External Validation of Obese/Critically Ill Vancomycin Population Pharmacokinetic Models in Critically Ill Patients Who Are Obese

Obesity combined with critical illness might increase the risk of acquiring infections and hence mortality. In this patient population the pharmacokinetics of antimicrobials vary significantly, making antimicrobial dosing challenging. The objective of this study was to assess the predictive performance of published population pharmacokinetic models of vancomycin in patients who are critically ill or obese for a cohort of critically ill patients who are obese. This was a multi-center retrospective study conducted at 2 hospitals. Adult patients with a body mass index of ≥30 kg/m2 were included. PubMed was searched for published population pharmacokinetic studies in patients who were critically ill or obese. External validation was performed using Monolix software. A total of 4 models were identified in patients who were obese and 5 models were identified in patients who were critically ill. In total, 138 patients who were critically ill and obese were included, and the most accurate models for these patients were the Goti and Roberts models. In our analysis, models in patients who were critically ill outperformed models in patients who were obese. When looking at the most accurate models, both the Goti and the Roberts models had patient characteristics similar to ours in terms of age and creatinine clearance. This indicates that when selecting the proper model to apply in practice, it is important to account for all relevant variables, besides obesity.

Recurrent ciprofloxacin induced hypoglycemia in a non-diabetic patient: A case report

BACKGROUND

Fluoroquinolones are a class of broad-spectrum antimicrobials used for various bacterial infections. Frequent use of fluoroquinolones has been questioned due to severe associated adverse effects, including dysglycemia (hypoglycemia or hyperglycemia) due to an alternation in glucose metabolism. Recent clinical trials showed the association of poor clinical outcomes with hypoglycemia in critically ill patients without diabetes. Many predisposing factors worsen fluoroquinolone-induced hypoglycemia, including diabetes, concomitant medication use like sulfonylureas or insulin, renal disease, and the elderly.

CASE SUMMARY

We report a case of recurrent hypoglycemia after ciprofloxacin initiation for a 71-year-old, non-diabetic, critically ill patient despite the presence of total parenteral nutrition and nasogastric tube feeding. The adverse drug reaction probability (Naranjo) scale was completed with a probable adverse drug reaction. The hypoglycemia resolved entirely after ciprofloxacin discontinuation.

CONCLUSION

Although ciprofloxacin-induced hypoglycemia is rare, special consideration is needed for the elderly due to their higher susceptibility to adverse side effects.

Role of Salvia officinalis Silver Nanoparticles in Attenuation Renal Damage in Rabbits Exposed to Methotrexate

Nanomaterials are now considered in an extensive range of applications in various fields such as biotechnology and biomedicine. The present study aimed to investigate the protective role of Salvia officinalis Silver Nanoparticles (SOSNPs) as an anti-oxidant on nephrotic damage induced by methotrexate (MTX) in adult rabbits. Green silver nanoparticles were synthesized using alcoholic extract of Salvia officinalis (S. Officinalis) leaves and were characterized by UV-spectrophotometry and scanning electron microscope. The mixing of the plant extract of S. Officinalis with silver nitrate solution leads to the change of the reaction mixture color to yellowish within 1 h and dark brown after 8 h. For studying the protective role of SOSNPs, a total of 28 adult Wistar albino rabbits were divided into four groups and treated intramuscularly (twice per week) for 45 days as follows: T1: S. Officinalis (150 mg/kg B.W), T2: SOSNPs (150 mg/kg B.W); T3: MTX (0.25 mg/kg B.W) and SOSNPs (150 mg/kg B.W); T4: MTX (0.25 mg/kg B.W). Blood was collected at 0, 15, 30, and 45 days using retro-orbital sinus and cardiac puncture technique, and the serum factors including malondialdehyde (MDA), glutathione (GSH) in serum, creatinine, as well as blood urea nitrogen and uric acid concentrations were measured at the next step. The results indicated that MTX (T4) caused a case of oxidative stress by a significant decrease in GSH and MDA as well as an increase in serum creatinine, urea, and uric acid concentrations. On the other hand, the protective roles of S. Officinalis and SOSNPs given concurrently with MTX were clarified in T2 and T3 groups, where there was the alleviation of renal damage through the correction of the previously mentioned parameters as well as the correction of anti-oxidant status. Finally, the present study documented the anti-oxidant activity and renal protective effects of SOSNPs against the damaging effects of MTX in rabbits.

Pharmacokinetics of meropenem in critically ill patients in Saudi Arabia

Background

Meropenem is commonly used in the ICU to treat gram-negative infections. Due to various pathophysiological changes, critically ill patients are at higher risk of having subtherapeutic concentrations and hence have a higher risk of treatment failure—especially in regions where gram-negative drug resistance is increasing, such as Saudi Arabia. No studies have evaluated the pharmacokinetics of meropenem in critically ill patients in Saudi Arabia. Our primary objective is to assess the percentage of patients achieving the therapeutic target for meropenem.

Methods

This prospective observational study was conducted in the ICUs of King Khalid University Hospital. Patient were included if >18 years-of-age and received meropenem for a clinically suspected or proven bacterial infection. The primary outcome was to assess the percentage of patients who achieved the pharmacokinetic/pharmacodynamic (PKPD) therapeutic target of a free trough concentration four times the MIC. The secondary outcome was to estimate the pharmacokinetics of meropenem. Pharmacokinetic analysis was performed using Monolix Suite 2020R1 (Lixoft, France).

Results

Trough concentrations were highly variable and ranged from <0.5 µg/mL to 39 µg/mL, with a mean ± SD trough concentration of 8.5 ± 8 µg/mL. Only 46% of patients achieved the therapeutic target. The only significant predictor of failing to achieve the PKPD target was augmented renal clearance.

Conclusion

In conclusion, more than half of our patients did not achieve the PKPD target. Thus, there is a need for better dosing strategies of meropenem in critically ill patients in Saudi Arabia such as extended and continuous infusion.

Assessment of anti-factor Xa activity in critically ill COVID-19 patients receiving three different anticoagulation regimens

Introduction:

Critically ill COVID-19 patients are at increased risk of thrombosis with an enhanced risk of bleeding. We aimed to explore the role of anti-factor Xa levels in optimizing the high-intensity anticoagulation’s safety and efficacy and finding possible associations between D-dimer levels, cytokine storm markers, and COVID-19-induced coagulopathy or thrombophilia.

Methods:

Retrospective cohort study conducted on 69 critically ill COVID-19 patients who received three regimens of higher intensity anticoagulation.

Results:

Seventeen patients (24.6%) received high-dose enoxaparin prophylaxis, 29 patients (42%) received therapeutic doses of enoxaparin, and 23 patients (33.3%) were on therapeutic unfractionated heparin infusion. Fewer than one-third of the whole cohort (n = 22; 31.8%) achieved the target range of anti-factor Xa. The patients were divided into three subgroups based on anti-factor Xa target status within each anticoagulation regimen; when compared, the only association observed among them was for interleukin-6 levels, which were significantly higher in both the “above the expected range” and “below the expected range” groups compared with the “within the expected range” group (p = 0.009). Major bleeding episodes occurred in 14 (20.3%) patients and were non-significantly more frequent in the “below the expected anti-factor Xa range group” (p = 0.415). Seven patients (10.1%) developed thrombosis. The majority of patients had anti-factor Xa levels below the expected ranges (four patients, 57.1%).

Conclusion:

Conventional anti-factor Xa ranges may not be appropriate as a predictive surrogate for bleeding in critically ill COVID-19. The clinical decision to initiate therapeutic anticoagulation preemptively may be individualized according to thrombosis and bleeding risks. Cytokine storm markers, namely, interleukin-6, may play a role in COVID-19-induced coagulopathy or thrombophilia.

Assessment of anti-factor Xa activity in critically ill COVID-19 patients receiving three different anticoagulation regimens

Introduction:

Critically ill COVID-19 patients are at increased risk of thrombosis with an enhanced risk of bleeding. We aimed to explore the role of anti-factor Xa levels in optimizing the high-intensity anticoagulation’s safety and efficacy and finding possible associations between D-dimer levels, cytokine storm markers, and COVID-19-induced coagulopathy or thrombophilia.

Methods:

Retrospective cohort study conducted on 69 critically ill COVID-19 patients who received three regimens of higher intensity anticoagulation.

Results:

Seventeen patients (24.6%) received high-dose enoxaparin prophylaxis, 29 patients (42%) received therapeutic doses of enoxaparin, and 23 patients (33.3%) were on therapeutic unfractionated heparin infusion. Fewer than one-third of the whole cohort ( n = 22; 31.8%) achieved the target range of anti-factor Xa. The patients were divided into three subgroups based on anti-factor Xa target status within each anticoagulation regimen; when compared, the only association observed among them was for interleukin-6 levels, which were significantly higher in both the “above the expected range” and “below the expected range” groups compared with the “within the expected range” group ( p = 0.009). Major bleeding episodes occurred in 14 (20.3%) patients and were non-significantly more frequent in the “below the expected anti-factor Xa range group” ( p = 0.415). Seven patients (10.1%) developed thrombosis. The majority of patients had anti-factor Xa levels below the expected ranges (four patients, 57.1%).

Conclusion:

Conventional anti-factor Xa ranges may not be appropriate as a predictive surrogate for bleeding in critically ill COVID-19. The clinical decision to initiate therapeutic anticoagulation preemptively may be individualized according to thrombosis and bleeding risks. Cytokine storm markers, namely, interleukin-6, may play a role in COVID-19-induced coagulopathy or thrombophilia.

Clinical, molecular and cytopathological characterization of a Newcastle disease virus from an outbreak in Baghdad, Iraq

BACKGROUND

The frequent outbreaks of Newcastle disease virus (NDV) in Iraq pose a constant threat to commercial poultry, despite the introduction of routine vaccination programmes. Several factors, particularly stress factors and coinfections, might play a role in increasing NDV outbreaks in poultry species.

OBJECTIVES

The current study was aimed to characterize an NDV isolate from an outbreak in North Baghdad, Iraq.

METHODS

Clinical pathogenicity of the isolate was determined experimentally in chickens. In vitro studies included cytopathological examination, as well as molecular and phylogenetic analyses.

RESULTS

Based on the clinical studies and pathogenicity indices (mean death time and intracerebral and intravenous pathogenicity indices), the isolate was characterized as velogenic (highly virulent). Reverse transcriptase polymerase chain reaction targeting the partial fusion protein gene of the NDV genome confirmed the detection. Partial sequencing of the hypervariable region of the fusion gene identified the presence of an avirulent (lentogenic) fusion protein motif (GRQGRL). Phylogenetic analysis of the new isolate along with previously known regional isolates revealed that the new isolate was related to genotype II strains. Additionally, sequence analysis indicated a distinct genetic lineage of the new isolate, which was related to some of the lineages identified in previous outbreaks in the Middle East.

CONCLUSION

The current study offers essential information on the epidemiology, characteristics and diagnosis of NDV for disease control in Iraq. The isolate was found to belong to genotype II and possess an avirulent fusion protein motif.

Molecular Epidemiology of Bovine Papillomatosis and Identification of Three Genotypes in Central Iraq

OBJECTIVE

This study aims to provide a molecular and epidemiological characterization of bovine papillomavirus (BPV) infections in Iraq.

METHODS

The present study focuses on identifying BPV based on clinical and epidemiological manifestations, histopathological examinations, and polymerase chain reactions (PCR). Samples were collected from 163 animals suffering from cutaneous bovine papillomatosis, including 129 females (79.14%) with an age range of 16-40 months and 34 males (20.85%) with an age range of 17-29 months.

RESULTS

The incidence rate was significantly higher in females than in males. The most commonly affected sites were the teats and neck, though warts were found in other areas of the body. Histological sections were diagnosed as fibropapilloma. PCR results showed that 80.13% of the extracted papilloma DNA samples corresponded to the BPV-1 genotype. Furthermore, 7.94% of the samples showed a mixed infection of BPV-1 and BPV-13. While, 40.63% of the extracted DNA blood samples showed 2 DNA fragments corresponding to both genotypes BPV-1 and BPV-2.

CONCLUSIONS

This study confirmed the presence of BPV-1, BPV-2, and BPV-13, which belong to the Deltapapillomavirus genera, for the first time in the DNA of Iraqi cattle. Understanding BPV diversity and epidemiology is of critical importance for starting prevention strategies.

Auto-brewery syndrome: Ethanol pseudo-toxicity in diabetic and hepatic patients

Endogenous alcohol has been applied for spontaneous ethanol production via different metabolic pathways of the human body. Auto-brewery syndrome describes the patients with alcohol intoxication after ingesting carbohydrate-rich meals. The main objective of this study is to investigate the effect of diabetes mellitus (DM), liver cirrhosis (LC) and presence of both (DM and LC) on blood alcohol concentration (BAC) especially after carbohydrate ingestion. BAC has been measured by headspace gas chromatography-mass spectrometry in three groups of humans namely control, DM, LC and both (DM and LC) groups. The results showed that BAC in control group was 0.01-.3 mg/dL with mean 0.3 ± 0.41 mg/dL. In patients with DM, BAC is significantly higher than that of control group 4.85 ± 3.96 mg/dL. In patients with LC, BAC was 3.45 ± 2.65 mg/dL. In patients with both DM and LC, BAC increases to reach 10.88 ± 5.36 mg/dL. Endogenous ethanol production appears to increase in DM and LC. Also, it increased much more in patients with both diseases, but it did not reach toxic levels. On comparing BAC and blood glucose level in each group, all groups show insignificant correlations ( p > 0.05).

Anomalous Left Anterior Descending Coronary Artery Arising from Pulmonary Artery in a 63 Year-old Male Patient: Case Report and Literature Review

To present a case of a rare congenital coronary anomaly in an adult patient, which was not reported before in Palestine, review the literature, and compare with previously reported cases.

Treatment of Bovine Papilloma

In this study (35) cows suffering from bovine papilloma were subjected for three differenttypes of treatments; The First group involved 15 animals treated with autogenous vaccine.The Second group involved 10 animals treated with prepared cell culture vaccine .While thethird group involved 10 cows treated with virulent local Newcastle disease virus. In the Firsttwo groups the warts were surgically removed from cows showing lump lesions on skin ofabdomen, neck and udder, and transferred aseptically to laboratory by using transport media.Treatment of cows in the first group involved preparation of autogenous formalin (0.5%)in activated vaccine. Vaccination of these animals result in regression of the warts startedafter 2 or 3 weeks and complete disappearance of the warts after 30-60 days with a meanduration of 44.9 days.Treatment of the second group involved preparation of papilloma cell culture inactivatedvaccine 0.5% formalin from 3 papilloma cases. The response of these vaccinated cows resultin regression of the warts lesions started after 2 or 3 weeks post the first vaccinal dose andcomplete disappearance of the warts after 30-60 days, with mean 43.8 days.Treatment of the third group involved using of virulent NDV by subcutaneous injectionand infiltration around the warts. Results showed successful regression of warts within ashorter period with mean of 30.1 days compared to treatment with autogenous and cell culturevaccine, with complete regression of the warts within 15-28 days.

Inactivation of [Fe-S] metalloproteins mediates nitric oxide-dependent killing of Burkholderia mallei

BACKGROUND

Much remains to be known about the mechanisms by which O(2)-dependent host defenses mediate broad antimicrobial activity.

METHODOLOGY/PRINCIPAL FINDINGS

We show herein that reactive nitrogen species (RNS) generated by inducible nitric oxide (NO) synthase (iNOS) account for the anti-Burkholderia mallei activity of IFNgamma-primed macrophages. Inducible NOS-mediated intracellular killing may represent direct bactericidal activity, because B. mallei showed an exquisite sensitivity to NO generated chemically. Exposure of B. mallei to sublethal concentrations of NO upregulated transcription of [Fe-S] cluster repair genes, while damaging the enzymatic activity of the [Fe-S] protein aconitase. To test whether [Fe-S] clusters are critical targets for RNS-dependent killing of B. mallei, a mutation was constructed in the NO-induced, [Fe-S] cluster repair regulator iscR. Not only was the iscR mutant hypersusceptible to iNOS-mediated killing, but its aconitase pool was readily oxidized by NO donors as compared to wild-type controls. Although killed by authentic H(2)O(2), which also oxidizes [Fe-S] clusters, B. mallei appear to be resilient to NADPH oxidase-mediated cytotoxicity. The poor respiratory burst elicited by this bacterium likely explains why the NADPH oxidase is nonessential to the killing of B. mallei while it is still confined within phagosomes.

CONCLUSIONS/SIGNIFICANCE

Collectively, these findings have revealed a disparate role for NADPH oxidase and iNOS in the innate macrophage response against the strict aerobe B. mallei. To the best of our knowledge, this is the first instance in which disruption of [Fe-S] clusters is demonstrated as cause of the bactericidal activity of NO congeners.

Laparoscopic sutured anastomosis of the bowel

BACKGROUND

Even though the safety and efficacy of sutured anastomosis have been proved in open surgery, laparoscopic sutured anastomosis is rarely performed because it is difficult and time-consuming. We aim at description of a standardized technique for laparoscopic sutured anastomosis of the bowel and definition of its learning curve.

METHODS

Fifty-six laparoscopic sutured anastomoses of cow small intestine were performed in a laparoscopic simulator. In a survival animal trial, 10 end-to-end, 2 gastrojejunostomy, 2 cholecystojejunostomy, 2 colocolic, and one side-to-side anastomoses were performed, using the same technique.

RESULTS

In the survival cases, we had no leaks or obstruction, minimal adhesions, and only one stenotic gastrojejunostomy. The mean end-to-end anastomotic time was 50 min. The technique was suitable for most sites in the GIT. The learning phase required 40 anastomoses in the simulator.

CONCLUSIONS

The described technique seems relatively fast, safe, and universal, and it needs about 40 anastomoses to be mastered.

Laparoscopic cholecystectomy under spinal anesthesia with nitrous oxide pneumoperitoneum: a feasibility study

BACKGROUND

Spinal anesthesia has been successfully used to perform various laparoscopic procedures. However, laparoscopic cholecystectomy under spinal anesthesia has not been reported. Is this feasible?

METHODS

Ten successive laparoscopic cholecystectomies were performed under spinal anesthesia. The surgical technique was modified using nitrous oxide insufflation, lower levels of intraabdominal pressure, modified trocar sites, and minimal surgical manipulation. We used spinal anesthesia by intrathecal hyperbaric 10-12 mg bupivacaine with 10 microg fentanyl to give an anesthetic level at T8-T6.

RESULTS

The mean age was 39.3 years and there were four females. Only one patient was converted to general anesthesia due to intolerable shoulder pain. One patient vomited intraoperatively. Nine patients considered the procedure well tolerated under spinal anesthesia. The mean operative time was 47.4 min. Postoperatively, there were minimal pain and no vomiting.

CONCLUSIONS

Laparoscopic cholecystectomy can be performed successfully under spinal anesthesia and is well tolerated.