Comparison of the safety and efficacy for different regimens of pharmaco-prophylaxis among severely burned patients: a randomized controlled trial

PURPOSE

Venous thromboembolism (VTE) is a common complication in critically ill patients, including severe burn cases. Burn patients respond differently to medications due to pharmacokinetic changes. This study aims to assess the feasibility and safety of different VTE pharmaco-prophylaxis in patients admitted to the ICU with severe burns.

METHODS

A pilot, open-label randomized controlled trial was conducted on ICU patients with severe burns (BSA ≥ 20%). By using block randomization, patients were allocated to receive high-dose enoxaparin 30 mg q12hours (E30q12), standard-dose enoxaparin 40 mg q24hours (E40q24), or unfractionated heparin (UFH) 5000 Units q8hours. In this study, the primary outcomes assessed were the recruitment and consent rates, as well as bleeding or hematoma at both the donor and graft site. Additionally, secondary measures were evaluated to provide further insights.

RESULTS

Twenty adult patients out of 114 screened were enrolled and received E30q12 (40%), E40q24 (30%), and UFH (30%). The recruitment rate was one patient per month with a 100% consent rate. Donor site bleeding occurred in one patient (16.7%) in the UFH group. On the other hand, graft site bleeding was only reported in one patient (12.5%) who received E30q12. Major bleeding happened in two patients, one in E30q12 and one in the UFH group. Five patients (25.0%) had minor bleeding; two patients (25.0%) received E30q12, two patients E40q24, and one patient UFH. RBC transfusion was needed in four patients, two on E30q12 and two on UFH. Only one patient had VTE, while four patients died in the hospital.

CONCLUSION

The study observed a low recruitment rate but a high consent rate. Furthermore, there were no major safety concerns identified with any of the three pharmacologic prophylaxis regimens that were evaluated.

TRIAL REGISTRATION NUMBER

NCT05237726.

The Impact of Midodrine Tapering Versus Nontapering Regimens on the Clinical Outcomes of Critically Ill Patients: A Retrospective Cohort Study

BACKGROUND

Midodrine has been used in the intensive care unit (ICU) setting to reduce the time to vasopressor discontinuation. The limited data supporting midodrine use have led to variability in the pattern of initiation and discontinuation of midodrine.

OBJECTIVES

To compare the effectiveness and safety of 2 midodrine discontinuation regimens during weaning vasopressors in critically ill patients.

METHODS

A retrospective cohort study was conducted at King Abdulaziz Medical City. Included patients were adults admitted to ICU who received midodrine after being unable to be weaned from intravenous vasopressors for more than 24 hours. Patients were categorized into two subgroups depending on the pattern of midodrine discontinuation (tapered dosing regimen vs. nontapered regimen). The primary endpoint was the incidence of inotropes and vasopressors re-initiation after midodrine discontinuation.

RESULTS

The incidence of inotropes or vasopressors' re-initiation after discontinuation of midodrine was lower in the tapering group (15.4%) compared with the non-tapering group (40.7%) in the crude analysis as well as regression analysis (odd ratio [OR] = 0.15; 95% CI = 0.03, 0.73, P = 0.02). The time required for the antihypertensive medication(s) initiation after midodrine discontinuation was longer in patients who had dose tapering (beta coefficient (95% CI): 3.11 (0.95, 5.28), P = 0.005). Moreover, inotrope or vasopressor requirement was lower 24 hours post midodrine initiation. In contrast, the two groups had no statistically significant differences in 30-day mortality, in-hospital mortality, or ICU length of stay.

CONCLUSION AND RELEVANCE

These real-life data showed that tapering midodrine dosage before discontinuation in critically ill patients during weaning from vasopressor aids in reducing the frequency of inotrope or vasopressor re-initiation. Application of such a strategy might be a reasonable approach among ICU patients unless contraindicated.

The association between tocilizumab therapy and the development of thrombosis in critically ill patients with COVID-19: a multicenter, cohort study

The use of tocilizumab for the management of COVID-19 emerged since it modulates inflammatory markers by blocking interleukin 6 receptors. Concerns regarding higher thrombosis risk while using tocilizumab were raised in the literature. The aim of this study is to investigate the association between tocilizumab therapy and the development of thromboembolic events in critically ill COVID-19 patients. A propensity score-matched, multicenter cohort study for critically ill adult patients with COVID-19. Eligible patients admitted to ICU between March 2020 and July 2021 were categorized into two sub-cohorts based on tocilizumab use within 24 h of ICU admission. The primary endpoint was to assess the incidence of all thrombosis cases during ICU stay. The secondary endpoints were 30-day mortality, in-hospital mortality, and the highest coagulation parameters follow-up (i.e., D-dimer, Fibrinogen) during the stay. Propensity score matching (1:2 ratio) was based on nine matching covariates. Among a total of 867 eligible patients, 453 patients were matched (1:2 ratio) using propensity scores. The thrombosis events were not statistically different between the two groups in crude analysis (6.8% vs. 7.7%; p-value = 0.71) and regression analysis [OR 0.83, 95% CI (0.385, 1.786)]. Peak D-dimer levels did not change significantly when the patient received tocilizumab (beta coefficient (95% CI): 0.19 (- 0.08, 0.47)), while there was a significant reduction in fibrinogen levels during ICU stay (beta coefficient (95% CI): - 0.15 (- 0.28, - 0.02)). On the other hand, the 30-day and in-hospital mortality were significantly lower in tocilizumab-treated patients (HR 0.57, 95% CI (0.37, 0.87), [HR 0.67, 95% CI (0.46, 0.98), respectively). The use of tocilizumab in critically ill patients with COVID-19 was not associated with higher thrombosis events or peak D-dimer levels. On the other hand, fibrinogen levels, 30-day and in-hospital mortality were significantly lower in the tocilizumab group. Further randomized controlled trials are needed to confirm our findings.

Using Herbal Medicine for Dental Pain in Saudi Arabia: Prevalence and Knowledge Assessment

Background: The dental community has started to use natural plant properties to relieve dental pain. Besides their significant serious side effect, Herb’s ingredients should be chosen wisely. However, many studies are conducted to find out the herb’s information due to the lack of randomized controlled clinical trials. The aim of this study was to assess the prevalence and the knowledge of the effect of using herbal medicine for dental pain among Saudi population. Methodology: An observational cross-sectional study was conducted in Saudi Arabia between September 2020 and October 2021. based on a structured questionnaire among Saudi populations. Structured self-administrated questionnaires in English and Arabic languages were used as a study tool. Authors collected the information using social media channels through google forms. SPSS 26 was used for data entry and data analysis. Results: The study included 4213 participants. 25% of study sample were males and 75% were females. 51.6% aged between 20- 30 years old. 61.8% of all participants use herbs to relieve toothache (82% of them use clove or clove oil and 36% use thyme). Think herbs are safe and free from side effects in treating toothache. 8% noticed side effects or damage while using herbs to relieve dental pain (27% of them swelling, 21% sharp stomach pain, 21% hypersensitive and 17% bleeding). Conclusion: The Saudi population show relatively good knowledge level and practice towards herbs use in dentistry. The use of herbs to relieve toothache was significantly associated with female gender, age, residence area in western region and average monthly income.

Prevalence and predictors of seizure in patients with Alzheimer’s disease at a tertiary care center in Riyadh, Saudi Arabia

Purpose: To assess the prevalence and predictors of seizures in patients with Alzheimer’s disease (AD) at a Saudi tertiary hospital.Methods: A retrospective, matched case-control study was conducted using the electronic medical records of patients with AD who had an unprovoked seizure, from October 2015 to May 2018.Results: Nineteen cases and 195 controls were identified. Statistically significant risk factors for an unprovoked seizure in patients diagnosed with AD were hypertension (p = 0.001), autoimmune disease, stroke and TIA (p = 0.001). The multivariate logistic regression analysis identified hypertension (OR = 2.89; p = 0.009) and autoimmune disease (OR = 19.6; p = 0.045) as predictors of unprovoked seizure in AD patients.Conclusion: The occurrence of unprovoked seizures is more likely in severe cases of AD. In addition, the risk of seizure in patients with AD increases with two co-morbid conditions, hypertension, and autoimmune disease. However, further studies are required to determine the underlying mechanism of the association between the two risk factors and AD.

The Use of Antidepressants in Patients with Heart Failure

Background

Heart failure (HF) is a chronic disease affecting patients' quality of life (QoL) and may cause depression. Recent studies reported that the prevalence of depression in patients with HF is 21.5%. Antidepressants, mainly selective serotonin reuptake inhibitors, are usually prescribed for HF patients diagnosed with depression. Some evidence supports antidepressant's role in improving symptoms by enhancing the psychological aspect of their QoL. Depression screening and treatment are important in the multidisciplinary management; however, their survival benefits are inconsistent. In our study, we aim to investigate the prevalence of depression and the use of antidepressants in patients with HF as well as to determine the acceptance of using antidepressants in such patients.

Methods

This is a cross-sectional study conducted by interviewing HF outpatients at National Guard Hospital in Riyadh. Patients were assessed using Hamilton depression rating scale.

Results

A total of 306 patients were included, with the majority (69%) being male and aged >61 years (60%). Patients' medical history was classified into different groups, with the largest proportion (39.9%) in the diabetic-hypertensive group, followed by a diabetic group (21.2%) and a hypertensive group (10.8%). Patients were classified according to the New York Heart Association Functional Classification, and most patients were in Class I (61.8%). Some of the patients (8.5%) had been diagnosed with depression. There was no statistically significant association between HF and depression (p > 0.05). However, 5.6% of patients had been prescribed antidepressants and 17.1% of patients believed that they required antidepressants. Moreover, there was a statically significant association between medical history and development of depression (p = 0.014).

Conclusions

The prevalence of depression in HF patients in our population was lower than reported. There was no association between HF stage, depression, and antidepressant use.

Insomnia among non-depressed multiple sclerosis patients: a cross-sectional study

Background

Insomnia is a common problem that affects approximately 50% of patients with multiple sclerosis (MS), who suffer from sleep disturbances. In general, persons with insomnia are at a higher risk of developing depression. This study was conducted to assess insomnia among non-depressed MS patients in Saudi Arabia.

Methods

Based on the Patient Health Questionnaire-9 (PHQ-9), those who scored 4 or less for depression out of 598 MS patients were selected (n = 112). A cross-sectional study was conducted to interview 112 non-depressed MS patients in order to assess insomnia among them. A data collection sheet has been designed by the researchers. It comprised socio-demographic variables (e.g., gender, age, area of residence, and marital status) and clinical variables (disease duration, age at disease onset, previous diagnosis of depression, and used antidepressant drugs). Insomnia was assessed by the Insomnia Severity Index (ISI), while severity of illness was assessed using the Patient Determined Disease Steps (PDDS).

Results

A total of 72 patients (64.3%) were females, and 62 (55.4%) were married. Their mean age was 32.6 years (SD = 8.9), ranging from 15 to 56 years. As for educational level, 64 (57.1%) had a Bachelor degree. The mean age at disease onset was 26 years (SD = 8.9). The mean duration of illness was 1.9 years. Symptoms of insomnia were present among 14 patients (12.5%). No statistical significance was found between the mean PDSS of insomnia and non-insomnia patients. Significant differences were present between insomnia and non-insomnia patients as regards their education level (P = 0.005) and use of antidepressant drugs (P = 0.008).

Conclusions

Prevalence of insomnia among non-depressed MS patients is low. Insomnia is associated with educational and use of antidepressants. Further research is needed to assess severity of different types of insomnia among depressed and non-depressed MS patients.