications.

RESULTS

A total of 3,393 patients (2.08%) had infectious complications, and 3,048 (1.87%) had thrombotic complications. Furthermore, 33,260 patients (20.4%) had a positive UDS for BZDs on admission. Univariate analysis showed that those positive for BZDs had higher rates of infectious (3.33% vs. 1.76%, p < 0.001) and thrombotic (2.84% vs. 1.62%, p < 0.001) complications. Multivariate analysis revealed that BZDs significantly increased the odds of infectious and thrombotic complications. Patients who tested positive for BZDs and subsequently developed infection had increased odds (adjusted odds ratio, 1.65; p < 0.001) of developing thrombotic complications.

CONCLUSION

Trauma patients with a positive UDS for BZDs had higher odds of both infectious and thrombotic complications. Moreover, odds of thrombotic complications were higher in those with infections.

LEVEL OF EVIDENCE

Epidemiological, level III.

GABAergic signaling by cells of the immune system: more the rule than the exception

Gamma-aminobutyric acid (GABA) is best known as an essential neurotransmitter in the evolved central nervous system (CNS) of vertebrates. However, GABA antedates the development of the CNS as a bioactive molecule in metabolism and stress-coupled responses of prokaryotes, invertebrates and plants. Here, we focus on the emerging findings of GABA signaling in the mammalian immune system. Recent reports show that mononuclear phagocytes and lymphocytes, for instance dendritic cells, microglia, T cells and NK cells, express a GABAergic signaling machinery. Mounting evidence shows that GABA receptor signaling impacts central immune functions, such as cell migration, cytokine secretion, immune cell activation and cytotoxic responses. Furthermore, the GABAergic signaling machinery of leukocytes is implicated in responses to microbial infection and is co-opted by protozoan parasites for colonization of the host. Peripheral GABA signaling is also implicated in inflammatory conditions and diseases, such as type 1 diabetes, rheumatoid arthritis and cancer cell metastasis. Adding to its role in neurotransmission, growing evidence shows that the non-proteinogenic amino acid GABA acts as an intercellular signaling molecule in the immune system and, as an interspecies signaling molecule in host–microbe interactions. Altogether, the data raise the assumption of conserved GABA signaling in a broad range of mammalian cells and diversification of function in the immune system.

Clinical characteristics, management and health related quality of life in young to middle age adults with COVID-19

Background

The outbreak of COVID-19 has rapidly spread to Italy, including Pesaro-Urbino province. Data on young to middle age adults with COVID-19 are lacking. We report the characteristics, management and health-related quality of life (HRQoL) in patients with COVID-19 aging ≤50 years.

Methods

A retrospective analysis was performed in all patients ≤50 years with a confirmed diagnosis of COVID-19 admitted to Emergency department (ED) of San Salvatore Hospital in Pesaro from February 28th to April 8th, 2020. Data were collected from electronical medical records. HRQoL was investigated after 1 month from hospital discharge using the SF-36 questionnaire. Outcomes were evaluated between hospitalized and not hospitalized patients.

Results

Among 673 patients admitted to the ED and diagnosed with COVID-19, 104 (15%) were ≤ 50 years old: 74% were discharged at home within 48 h, 26% were hospitalized. Fever occurred in 90% of the cases followed by cough (56%) and dyspnoea (34%). The most frequent coexisting conditions were hypertension (11%), thyroid dysfunction (8%) and neurological and/or mental disorders [NMDs] (6%). Mean BMI was 27. Hypokalaemia and NMDs were significantly more common in patients who underwent mechanical ventilation. Regardless of hospitalization, there was an impairment in both the physical and mental functioning.

Conclusions

Overweight and hypertension are frequent conditions in young to middle age adults with COVID-19. Hypokalaemia and NMDs are commonly associated with progressive disease. A significant impact on HRQoL in the early stage of post-discharge is common in this population.

The Impact of Type 1 Interferons on Alveolar Macrophage Tolerance and Implications for Host Susceptibility to Secondary Bacterial Pneumonia

That macrophages adapt to environmental cues is well-established. This adaptation has had several reiterations, first with innate imprinting and then with various combinations of trained, tolerant, paralyzed, or primed. Whatever the nomenclature, it represents a macrophage that is required to perform very different functions. First, alveolar macrophages are one of the sentinel cells that flag up damage and release mediators that attract other immune cells. Next, they mature to support T cell priming and survival. Finally they are critical in clearing inflammatory immune cells by phagocytosis and extracellular matrix turnover components by efferocytosis. At each functional stage they alter intrinsic components to guide their activity. Training therefore is akin to changing function. In this mini-review we focus on the lung and the specific role of type I interferons in altering macrophage activity. The proposed mechanisms of type I IFNs on lung-resident alveolar macrophages and their effect on host susceptibility to bacterial infection following influenza virus infection.

Impact of Anesthetics on Human Neutrophil Function

Anesthetics are widely used drugs administered in a multitude of clinical settings. Their impacts on various functions of the immune system have been studied but are still not fully understood. Neutrophil granulocytes are a critical first-line host defense mechanism against infections and contribute to the inflammatory phase of wound healing, but dysregulated neutrophil activation can also precipitate perioperative organ injury. A better understanding of the interactions between common anesthetics and neutrophils may reveal considerations toward optimizing treatment of our most vulnerable patients in the intensive care unit and in the perioperative setting.

Incidence and Related Factors for Hospital-Acquired Pneumonia Among Older Bedridden Patients in China: A Hospital-Based Multicenter Registry Data Based Study

Objective: To identify the incidence and related factors for hospital-acquired pneumonia (HAP) among older bedridden patients in China.

Study design and setting: This multicenter registry data-based study conducted between November 2015 and March 2016 surveyed 7,324 older bedridden patients from 25 hospitals in China (six tertiary, 12 non-tertiary, and seven community hospitals). The occurrence of HAP among all participants was monitored by trained investigators. Demographics, hospitalization information and comorbidity differences were compared between patients with and without HAP. A multilevel regression analysis was used to explore the factors associated with HAP.

Results: Among 7,324 older bedridden patients, 566 patients were diagnosed with HAP. The incidence of HAP in this study was 13.9 per 1,000 person-days. There were statistical differences in gender, age, length of bedridden days, BMI, smoking, department, undergoing general anesthesia surgery, ventilator application, Charlson comorbity index (CCI) score, disturbance of consciousness, tranquilizer use, glucocorticosteroid use, and antibiotic use between patients with HAP and patients without HAP (all p < 0.05). Multilevel regression analysis found no significant variance for HAP at the hospital level (0.332, t = 1.875, p > 0.05). There were significant differences for the occurrence of HAP among different departments (0.553, t = 4.320, p < 0.01). The incidence density of HAP was highest in the ICU (30.1‰) among the selected departments, followed by the departments of neurosurgery (18.7‰) and neurology medicine (16.6‰). Individual patient-level factors, including older age, disturbance of consciousness, total CCI score, ICU admission, and glucocorticoid and antibiotic use, were found to be associated with the occurrence of HAP (all p < 0.05).

Conclusion: A relatively high incidence density of HAP among older bedridden patients was identified, as well as several factors associated with HAP among the population. This suggests that attention should be paid to the effective management of these related factors of older bedridden patients to reduce the occurrence of HAP.

NMDA receptor modulation of glutamate release in activated neutrophils

Background

Neutrophil depletion improves neurologic outcomes in experimental sepsis/brain injury. We hypothesized that neutrophils may exacerbate neuronal injury through the release of neurotoxic quantities of the neurotransmitter glutamate.

Methods

Real-time glutamate release by primary human neutrophils was determined using enzymatic biosensors. Bacterial and direct protein-kinase C (Phorbol 12-myristate 13-acetate; PMA) activation of neutrophils in human whole blood, isolated neutrophils or human cell lines were compared in the presence/absence of N-Methyl-d-aspartic acid receptor (NMDAR) antagonists. Bacterial and direct activation of neutrophils from wild-type and transgenic murine neutrophils deficient in NMDAR-scaffolding proteins were compared using flow cytometry (phagocytosis, reactive oxygen species (ROS) generation) and real-time respirometry (oxygen consumption).

Findings

Both glutamate and the NMDAR co-agonist d-serine are rapidly released by neutrophils in response to bacterial and PMA-induced activation. Pharmacological NMDAR blockade reduced both the autocrine release of glutamate, d-serine and the respiratory burst by activated primary human neutrophils. A highly specific small-molecule inhibitor ZL006 that limits NMDAR-mediated neuronal injury also reduced ROS by activated neutrophils in a murine model of peritonitis, via uncoupling of the NMDAR GluN2B subunit from its' scaffolding protein, postsynaptic density protein-95 (PSD-95). Genetic ablation of PSD-95 reduced ROS production by activated murine neutrophils. Pharmacological blockade of the NMDAR GluN2B subunit reduced primary human neutrophil activation induced by Pseudomonas fluorescens, a glutamate-secreting Gram-negative bacillus closely related to pathogens that cause hospital-acquired infections.

Interpretation

These data suggest that release of glutamate by activated neutrophils augments ROS production in an autocrine manner via actions on NMDAR expressed by these cells.

Fund

GLA: Academy Medical Sciences/Health Foundation Clinician Scientist. AVG is a Wellcome Trust Senior Research Fellow.

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Neutrophil depletion improves neurologic outcome after injury and infection.

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Pharmacologic NMDAR blockade reduces rapid autocrine release of glutamate/d-serine from activated neutrophils.

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Genetic ablation/small-molecule inhibition of PSD-95 reduces neutrophil ROS.

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NMDAR blockade reduces human neutrophil activated by glutamate-secreting bacteria.

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Activated neutrophils may exacerbate neuronal injury in various forms of critical illness through the release of glutamate.

Impact of PReOperative Midazolam on OuTcome of Elderly patients (I-PROMOTE): study protocol for a multicentre randomised controlled trial

INTRODUCTION

Premedication of surgical patients with benzodiazepines has become questionable regarding risk-benefit ratio and lack of evidence. Though preoperative benzodiazepines might alleviate preoperative anxiety, a higher risk for adverse events is described, particularly for elderly patients (≥ 65 years). Several German hospitals already withhold benzodiazepine premedication from elderly patients, though evidence for this approach is lacking. The patient-centred outcome known as global postoperative patient satisfaction is recognised as a substantial quality indicator of anaesthesia care incorporated by the American Society of Anesthesiologists. Therefore, we aim to assess whether the postoperative patient satisfaction after premedication with placebo compared to the preoperative administration of 3.75 mg midazolam in elderly patients differs.

METHODS

This study is a multicentre, randomised, placebo-controlled, double-blinded, two-arm parallel, interventional trial, conducted in nine German hospitals. In total 614 patients (≥ 65-80 years of age) undergoing elective surgery with general anaesthesia will be randomised to receive either 3.75 mg midazolam or placebo. The primary outcome (global patient satisfaction) will be assessed with the validated EVAN-G questionnaire on the first postoperative day. Secondary outcomes will be assessed until the first postoperative day and then 30 days after surgery. They comprise among other things: functional and cognitive recovery, postoperative delirium, health-related quality of life assessment, and mortality or new onset of serious cardiac or pulmonary complications, acute stroke, or acute kidney injury. Analysis will adhere to the intention-to-treat principle. The primary outcome will be analysed with the use of mixed linear models including treatment effect and study centre as factors and random effects for blocks. Exploratory adjusted and subgroup analyses of the primary and secondary outcomes with regard to gender effects, frailty, pre-operative anxiety level, patient demographics, and surgery experience will also be performed.

DISCUSSION

This is, to the best of our knowledge, the first study analysing patient satisfaction after premedication with midazolam in elderly patients. In conclusion, this study will provide high-quality data for the decision-making process regarding premedication in elderly surgical patients.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03052660 . Registered on 14 February 2017. EudraCT 2016-004555-79 .

Association between benzodiazepine use and risks of chronic-onset poststroke pneumonia: a population-based cohort study

OBJECTIVES

To investigate the association between benzodiazepine (BZD) use and the risk of chronic-onset poststroke pneumonia.

DESIGN

Population-based propensity-matched retrospective cohort study.

SETTING

Taiwan's National Health Insurance Research Database.

PARTICIPANTS

Patients newly diagnosed with stroke between 2000 and 2012 were identified and, after propensity score matching, 7516 patients were enrolled. Among these, 3758 patients received BZDs after stroke while 3758 did not.

OUTCOME MEASURES

HRs for developing pneumonia over 1 month after stroke according to BZD use were assessed using Cox proportional hazards regression models. Analyses according to cumulative defined daily doses (cDDDs) of BZDs and stratification for age and sex were also performed.

RESULTS

During a mean follow-up time of 4.4 years, 1027 patients in the BZD cohort and 478 patients in the non-BZD cohort developed pneumonia over 1 month after stroke. Patients using BZDs after stroke had a higher pneumonia risk than did those not using BZDs (52.2vs32.6 per 1000 person-years, adjusted HR (aHR)=2.21, 95% CI (CI)=1.97 to 2.48, p<0.001). Analyses based on cumulative BZD dose revealed that all BZD user subgroups were associated with a higher risk of pneumonia. The aHRs for patients taking 1-90, 91-365 and >365 cDDDs of BZDs were 2.28 (95% CI=2.01 to 2.58; p<0.001), 2.09 (95% CI=1.77 to 2.47; p<0.001) and 2.08 (95% CI=1.72 to 2.52; p<0.001), respectively. The significant association between BZD use and increased pneumonia risk persisted even after stratifying subgroups by age and sex.

CONCLUSIONS

BZD use is associated with an increased risk of chronic-onset poststroke pneumonia.

Midazolam and Dexmedetomidine Affect Neuroglioma and Lung Carcinoma Cell Biology In Vitro and In Vivo

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Several factors within the perioperative period may influence postoperative metastatic spread. Dexmedetomidine and midazolam are widely used general anesthetics during surgery. The authors assessed their effects on human lung carcinoma (A549) and neuroglioma (H4) cell lines in vitro and in vivo.

Methods

Cell proliferation and migration were measured after dexmedetomidine (0.001 to 10 nM) or midazolam (0.01 to 400 μM) treatment. Expression of cell cycle and apoptosis markers were assessed by immunofluorescence. Mitochondrial membrane potential and reactive oxygen species were measured by JC-1 staining and flow cytometry. Antagonists atipamezole and flumazenil were used to study anesthetic mechanisms of action. Tumor burden after anesthetic treatment was investigated with a mouse xenograft model of lung carcinoma.

Results

Dexmedetomidine (1 nM) promoted cell proliferation (2.9-fold in A549 and 2-fold in H4 cells vs. vehicle, P &lt; 0.0001; n = 6), migration (2.2-fold in A549 and 1.9-fold in H4 cells vs. vehicle, P &lt; 0.0001; n = 6), and upregulated antiapoptotic proteins in vitro. In contrast, midazolam (400 μM) suppressed cancer cell migration (2.6-fold in A549 cells, P &lt; 0.0001; n = 4), induced apoptosis via the intrinsic mitochondrial pathway, decreased mitochondrial membrane potential, and increased reactive oxygen species expression in vitro—effects partly attributable to peripheral benzodiazepine receptor activation. Furthermore, midazolam significantly reduced tumor burden in mice (1.7-fold vs. control; P &lt; 0.05; n = 6 per group).

Conclusions

Midazolam possesses antitumorigenic properties partly mediated by the peripheral benzodiazepine receptor, whereas dexmedetomidine promotes cancer cell survival through signaling via the α2-adrenoceptor in lung carcinoma and neuroglioma cells.

Autocrine GABA signaling distinctively regulates phenotypic activation of mouse pulmonary macrophages

In response to micro-environmental cues such as microbial infections or T-helper 1 and 2 (T_H1 and T_H2) cytokines, macrophages (Mϕs) develop into M1- or M2-like phenotypes. Phenotypic polarization/activation of Mϕs are also essentially regulated by autocrine signals. Type-A γ-aminobutyric acid receptor (GABA_AR)-mediated autocrine signaling is critical for phenotypic differentiation and transformation of various cell types. The present study explored whether GABA_AR signaling regulates lung Mϕ (LMϕ) phenotypic activation under M1/T_H1 and M2/T_H2 environments. Results showed that GABA_AR subunits were expressed by primary LMϕ of mice and the mouse Mϕ cell line RAW264.7. The expression levels of GABA_AR subunits in mouse LMϕs and RAW264.7 cells decreased or increased concurrently with classical (M1) or alternative (M2) activation, respectively. Moreover, activation or blockade of GABA_ARs distinctively influenced the phenotypic characteristics of Mϕ. These results suggested that microenvironments leading to LMϕ phenotypic polarization concurrently modulates autocrine GABA signaling and its role in Mϕ activation.

Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research

Various adverse events resulting from, or associated with, benzodiazepine and/or Z-drug use have been extensively reported on and discussed in great detail within the biomedical literature. It is widely accepted that motor vehicle accidents and falls leading to fractures in older adults are major adverse events that have been shown to occur more frequently in users of sedative-hypnotic medication, especially of the benzodiazepine and related Z-drug variety. However, the last few years have seen increasing reports in the literature raising the issue of benzodiazepine and Z-drug exposure in the development of other serious medical issues including dementia, infections, respiratory disease exacerbation, pancreatitis, and cancer. This article provides an overview and interpretation on the current state of evidence regarding each of these associations and proposes what gaps in the evidence for drug-exposure–harm associations need to be addressed in the future for the purpose of evaluating causality of harm as it relates to these drugs.

The Use of Benzodiazepine Receptor Agonists and the Risk of Hospitalization for Pneumonia: A Nationwide Population-Based Nested Case-Control Study

BACKGROUND

The relationship between the use of benzodiazepine-receptor agonists (BZRAs) and the risk of hospitalization for pneumonia remains inconclusive. This study aimed to explore the association between BZRA use and hospitalization for pneumonia in a general population.

METHODS

This population-based nested case-control study used Taiwan's National Health Insurance Research Database between 2002 and 2012. We included only new users who did not have any BZRA prescriptions on record in the preceding 2 years and identified 12,002 subjects who were hospitalized for pneumonia (International Classification of Diseases, Ninth Revision codes 480-486, and 507) and 12,002 disease risk score-matched control subjects. A logistic regression model was used to determine the association of BZRA use and hospitalization for pneumonia. The exposure date, dose-response relationship, and class of BZRAs were comprehensively assessed.

RESULTS

Current BZRA exposure was associated with hospitalization for pneumonia (adjusted OR [aOR],1.86; 95% CI, 1.75-1.97). Benzodiazepine hypnotic agents (aOR, 2.42; 95% CI, 2.16-2.71) had a higher risk of pneumonia than did benzodiazepine anxiolytic agents (aOR, 1.53; 95% CI, 1.44-1.63) or nonbenzodiazepine hypnotic agents (aOR, 1.60; 95% CI, 1.46-1.76). The pneumonia risk was increased with ultrashort-acting and short- to intermediate-acting agents, a higher defined daily dose, and the number of BZRAs used. Among individual BZRAs examined, midazolam had a higher risk (aOR, 5.77; 95% CI, 4.31-7.73) of hospitalization for pneumonia than did the others.

CONCLUSIONS

This study suggests that there is a dose-response relationship between current BZRA use and the risk of hospitalization for pneumonia. In addition, benzodiazepine hypnotic agents, especially midazolam, present a greater risk of hospitalization for pneumonia. These findings reinforce the importance of a careful analysis of the benefits vs the risks of BZRA use.

Benzodiazepine and Z-drug use and risk of pneumonia in patients with chronic kidney disease: A population-based nested case-control study

BACKGROUND

Concerns were raised about pneumonia development from benzodiazepines (BZDs) and Z-drugs, but direct evidence is limited, conflicting and without examining the highly susceptible patients with chronic kidney disease (CKD) nor specifying the risk for different drug utilizations. This study aimed to investigate whether use of BZDs and Z-drugs was each associated with an increased risk of pneumonia in a CKD population.

METHODS

We performed a nested case-control study of 36,880 CKD patients analyzing the Taiwan National Health Insurance Database between 01/1/2000 and 12/31/2011. Among the study cohort, we identified 4,533 cases of pneumonia based on validated disease codes, chest x-ray examination, and prescriptions of respiratory antibiotics, and randomly selected 16,388 controls from risk sets, matched by sex, age, and number of CKD-related hospitalizations. All prescription filling records of BZDs and Z-drugs in the year before the event/index date were analyzed for cases and controls. Conditional logistic regressions were performed to estimate the odds ratios (ORs).

RESULTS

Current use of BZDs was associated with a 1.31-fold (95% CI, 1.18-1.26) increased risk of pneumonia compared to nonuse, but not for recent and past use. The risk from current BZD use was confined to new initiation (adjusted OR, 2.47; 95% CI, 2.02-3.03) or use for ≤ 30 days, and elevated to 2.88-fold (95% CI, 1.87-4.42) with parenteral administration. New initiation and current short-term use of Z-drugs was associated with a 2.94-fold (95% CI, 1.65-5.26) and 1.75-fold (95% CI, 1.13-2.72) increased risk of pneumonia, respectively. The findings were robust to adoption of a case-crossover study that analyzed cases only.

CONCLUSIONS

Use of BZRAs is associated with an increased risk of pneumonia in CKD patients, especially for patients newly initiating BZDs or Z-drugs or those injected with BZDs. Physicians should exercise cautions for signs of pneumonia when prescribing BZDs or Z-drugs to CKD patients.

Endothelial Activation and Blood-Brain Barrier Injury as Risk Factors for Delirium in Critically Ill Patients

OBJECTIVES

During critical illness, impaired endothelial vascular reactivity predicts prolonged acute brain dysfunction, but relationships between endothelial activation, blood-brain barrier/neurological injury, and acute brain dysfunction, including delirium, remain unexamined. We tested the hypothesis that elevated plasma markers of endothelial activation and blood-brain barrier/neurological injury are associated with delirium duration during critical illness.

DESIGN

Prospective cohort study.

SETTING

Medical and surgical ICUs in an academic medical center.

PATIENTS

Adults in acute respiratory failure and/or shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We enrolled subjects within 72 hours of organ failure diagnosis in the ICU. We measured plasma concentrations of plasminogen activator inhibitor-1, E-selectin, and angiopoietin-2 as markers of endothelial activation and S100B as a marker of blood-brain barrier/neurological injury in blood collected at enrollment. We assessed patients for delirium and coma twice daily after enrollment using the Confusion Assessment Method for the ICU and the Richmond Agitation-Sedation Scale. Among 134 patients with a median (interquartile) age of 57 years (46-66 yr) and Acute Physiology and Chronic Health Evaluation II of 26 (19-31), delirium occurred in 94 patients (70%) with a median duration of 2 days (0-4 d). Higher plasminogen activator inhibitor-1 (p = 0.002), E-selectin (p = 0.02), and S100B (p < 0.001) concentrations were associated with fewer delirium/coma-free days after adjusting for age, Charlson comorbidity index, modified Sequential Organ Failure Assessment score, and severe sepsis. Similarly, higher plasminogen activator inhibitor-1 (p = 0.007) and S100B (p = 0.01) concentrations were associated with longer delirium duration in survivors. Adjusting for S100B did not alter plasminogen activator inhibitor-1 and E-selectin associations with delirium, suggesting that these associations were not mediated by blood-brain barrier/neurological injury.

CONCLUSIONS

Elevated plasma markers of endothelial activation and blood-brain barrier/neurological injury during critical illness are associated with prolonged delirium after biomarker measurement. Future research is needed to determine whether these processes have pathophysiologic roles in delirium and whether therapies targeted at the endothelium or blood-brain barrier can prevent and/or treat delirium during critical illness.

GABAA receptor α4-subunit knockout enhances lung inflammation and airway reactivity in a murine asthma model

Emerging evidence indicates that hypnotic anesthetics affect immune function. Many anesthetics potentiate γ-aminobutyric acid A receptor (GABA_AR) activation, and these receptors are expressed on multiple subtypes of immune cells, providing a potential mechanistic link. Like immune cells, airway smooth muscle (ASM) cells also express GABA_ARs, particularly isoforms containing α₄-subunits, and activation of these receptors leads to ASM relaxation. We sought to determine if GABA_AR signaling modulates the ASM contractile and inflammatory phenotype of a murine allergic asthma model utilizing GABA_AR α₄-subunit global knockout (KO; Gabra4^0/0 ) mice. Wild-type (WT) and Gabra4 KO mice were sensitized with house dust mite (HDM) antigen or exposed to PBS intranasally 5 days/wk for 3 wk. Ex vivo tracheal rings from HDM-sensitized WT and Gabra4 KO mice exhibited similar magnitudes of acetylcholine-induced contractile force and isoproterenol-induced relaxation (P = not significant; n = 4). In contrast, in vivo airway resistance (flexiVent) was significantly increased in Gabra4 KO mice (P < 0.05, n = 8). Moreover, the Gabra4 KO mice demonstrated increased eosinophilic lung infiltration (P < 0.05; n = 4) and increased markers of lung T-cell activation/memory (CD62L low, CD44 high; P < 0.01, n = 4). In vitro, Gabra4 KO CD4⁺ cells produced increased cytokines and exhibited increased proliferation after stimulation of the T-cell receptor as compared with WT CD4⁺ cells. These data suggest that the GABA_AR α₄-subunit plays a role in immune cell function during allergic lung sensitization. Thus GABA_AR α₄-subunit-specific agonists have the therapeutic potential to treat asthma via two mechanisms: direct ASM relaxation and inhibition of airway inflammation.

The Risk of Pneumonia in Older Adults Using Nonbenzodiazepine Hypnotics

BACKGROUND

Previous studies have shown an increased risk of pneumonia with benzodiazepines (BZD) and an increased risk of any infection with non-BZD hypnotics, but no analysis has specifically investigated the risk of pneumonia with non-BZD hypnotic use.

OBJECTIVE

To evaluate the risk of pneumonia associated with non-BZD hypnotic use in the elderly.

METHODS

This was a retrospective case-control study of members aged 65 years and older enrolled in an integrated health care system. Cases were identified as patients aged 65 years and older with a diagnosis of pneumonia from January 2011 to December 2012. Controls were matched in a 4:1 ratio to cases based on age, gender, and active enrollment. Non-BZD hypnotic exposure was evaluated for all cases and controls 1 year before the index date. Proximity of exposure to index date and duration of use were analyzed. Conditional logistic regression adjusted for covariates was performed.

RESULTS

We identified 51,029 cases with pneumonia and matched 188,391 controls without pneumonia. Of the cases with pneumonia, 5.5% (2,790) of cases had exposure to a non-BZD hypnotic, compared with 3.4% (6,345) of controls. Non-BZD hypnotic exposure was associated with an increased risk of pneumonia (OR = 1.14; 95% CI = 1.08-1.20). When exposure was stratified by proximity to index date, only current exposure was associated with an increased risk of pneumonia (OR = 1.27; 95% CI = 1.18-1.36). Short-term exposure was associated with a relatively higher risk of pneumonia (OR = 1.57; 95% CI = 1.39-1.77) compared with long-term use (OR = 1.16; 95% CI = 1.06-1.25).

CONCLUSIONS

Current use of non-BZD hypnotics in older adults is associated with an increased risk of pneumonia. The findings of this study provide additional support for reducing the use of non-BZD hypnotics in older adults and for pursuing safer alternatives for treating insomnia.

DISCLOSURES

No outside funding supported this study. At the time of this study, Jung was a PGY2 resident in drug information at Kaiser Permanente Drug Information Services. All authors are employed by Kaiser Permanente and report no other potential financial conflicts of interest. Study concept and design were contributed by Jung, Spence, Lee, and Gibbs. Jung, Spence, and Hui were responsible for data collection, and data interpretation was performed by Jung and Spence, with assistance from Escasa, Lee, and Hui. The manuscript was primarily written by Jung, along with Spence and Escasa, and revised by Spence, Escasa, and Lee, along with the other authors.

Surgery increases cell death and induces changes in gene expression compared with anesthesia alone in the developing piglet brain

In a range of animal species, exposure of the brain to general anaesthesia without surgery during early infancy may adversely affect its neural and cognitive development. The mechanisms mediating this are complex but include an increase in brain cell death. In humans, attempts to link adverse cognitive development to infantile anaesthesia exposure have yielded ambiguous results. One caveat that may influence the interpretation of human studies is that infants are not exposed to general anaesthesia without surgery, raising the possibility that surgery itself, may contribute to adverse cognitive development. Using piglets, we investigated whether a minor surgical procedure increases cell death and disrupts neuro-developmental and cognitively salient gene transcription in the neonatal brain. We randomly assigned neonatal male piglets to a group who received 6h of 2% isoflurane anaesthesia or a group who received an identical anaesthesia plus 15 mins of surgery designed to replicate an inguinal hernia repair. Compared to anesthesia alone, surgery-induced significant increases in cell death in eight areas of the brain. Using RNAseq data derived from all 12 piglets per group we also identified significant changes in the expression of 181 gene transcripts induced by surgery in the cingulate cortex, pathway analysis of these changes suggests that surgery influences the thrombin, aldosterone, axonal guidance, B cell, ERK-5, eNOS and GABA_A signalling pathways. This suggests a number of novel mechanisms by which surgery may influence neural and cognitive development independently or synergistically with the effects of anaesthesia.

Etomidate Mitigates Lipopolysaccharide-Induced CD14 and TREM-1 Expression, NF-κB Activation, and Pro-inflammatory Cytokine Production in Rat Macrophages

This study was aimed at investigating the effect of etomidate on the viability of rat macrophages and the function of lipopolysaccharide (LPS)-stimulated macrophages as well as the potential mechanisms. Rat macrophages were isolated and treated with different doses of etomidate for 24 h, and their viability was determined by the CCK-8 assay. Furthermore, macrophages were treated with, or without, 1 μg/ml of LPS, and/or 2.5 or 5 μM etomidate in the presence or absence of a TREM-1 inhibitor (LP17, 100 ng/ml), and the levels of TNF-α, IL-6, CD14, and TREM-1 in the different groups of cells were determined by quantitative RT-PCR, ELISA, and Western blot assays. The levels of NF-κB activation in the different groups of cells were analyzed by an electrophoretic mobility shift assay (EMSA). Etomidate at 31.25 μM or a low dose did not affect the viability of rat macrophages, while etomidate at higher doses reduced the viability of macrophages in vitro. Treatment with 2.5 or 5 μM etomidate or with LP17 alone did not affect the levels of TNF-α, IL-6, CD-14, and TREM-1 in macrophages. Treatment with etomidate significantly mitigated LPS-stimulated TNF-α, IL-6, CD-14, and TREM-1 expression (p < 0.05 for all) and inhibited LPS-induced NF-κB activation in macrophages in vitro. However, treatment with both etomidate and LP17 did not enhance the inhibitory effects in macrophages. Hence, etomidate mitigates LPS-up-regulated pro-inflammatory cytokine production and inhibits LPS-enhanced CD14 and TREM-1 expression and NF-κB activation in macrophages.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits. Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality (especially overdose deaths, quiet deaths at night, and suicides), infections, cancer, depression, automobile crashes, falls, other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with even greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse (not better) and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). This review includes new information on the growing USA overdose epidemic, eight new epidemiologic studies of hypnotics' mortality not available for previous compilations, and new emphasis on risks of short-term hypnotic prescription. The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. The short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics are usually prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders might offer safer and more effective alternative approaches to insomnia.

Modulating antibiotic activity towards respiratory bacterial pathogens by co-medications: a multi-target approach

Non-antibiotic drugs can modulate bacterial physiology and/or antibiotic activity, opening perspectives for innovative therapeutic strategies. Focusing on respiratory pathogens and considering in vitro, in vivo, and clinical data, here we examine the effect of these drugs on the expression of resistance mechanisms, biofilm formation, and intracellular survival, as well as their influence on the activity of antibiotics on bacteria. Beyond the description of the effects observed, we also comment on concentrations that are active and discuss the mechanisms of drug-drug or drug-target interactions. This discussion should be helpful in defining useful targets for adjuvant therapy and establishing the corresponding pharmacophores for further drug fine-tuning.

Comfort and patient-centred care without excessive sedation: the eCASH concept

We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH—early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.

Haloperidol Suppresses NF-kappaB to Inhibit Lipopolysaccharide-Induced Pro-Inflammatory Response in RAW 264 Cells

Background

Haloperidol, a tranquilizing agent, is administered both to treat symptoms of psychotic disorders and to sedate agitated and delirious patients. Notably, haloperidol has been suggested to inhibit the immune response through unknown mechanisms. We hypothesized that the sedative modulates the immune response via NF-κB.

Material/Methods

Using flow cytometry, we analyzed the effects of haloperidol on expression CD80 and CD86 in RAW 264 cells and in primary macrophages derived from bone marrow. Secretion of interleukin (IL)-1β, IL-6, and IL-12 p40 was measured by enzyme-linked immunosorbent assay. In addition, NF-κB activation was evaluated using a reporter assay based on secretory embryonic alkaline phosphatase. Finally, synthetic antagonists were used to identify the dopamine receptor that mediates the effects of haloperidol.

Results

Haloperidol inhibited NF-κB activation, and thereby suppressed expression of CD80, as well as secretion of IL-1β, IL-6, and IL-12 p40. CD80 and IL-6 levels were similarly attenuated by a D2-like receptor antagonist, but not by a D1-like receptor antagonist.

Conclusions

The data strongly suggest that haloperidol inhibits the immune response by suppressing NF-κB signaling via the dopamine D2 receptor.

Risk of arteriovenous fistula failure associated with hypnotic use in hemodialysis patients: a nested case-control study

PURPOSE

Hypnotic use might cause altered inflammatory processes, which have been suggested as being related to the mechanisms of arteriovenous fistula (AVF) failure. Therefore, we examined the association between the risk of AVF failure and hypnotic use in patients receiving hemodialysis (HD).

METHODS

A nested case-control study was conducted using data from the National Health Insurance Research Database of Taiwan. From 34 165 HD patients, 3676 patients receiving percutaneous transluminal angioplasty or surgical thrombectomy for AVF failure were matched to 14 704 control patients according to sex, age (±1 year), and the year of initial HD therapy. The risk of AVF failure was estimated based on conditional logistic regression after adjustment for the timing of AVF creation, HD frequency, comorbidities, and prescribed medications. Hypnotic use was measured prior to the date of AVF failure of case patients and the date of pseudo-AVF failure of controls.

RESULTS

Compared with matched controls, case patients were more likely to be exposed to hypnotics 30 days or an average daily defined dose > 0.5 within 90 days before the date of AVF failure, with an adjusted odds ratio of 1.21 (95% confidence interval [CI]: 1.09-1.35, p < 0.001) and 1.36 (95%CI: 1.13-1.63, p = 0.001), respectively. Risk of AVF failure associated with hypnotic use was also observed among HD patients who were male, were younger than 65 years, had hypertension, and did not use statins.

CONCLUSIONS

Hypnotic use among HD patients was associated with an increased risk of AVF failure. Copyright © 2016 John Wiley & Sons, Ltd.

Association between benzodiazepine use and exacerbations and mortality in patients with asthma: a matched case-control and survival analysis using the United Kingdom Clinical Practice Research Datalink

PURPOSE

To investigate the association between the gamma-aminobutyric acid (GABA)ergic drugs, benzodiazepines or zopiclone and the occurrence of asthma exacerbations and subsequent mortality in a cohort of asthma patients.

METHODS

The number of patients that were included were 105,747 for those without asthma exacerbation and 25,895 for those with exacerbated asthma. A nested case-control study probed the association between benzodiazepines or zopiclone and occurrence of asthma exacerbation (primary outcome) using conditional logistic regression. Cox regression was used to determine the association between the drugs and all-cause mortality in patients with recorded asthma exacerbation. Adjusted matched odds ratios (adj mOR) and adjusted hazard ratios (adj HR) with 95% confidence intervals (CI) are presented.

RESULTS

Current benzodiazepine use was associated with increased occurrence of asthma exacerbation (adj mOR 1.49; 95%CI [1.15, 1.93]; P = 0.001) as was current zopiclone use (adj mOR 1.59; 95%CI [1.37, 1.85]; P < 0.001). In patients with an asthma exacerbation, current benzodiazepine use was associated with increased all-cause mortality during a median follow-up of 2 years (adj HR 2.78; 95%CI [1.26, 6.12]; P = 0.011), and the association between zopiclone use and all-cause mortality showed borderline statistical significance (adj HR 1.58; 95%CI [0.98, 2.54]; P = 0.058).

CONCLUSION

Benzodiazepines and zopiclone may increase the likelihood of asthma exacerbation, and benzodiazepines may also increase the likelihood of mortality following exacerbation. These data suggest that caution should be exercised when prescribing benzodiazepines to patients with asthma.

Use of sleep medications and risk of cancer: a matched case-control study

BACKGROUND

Previous research suggests a possible link between sleep-medication use and mortality, especially cancer deaths, but findings are mixed, and large population-based studies are lacking.

METHODS

Data from the Finnish Public Sector study were linked to the Finnish Cancer Register and the Drug Prescription Register of Finland. A total of 5053 cancer cases (mean age of 57.4 years) diagnosed in 2002-2011, and their 24,388 controls free of cancer and matched for sex, age, socioeconomic status, employer, and geographical area, were identified. The use of sleep medications was defined as purchases of prescribed sleep medications.

RESULTS

Both quantity and duration of prior sleep-medication use during the seven years studied were associated with increased odds of having cancer. Compared with participants not using sleep medications, the odds ratio was 1.18-fold (95% confidence interval (CI): 1.01-1.39) for those who used >100 defined daily doses per year and 1.16-fold (95% CI: 1.01-1.34) for those who had such a medication for >3 years. Site-specific analyses showed a more pronounced association of quantity and duration of sleep-medication use with subsequent cancer of the respiratory system (odds ratio for >100 defined daily doses per year vs. no use: 3.47; 95% CI: 1.97-6.11). No associations were found with other cancer sites.

CONCLUSION

In this register-based study, sleep-medication use was associated with an increased cancer incidence of the respiratory system. Further studies are needed to examine potential carcinogenic mechanisms associated with hypnotic medications.