Variable Levels of Oxytocin During Sepsis: The Role of Oxytocin in Sepsis Pathophysiology

BACKGROUND

Although the role of oxytocin in the pathophysiology of sepsis is still unknown, rising preclinical evidence suggests that oxytocin is possibly involved. However, no direct clinical studies have measured the levels of oxytocin during sepsis. In this preliminary study, the serum oxytocin levels were evaluated throughout the duration of sepsis.

METHOD

Twenty-two male patients over 18 years of age with a SOFA score of 2 points or more who were admitted to the ICU were included. Patients with a history of neuroendocrine, psychiatric, and neurologic disorders, cancer, an infection caused by COVID-19, shock due to reasons other than sepsis, a history of psychiatric or neurologic medication use, and those who died during the study were excluded. The main endpoint included the measurement of serum oxytocin levels using radioimmunoassay at 6, 24, and 48 h of the ICU admission.

RESULTS

Mean serum oxytocin level was higher at 6 h of ICU admission (41.27 ± 13.14 ng/L) than after 24 and 48 h of ICU admission (22.63 ± 5.75 and 20.97 ± 7.61 ng/L respectively) (P-value < .001).

CONCLUSION

Our study, while reporting increased serum oxytocin levels in the initial phase of sepsis and decline afterward, supports the possible contribution of oxytocin in the pathophysiology of sepsis. Given that oxytocin seems to modulate the innate immune system, future investigations are necessary to assess the potential role of oxytocin in the pathophysiology of sepsis.

Surviving surgery; succumbing to pharmacotherapy: A case report underscoring the importance of PRN order clarification for patient safety

"Pro re nata" (PRN) or "as needed" medicine administration and usage is a relatively neglected area in medication management (pharmacotherapy/pharmaceutical care) which contributes to error-prone use of medications and is unsafe for patients. In this case, we report the incident of diclofenac toxicity in a 51-year-old woman due to a prescription of 100 mg diclofenac suppositories PRN, or as needed, for postoperative pain control without explanation of the maximum daily dose (150 mg daily), which led to arbitrary consumption of 3 g of diclofenac over 5 days (600 mg daily) by the patient, and subsequent development of metabolic acidosis, acute kidney injury, and sudden cardiac arrest. The implementation of practical guidelines and training programs for health care workers to appropriately prescribe, dispense, and administer PRN medicines are necessary, and should at least include providing clarification for their indication, dose and frequency, as well as any cautionary instructions to ensure safe and effective use of such medicines.

A comparative study to assess the effectiveness of curcumin, mucosamin, and chlorhexidine in chemotherapy-induced oral mucositis

BACKGROUND

Oral mucositis is one of the most frequent and challenging side effects of chemotherapy. At present, none of the guidelines recommend the use of various mouthwashes available for the treatment of oral mucositis.

METHODS

This study was designed to evaluate the efficacy of curcumin, mucosamin, and chlorhexidine in the treatment of chemotherapy-induced oral mucositis. In this randomized and double-blind study, 71 patients over 18 years, who received chemotherapy and suffered from chemotherapy-induced oral mucositis, were randomized into curcumin, mucosamin, and chlorhexidine groups. The World Health Organization (WHO) Oral Toxicity Scale, the Oral Mucositis Assessment Scale (OMAS), and the Numerical Rating Scale (NRS) were used to evaluate oral mucositis. The main endpoint included the onset of complete recovery after starting the treatment.

FINDINGS

Based on the WHO, OMAS for erythema, and NRS criteria, complete recovery was achieved from the third day in the curcumin group, which was significantly earlier compared to the other two groups (P < 0.05). The OMAS score for ulceration represented an improvement from day 5 in the curcumin group, which was significantly faster compared to the other two groups (P = 0.04).

CONCLUSIONS

Our results indicated that all three approaches were effective in improving oral mucositis; however, curcumin could result in faster recovery in comparison with mucosamin and chlorhexidine. The use of curcumin in the treatment of oral mucositis appears to be a viable intervention for reducing potential compromise to treatment and improving the quality of life.

An Open-Label, Single-Arm, Pilot Intervention Study to Assess the Efficacy and Safety of Apixaban in Heparin-Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction due to its related risk of life- and limb-threatening thrombosis. Apixaban is a direct factor Xa inhibitor that may be intended as an ideal alternative for the management of HIT. In this open-label, single-arm, pilot intervention study, the efficacy and safety of apixaban were evaluated in 30 patients over the age of 18 with clinically suspected HIT (4Ts score 4 points or greater). Patients with mechanical heart valves, chronic kidney disease, hepatic impairment, and active bleeding were excluded. In all patients with inclusion criteria, heparin or enoxaparin was discontinued and apixaban was started. The dose of apixaban for HIT suspected patients were defined based on the reason for anticoagulant therapy. Endpoints included confirmed thrombosis, mortality, and adverse treatment-related events. After Apixaban therapy, platelet counts normalized in all patients, none of the 30 subjects developed new, progressive, or recurrent thrombosis, and only 1/30 patients developed hemorrhagic events. Five patients (16.7%) died, but the reason for death was not linked to thrombosis, hemorrhage, or adverse effects of apixaban. Along with the available emerging data, our results propose that apixaban could be a safe and effective drug for the management of suspected HIT in clinically stable patients. This article is protected by copyright. All rights reserved.

Sensitivity of Acinetobacter baumannii and Pseudomonas aeruginosa Microorganisms to Colistin Antibiotic by MIC (E-test) in Patients Admitted to the Intensive Care Unit of Firoozgar Hospital

Background: Nosocomial infections are associated with increased morbidity, mortality, and medical burdens. Pseudomonas aeruginosa and Acinetobacter baumannii are not-fermentative gram-negative bacteria that considered as the most important nosocomial infection. In the current study, we have aimed to evaluate the sensitivity of Acinetobacter baumannii and Pseudomonas aeruginosa microorganisms to the colistin antibiotic. Methods: In this descriptive cross-sectional study, patients admitted to the ICU ward of Firoozgar Hospital from July 2018 to March 2019 were evaluated, and 169 Patients infected with Acinetobacter baumannii, and Pseudomonas aeruginosa were included. Acinetobacter baumannii and Pseudomonas aeruginosa were isolated, and antibiotic sensitivity was determined by the disk diffusion method according to Clinical & Laboratory Standards Institute (CLSI) criteria. E test was also used to determine MIC-50 and MIC-90 of colistin. Results: Acinetobacter baumannii was around 8 times more frequent than Pseudomonas aeruginosa. Colistin resistance was detected in only 4(2.4%). The mean age of patients infected by Acinetobacter baumannii was significantly higher than those infected with Pseudomonas aeruginosa. Moreover, the mean time of the hospitalization period did not show any significant differences in the different groups. Conclusion: Our findings indicated that the majority of isolated Pseudomonas aeruginosa and Acinetobacter baumannii were sensitive to Colistin. Therefore, it could be effectively used for patients with a confirmed diagnosis of Pseudomonas aeruginosa and Acinetobacter baumannii.

Rivaroxaban as an Alternative Agent for Heparin-Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a high-risk adverse drug reaction because of its associated risk of life- and limb-threatening thrombosis. Rivaroxaban may be considered as an ideal nonheparin anticoagulant alternative for the management of HIT. In this preliminary retrospective study, the efficacy and safety of rivaroxaban to control the clinically suspected HIT (4Ts score 4 points or greater) were evaluated. Patients with chronic kidney disease, hepatic impairment, mechanical heart valves, and active bleeding were excluded. Forty-two eligible patients who received rivaroxaban for clinically suspected HIT were evaluated by medical records review, with 12-month follow-up after the first dose of rivaroxaban. End points included confirmed thrombosis (primary end point), mortality, and adverse treatment-related events. HIT-associated thrombosis was found in 17/42 (40.5%) patients before receiving rivaroxaban. After rivaroxaban therapy, platelet counts normalized in all patients, with only 1/42 (2.3%) patients developing new thrombosis. No hemorrhagic event was recorded in the patients. Twelve patients (28.6%) died, but the cause of death was not related to the thrombosis, hemorrhage, or adverse effects of rivaroxaban. Our findings are consistent with the available emerging data, suggesting that rivaroxaban is a safe and effective drug for the management of clinically suspected HIT. Rivaroxaban is a particularly valuable treatment option in developing countries, where there are issues of cost and availability of approved alternative agents.

Rituximab Utilization Evaluation with Focused on Available Evidence for Off-Labeled Indications

Background: To investigate the on-labeled and off-labeled indications of rituximab according to available evidence and the cost benefit of using this expensive drug. Methods: This retrospective cross-sectional study was conducted between August 2016 and August 2017 at a teaching hospital affiliated to Iran University of Medical Sciences, Tehran, Iran. Patients’ demographic data and disease, indication for rituximab use, its dosage and treatment regimen and previous and concurrent treatments was assessed. The collected data were compared with the current criteria for the pattern of rituximab use. The last version of Lexicomp® acquired by Wolters Kluwer was used as the reference for on-labeled and off-labeled indications of the prescribed drug and its dosage. Level of evidences for applied indications and cost has also been evaluated. Results: A total of 85 patients received rituximab during the study period. The most frequent reasons for rituximab prescription were: multiple sclerosis (50.58%), systemic sclerosis (10.58%), rheumatoid arthritis (7.05%) and Idiopathic inflammatory myopathies (4.70%).Rituximab was used in 8 (9.4%) cases according to on-labeled indications. There was level C evidence for rituximab use in off-labeled indications in 47 (55.29%) cases according to available evidences which accounts for the highest calculated cost. Conclusion:Based on our results, rituximab was frequently administrated for off-labeled indications most of which are not supported by established levels of evidence. The total cost was higher for level C evidence indications of off labeled rituximab than for indications with a higher level of evidence (A and B). So, strong evidence is necessary for decision making regarding its effectiveness and its cost benefit. J Pharm Care 2019; 7(1-2): 14-20.

Prevalence of Gram Negative Infections by Acinetobacter and Pseudomonas Severely Resistant to Antibiotic Susceptibility Based on Minimum Growth Inhibitor Concentration

Introduction: Currently, we are witnessing the formation of various species of gram-negative microorganisms, including Enterobacteriaceae, Pseudomonas aeruginosa and acinetobacter, resistant to antibiotics such as MDR, XDR and PDR. This study is important to confirm microbial resistance to an antimicrobial agent and also to monitor the activity of new antimicrobial agents. Regarding XDR gram-negative microorganisms isolated from samples, it was considered necessary to determine MIC. Methods: Patients suspected of various infections with septicemia diagnosed in different wards of the Firoozgar Hospital were enrolled. The quantitative value of minimum growth inhibitor concentration (MIC) was determined for infections caused by highly resistant gram-negative bacteria (acinetobacter and Pseudomonas species) (XDR) reported by antibiogram disk. Results: sample size was 117, of which 41.9% were female and 58.1% were male. Regarding Colistin, 80% of the cultures were resistant and 12% were intermittent; this value was 52% in the MIC test. Regarding tigecycline, 100% of the acinetobacter samples were susceptible to this antibiotic. Most of cultures which had antibiotic resistance were acinetobacter (61.4%) and pseudomonas (39.6%). Discussion: Acinetobacter baumannii is susceptible to tigecycline. Emergence of multi-drug resistance in Pseudomonas aeruginosa and A. baumannii is a major concern in the world, because several drugs, except polymyxins, are available to treat these infections. A significant resistance was found in MIC to Colistin (31.1%). Thus, there is resistance to Colistin, which is one of the last lines of antibiotic treatment. Conclusion: This study shows an increase in percentage resistance of these bacteria to antibiotics. This trend is a worrying process for antibiotic treatment of diseases.

Intravenous Immunoglobin Utilization Study in a Teaching Hospital

BACKGROUND

Intravenous immunoglobulin (IVIG) is an immunomodulating agent that has several actions. The aim of this study was to investigate the indications of IVIG according to available evidence and the cost in our center.

METHODS

This retrospective study was conducted between September 2017 and June 2018 at a teaching hospital affiliated with Iran University of Medical Sciences, Tehran, Iran. Patients' demographic data and disease, indication for IVIG use, its dosage and treatment regimen and previous and concurrent treatments were assessed. The collected data were compared with the present criteria for the pattern of IVIG usage. The last version of Lexicomp® was used as the reference for indications of the administrated drug and its dosage.

RESULTS

A total of 119 patients received IVIG during the study period. The wards with the most frequent IVIG prescription were the neurology (46.2%) and neonatal intensive care unit (21%). The most common reasons of IVIG therapy were various inflammatory neurological disorders. IVIG was used in 22, 43 and 54 cases according to on-label, off- label and other indications, respectively. The total price was higher for off-label indications for IVIG ($254343.75) than on-label indications ($152625). As well, $107250 was exhausted for cases in which there was not sufficient evidence.

CONCLUSION

One important aspects of this study was the use of IVIG in cases other than on-label indications. Although a number of studies support IVIG therapy in some diseases, further trials are needed to establish efficacy and safety in these fields.

Albumin Utilization Evaluation in a Major Teaching Hospital in Iran: Recommendations for Guideline Development

Objective:

Human albumin solution is an expensive colloidal preparation which is commonly used in clinical practice. Due to high cost of albumin, increased rate of the inappropriate use worldwide, and many other reasons, it is imperative to establish a practical protocol to use albumin products and limit its usage. The aim of this study was to identify albumin utilization patterns in a teaching hospital and to demonstrate the importance of the need to reconsider prescribing strategies for albumin administration.

Methods:

This retrospective cross-sectional study was performed between August 2016 and December 2016 at Firoozgar Hospital affiliated to Iran University of Medical Sciences, Tehran, Iran. All albumin prescriptions for adult patients during the study period were enrolled for appropriateness evaluation according to the latest evidence-based studies and guidelines.

Findings:

Among 320 albumin prescriptions, 168 (52.5%) were inappropriate according to the current evidence. The most common irrational causes for the albumin usage were hypoalbuminemia (23.4%), nutritional support (13.7%), neuroprotection in subarachnoid hemorrhage (3%), pretreatment for cancer surgery (2.8%), edema (1.6%), hepatic failure (1.6%), and paracentesis (3%). The total amount of albumin used for 320 patients was 52,050 g, from which 28,470 g was inappropriate resulting in $97,398 wastage.

Conclusion:

These findings, along with aforementioned guidelines, support the requirement for physicians' educational programs and proper strategies for appropriate prescriptions and could also be important in modifying the available guidelines concerning expensive drugs such as albumin.

The Content of Plasma Selenium in Early Admitted Septic Patients

OBJECTIVE

Selenium depletion has been reported in critical illness correlates with an increase in mortality and morbidity. In this study, we aimed to access the selenium plasma levels of septic patients early at the Intensive Care Unit (ICU) admission in order to compare with reference range.

METHODS

We conducted a cross-sectional study in a university affiliated hospital aiming to assess the early plasma level of selenium in ICU admitted patients. eighty patients diagnoses with sepsis were included and considered for characteristic evaluation, monitoring criteria assessment and also blood sampling. All blood sampling was performed during 48 hours of the ICU admission in order to determined the plasma Selenium level by atomic absorption method.

FINDINGS

The mean plasma levels of selenium in male and female was 98.14 ± 23.52 and 78.1 ± 24.46 μ/L, respectively. Although selenium plasma levels was higher in the ICU male patients significantly, both had near normal range (80 μ/L).

CONCLUSION

In this study we found that in early admitted Iranian ICU patients in Tehran, selenium deficiency has not routinely seen but probably will happen during ICU hospitalization.

Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data

Abnormally invasive placenta is characterized by direct attachment of chorionic villi to the uterine wall. This adherent placenta traditionally has been managed by peripartum hysterectomy. Nowadays, there is a lot of interest toward gradual shift from traditional management of invasive placentation to conservative ones leaving the placenta in situ to avoid the surgical morbidity of hysterectomy and loss of future fertility. Administration of methotrexate (MTX), as an adjunctive antimetabolite drug, resulted in conflicting data during conservative management of abnormal placentation. This review assessed all published data on efficacy and safety of MTX therapy as conservative management of invasive placentation. Fifty-three articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports were identified. Conservative management has beneficial effects on the avoidance of major surgery with the consequent morbidity and the preservation of future fertility. Infection and vaginal bleeding were main complications of MTX therapy. Although MTX therapy may result in accelerated involution or expulsion of placenta and has some beneficial effects on hemorrhagic events, but there is not enough evidence on its efficacy and safety to recommend its routine uses in all cases of invasive placenta.

Antipyretic Effect of Clonidine in Intensive Care Unit Patients: A Nested Observational Study

Fever in the intensive care unit (ICU) is usually an adaptive response to infection or inflammation. Pharmacological intervention is often required in addition to addressing the underlying causes of fever. Animal studies have examined the antipyretic effect of clonidine; however, to our knowledge there are no clinical data available in humans. The observation of an antipyretic effect of clonidine was made during a single-center randomized control trial that was designed to study the effect of clonidine addition to the commonly used sedative agents in mechanically ventilated ICU patients. Forty patients 18 years or older on mechanical ventilation for 3 days or longer were randomized into 2 groups receiving clonidine and placebo. In addition to the usual sedation/analgesia, patients in the clonidine arm received enteral clonidine in doses of 0.1 mg 3 times a day (TID), which was increased to 0.2 mg TID if the hemodynamics remained stable. Vital signs, laboratory data, all cultures, and daily ICU events were recorded. The odds ratio of temperature higher than 38.3°C was 3.96 times higher in the placebo group, after adjustment for the illness severity and the time of follow-up (P = .049). A lower temperature (0.52°C) was observed in the clonidine group after adjustment for the time of follow-up (P = .006). Our report is the first of its kind in humans that demonstrates possible antipyretic properties of enteral clonidine in the critically ill intensive care unit patient.

Solitary Psoas Muscle Metastasis of Gastroesphageal Junction Adenocarcinoma

Metastasis of gastroesphageal junction (GEJ) adenocarcinoma in skeletal muscle is rare and primary sites for skeletal muscle metastases are usually lung, renal and colorectal cancer. We have encountered with the first case report of solitary psoas muscle metastasis of GEJ adenocarcinoma. Here we describe a 65 years old man was diagnosed with GEJ adenocarcinoma in Gastroenterology Department, Imam Hussein Hospital, Tehran, Iran in February 2014. We were not able to use PET techniques due to lack of access. Staging CT scans demonstrated a small mass lateral to right psoas muscle. A CT-guided core needle biopsy of right psoas muscle was performed that supported a diagnosis of adenocarcinoma consistent with primary adenocarcinoma of the GEJ. Distant metastasis to skeletal muscle rarely occurs in patients with GEJ adenocarcinoma, but heightened awareness to these soft tissue lesions is warranted. CT or MR imaging could show findings suggestive of metastatic disease, although PET is preferable modality.

Jaw Pain as a First Presentation in the Diagnosis of Breast Cancer

The oral cavity is uncommon site for metastatic disease usually discovered secondary to malignancy. We encountered with a rare case in which metastasis to mandibular bone was the first clinical sign in the diagnosis of breast cancer without any radiographic findings. A 49-yr-old premenopausal woman, was referred to the Department of Medical Oncology of Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran in 2014, presented with pain and tenderness in the left mandibular and temporal bone and paresthesia of the lower left lip and chin. CT scan of mandible showed no significant finding. Four months later, she was referred with complaints left breast pain for 4 wk and worsening swelling, pain and paresthesia. Breast examination revealed a 2 cm firm nodule on the left breast. Based on her medical history and histopathological study, metastatic carcinoma of the breast was suspected. She has received chemoradiotherapy that led to complete relief of her symptoms and remission of the disease. In the presence of an ambiguous sign in oral cavity such as jaw pain or paresthesia, diagnostic examination of malignancy is recommended.

Oxaliplatin-induced renal tubular vacuolization

OBJECTIVE

Chemotherapy with oxaliplatin is used for a wide range of malignancies. Unlike other platinum derivatives, oxaliplatin has less nephrotoxicity. However, in recent years, there have been multiple reports of different forms of renal toxicity related to this agent.

CASE SUMMARY

A 40-year-old woman with colon adenocarcinoma developed jaundice, hematuria, and oliguria after the 36th cycle of oxaliplatin chemotherapy. Laboratory data revealed severe anemia, thrombocytopenia, increased creatinine, indirect hyperbilirubinemia, and high lactate dehydrogenase. A negative direct antiglobulin test and presence of <1% schistocytes in the peripheral blood smear stood against the diagnosis of immune-mediated hemolytic anemia or hemolytic uremic syndrome/thrombotic thrombocytopenic purpura. Renal biopsy was consistent with interstitial nephritis with tubular vacuolization in favor of drug-induced renal injury. Based on the Naranjo Probability Scale, the likelihood of oxaliplatin-induced renal injury in this case was probable.

DISCUSSION

To our knowledge, this is the first case report of renal tubular vacuolization with symptoms mimicking thrombotic microangiopathy in a patient on long-term chemotherapy with oxaliplatin.

CONCLUSIONS

Oxaliplatin can induce various forms of nephrotoxicity such as renal tubular vacuolization, acute tubular necrosis, renal tubular acidosis, and acute kidney injury secondary to hematological toxicity. Monitoring for renal function abnormalities and hemolysis should be considered during oxaliplatin-based chemotherapy.

Increasing the number of adverse drug reactions reporting: the role of clinical pharmacy residents

Detection of adverse drug reactions (ADRs) in hospitals provides an important measure of the burden of drug related morbidity on the healthcare system. Spontaneous reporting of ADRs is scare and several obstacles to such reporting have been identified formerly. This study aimed to determine the role of clinical pharmacy residents in ADR reporting within a hospital setting. Clinical pharmacy residents were trained to report all suspected ADRs through ADR-reporting yellow cards. The incidence, pattern, seriousness, and preventability of the reported ADRs were analyzed. During the period of 12 months, for 8559 patients, 202 ADR reports were received. The most frequently reported reactions were due to anti-infective agents (38.38%). Rifampin accounted for the highest number of the reported ADRs among anti-infective agents. The gastro-intestinal system was the most frequently affected system (21.56%) of all reactions. Fifty four of the ADRs were reported as serious reactions. Eighteen of the ADRs were classified as preventable. Clinical pharmacy residents' involvement in the ADR reporting program could improve the ADR reporting system.

Efavirenz severe hypersensitivity reaction: case report and rapid desensitization protocol development

OBJECTIVE

Long-term efavirenz desensitization protocols have been reported; however, publication of a rapid desensitization protocol has not been noted to date. We report a case of severe hypersensitivity reaction that was successfully managed using a rapid desensitization protocol.

CASE SUMMARY

In a 52-year old HIV-positive woman, antiretroviral therapy was started with lamivudine 150 mg twice daily, zidovudine 300 mg twice daily, and efavirenz 600 mg daily. Nine days after starting antiretroviral therapy, she developed a generalized maculopapular rash. Despite concomitant chlorpheniramine administration, the rash did not improve. With suspicion of efavirenz hypersensitivity reaction, efavirenz was discontinued for 5 days and when the patient's rash resolved, the drug was restarted at 600 mg daily. The patient developed a severe generalized pruritic rash the next day and all antiretroviral agents were discontinued. One week later, lamivudine and zidovudine were restarted and were well tolerated. An

OBJECTIVE

20,000 solution of the target therapeutic dose, was successful. The patient was followed for 6 weeks and had no further signs or symptoms of a hypersensitivity reaction.

DISCUSSION

Efavirenz hypersensitivity reactions typically include cutaneous reactions that are observed in the first 2 weeks of treatment, are often mild to moderate without systemic manifestation, and improve with continued therapy. Previously, successful desensitization protocols have been described in patients receiving efavirenz who developed rash without systemic symptoms, but these protocols were carried out over 7 or 14 days. This case report indicates a rapid desensitization protocol that may be an available option for some patients.

CONCLUSIONS

Considering that efavirenz can be the cornerstone of many antiretroviral therapy regimens and hypersensitivity reactions can restrict regimen options, effective desensitization protocols are valuable, especially in the developing countries with limited available antiretroviral drugs.