Efficacy and Safety of Immediate-Release Nifedipine in Critically Ill Patients

BACKGROUND

Immediate-release nifedipine (IRN) is a calcium channel blocker with potent vasodilatory and antihypertensive properties. Safety concerns led to a black box warning for increased risk of myocardial infarction, stroke, and arrhythmias.

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of IRN for acute blood pressure lowering in critically ill patients.

METHODS

A retrospective, single-center study was performed in critically ill patients who received at least one dose of IRN. The primary endpoint was the change in systolic blood pressure (SBP) measured at baseline and 1 hour after first administration of IRN. Secondary outcomes included clinically significant hypotension, defined as an absolute reduction in SBP ≥ 15% or vasopressor initiation within 1 hour after administration; incidence of arrhythmias, stroke, or myocardial injury; and time to transition off antihypertensive infusions.

RESULTS

IRN resulted in a median [interquartile range] SBP change of -10 [-21 to -1] mmHg between baseline 142 mmHg [124-155] and 1 h post-administration 127 mmHg [114-144]; P < .001. Twenty-seven percent of patients experienced clinically significant hypotension, with hypotension observed in 24% and vasopressors initiated in 4% of patients. Sixteen percent of patients experienced new-onset arrhythmia and 18% experienced myocardial injury following IRN during hospitalization. Median time to transition off intravenous (IV) continuous infusion antihypertensives was 8.5 [0-31.5] hours.

CONCLUSION

IRN led to a reduction in SBP which may have been associated with clinically significant hypotension and need for vasopressor support. Further studies with direct comparisons to alternatives are needed to determine the true association of adverse events with IRN.

HIV Epidemic in Libya: Identifying Gaps

BACKGROUND

HIV (human immunodeficiency virus) and AIDS (acquired immunodeficiency syndrome) became a public issue in Libya after the infection of 400 children in El-Fatih Hospital in 1988. Due to the civil war, social and religious barriers, HIV prevalence is hard to establish, but it is generally believed to be increasing.

OBJECTIVE

This review (a) assesses the size and scope of the available literature on the HIV epidemic in Libya; and, (b) identifies the nature and extent of research conducted to date.

METHODS

A comprehensive search was performed using PubMed, Medline, Web of Science, ScienceDirect, Scopus, Academic Search Ultimate, Cochrane Library and Google Scholar. Primary research studies and official reports that are exclusively on Libya published during 1988-2021 were considered.

RESULTS

In total 25 studies were included: Ten primary research studies, four online news articles, six Government reports, one letter to the editor, one manuscript, three online databases.

CONCLUSION

Despite the low-quality data, the literature suggests there is an increase in HIV infection rates in Libya. Culturally sensitive research on sexual activities, women, HIV preventative methods and attitudes of the Libyan public will assist in developing an effective National AIDS Programme, reducing HIV stigma, supporting People Living with HIV (PLHIV) and decreasing infection rates.

10 COVID-19 and Changing Perceptions Towards Postgraduate Surgical Training in United Kingdom

Aim

The evolution of the current coronavirus disease-2019 (COVID-19) pandemic continues to impact global healthcare systems on an unprecedented scale. Here, we use data from a local NHS trust within the United Kingdom (UK) to examine the perception of medical students and foundation doctors towards postgraduate surgical training.

Method

This tri-centric cross-sectional study was carried out via a survey disseminated within the East Sussex Healthcare NHS trust, King’s College Hospital, and King’s College London Medical School. The survey was active for 14 days (from 15th March 2020 to 28th March 2020), comprising a total of 40 foundation doctors and 10 medical students.

Results

A total of 50 responses were received across five hospitals and their associated medical school. A decrease of 10% and 25% was observed in interest to pursue surgery in medical students and foundation doctors, respectively, following the outbreak of COVID-19. Over 40% of foundation doctors holding postgraduate surgical training offers were not accepting them, and of those, over 40% would not consider reapplying to surgery. There was a drop in interest across a select set of specialities, and this was more obvious where aerosol-generating-procedures was a common occurrence.

Conclusions

These results highlight the need for a more efficient and effective response to address the immediate situation, as well as a robust contingency plan to avert the repercussions the surgical field could face.

An examination of sedation requirements and practices for mechanically ventilated critically ill patients with COVID-19

PURPOSE

Preliminary reports suggest that critically ill patients with coronavirus disease 2019 (COVID-19) infection requiring mechanical ventilation may have markedly increased sedation needs compared with non-mechanically ventilated patients. We conducted a study to examine sedative use for this patient population within multiple intensive care units (ICUs) of a large academic medical center.

METHODS

A retrospective, single-center cohort study of sedation practices for critically ill patients with COVID-19 during the first 10 days of mechanical ventilation was conducted in 8 ICUs at Massachusetts General Hospital, Boston, MA. The study population was a sequential cohort of 86 critically ill, mechanically ventilated patients with COVID-19. Data characterizing the sedative medications, doses, drug combinations, and duration of administration were collected daily and compared to published recommendations for sedation of critically ill patients without COVID-19. The associations between drug doses, number of drugs administered, baseline patient characteristics, and inflammatory markers were investigated.

RESULTS

Among the study cohort, propofol and hydromorphone were the most common initial drug combination, with these medications being used on a given day in up to 100% and 88% of patients, respectively. The doses of sedative and analgesic infusions increased for patients over the first 10 days, reaching or exceeding the upper limits of published dosage guidelines for propofol (48% of patients), dexmedetomidine (29%), midazolam (7.7%), ketamine (32%), and hydromorphone (38%). The number of sedative and analgesic agents simultaneously administered increased over time for each patient, with more than 50% of patients requiring 3 or more agents by day 2. Compared with patients requiring 3 or fewer agents, as a group patients requiring more than 3 agents were of younger age, had an increased body mass index, increased serum ferritin and lactate dehydrogenase concentrations, had a lower PaO2:FIO2 (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen), and were more likely to receive neuromuscular blockade.

CONCLUSION

Our study confirmed the clinical impression of elevated sedative use in critically ill, mechanically ventilated patients with COVID-19 relative to guideline-recommended sedation practices in other critically ill populations.

A low dose heparinized saline protocol is associated with improved duration of arterial line patency in critically ill COVID-19 patients

Purpose

Critically ill patients with Coronavirus Disease 2019 (COVID-19) have high rates of line thrombosis. Our objective was to examine the safety and efficacy of a low dose heparinized saline (LDHS) arterial line (a-line) patency protocol in this population.

Materials and Methods

In this observational cohort study, patients ≥18 years with COVID-19 admitted to an ICU at one institution from March 20–May 25, 2020 were divided into two cohorts. Pre-LDHS patients had an episode of a-line thrombosis between March 20–April 19. Post-LDHS patients had an episode of a-line thrombosis between April 20–May 25 and received an LDHS solution (10 units/h) through their a-line pressure bag.

Results

Forty-one patients (pre-LDHS) and 30 patients (post-LDHS) were identified. Baseline characteristics were similar between groups, including age (61 versus 54 years; p = 0.24), median Sequential Organ Failure Assessment score (6 versus 7; p = 0.67) and systemic anticoagulation (47% versus 32%; p = 0.32). Median duration of a-line patency was significantly longer in post-LDHS versus pre-LDHS patients (8.5 versus 2.9 days; p < 0.001). The incidence of bleeding complications was similar between cohorts (13% vs. 10%; p = 0.71).

Conclusions

A LDHS protocol was associated with a clinically significant improvement in a-line patency duration in COVID-19 patients, without increased bleeding risk.

•

Critically ill COVID-19 patients have frequent arterial line (a-line) thrombosis.

•

A low dose heparinized saline (LDHS) a-line patency protocol was examined.

•

Two a-line thrombosis cohorts were identified: “post-LDHS” and “pre-LDHS”.

•

A-line patency was longer in post- vs. pre-LDHS patients (8.5 vs. 2.9 d; p < 0.001).

•

Bleeding complications were similar between groups (13% vs. 10%, p = 0.7).

Clinical and bacteriological examinations of dogs with tonsillitis

The aim of this study was to investigate the presence of tonsillitis in dogs and isolation of bacteria involved as well as their antimicrobial susceptibility. For this purpose from June 2015 to August 2017, 12 clinical cases of dogs with tonsillitis have been examined, and a total of 24 samples were collected. Diagnosis was based on anamnesis, clinical signs, haematology and biochemical tests and bacteriological analyses. The isolation and identification of bacteria was carried out according to conventional microbiological methods and biochemical tests, while the antimicrobial susceptibility of bacterial isolates was tested using the disk diffusion method. Escherichia coli was the most commonly isolated bacteria with isolation rate 35.0%, followed by Streptococcus pyogenes (27.50%), Staphylococcus aureus (20%), Staphylococcus intermedius (10%) and Pasteurella spp. (7.5%). A high resistance to ampicillin, streptomicin and penicillin G was shown by E. coli, S. intermedius, S. pyogenes isolates. None of S. pyogenes, S. aureus, S. intermedius and Pasteurella spp., isolates was resistant to amoxicillin/clavulanic acid.

Vitamin D status and insulin sensitivity are novel predictors of resting metabolic rate: a cross-sectional analysis in Australian adults

PURPOSE

Resting metabolic rate (RMR) accounts for two-thirds of the total energy expenditure in sedentary individuals. After accounting for traditional factors, there still remains a considerable unexplained variance in RMR. There is a pandemic of obesity and metabolic syndrome (MetS) which coexists with a high prevalence of vitamin D insufficiency. The aim of this study was to evaluate the potential effects of vitamin D status, insulin sensitivity (IS) and the metabolic syndrome (MetS) on RMR in Australian adults.

METHODS

RMR, respiratory quotient (RQ), McAuley's insulin sensitivity index, fat mass (FM), fat-free mass (FFM) and vitamin D status were assessed in Australian adults. The presence of MetS was evaluated by current standard criteria. Predictors of RMR were examined through multiple linear regression based on stepwise and backward regression approaches with attention to multi-collinearity. All analyses were conducted on SPSS version 21.

RESULTS

One hundred and twenty-seven participants (45 men, 82 women), aged 53.4 ± 11.7 years and BMI 31.9 ± 5.2 kg/m(2), were included. Forty-one subjects were insufficient in vitamin D status (<50 nmol/L), and 75 participants had the MetS. A parsimonious regression model explained 85.8 % of RMR and was given by: RMR (kJ/d) = 1931 + 83.5 × FFM (kg) + 29.5 × FM (kg) + 5.65 × 25(OH)D (nmol/L) - 17.6 × age (years) - 57.51 × IS.

CONCLUSION

Vitamin D status and IS are novel independent predictors of RMR in adults. Future studies could validate a causal role for these factors in human energy metabolism.

Isolation and Identification of Brucella melitensis Biovar 3 from Vaccinated Small Ruminants: A Public Health Threat in Kosovo

In 2011, a human brucellosis case with severe clinical symptoms was reported at the University Clinic for Infectious Diseases in Prishtina, Kosovo. A trace-back investigation was conducted to find the source of human infection. A total of 49 blood samples and 15 corresponding milk samples from sheep and goats raised on the patient's farm were taken for serological and molecular analysis. Serology using RBT and CFT revealed 11 positive animals. Twelve milk samples were PCR positive. A Brucella strain isolated from a goat's milk sample was classified as Brucella melitensis biovar 3, indicating the first ever isolation and report in Kosovo. The use of the Bruce-ladder PCR provided differentiation between the field strain and the vaccine strain. Hence, the accidental transmission of the vaccine strain Rev 1 that was previously used for the vaccination of the farm animals could be excluded. The findings of this study show that brucellosis is still a public health threat in Kosovo despite control measures.

Quantification of water as a potential risk factor for cross-contamination with Salmonella, Campylobacter and Listeria in a poultry abattoir

Water used in a modern poultry processing line was tested from October 2005 to June 2006 to determine the level of bacteria in an abattoir in Germany. A total of 420 water samples were taken from 14 processing sites (PSs), at 10 times, and from three different hours of the working shift at three sampling hours (SHs) at 5:00 a.m. (SH 1), 9:00 a.m. (SH 2) and 12:00 a.m. (SH 3). Each sample was assessed for the aerobic plate count (APC) and the prevalence of Salmonella, Campylobacter, Listeria and Yersinia over 30 sampling weeks. The APC numbers of each PS from three SHs were compared, and the prevalence of Salmonella, Campylobacter, Listeria and Yersinia from each PS of three SHs was determined as well as change from the initial PS to the end of the processing line. A total of 46 water samples were positive for Salmonella, 120 positive for Campylobacter and 4 positive for Listeria. None of the water samples was found to be positive for Yersinia. During the course of the day, the APC increased. Salmonella was mostly found during SH 1 (5 a.m.) in water from all PSs. A high number of Campylobacter were observed at SH 2 (9 a.m.) and SH 3 (12 a.m.) from all PSs. The results show that water, which is still used in substantial amounts in present poultry processing technology, can serve as a carrier for Salmonella and Campylobacter. The findings indicate that birds might progressively contaminate the equipment and become contaminated via the same equipment, that water at every processing position of the line constitutes a risk and that more attention should be paid to effective water management in the processing plan.

Influence of methods for Trichinella detection in pigs from endemic and non-endemic European region

A total of 1401 German and 226 Croatian pigs raised either indoors or outdoors were tested for Trichinella infection by direct and indirect detection methods. A 10 g sample of diaphragm were examined for muscle larvae by the artificial digestion method; the species was determined by multiplex polymerase chain reaction (PCR). For detection of anti-Trichinella IgG, serum samples diluted 1:100, and meat juice samples diluted 1:10, were tested by enzyme-linked immunosorbent assay. All German pigs and those Croatian pigs raised indoors proved to be Trichinella-negative by all methods. Muscle larvae were detected in a total of eleven of the Croatian pigs, which were raised on small outdoor farms. For eight isolates, PCR results demonstrated that recovered larvae were Trichinella spiralis. Anti-Trichinella-IgG was detected in serum and meat juice of digestion positive animals when the worm burdens exceeded 0.38 larvae per gram of muscle. Positive results in Croatian pigs indicate a higher risk of infection for outdoor farming in areas where Trichinella is endemic. Results of direct and indirect detection were compared and are discussed with special regard to specificity and sensitivity of methods.