Use of remdesivir for COVID-19 pneumonia in patients with advanced kidney disease: A retrospective multicenter study

Background and objectives

Remdesivir, an antiviral drug routinely used in the treatment of COVID-19 has not yet received FDA approval for use in patients with advanced kidney disease defined as GFR < 30 mL/min/1.73 m². There is concern that an excipient in Veklury (Gilead's proprietary name for remdesivir) called sulfobutylether-beta-cyclodextrin (SBECD), which is renally cleared, may accumulate and reach toxic levels in patients with advanced kidney disease. The aim of this study was to summarize characteristics and incidence of adverse events of chronic kidney disease (CKD) patients who received remdesivir during hospitalization.Design, setting, participants, and measurements.We retrospectively studied patients admitted to one of several hospitals of the Mayo Clinic Foundation with the diagnosis of COVID-19 pneumonia and CKD. Laboratory values were also measured when remdesivir was first administered and stopped. All analyses were performed in the overall patient group and three separate subgroups of patients with a GFR ≥ 15, a GFR < 15 and dialysis, and a GFR < 15 and no dialysis.

Results

A total of 444 CKD patients who were admitted to the hospital with COVID-19 pneumonia between May 2020 and September 2021 were included. Information was collected on patient characteristics, hospitalization, and adverse events. In the overall cohort, median age was 72 years (Range: 21-100 years), 55.2 % of patients were male, and most (86.5 %) were Caucasian. CKD stage was 3 for 114 patients (25.7 %), 4 for 229 patients (51.6 %), and 5 for 101 patients (22.7 %). A total of 146 patients (32.9 %) were admitted to the ICU, 103 (23.2 %) died in the hospital, and 120 (27.0 %) were on dialysis. The proportion of patients with an adverse event did not differ dramatically between the GFR ≥ 15 (20.9 %), GFR < 15 and dialysis (30.2 %), and GFR < 15 and no dialysis (32.3 %) groups (P = 0.12).

Conclusion

Our results suggest that the use of remdesivir in patients with very severe CKD is safe, even in those who are not on renal replacement therapy.

Effect of sciatic nerve mobilisation on muscle flexibility among diabetic and non-diabetic sedentary individuals: a comparative study

The purpose of the present study was to compare the effect of sciatic nerve mobilisation on muscle flexibility among diabetic and non-diabetic sedentary individuals. The study was a pre-post experimental-group design. A sample of 40 sedentary subjects was assigned into two groups; Group A (diabetics: 10 males and 10 females) and Group B (non-diabetics: 10 males and 10 females). Both groups were tested for hamstring and calf flexibility following which sciatic nerve mobilisation was given to the most affected lower limb in terms of reduced hamstring and calf flexibility. Hamstring flexibility was checked by active knee extension test and calf flexibility was checked with the distance-to-wall technique using a tape measure. It was a two-week program in which subjects were given sciatic nerve mobilisation using sliders technique after which flexibility was checked. Three sessions per week were given for two weeks and muscle flexibility of hamstring and calf was measured after the intervention. The present study findings reveal that sciatic nerve mobilisation by sliders technique when given to diabetic and non-diabetic groups of sedentary individuals for two weeks, enhance patient outcomes in both the groups in terms of increase in hamstring and calf flexibility, but results were more significant in non-diabetic individuals as compared to diabetic individuals. In conclusion, sciatic nerve mobilisation resulted in an increase of muscle flexibility of hamstring and calf muscles in both groups.

The surgical treatment of Balanitis Xerotica Obliterans

Background: Balanitis Xerotica Obliterans (BXO) is a chronic, often progressive disease, which can lead to phimosis and urethral stenosis, affecting both urinary and sexual function. Steroid creams are usually the first-line treatment but have a limited role and surgical intervention is frequently necessary. Conservative surgical procedures (circumcision) are often preferred in the first instance with the premise that recurrence of disease will require a more definitive reconstruction. This study looked at patients with pathologically proven BXO referred to the Plastic Surgery Unit at James Cook University Hospital between 2005 and 2009. The aim was to look at their management in the past and subsequent management by us. We also looked at whether early referral of progressive and recurrent BXO patients to reconstructive surgery could have prevented unnecessary delay in resolving symptoms at an earlier stage. Materials and Methods: Data was collected retrospectively and information regarding the exact anatomical location affected, the extent of the disease, the referring specialty and any previous surgical interventions was obtained. Alterations in urinary and sexual function and relief of symptoms following reconstructive surgery were analysed. Results: Of the 23 patients in the study, 43% had previous surgery and 60% of those had undergone two or more procedures. Twenty-one percent of patients had a history of BXO for over five years. Forty-seven percent of patients had alteration in their urinary function and 48% alteration in their sexual function due to the disease, prior to referral. Early results showed remarkable improvement in urinary and sexual function following reconstructive surgery in this group. Conclusions: Steroid creams have been shown to limit the progression of the disease but do not offer a cure in the majority of cases. Circumcision can be a curative procedure in early disease. Although there is conflicting evidence for treatment of recurring urethral strictures, repeated urethrotomy or urethral dilatation has poor long-term outcome. In patients with recurrent disease and associated complications we propose early referral to a plastic surgeon with genitourinary interest or reconstructive urologist for definitive treatment.

Multi-disciplinary management of complex pressure sore reconstruction: 5-year review of experience in a spinal injuries centre

INTRODUCTION In our regional spinal injuries unit, complex pressure ulcer reconstruction is facilitated by a monthly multidisciplinary team clinic. This study reviews a series of the more complex of these patients who underwent surgery as a joint case between plastics and other surgical specialties, aiming to provide descriptive data as well as share the experience of treating these complex wounds. MATERIALS AND METHODS Patients operated on as a joint case from 2010 to 2014 were identified through a locally held database and hospital records were then retrospectively reviewed for perioperative variables. Descriptive statistics were collected. RESULTS 12 patients underwent 15 procedures as a joint collaboration between plastic surgery and other surgical specialties: one with spinal surgery, 12 with orthopaedic and two with both orthopaedic and urology involvement. Ischial and trochanteric wounds accounted for 88% of cases with five Girdlestone procedures being performed and 12 requiring soft-tissue flap reconstruction. Mean operative time was 3.8hours. Four patients required high-dependency care and 13 patients received long-term antibiotics. Only three minor complications (20%) were seen with postoperative wound dehiscence. DISCUSSION The multidisciplinary team clinic allows careful assessment and selection of patients appropriate for surgical reconstruction and to help match expectations and limitations imposed by surgery, which are likely to influence their current lifestyle in this largely independent patient group. Collaboration with other specialties gives the best surgical outcome both for the present episode as well as leaving avenues open for potential future reconstruction.

Improving outcomes following reconstruction of pressure sores in spinal injury patients: A multidisciplinary approach

BACKGROUND AND AIM

Pressure sore treatment in spinal injury patients is challenging. A multidisciplinary approach with joint management by the plastic surgery and spinal injury teams was initiated at our institution in 2005 to improve patient care and surgical outcomes following reconstruction. This study assessed the surgical outcomes following reconstruction using the team approach and to compare inpatient stay and readmissions for complications before and after the multidisciplinary protocol was introduced.

METHODS

A retrospective review of consecutive patients in the multidisciplinary pressure sore clinic was performed. Data were collected on patient demographics, reconstructive techniques, surgical outcomes and readmission for any complications.

RESULTS

In total, 45 patients with 60 pressure sores (grade 3 or 4) were reviewed in the joint clinic between 2005 and 2011. The majority of patients were paraplegic (78%), while the remaining 22% were tetraplegic. Ischial sores were the most common (45%) followed by trochanteric (23%) and sacral (20%) sores. Multiple sores were noted in 44% of patients. Flap reconstruction was required in 32 patients (71%); after a mean follow-up time of 33 months (range 25-72 months), there were three (9%) major complications (two recurrences of pressure sores and one sinus) and seven (22%) minor complications. After introduction of patient care pathways through the multidisciplinary approach, the rate of readmission for complications decreased from 14% to 5.5% and inpatient stay upon readmission reduced from 65 to 45 days.

CONCLUSIONS

Implementation of a multidisciplinary approach was key to optimising surgical outcomes, achieving a low recurrence rate (6%) and reducing readmissions.

A kick in the shins: the financial impact of uncontrolled warfarin use in pre-tibial haematomas

Warfarin is increasingly prescribed in the elderly population for a number of medical conditions. Pre-tibial haematomas are a common cause of morbidity in this group. The aim of the study was to identify the proficiency of INR monitoring at a primary care level in correlation with their recommended INR range and to study the treatment outcome in this group. A retrospective single-centre study of patients diagnosed with pre-tibial haematomas was conducted over a two-year period. Length of hospital stay, time delay until operative intervention, blood transfusion and warfarin reversal requirements, social care input and cost to the NHS were considered. A total of 62 patients were admitted with pre-tibial haematomas of which 20 were on Warfarin. Females were predominantly more affected (5.6:1). The mechanism of injury was as a result of minor trauma. The mean INR level was 3.8 with a standard deviation of 3.1. Mean length of hospital stay was 11 days with a standard deviation of 13.6. Nine patients required skin grafting. Average cost for the acute episode was £3500 per patient. INR levels were significantly outwith the target range causing substantial patient morbidity and imposing a significant financial burden on the NHS. Tighter regulation at a primary care level should help reduce this risk.

The surgical treatment of Balanitis Xerotica Obliterans

BACKGROUND

Balanitis Xerotica Obliterans (BXO) is a chronic, often progressive disease, which can lead to phimosis and urethral stenosis, affecting both urinary and sexual function. Steroid creams are usually the first-line treatment but have a limited role and surgical intervention is frequently necessary. Conservative surgical procedures (circumcision) are often preferred in the first instance with the premise that recurrence of disease will require a more definitive reconstruction. This study looked at patients with pathologically proven BXO referred to the Plastic Surgery Unit at James Cook University Hospital between 2005 and 2009. The aim was to look at their management in the past and subsequent management by us. We also looked at whether early referral of progressive and recurrent BXO patients to reconstructive surgery could have prevented unnecessary delay in resolving symptoms at an earlier stage.

MATERIALS AND METHODS

Data was collected retrospectively and information regarding the exact anatomical location affected, the extent of the disease, the referring specialty and any previous surgical interventions was obtained. Alterations in urinary and sexual function and relief of symptoms following reconstructive surgery were analysed.

RESULTS

Of the 23 patients in the study, 43% had previous surgery and 60% of those had undergone two or more procedures. Twenty-one percent of patients had a history of BXO for over five years. Forty-seven percent of patients had alteration in their urinary function and 48% alteration in their sexual function due to the disease, prior to referral. Early results showed remarkable improvement in urinary and sexual function following reconstructive surgery in this group.

CONCLUSIONS

Steroid creams have been shown to limit the progression of the disease but do not offer a cure in the majority of cases. Circumcision can be a curative procedure in early disease. Although there is conflicting evidence for treatment of recurring urethral strictures, repeated urethrotomy or urethral dilatation has poor long-term outcome. In patients with recurrent disease and associated complications we propose early referral to a plastic surgeon with genitourinary interest or reconstructive urologist for definitive treatment.

Prevalence and correlates of HIV, syphilis, and hepatitis knowledge among intrapartum patients and health care providers in Kabul, Afghanistan

Little is known about blood-borne infection awareness and knowledge among obstetric populations and health care providers in Afghanistan. HIV and hepatitis B awareness and knowledge are described among 4452 intrapartum patients completing an interviewer-administered questionnaire and whole-blood rapid testing and 123 obstetric care providers completing a questionnaire between June 2006 and September 2006. Participants were enrolled from three Kabul public maternity hospitals. Most participants were aware of HIV (50.8% of patients and 95.9% of providers) and hepatitis (72.1% of patients and 91.1% of providers). Correct transmission knowledge (defined as naming three correct routes and no incorrect routes) was lower for both groups (HIV: 19.4% for patients and 59.7% for providers; hepatitis B: 1.90% for patients and 33.9% for providers). Correct HIV transmission knowledge among providers was independently associated with level of education (AOR=1.75, 95% CI: 1.20-2.55). While HIV and hepatitis B awareness is common, correct and comprehensive knowledge is not. Continuing education for providers and health communications strategies should address identified knowledge gaps.

Utilising field assignments in survey methodology course at Ziauddin Medical University, Karachi

OBJECTIVE

To describe the teaching-learning strategy employed in the module of Survey Methodology for undergraduate medical students at Ziauddin Medical University.

SETTING

Medical students of Ziauddin Medical University, Clifton, Karachi.

METHODS

The objectives of the Survey Methodology course were developed so that a student would be able to design and conduct a small survey independently. For this purpose the students were required to participate in a census survey of a squatter settlement. The questionnaire for the survey was developed with the students, which included the demographic information of the households. It was discussed and pretested with the medical students. The students edited and entered the data on computer using Epi-Info. They were trained in sampling methods, data collection, data editing and entry through lectures and small group sessions. At the end of the course, students filled the course evaluation form.

RESULTS

Out of 117 students who responded, 63% found the course to be useful. Small group sessions were regarded as the most helpful teaching strategy by 91% of the students. Majority (74%) of the students recommended that field visits should be a part of teaching strategy.

CONCLUSION

The Survey Methodology course reinforces the importance and practical application of research methods. The students appreciate the course especially the small group sessions and the field visits.

Cannula related suppurative thrombophlebitis in the burned patient

Suppurative thrombophlebitis is a well recognised and potentially fatal complication of intravenous cannulation in burns patients. We report a case of an Afro-Caribbean patient with noninsulin-dependent diabetes who developed signs of systemic sepsis two weeks after a 14% total body surface area flame burn. Despite an initial paucity of clinical signs at the cannulation site, exploratory venotomy revealed frank suppuration within the long saphenous vein from the ankle to the groin. This was treated successfully by total excision of the vein and its tributaries and delayed wound closure. Following this, a retrospective analysis of the measured clinical parameters and blood tests revealed no obvious, missed pointers to the impending sepsis other than a dramatic increase in the overall daily insulin requirement. This had doubled over a 48-h period, preceding the clinical diagnosis by three days. The relevant literature and guidelines for management are reviewed.

Systemic lupus erythematosus in Kuwait--hospital based study

The present study describes the clinical characteristics of patients with systemic lupus erythematosus (SLE), from the rheumatology service of the two main teaching hospitals in Kuwait. It was a retrospective-cum-prospective clinical study of 108 SLE patients. There were 98 females and 10 males, with a median age of 31.5y. Kuwaitis constituted 69%, while 31% were expatriates. The mean disease duration was 62 months. The main clinical features were: musculoskeletal involvement (87%), photosensitivity (48%), malar rash (43%), discoid lesions (10%), oral ulcers (33%), vasculitic skin lesions (10%), haematological features (53%), constitutional symptoms (51.4%), neuropsychiatric manifestations (23%), renal involvement (37%), serositis (29%), clinical manifestations of antiphospholipid syndrome (21%), cardiac involvement (10%) and pulmonary manifestations (19%). In conclusion, the clinical features of SLE in Kuwait were similar to most major studies from developed countries. Main differences included prominent haematological and mucocutaneous manifestations and possibly a low prevalence of anti-Sm antibodies. Whether these differences are due to the environment or genetic factors, remains to be studied.

Further observations concerning steroidal, β-lactones. Boron trifluoride catalysed rearrangements of β-lactones in the cholestane series

B-Nor-5β-cholestane-3,3,5-diol-6-carboxylic acid 5,6-lactone 3-acetate on treatment with BF3 etherate in ether or ether-acetic anhydride gave B-norcholest-5-en-3β-ol-6-carboxylic acid 3-acetate and 19-nor-5-methyl-B-nor-5β-cholest-9(10)-en-3,3-ol-6-carboxylic acid 3-acetate, a product of the Westphalen rearrangement. B-Nor-5β-cholestan-5-ol-6-carboxylic acid 5,6-lactone under similar reaction conditions provided the product of the Westphalen rearrangement, 19-nor-5-methyl-B-nor-5β-cholest-9(10)-ene-6-carboxylic acid.