The safety and efficacy of stem cells for the treatment of severe community-acquired bacterial pneumonia: A randomized clinical trial

PURPOSE

Evaluate the safety profile of expanded allogeneic adipose-derived mesenchymal stem cell (eASC) for the treatment of severe community-acquired bacterial pneumonia (CABP).

MATERIALS AND METHODS

Randomized, multicenter, double-blind, placebo-controlled, phase 1b/2a trial. Patients with severe CABP were enrolled to receive intravenous infusions of Cx611 or placebo. The primary objective was safety including hypersensitivity reactions, thromboembolic events, and immunological responses to Cx611. The secondary endpoints included the clinical cure rate, ventilation-free days, and overall survival (Day 90).

RESULTS

Eighty-three patients were randomized and received infusions (Cx611: n = 42]; placebo: n = 41]. The mean age was similar (Cx611: 61.1 [11.2] years; placebo: 63.4 [10.4] years). The number of AEs and treatment-emergent AEs were similar (243; 184 and 2; 1) in Cx611 and placebo respectively. Hypersensitivity reactions or thromboembolic events were similar (Cx611: n = 9; placebo: n = 12). Each study arm had similar anti-HLA antibody/DSA levels at Day 90. The clinical cure rate (Cx611: 86.7%; placebo: 93.8%), mean number of ventilator-free days (Cx611: 12.2 [10.29] days; placebo: 15.4 [10.75] days), and overall survival (Cx611: 71.5%; placebo: 77.0%) did not differ between study arms.

CONCLUSION

Cx611 was well tolerated in severe CABP. These data provide insights for future stem cell clinical study designs, endpoints and sample size calculation.

TRIAL REGISTRATION

NCT03158727 (retrospectively registered: May 09, 2017). Full study protocol: https://clinicaltrials.gov/ProvidedDocs/27/NCT03158727/Prot_000.pdf.

Predictors of mechanical ventilation and mortality in critically ill patients with COVID-19 pneumonia

OBJECTIVE

To determine if potential predictors for invasive mechanical ventilation (IMV) are also determinants for mortality in COVID-19-associated acute respiratory distress syndrome (C-ARDS).

DESIGN

Single center highly detailed longitudinal observational study.

SETTING

Tertiary hospital ICU: two first COVID-19 pandemic waves, Madrid, Spain.

PATIENTS OR PARTICIPANTS

280 patients with C-ARDS, not requiring IMV on admission.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Target: endotracheal intubation and IMV, mortality.

PREDICTORS

demographics, hourly evolution of oxygenation, clinical data, and laboratory results.

RESULTS

The time between symptom onset and ICU admission, the APACHE II score, the ROX index, and procalcitonin levels in blood were potential predictors related to both IMV and mortality. The ROX index was the most significant predictor associated with IMV, while APACHE II, LDH, and DaysSympICU were the most with mortality.

CONCLUSIONS

According to the results of the analysis, there are significant predictors linked with IMV and mortality in C-ARDS patients, including the time between symptom onset and ICU admission, the severity of the COVID-19 waves, and several clinical and laboratory measures. These findings may help clinicians to better identify patients at risk for IMV and mortality and improve their management.

Influence of age on the clinical efficacy of tigecycline in severely ill patients

OBJECTIVES

The aim of this study was to define the relationship between age and response to tigecycline among patients treated for complicated skin and soft-tissue infections (cSSTIs) and complicated intra-abdominal infections (cIAIs).

METHODS

Pooled data derived from five European observational studies on the use of tigecycline (July 2006-October 2011), either as monotherapy or in combination with other antibiotics, for the treatment of cSSTI or cIAI were used in the analysis.

RESULTS

The total population (N=1782 patients) was divided into three age categories: <65 years (804 patients); 65-80 years (836 patients) and >80 years (139 patients) (data unknown/missing for 3 patients). The overall mean Acute Physiology and Chronic Health Evaluation (APACHE) II score for patients with cSSTI and cIAI was 15.0±7.9 and 16.9±7.6, respectively, and the overall mean Sequential Organ Failure Assessment (SOFA) score was 5.8±3.9 and 7.0±4.2, respectively. Overall, patients with cSSTI and cIAI in the three age groups showed a good response to tigecycline treatment (76.2-80.0% and 69.2-81.1%, respectively) with patients aged ≤80 years showing higher response rates. Patients with cIAI appeared to be at greater risk for all types of adverse events compared with those with cSSTI, particularly in the older age groups.

CONCLUSION

In these real-life studies, tigecycline, either alone or in combination, achieved favourable clinical response rates in all age categories of patients with cSSTIs and cIAIs with a high severity of illness.

Big data and machine learning in critical care: Opportunities for collaborative research

The introduction of clinical information systems (CIS) in Intensive Care Units (ICUs) offers the possibility of storing a huge amount of machine-ready clinical data that can be used to improve patient outcomes and the allocation of resources, as well as suggest topics for randomized clinical trials. Clinicians, however, usually lack the necessary training for the analysis of large databases. In addition, there are issues referred to patient privacy and consent, and data quality. Multidisciplinary collaboration among clinicians, data engineers, machine-learning experts, statisticians, epidemiologists and other information scientists may overcome these problems. A multidisciplinary event (Critical Care Datathon) was held in Madrid (Spain) from 1 to 3 December 2017. Under the auspices of the Spanish Critical Care Society (SEMICYUC), the event was organized by the Massachusetts Institute of Technology (MIT) Critical Data Group (Cambridge, MA, USA), the Innovation Unit and Critical Care Department of San Carlos Clinic Hospital, and the Life Supporting Technologies group of Madrid Polytechnic University. After presentations referred to big data in the critical care environment, clinicians, data scientists and other health data science enthusiasts and lawyers worked in collaboration using an anonymized database (MIMIC III). Eight groups were formed to answer different clinical research questions elaborated prior to the meeting. The event produced analyses for the questions posed and outlined several future clinical research opportunities. Foundations were laid to enable future use of ICU databases in Spain, and a timeline was established for future meetings, as an example of how big data analysis tools have tremendous potential in our field.

Efficacy and safety of trimodulin, a novel polyclonal antibody preparation, in patients with severe community-acquired pneumonia: a randomized, placebo-controlled, double-blind, multicenter, phase II trial (CIGMA study)

Purpose

The CIGMA study investigated a novel human polyclonal antibody preparation (trimodulin) containing ~ 23% immunoglobulin (Ig) M, ~ 21% IgA, and ~ 56% IgG as add-on therapy for patients with severe community-acquired pneumonia (sCAP).

Methods

In this double-blind, phase II study (NCT01420744), 160 patients with sCAP requiring invasive mechanical ventilation were randomized (1:1) to trimodulin (42 mg IgM/kg/day) or placebo for five consecutive days. Primary endpoint was ventilator-free days (VFDs). Secondary endpoints included 28-day all-cause and pneumonia-related mortality. Safety and tolerability were monitored. Exploratory post hoc analyses were performed in subsets stratified by baseline C-reactive protein (CRP; ≥ 70 mg/L) and/or IgM (≤ 0.8 g/L).

Results

Overall, there was no statistically significant difference in VFDs between trimodulin (mean 11.0, median 11 [n = 81]) and placebo (mean 9.6; median 8 [n = 79]; p = 0.173). Twenty-eight-day all-cause mortality was 22.2% vs. 27.8%, respectively (p = 0.465). Time to discharge from intensive care unit and mean duration of hospitalization were comparable between groups. Adverse-event incidences were comparable. Post hoc subset analyses, which included the majority of patients (58–78%), showed significant reductions in all-cause mortality (trimodulin vs. placebo) in patients with high CRP, low IgM, and high CRP/low IgM at baseline.

Conclusions

No significant differences were found in VFDs and mortality between trimodulin and placebo groups. Post hoc analyses supported improved outcome regarding mortality with trimodulin in subsets of patients with elevated CRP, reduced IgM, or both. These findings warrant further investigation.

Trial registration: NCT01420744.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5143-7) contains supplementary material, which is available to authorized users.

Track Analysis of the North, Central, and South American Species of the Epicauta maculata Group (Coleoptera: Meloidae)

We undertook a panbiogeographic analysis of 23 species of the Epicauta maculata group of America-Epicauta abeona Pinto, Epicauta adspersa (Klug), Epicauta andersoni Werner, Epicauta atomaria (Germar), Epicauta apache Pinto, Epicauta cavernosa (Courbon), Epicauta dilatipennis Pic, Epicauta fulvicornis (Burmeister), Epicauta horni Champion, Epicauta jeffersi Pinto, Epicauta koheleri Denier, Epicauta lizeri Denier, E. maculata (Say), Epicauta magnomaculata Martin, Epicauta minutepunctata Borchmann, Epicauta nigropunctata (Blanchard), Epicauta normalis Werner, Epicauta ocellata (Dugès), Epicauta pardalis LeConte, picauta phoenix Werner, Epicauta pluvialis Borchmann, Epicauta proscripta Werner, Epicauta rubella Denier, and Epicauta ventralis Werner-with the purpose of analyzing the distributional data for taxa, to establish patterns of distribution of an ancestral biota and areas where these groups have interacted. Based on the overlap of 20 individual tracks, four generalized tracks constituted by different numbers of species were identified; two of them are located in the Nearctic region and the Mexican transition zone (tracks "A" and "B"), and the other two are distributed in the Neotropical region and the South America transition zone ("C", "D"). Six nodes were recognized: Two of them are included in the Nearctic Region, node 'I' located in northern USA and node 'II' located in southwestern USA, both at the intersection of the tracks "A" and "B". The other four are included in the Neotropical Region at the intersection of the tracks "C" and "D": Node 'III' is located in Chaco province; node 'IV' is located in Parana Forest province; node 'V' is located in the northwest of Argentina in Puna province, and node 'VI' is located in Monte province.

Combatting resistance in intensive care: the multimodal approach of the Spanish ICU "Zero Resistance" program

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Efficacy of tigecycline for the treatment of complicated intra-abdominal infections in real-life clinical practice from five European observational studies

OBJECTIVES

Tigecycline is a broad-spectrum antibiotic approved for the treatment of complicated intra-abdominal infections (cIAIs). The efficacy of tigecycline when administered as monotherapy or in combination with other antibacterials in the treatment of cIAIs in routine clinical practice is described.

PATIENTS AND METHODS

Individual patient-level data were pooled from five European observational studies (July 2006 to October 2011).

RESULTS

A total of 785 cIAI patients who received tigecycline were included (mean age 63.1 ± 14.0 years). Of these, 56.6% were in intensive care units, 65.6% acquired their infection in hospital, 88.1% had at least one comorbidity and 65.7% had secondary peritonitis. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores at the beginning of treatment were 16.9 ± 7.6 (n = 614) and 7.0 ± 4.2 (n = 108), respectively, indicating high disease severity. Escherichia coli (41.8%), Enterococcus faecium (40.1%) and Enterococcus faecalis (21.1%) were the most frequently isolated pathogens; 49.1% of infections were polymicrobial and 17.5% were due to resistant pathogens. Overall, 54.8% (n = 430) received tigecycline as monotherapy and 45.2% (n = 355) as combination therapy for a mean duration of 10.6 days. Clinical response rates at the end of treatment were 77.4% for all patients (567/733), 80.6% for patients who received tigecycline as monotherapy (329/408), 75.2% for patients with a nosocomial infection (354/471), 75.8% for patients with an APACHE II score >15 (250/330) and 54.2% (32/59) for patients with a SOFA score ≥ 7.

CONCLUSIONS

In these real-life studies, tigecycline, alone and in combination, achieved favourable clinical response rates in patients with cIAI with a high severity of illness.

Safety and tolerability of tigecycline for the treatment of complicated skin and soft-tissue and intra-abdominal infections: an analysis based on five European observational studies

OBJECTIVES

Tigecycline is approved for the treatment of complicated skin and soft-tissue infections (cSSTIs) and complicated intra-abdominal infections (cIAIs) in adults. In this analysis the safety and tolerability profile of tigecycline (used alone or in combination) for the treatment of patients with approved indications of cSSTI and cIAI were examined under real-life clinical conditions.

PATIENTS AND METHODS

Individual patient-level data were pooled from five European observational studies (July 2006 to October 2011). A total of 254 cSSTI and 785 cIAI patients were included. The mean age was 63 years; 34.4% and 56.6% were in intensive care units, 90.9% and 88.1% had at least one comorbidity and mean Acute Physiology and Chronic Health Evaluation (APACHE) II scores at the beginning of treatment were 15.0 ± 7.9 and 16.9 ± 7.6, respectively.

RESULTS

Data on adverse events (AEs) were available for 198 cSSTI and 590 cIAI patients in three studies. Nausea and vomiting were reported in ≤ 2% of patients. The most common serious AEs were multi-organ failure (4.0% and 10.0% in cSSTI and cIAI patients, respectively) and sepsis (4.0% and 6.1%, respectively). Death was recorded for 24/254 (9.4%) cSSTI and 147/785 (18.7%) cIAI patients. Mortality rates were higher in the group with a baseline APACHE II score of >15 compared with those with a score of ≤ 15 (18.7% versus 3.5% for cSSTI patients and 23.8% versus 16.0% for cIAI patients). A similar trend was seen when cIAI patients were stratified by Sequential Organ Failure Assessment (SOFA) score.

CONCLUSIONS

The safety and tolerability of tigecycline, alone and in combination, are consistent with the level of critical illness among patients in these real-life studies.

Efficacy of tigecycline for the treatment of complicated skin and soft-tissue infections in real-life clinical practice from five European observational studies

OBJECTIVES

Tigecycline is an approved treatment for complicated skin and soft-tissue infections (cSSTIs). The efficacy of tigecycline as monotherapy or in combination with other antibacterials in the treatment of cSSTI in routine practice is described.

PATIENTS AND METHODS

Individual patient-level data were pooled from five European observational studies (July 2006 to October 2011).

RESULTS

A total of 254 cSSTI patients who received tigecycline were included (mean age 63.2 ± 14.9 years). Of these, 34.4% were in intensive care units, 54.5% acquired their infection in hospital and 90.9% had at least one comorbidity. Infection most commonly affected the limbs (62.4%) and 43.8% of infections were classified as necrotizing. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores at the beginning of treatment were 15.0 ± 7.9 (n = 205) and 5.8 ± 3.9 (n = 32), respectively, indicating high disease severity. Staphylococcus aureus (52.7%), Escherichia coli (18.0%) and Enterococcus faecium (12.0%) were the most frequently isolated pathogens; 32.9% of infections were polymicrobial and 30.5% were due to resistant pathogens. Overall, 71.8% received tigecycline as monotherapy and 28.2% as combination therapy for a mean duration of 12 days. Clinical response rates at the end of treatment were 79.6% for all patients who received the standard dosage (183/230), 86.7% for patients who received tigecycline as monotherapy (143/165), 75.0% for patients with a nosocomial infection (96/128), 75.3% for patients with an APACHE II score >15 (61/81) and 58.3% for patients with a SOFA score ≥ 7 (7/12).

CONCLUSIONS

In these real-life studies, tigecycline, alone and in combination, achieved favourable clinical response rates in patients with cSSTI with a high severity of illness.

Prescription behaviours for tigecycline in real-life clinical practice from five European observational studies

OBJECTIVES

There is limited information on the use of tigecycline in real-life clinical practice. This analysis aims to identify and understand tigecycline prescribing patterns and associated patient outcomes for approved indications.

PATIENTS AND METHODS

A pooled analysis of patient-level data collected on the prescription of tigecycline in five European observational studies (July 2006 to October 2011) was conducted.

RESULTS

A total of 1782 patients who received tigecycline were included in the analysis. Of these patients, 61.6% were male, the mean age was 63.4 ± 14.7 years, 56.4% were in intensive care units, 80.2% received previous antibiotic treatment and 91% had one or more comorbid conditions. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores at the beginning of treatment were 17.7 ± 7.9 and 7.0 ± 4.0, respectively. The majority of patients (58.3%) received tigecycline for treatment of complicated skin and soft-tissue infections (cSSTIs; n = 254) or complicated intra-abdominal infections (cIAIs; n = 785). Tigecycline was given at the standard dose (100 mg plus 50 mg twice daily) to 89.3% of patients for a mean duration of 11.1 ± 6.4 days. The main reasons for prescribing tigecycline were failure of previous therapy (46.1%), broad-spectrum antibiotic coverage (41.4%) and suspicion of a resistant pathogen (39.3%). Tigecycline was prescribed first-line in 36.3% of patients and as monotherapy in 50.4%. Clinical response rates to treatment with tigecycline alone or in combination were 79.6% (183/230; cSSTIs) and 77.4% (567/733; cIAIs).

CONCLUSIONS

Although tigecycline prescription behaviour showed some heterogeneity across the study sites, these results confirm a role for tigecycline in real-life clinical practice for the treatment of complicated infections, including those in critically ill patients, across Europe.

Resistance mechanisms and epidemiology of multiresistant pathogens in Europe and efficacy of tigecycline in observational studies

OBJECTIVES

Antimicrobial drug resistance is a growing problem in Europe and, even with differences in epidemiology, it is of great concern. The treatment of complicated skin and soft-tissue infections (cSSTIs) and complicated intra-abdominal infections (cIAIs) is hindered further by pathogens that are resistant to methicillin, carbapenems, third-generation cephalosporins and glycopeptides.

PATIENTS AND METHODS

An analysis of the microbiological results from five European observational studies (July 2006 to October 2011) evaluating the efficacy of tigecycline (prescribed as monotherapy or in combination with other antibacterials) for the treatment of cSSTI and cIAI is presented.

RESULTS

In total, 213 cSSTI and 623 cIAI patients were included; 34.4% and 56.6%, respectively, were critically ill in intensive care units. At baseline, at least one pathogen was isolated in 167 (78.4%) cSSTI and 464 (74.5%) cIAI patients, and 32.9% and 49.1% of infections were polymicrobial. In cSSTI, Staphylococcus aureus and Escherichia coli (52.7% and 18.0%, respectively) were the most frequently isolated pathogens, whereas in cIAI most infections were due to E. coli (41.8%), Enterococcus faecium (40.1%) and Enterococcus faecalis (21.1%). Clinical response was observed in >80% of patients with E. coli in both cIAI and cSSTI. In cSSTI patients, the clinical response rate to S. aureus was 80.8%. For cIAI, 77.4% of E. faecium and 79.5% of E. faecalis patients responded to treatment.

CONCLUSIONS

Tigecycline when given alone or in combination with other antibacterials appeared to be efficacious against multiple pathogens, affirming its role in real-life clinical practice as a broad-spectrum antibacterial for the treatment of patients with cSSTI and cIAI, including the critically ill, across Europe.

BAY41-6551 achieves bactericidal tracheal aspirate amikacin concentrations in mechanically ventilated patients with Gram-negative pneumonia

PURPOSE

To conduct a multicenter, randomized, placebo-controlled, double-blind, phase II study of BAY41-6551 (NCT01004445), an investigational drug-device combination of amikacin, formulated for inhalation, and a proprietary Pulmonary Drug Delivery System, for the treatment of Gram-negative pneumonia in mechanically ventilated patients.

METHODS

Sixty-nine mechanically ventilated patients with Gram-negative pneumonia, a clinical pulmonary infection score ≥6, at risk for multidrug-resistant organisms, were randomized to BAY41-6551 400 mg every 12 h (q12h), 400 mg every 24 h (q24h) with aerosol placebo, or placebo q12h for 7-14 days, plus standard intravenous antibiotics. The combined primary endpoint was a tracheal aspirate amikacin maximum concentration ≥6,400 μg/mL (25 × 256 μg/mL reference minimum inhibitory concentration) and a ratio of area under the aspirate concentration-time curve (0-24 h) to minimum inhibitory concentration ≥100 on day 1.

RESULTS

The primary endpoint was achieved in 50% (6/12) and 16.7% (3/18) of patients in the q12h and q24h groups, respectively. Clinical cure rates, in the 48 patients getting ≥7 days of therapy, were 93.8% (15/16), 75.0% (12/16), and 87.5% (14/16) in the q12h, q24h, and placebo groups, respectively (p = 0.467). By the end of aerosol therapy, the mean number of antibiotics per patient per day was 0.9 in the q12h, 1.3 in the q24h, and 1.9 in the placebo groups, respectively (p = 0.02 for difference between groups). BAY41-6551 was well tolerated and attributed to two adverse events in one patient (mild bronchospasm).

CONCLUSIONS

BAY41-6551 400 mg q12h warrants further clinical evaluation.

Clinical outbreak of linezolid-resistant Staphylococcus aureus in an intensive care unit

CONTEXT

Linezolid resistance is extremely uncommon in Staphylococcus aureus.

OBJECTIVE

To report an outbreak with linezolid and methicillin-resistant S. aureus (LRSA) in an intensive care department and the effective control measures taken.

DESIGN, SETTING, AND PATIENTS

Outbreak study of consecutive critically ill patients colonized and/or infected with LRSA at an intensive care department of a 1000-bed tertiary care university teaching hospital in Madrid, Spain. Patients were placed under strict contact isolation. Daily updates of outbreak data and recommendations for the use of linezolid were issued. Extensive environmental sampling and screening of the hands of health care workers were performed.

MAIN OUTCOME MEASURES

Linezolid use and clinical and epidemiological characteristics and outcomes using minimal inhibitory concentrations, pulsed-field gel electrophoresis, and polymerase chain reaction of LRSA isolates.

RESULTS

Between April 13 and June 26, 2008, 12 patients with LRSA were identified. In 6 patients, LRSA caused ventilator-associated pneumonia and in 3 patients it caused bacteremia. Isolates were susceptible to trimethoprim-sulfamethoxazole, glycopeptides, tigecycline, and daptomycin. Genotyping identified 1 predominant clone and 3 other types. Cfr-mediated linezolid resistance was demonstrated in all isolates. Potential hospital staff carriers and environmental samples were negative except for one. Six patients died, 5 of them in the intensive care unit, with 1 death attributed to LRSA infection. Linezolid use decreased from 202 defined daily doses in April 2008 to 25 defined daily doses in July 2008. Between July 2008 and April 2010, no new cases have been identified in the weekly surveillance cultures or diagnostic samples.

CONCLUSIONS

The first clinical outbreak, to our knowledge, with LRSA mediated by the cfr gene developed at our center, was associated with nosocomial transmission and extensive usage of linezolid. Reduction of linezolid use and infection-control measures were associated with the termination of the outbreak.

[Clinical spectrum of invasive candidiasis in critically ill non-neutropenic patients]

Invasive Candida spp. infections in non-neutropenic critically ill patients admitted to intensive care units can be classified as focal and systemic. Both types of infection usually occur after episodes of candidemia, although some focal infections may be of exogenous development, like those occurring after trauma or be device-related.The clinical spectrum of invasive Candida spp. infections includes focal urinary tract, abdominal, ocular, respiratory tract, renal and hepato-biliary infections, as well as systemic infections like candidemia and acute systemic candidiasis with multiorgan involvement after hematogenous seeding. Candida spp. isolates in "significant" samples, like synovial fluid, cerebrospinal fluid and blood cultures, represent true infection. However, the diagnosis of invasive infection based on "non-significant" samples, like surgical drains and digestive tract exudates, requires additional criteria. The total number of isolates from different sites, the presence of risk factors, the clinical host response, as well as severity of illness need to be taken into account for the diagnosis of invasive candidiasis. The clinical signs of systemic infection due to Candida spp. are completely non-specific and cannot be differentiated from bacterial peritonitis, urinary tract infection or bacteremia. These infections may be associated with signs of sepsis,severe sepsis, septic shock or multiorgan dysfunction. In the future clinical multicentre observational and interventional studies are necessary to reach agreement on clinical definitions and classification of invasive Candida spp. infections in critically ill non-immunocompromised patients.

A Randomized Double-Blind Trial of Iseganan in Prevention of Ventilator-associated Pneumonia

RATIONALE

Iseganan, an antimicrobial peptide, is active against aerobic and anaerobic gram-positive and gram-negative bacteria as well as fungi and yeasts. The drug has shown little resistance in vitro and to be safe and well tolerated in 800 patients with cancer treated for up to 6 wk.

OBJECTIVES

To determine the efficacy of iseganan for the prevention of ventilator-associated pneumonia (VAP).

METHODS

Mechanically ventilated patients in the United States and Europe were randomized to oral topical iseganan or placebo (1:1) and treated six times per day while intubated for up to 14 d. Patients were eligible if randomized within 24 h of intubation and estimated to survive and remain mechanically ventilated for 48 h or more. The primary efficacy endpoint of the study was VAP measured among survivors at Day 14.

MEASUREMENTS AND MAIN RESULTS

A total of 709 patients were randomized and received at least one dose of study drug. The two groups were comparable at baseline except iseganan-treated patients were, on average, 3 yr older. The rate of VAP among survivors at Day 14 was 16% (45/282) in patients treated with iseganan and 20% (57/284) in those treated with placebo (p = 0.145). Mortality at Day 14 was 22.1% (80/362) in the iseganan group compared with 18.2% (63/347) in the placebo group (p = 0.206). No pattern of excess adverse events in the iseganan group compared with placebo was observed.

CONCLUSIONS

Iseganan is not effective in improving outcome in patients on prolonged mechanical ventilation.

Determination of zinc (II) in pharmaceuticals based on a flow-through bulk optode

A method based on flow injection (FI), was applied for the determination of Zn (II) using a flow-through bulk optode membrane that incorporates 1-(2-pyridylazo)-2-naphthol in a plasticized poly (vinyl chloride) membrane entrapped in a cellulose support. The calibration graph plotting the reflectance at 562 nm versus [Zn (II)] was linear in the range 0.16-3.27 mgl(-1) (2.5 x 10(-6)-5 x 10(-5) M) with a detection limit of 0.10 mgl(-1). The variation coefficients of the sensor response for 0.33 mgl(-1) of Zn (II) were +/-0.11% for consecutive measurements (n=10), +/-0.19% between days (n=5) and +/-0.22% between different membranes (n=6). The sensor can be readily regenerated with the same acetic/acetate carrier of pH 3.9. The FI method proposed was applied to the determination of zinc (II) in pharmaceuticals.

Development of a new flow-through bulk optode for the determination of manganese(II)

A flow-through bulk optode based on the use of 1-(2-pyridylazo)-2-naphthol (PAN) immobilized in a plasticized poly(vinyl chloride) membrane entrapped in a cellulose support, in conjuntion with the flow injection analysis technique, is proposed for the determination of manganese(II). The calibration graph obtained at 570 nm was linear in the range 0.27-27.5 mg L(-1) (5 x 10(-6)-5 x 10(-4) M) Mn(II) with a detection limit of 0.18 mg L(-1). The coefficients of variation of the sensor response for 5.5 mg L(-1) of Mn(II) were +/-0.22% for consecutive measurements (n = 10), +/-0.48% between days (n = 5) and +/-0.38% between different membranes (n = 6). The sensor was readily regenerated with the carrier acetic acid/acetate buffer of pH 4.5. The method was applied to the determination of manganese in steels, waters and lemon tree leaves.

Spectrophotometric methods for determining meloxicam in pharmaceuticals using batch and flow-injection procedures

Two sensitive and fast spectrophotometric methods using batch and flow-injection procedures for the determination of meloxicam (MX) are proposed. The methods are based on the formation of a green complex between this drug and Fe(III) [2MX/Fe(III)] in a methanolic medium. The calibration graphs resulting from measuring the absorbance at 570 nm are linear over the ranges 2.0-200 and 5.00-250 mg l(-1) with detection limits of 0.47 and 0.72 mg l(-1), respectively. Furthermore, a flow-injection spectrophotometric method involving measurement of the absorbance of the drug at 362 nm in 0.1 M NaOH is presented. The calibration graph is linear over the range 0.5-20 mg l(-1) with a detection limit of 0.04 mg l(-1). The methods are applied to the routine analysis of MX in pharmaceuticals.

Flow-injection spectrophotometric methods for the determination of tenoxicam

Two sensitive and rapid flow-injection spectrophotometric methods are proposed for the determination of tenoxicam (TX). In the first method, a Fe(III)-tenoxicam complex is formed in a methanolic medium and the absorbance is measured at 540 nm, while the second method involves measurement of the absorbance at 355 nm of a solution containing the drug in hydrochloric acid medium. In both methods, the peak heights were proportional to tenoxicam concentration over the ranges 7.0-320 and 0.5-8.5 mg/l(-1), respectively. The methods have been applied to the routine determination of the drug in dosage forms.

[Electro-clinical and neuroimaging studies in epilepsy in elderly patients]

INTRODUCTION

Due to the aging population in developed countries, epidemiological studies show an increasing tendency to the prevalence of epilepsy in the elderly.

PATIENTS AND METHODS

During 54 months, we have studied the electroclinical and neuroimaging features in outpatients older than 60, with active epilepsy. Every patient was interviewed by one of the authors. Then, we have reviewed the medical records about the clinical features, EEG and neuroimaging (NI) studies and seizures frequency (SF) outcome. Differences in crude proportions were assessed by chi 2 test for independence by 2 x 2 tables.

RESULTS

The study was been performed in 78 patients with 70.3 +/- 7.3 years of mean age at review. Partial seizures were significantly related with an higher SF at onset and, in the series of complex partial seizures was more frequent a temporal EEG topography. There was predominance of men, NI abnormal, symptomatic etiology and SF at onset > or = 1 by day in that patients who started their epilepsy after 60 years. A 51.3% was seizures-free in the last year and in 80% the SF was improved a 50% or more from the beginning.

CONCLUSION

A significantly greater percentage of patients remained with seizures in four cases: in those with a SF at onset greater than 1 every day, in those suffering complex partial seizures, in women and in patients with temporal EEG topography.

Simultaneous determination of piroxicam and its major metabolite 5'-hydroxypiroxicam in human plasma by derivative spectrophotometry

A first-derivative spectrophotometric method for the simultaneous determination of piroxicam (PX) and its major metabolite 5'-hydroxypiroxicam (OH PX) in human plasma is described. The method consists of direct extraction of the two drugs from the plasma samples with hydrochloric and trichloroacetic acid prior to their determination by measuring the first-derivative signals at 337.0 nm for PX and at 327.0 nm for OHPX (zero-crossing wavelength). The calibration graphs were linear up to 10.0 and 8.0 mg l-1 of PX and OH PX, respectively, and the limits of quantification were 0.27 and 0.56 mg l-1. The possible interfering effects of other substances were studied.

Flow-injection spectrophotometric determination of diclofenac sodium in pharmaceuticals and urine samples

A sensitive and fast flow-injection spectrophotometric method for the determination of diclofenac sodium based on the formation of coloured compound with Ce(IV)-3-methyl-2-benzothiazolinone hydrazone hydrochloride (MBTH) in H2SO4 3 x 10(-2) M medium is proposed. Using the peak height as a quantitative parameter diclofenac was determined at 580 nm over the range 0.20-8.0 micrograms ml-1. The proposed method was successfully applied to the determination of diclofenac in pharmaceuticals and urine samples.

Spectrophotometric methods for the determination of cephradine or ceftazidine in human urine using batch and flow-injection procedures

Sensitive and fast spectrophotometric methods for the determination of cephradine or ceftazidine in human urine, based on the formation of compounds between these drugs and Pd(II), are described. In the batch procedures the calibration graphs resulting from the measurement of the absorbance at 330 nm is linear over the range 5.0-60.0 micrograms. ml-1 for cephradine and 3.0-60.0 micrograms ml-1 for ceftazidine. The methods were successfully adapted to FI-systems, the peak heights being proportional to cephalosporin concentration over the range 5.0-60.0 micrograms ml-1 for cephradine and 3.0-60.0 micrograms ml-1 for ceftazidine. The sampling frequency was 60 h-1 with a sample injection of 72 microliters.

Flow-injection spectrophotometric determination of frusemide or sulphathiazole in pharmaceuticals

Two sensitive and fast flow-injection spectrophotometric methods are proposed for the determination of frusemide or sulphathiazole based on the formation of coloured complexes between these compounds and Pd(II) at pH 5.0 and 55 degrees C. Using the peak height as a quantitative parameter, frusemide or sulphathiazole was determined at 410 nm over the range 2.0 x 10(-5)-4.0 x 10(-4) M or 5.0 x 10(-5)-3 x 10(-4) M, respectively. The methods were applied to the determination of these sulphonamides in pharmaceuticals.

Myocardial infarction and cardiovascular risk factors in Mexico City and San Antonio, Texas

Because the epidemiology of cardiovascular disease in Mexico is largely unknown, we examined the prevalence of cardiovascular risk factors and myocardial infarction (MI) in adults from low-income colonias in Mexico City. Data were collected as part of the Mexico City Diabetes Study, a population-based survey of diabetes and cardiovascular disease conducted between 1987 and 1992. Results were compared with those obtained from a comparable survey conducted previously among low-income Mexican Americans in San Antonio, Tex. A total of 2271 individuals between the ages of 35 and 64 years from Mexico City and 1143 adults of the same age range from San Antonio were studied. Despite being leaner and having lower levels of total cholesterol, Mexicans in Mexico City had markedly higher levels of triglycerides (P < .001) and lower levels of HDL cholesterol (P < .001) than Mexican Americans in San Antonio. MI was assessed by Minnesota-coded electrocardiograms and by a self-reported history of physician-diagnosed heart attack. In men, the prevalence of self-reported heart attack was significantly higher in San Antonio than in Mexico City (odds ratio, 5.85; P < .001), and in women, the prevalence of electrocardiogram-documented MI was significantly higher in San Antonio than Mexico City (odds ratio, 2.51; P < .001). The apparent excess of MI in San Antonio relative to Mexico City could be due to higher case-fatality in Mexico City or to a higher incidence in San Antonio.

Determination of captopril in pharmaceutical samples by flow injection analysis

A flow injection spectrophotometric method for the determination of captopril involving measurement of the absorbance of the captopril complex with palladium(II) in a 0.12 M HCl medium at 400 nm is presented. The calibration graph was linear over the range 2 x 10(-5)-6 x 10(-4) M. The sampling frequency was 90 h-1 with sample injections of 70 microliters. The proposed method was applied to the determination of captopril in pharmaceutical samples.

Circulating immune complexes in breast and lung cancer, before and after chemotherapy

Circulating immune complexes (CIC) levels were evaluated in two groups of cancerous patients to try to correlate CIC levels, tumor stage and chemotherapy received. There were 40 patients with Lung Cancer (LC) clinical stages III and IV; 60 patients with Breast Cancer (BC) stages II, III and IV and 38 normal controls. LC patients showed significant increase in CIC values before, during and after treatment as compared to controls, without any difference among groups under different treatment combinations and tumor stage. Stage II BC patients showed decreased CIC levels during treatment (p less than 0.01 vs initial value). This decrease was maintained after treatment (p less than 0.02). Stage III BC patients showed different behaviour according to treatment: those who only received chemotherapy (ADM + CTX) showed no significant differences during treatment, and those treated with ADM + CTX and megestol acetate (MA) displayed decreased CIC levels after treatment (p less than 0.05) reaching similar control values. Stage IV patients treated with ADM + CTX + MA returned to normal CIC values during treatment. These results proved that combined treatment of chemotherapy and hormone therapy diminished CIC levels in BC patients, while therapy given to LC patients did not present any modifications.

[Effect of BCG on the growth rate of Sarcoma in normal and splenectomized mice]

A study was carried out on the growth of Sarcoma 180 alone or mixed with BCG in normal and splenectomized BALB/c mice, with or without previous immunization with BCG intradermally (id), 40 days before tumor challenge. No survival was observed in non splenectomized mice inoculated with Sarcoma 180, both in normal mice and in those previously treated with BCG, whereas the inoculation of Sarcoma 180 mixed with BCG produced a 37 % increase in the survival rate in normal animals and an 83 % increase in the group previously treated with BCG. In splenectomized mice the survival rate was 56 % in those inoculated with Sarcoma 180 alone, rising to 100 % in the group inoculated with Sarcoma 180 mixed with BCG. Previous immunization with BCG in splenectomized animals did not affect tumor incidence significantly. These results suggest the participation of the spleen in the mechanism of tumoral rejection favoured by BCG inoculation.