Use of Remdesivir in the treatment of Coronavirus Disease 2019 (COVID-19) infection among Sudanese patients: a case series

Introduction: The coronavirus disease 2019 (COVID-19) pandemic is affecting populations worldwide. Remdesivir is an anti-retroviral agent, with a broad spectrum of usage. Remdesivir usage against COVID-19 had been studied both in vitro and in vivo but is still considered a new treatment for COVID-19 and is not available in all countries. The aim of our study was to report several cases of the use of Remdesivir in Sudanese patients and report the adverse events related to the course of treatment.

Methods: A case series study was conducted in Imperial Hospital, Khartoum, Sudan reporting two cases who received Remdesivir for treating COVID-19 besides other treatments such as steroids and supportive therapy in December 2020. Cases were males aged over 65 years.

Cases presentation: Both patients were severe cases of COVID-19 admitted to the intensive care unit (ICU), who received Remdesivir for treating COVID-19 infection. Several side effects were reported: the first case had increased liver enzymes and then unexpectedly died from severe resistant hypotension; and hypoalbuminemia was noticed in the second case.

Conclusions: Remdesivir use among patients in Sudan must be studied extensively in order to determine the unexpected fatal event and assess the association of this event to Remdesivir use, as well as to report the frequency of the side effects.

909 ENT Telephone Clinic During COVID-19 Pandemic

Introduction

In response to the COVID-19 pandemic, ENT services in NHS hospitals have fundamentally changed the way they function. Focus is narrowed on emergency care and cancer care, with cancellation of most elective procedures. In response to this, 2 week wait (2ww) ENT telephone clinics were set up.

This project reviewed the effectiveness of ENT telephone clinic appointments in managing 2ww referrals and to determine whether the introduction of 2ww telephone clinics improves patient waiting times and appropriates of referrals.

Method

Retrospective review of ENT telephone clinic 2ww referral outcomes at Eastbourne District General Hospital and the effectiveness of managing these patients.

Results

A total of 58 ENT Telephone Clinic 2ww referrals from the GP were reviewed. After a telephone consultation 63% of patients were referred to 2ww imaging, from which 70% were discharged following imaging. 83% of patient offered face to face appointment following imaging, required further investigation or treatment, again reducing delay in diagnosis.

Conclusions

Telephone clinic is an effective way of managing 2ww referral patients. In the ongoing pandemic, telephone clinics will be used to manage cancer pathways. This study shows that a large number of patients are discharged after imaging following a telephone clinic. Further study is required to determine whether low scoring patients on symptom-based risk calculators for cancer referrals could be directly referred to imaging to avoid delay in diagnosis, reduce anxiety as well as allow appropriate resource allocation.

Use of Remdesivir in the treatment of Coronavirus Disease 2019 (COVID-19) infection among Sudanese patients: a case series

Introduction: The coronavirus disease 2019 (COVID-19) pandemic is affecting populations worldwide. Remdesivir is an anti-retroviral agent, with a broad spectrum of usage. Remdesivir usage against COVID-19 had been studied both in vitro and in vivo but is still considered a new treatment for COVID-19 and is not available in all countries. The aim of our study was to report several cases of the use of Remdesivir in Sudanese patients and report the adverse events related to the course of treatment. Methods: A case series study was conducted in Imperial Hospital, Khartoum, Sudan reporting two cases who received Remdesivir for treating COVID-19 besides other treatments such as steroids and supportive therapy in December 2020. Cases were males aged over 65 years. Cases presentation: Both patients were severe cases of COVID-19 admitted to the intensive care unit (ICU), who received Remdesivir for treating COVID-19 infection. Several side effects were reported: the first case had increased liver enzymes and then unexpectedly died from severe resistant hypotension; and hypoalbuminemia was noticed in the second case. Conclusions: Remdesivir use among patients in Sudan must be studied extensively in order to determine the unexpected fatal event and assess the association of this event to Remdesivir use, as well as to report the frequency of the side effects.

Generic daclatasvir plus sofosbuvir, with or without ribavirin, in treatment of chronic hepatitis C: real-world results from 18 378 patients in Egypt

BACKGROUND

Treatment of chronic hepatitis C using combination of sofosbuvir (SOF) and daclatasvir (DCV) was used in several clinical trials and multicentre studies, which were somewhat limited to genotypes 1-3. The national program in Egypt is using SOF-DCV combination for large scale treatment.

AIM

To assess the efficacy and safety of combined SOF-DCV in treating patients with HCV-G4 in a real-world setting.

METHODS

Data and outcome of chronic HCV patients who were treated for 12 weeks with generic medications: DCV 60 mg plus SOF 400 mg ± ribavirin (RBV) within the national hepatitis C treatment program in Egypt are presented. Treatment-naïve patients without cirrhosis were treated without RBV, and those who had cirrhosis or were treatment-experienced (interferon experienced or SOF experienced) received RBV. Efficacy and safety were assessed, and baseline factors associated with sustained virological response at post-treatment week 12 (SVR12) were explored.

RESULTS

During the first 2 months of the programme, 18 378 patients with HCV-G4 started treatment with SOF-DCV with or without RBV. Overall, 95.1% achieved SVR12 (95.4% among patients treated without RBV and 94.7% for patients treated with RBV, P = .32). Treatment was prematurely discontinued in only 1.5% of patients. The most common events leading to discontinuation were patient withdrawal (n = 76) and pregnancy (n = 5). Five deaths occurred within this group.

CONCLUSIONS

Real-world experience of generic SOF-DCV in patients with chronic HCV-G4 proved to be safe and associated with a high SVR12 rate, in patients with different stages of fibrosis.

Pharmaceutical care of patients with heart failure

AIM

The aim of this study was to investigate the impact of a pharmacist-led pharmaceutical care programme, involving optimization of drug treatment and intensive education and self-monitoring of patients with heart failure (HF) within the United Arab Emirates (UAE), on a range of clinical and humanistic outcome measures.

METHODS

The study was a randomized, controlled, longitudinal, prospective clinical trial at Al-Ain Hospital, Al-Ain, UAE. Patients were recruited from the general medical wards and from cardiology and medical outpatient clinics. HF patients who fulfilled the entrance criteria, and had no exclusion criteria present, were identified for inclusion in the study. After recruitment, patients were randomly assigned to one of two groups: intervention group or control group. Intervention patients received a structured pharmaceutical care service while control patients received traditional services. Patient follow-up took place when patients attended scheduled outpatient clinics (every 3 months). A total of 104 patients in each group completed the trial (12 months). The patients were generally suffering from mild to moderate HF (NYHA Class 1, 29.5%; Class 2, 50.5%; Class 3, 16%; and Class 4, 4%).

RESULTS

Over the study period, intervention patients showed significant (P < 0.05) improvements in a range of summary outcome measures [AUC (95% confidence limits)] including exercise tolerance [2-min walk test: 1607.2 (1474.9, 1739.5) m.month in intervention patients vs. 1403.3 (1256.5, 1549.8) in control patients], forced vital capacity [31.6 (30.8, 32.4) l.month in the intervention patients vs. 27.8 (26.8, 28.9) in control patients], health-related quality of life, as measured by the Minnesota living with heart failure questionnaire [463.5 (433.2, 493.9) unit.month in intervention patients vs. 637.5 (597.2, 677.7) in control patients; a lower score in this measure indicates better health-related quality of life]. The number of individual patients who reported adherence to prescribed medications was higher (P < 0.05) in the intervention group (85 vs. 35), as was adherence to lifestyle advice (75 vs. 29) at the final assessment (12 months). There was a tendency to have a higher incidence of casualty department visits by intervention patients, but a lower rate of hospitalization.

CONCLUSIONS

The research provides clear evidence that the delivery of pharmaceutical care to patients with HF can lead to significant clinical and humanistic benefits.

Buspirone, a 5-HT1A receptor agonist, dilates the perfused rat uterine vascular bed through α1-adrenoceptor blockade

In the perfused rat uterine vascular bed, 5-hydroxytryptamine (5-HT) produced dose-dependent vasoconstrictor responses. Buspirone, a selective 5-HT(1A) receptor agonist, was not effective at low doses but produced a response at high doses. When perfusion pressure was raised with phenylephrine, responses to 5-HT were enhanced while buspirone produced dose-dependent vasodilator responses. Buspirone did not produce vasodilation when perfusion pressure was raised with vasopressin or U46619. Buspirone-induced vasodilator responses were not affected by selective 5-HT(1A) receptor antagonists, 8-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-8-azaspiro[4,5]-decane-7,9-dione (BMY 7378) and N-tert-butyl-3-(4-[2-methoxyphenyl]piperazin-1-yl)-2-phenylpropanamide (WAY 100478), indicating that specific 5-HT(1A) receptors might not be involved in buspirone-induced vasodilation. Buspirone (3 x 10 (-5) M) and prazosin (3 x 10(-9) M) antagonized noradrenaline-induced constriction with dose ratios of 19.1+/-2.9 and 11.7+/-2.1, respectively. The dose ratio of these antagonists in combination was 46.6+/-8.1. Since the combination ratio is closer to the sum of their individual dose ratios less 2 (i.e. DR(p)+DR(b)-2) than it is to the product of their individual dose ratios, our data suggest an interaction of buspirone with alpha(1)-adrenoceptors. Buspirone also protected adrenoceptors against inactivation by phenoxybenzamine confirming that buspirone interacted with alpha(1)-adrenoceptors. We concluded that buspirone-induced vasodilation of the perfused rat uterine vascular bed is mediated through blockade of alpha(1)-adrenoceptors rather than through 5-HT(1A) receptors.

Beta1- and beta3-adrenoceptors mediate relaxation in ovine trachealis smooth muscle

Isoprenaline (non-selective) and noradrenaline (beta1-selective) concentration-dependently relaxed ovine tracheal strips precontracted with carbachol. The pD2 values were 7.07 +/- 0.08 and 6.13 +/- 0.10 for isoprenaline and noradrenaline, respectively. In the same preparation, salbutamol either produced weak relaxation or in some cases, contractile responses indicating the presence of very little or no beta2-adrenoceptors in this preparation. Isoprenaline-and noradrenaline-induced relaxations were antagonized by propranolol and atenolol with pA2 values in the range reported in the literature for an action on beta1-adrenoceptors. ICI 118551 also antagonized isoprenaline- and noradrenaline-induced relaxation but at concentrations much higher than are required to block beta2-adrenoceptors, confirming that beta2-adrenoceptors do not contribute significantly to these responses. The selective beta3-adrenoceptor agonist, BRL 37344A produced concentration-dependent relaxation of tracheal strips. BRL 37344A was a full agonist producing 100% relaxation of carbachol-induced tone. BRL 37344A-induced relaxation was weakly antagonized by propranolol confirming an action, mainly, on beta3-adrenoceptors. Cyanopindolol antagonized isoprenaline-induced relaxation (in the presence of propranolol, 10(-7) M) with a pA2 value of 8.06 +/- 0.24. It was therefore concluded that beta1- and beta3-adrenoceptors mediated agonist-induced relaxation in sheep tracheal strips.

Heterogeneity of alpha 1-adrenoceptor subtypes mediating noradrenaline-induced contractions of the rat superior mesenteric artery

The effects of subtype-selective alpha 1-adrenoceptor antagonists on noradrenaline-induced contractions of ring segments of rat superior mesenteric artery were investigated to determine the subtype(s) of alpha 1-adrenoceptors mediating contractions in this preparation. Noradrenaline-induced contractions of rat mesenteric artery ring segments were potently and surmountably antagonized by prazosin, WB 4101 and BMY 7378. Judging from the slopes of the Schild regression lines, which were significantly different from 1, WB 4101 and BMY 7378 behaved as noncompetitive antagonists. Spiperone and 5-methylurapidil were only effective at high concentrations. Chloroethylclonidine (CEC, 100 mumol/l) displaced the noradrenaline concentration-response curve to the right reducing its potency approximately 100-fold. Noradrenaline-induced contractions post-CEC were also antagonized by prazosin. However, prazosin was less potent against these contractions. A 61,603, a selective alpha 1A-adrenoceptor agonist, contracted ring segments of the mesenteric artery. These contractions were antagonized by prazosin, however with a low affinity, indicating interaction with a low-affinity receptor subtype. It was therefore concluded that alpha 1D- and, possibly, alpha 1L-adrenoceptor subtypes mediated noradrenaline- induced contractions of the rat superior mesenteric artery.

Characterization of alpha-adrenoceptor subtype(s) mediating vasoconstriction in the perfused rabbit ovarian vascular bed

1. alpha 1-Adrenoceptor agonists, noradrenaline, phenylephrine, methoxamine, oxymetazoline and SDZ NVI 085 but not alpha 2-adrenoceptor agonists, UK 14304, tizanidine or clonidine evoked dose-dependent vasoconstriction of the isolated perfused rabbit ovarian vascular bed. The rank order of agonist potency was noradenaline > oxymetazoline > phenylephrine > SDZ NVI 085 > methoxamine. 2. Prazosin (10(-8) M - 10(-5) M) displaced agonist dose-response curves to the right. The pA2/pKB values ranged between 7.27 and 7.66 against noradrenaline, phenylephrine, methoxamine and SDZ NVI 085 and were not significantly different from each other. Prazosin was however significantly less potent against oxymetazoline (pA2 6.38). Yohimbine (10(-6) M - 10(-5) M) was not very effective against any of the agonists. 3. WB 4101 (10(-8) M - 10(-5) M) displaced agonist dose-response curves to the right. The pA2/ pKB values ranged between 7.08 and 7.93 against noradrenaline, phenylephrine, methoxamine and SDZ NVI 085. WB 4101 was significantly less potent against oxymetazoline (pKB 6.85). 4. SZL-49 (5 x 10(-6) M) but not chloroethylclonidine (3 x 10(-5) M) significantly reduced vasoconstrictor responses to all the agonists. 5. Electrical field stimulation of the ovarian bed produced frequency-dependent vasoconstrictor effects which were abolished by 6-OHDA. The responses were also antagonized in a concentration-dependent by prazosin (10(-7) M - 10(-5) M) and WB 4101 (3 x 10(-8) M - 3 x 10(-7) M). Yohimbine reduced the response to electrical stimulation by 20% at 10(-5) M. The vasoconstrictor effect was also inhibited by SZL-49 but not by chloroethylclonidine. 6. These results would suggest that the vasoconstrictor responses of the ovarian vascular bed to adrenergic agonists and to electrical stimulation are mediated via the alpha 1A-adrenoceptor subtype.

Binding of substituted and conformationally restricted derivatives of N-(3-phenyl-n-propyl)-1-phenyl-2-aminopropane at sigma-receptors

Certain benzomorphans, such as N-allylnormetazocine, are classical "sigma-opiates" that bind both at sigma and phencyclidine (PCP) binding sites with modest affinity. Recently, we identified N-substituted 2-phenylaminoethane as being the primary sigma-pharmacophore of the benzomorphans and demonstrated that 1-phenyl-2-aminopropane (2) derivatives, depending upon their terminal amine substituents, constitute a novel class of high-affinity sigma-selective agents. With this pharmacophore, it is shown in the present investigation that the aromatic hydroxyl group (a prime feature of all the sigma-opiates) contributes little to the binding of 2 at sigma-sites. It is also demonstrated that an N-substituted aminotetralin moiety (such as 17, a conformationally restricted analogue of 2) may also be considered a sigma-opiate pharmacophore. Unlike the sigma-opiates, derivatives of 2 and 17 display no affinity for PCP sites and must consequently lack those structural features important for the binding of benzomorphans at PCP sites. Because 3-phenylpiperidines and related sigma-ligands also possess a phenylalkylamine imbedded within their structures, we propose that the 2-phenylaminoethane moiety is a common sigma-pharmacophore for derivatives of 2, the 3-phenylpiperidines, and the sigma-opiates.

Stimulus properties of 1-(3,4-methylenedioxyphenyl)-2-aminopropane (MDA) analogs

Using a standard two-lever operant procedure, groups of rats were trained to discriminate intraperitoneal doses of the phenylisopropylamines (+)amphetamine (1.0 mg/kg) or racemic 1-(2,5-dimethoxy-4-methylphenyl)-2-aminopropane (DOM; 1.0 mg/kg) from saline using a VI 15-sec schedule of reinforcement for food reward. Once trained, the animals were administered doses of several methylenedioxy analogs (MDAs) of phenylisopropylamine including the N-monomethyl [S(+)MDMA and R(-)MDMA], N-monoethyl [(+/-)MDE, S(+)MDE, and R(-)MDE], and the N-hydroxyl [(+/-)N-OH MDA] derivatives. The DOM-stimulus did not generalize to any of these agents. The amphetamine-stimulus generalized to S(+)MDMA, S(+)N-ethylamphetamine and (+/-)N-hydroxyamphetamine, but not to R(-)MDMA, (+/-)MDE, S(+)MDE, R(-)MDE, or N-OH MDA. The present results are consistent with other reports in the literature suggesting that the psychoactive effects of certain MDA derivatives may be other than simply amphetamine- or DOM-like.

Methcathinone: a new and potent amphetamine-like agent

The purpose of the present investigation was to examine the effect of N-monomethylation of phenylisopropylamine derivatives on amphetamine-like activity. In tests of stimulus generalization using rats trained to discriminate 1.0 mg/kg of (+)-amphetamine from saline, the N-monomethyl derivatives of 1-(X-phenyl)-2-aminopropane, where X = 2,4-dimethoxy (2,4-DMA), 3,4-dimethoxy (3,4-DMA), 2,4,5-trimethoxy (2,4,5,-TMA), and 2-methoxy-4,5-methylenedioxy (MMDA-2), did not produce amphetamine-appropriate responding at the doses evaluated. However, the N-monomethyl derivative of cathinone (i.e., methcathinone), like cathinone, resulted in stimulus generalization. Further studies with this agent revealed that (a) in the amphetamine-trained animals, methcathinone (ED50 = 0.37 mg/kg) is more potent than racemic cathinone or racemic amphetamine (ED50 = 0.71 mg/kg in both cases), (b) methcathinone is capable of inducing release of radioactivity from [3H]dopamine-prelabeled tissue of rat caudate nucleus in a manner similar to that observed with cathinone, amphetamine, and methamphetamine, and (c) methcathinone is more potent than cathinone as a locomotor stimulant in mice as determined by their effect on spontaneous activity. The results of the present study provide evidence for a structural analogy between the prototypic psychostimulants amphetamine/methamphetamine and cathinone/methcathinone, and lend further support to the concept that amphetamine and cathinone correspond in their pharmacological effects.

The effect of MDMA ("Ecstasy") and its optical isomers on schedule-controlled responding in mice

Eleven mice were trained to respond under an FR 20 schedule of reinforcement and, after learning the schedule, were administered doses of saline and the following phenylisopropylamines: (+/-)-MDMA, S(+)-MDMA, R(-)-MDMA and (+)-amphetamine. Each of the phenylisopropylamines decreased rates of operant responding in a dose-dependent manner. S(+)-MDMA (ED50 = 3.1 mg/kg) was nearly equipotent with racemic MDMA and four times more potent than R(-)-MDMA (ED50 = 4.1 and 11.6 mg/kg, respectively), but less potent than (+)-amphetamine (ED50 = 0.74 mg/kg). The present study constitutes the first enantiomeric behavioral-potency comparison for the optical isomers of MDMA.

Anaesthetic management of congenital fusion of the jaws in a neonate

Fusion of the jaws in the neonate is a very rare congenital anomaly which may be associated with other congenital defects such as aglossia, facial hemiatrophy or retrognathia. Ventilatory management for surgical separation of the fused jaws presents severe problems. In a recent case of a neonate with almost completely fused jaws requiring general anaesthesia, we used subanaesthetic doses of ketamine in combination with an insufflation technique. It took 45 minutes to reach the surgical stage of anaesthesia due to misplacement of the nasotracheal tube through an unsuspected cleft palate towards a gap between the jaws, a previously unreported combination of complications.