Investigating the Prevalence of Contrast-associated Nephropathy and the Related Risk Factors in Patients Undergoing Elective Angioplasty

Objective

Contrast-associated nephropathy (CAN) is a sudden decrease in kidney function following contrast media administration. Considering the importance of CAN in the patient's outcome and the high prevalence of this complication in cardiac catheterizing centers, this study was designed to investigate the prevalence and the related risk factors of CAN in patients undergoing angioplasty in Chamran Heart Hospital, Isfahan, Iran, from January 2022 to June 2022.

Methods

The inclusion criteria were adult patients above 18 admitted for elective percutaneous coronary intervention (PCI). Patient demographic information, underlying diseases and medications, dehydration state, type and amount of contrast media, and serum levels of blood urea nitrogen (BUN) and serum creatinine (SrCr) at 24 and 72 h after contrast injection were all recorded.

Findings

Out of 340, 128 patients developed CAN after PCI, giving an incidence of 37.64%. Adjusted analysis showed a significant relation between age over 65, the amount of contrast media administered, and the use of furosemide with the incidence of CAN. However, adjusted logistic regression analysis failed to show any significant relationship between the risk of CAN and the hydration status of the patients at 24 and 48 h after receiving contrast media as diagnosed by BUN/SrCr >20.

Conclusion

The prevalence of CAN in this study was higher than in other studies since this high-risk population was under risk factors such as arterial injection of contrast material and a higher amount of contrast material administration. In addition, advanced age, volume of contrast material, and previous or concurrent furosemide administration were associated with an increased risk of CAN.

Arrhythmia in a COVID-19 patient: A case report

In this study, we considered an 83-year-old male patient admitted to the Al-Zahra hospital emergency department in Isfahan. He complained of fatigue, weakness, headache, and cough. In addition, he had hallucinations and delusions for two days; but he had no fever and chill. His physical examination showed a blood pressure of 170/100 mm Hg, heart rate of 142 beats per minute (bpm), respiratory rate of 23 pbm, oxygen saturation (in room air) of 83%, and oxygen bag reserve mask of 93%. We realized cardiac involvement during hospitalization, including sinus bradycardia, first-degree atrioventricular (AV) block, recurrent premature ventricular from tricuspid ring, atrial tachycardia (AT) rhythm with variable AV conduction block, increased heart rate with functional bundle branch block, and negative troponin. The patient was treated with medicines to control heart rate and admitted to the cardiac care unit (CCU). Next, the patient was intubated due to a worsening lung condition. Afterward, he was admitted to the intensive care unit (ICU) and died the next day. According to the literature, compromised cardiac vascular is the most common complications in hospitalized patients due to COVID-19 infection and has a higher mortality risk. Cardiac arrhythmias are additionally common clinical manifestations. These arrhythmias seem to be caused by inflammatory responses in the myocardium, electrolyte disorders, and hypoxia. Our patient showed that the COVID-19 virus might induce different types of arrhythmias.

Lactate Dehydrogenase to Albumin ratio as a Predictive Factor of COVID-19 Patients' Outcome; a Cross-sectional Study

INTRODUCTION

 Despite the increasing vaccination coverage, COVID-19 is still a concern. With the limited health care capacity, early risk stratification is crucial to identify patients who should be prioritized for optimal management. The present study investigates whether on-admission lactate dehydrogenase to albumin ratio (LAR) can be used to predict COVID-19 outcomes.

METHODS

This retrospective cross-sectional study evaluated hospitalized COVID-19 patients in an academic referral center in Iran from May 2020 to October 2020. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the value of LAR in the prediction of mortality. The Yuden index was used to find the optimal cut-off of LAR to distinguish severity. Patients were classified into three groups (LAR tertiles), first: LAR<101.46, second: 101.46≤LAR< 148.78, and third group: LAR≥148.78. Logistic regression analysis was used to identify the association between tertiles of LAR, as well as the relationship between each one-unit increase in LAR with mortality and ICU admission in three models, based on potential confounding variables.

RESULTS

A total of 477 patients were included. Among all patients, 100 patients (21%) died, and 121 patients (25.4%) were admitted to intensive care unit (ICU). In the third group, the risk of mortality and ICU admission increased 7.78 times (OR=7.78, CI: 3.95-15.26; p <0.0001) and 4.49 times (OR=4.49, CI: 2.01-9.04; p <0.0001), respectively, compared to the first group. The AUC of LAR for prediction of mortality was 0.768 (95% CI 0.69- 0.81). LAR ≥ 136, with the sensitivity and specificity of 72% (95%CI: 62.1-80.5) and 70% (95%CI: 64.9-74.4), respectively, was the optimal cut-off value for predicting mortality.

CONCLUSION

High LAR was associated with higher odds of COVID-19 mortality, ICU admission, and length of hospitalization. On-admission LAR levels might help health care workers identify critical patients early on.

Evaluation of the Possible Effect of the Influenza Vaccine on the Severity, Mortality, and Length of Hospitalization among Unvaccinated COVID-19 Patients; An Observational, Cross-Sectional Study

Background: Based upon WHO (World Health Organization) Coronavirus Dashboard more than 5 million deaths worldwide have been attributed to the COVID-19 (Coronavirus Disease 2019) caused by the SARS-Cov-2 virus (Severe Acute Respiratory Syndrome Coronavirus) till November 2021. The annual flu vaccination has raised many questions about the vaccine's effects on Covid-19 outcomes. Several possible mechanisms including cross-reactivity and cross-protection have been reported to be responsible for the potential protective effect of the flu vaccine on the COVID-19 infection. This study was performed to evaluate the possible effect of the influenza vaccine on the disease severity, the mortality rate, and the length of hospitalization in COVID-19 patients.  Methods: The data of 1300 patients were recorded from May 2020 to October 2020. Patients with a previous history of COVID-19, patients under 18 years old, and patients who did not have accurate information about their influenza vaccination history were excluded. 498 hospitalized unvaccinated COVID-19 patients with typical clinical manifestations and a positive PCR (Polymerase Chain Reaction) test for COVID-19 were included in this observational, cross-sectional study. The participants were divided into two groups (vaccinated and unvaccinated) based on the history of influenza vaccination at the time of admission. Results: The length of hospital stay was lower in the vaccinated compared to the unvaccinated group (p < 0.05). However, there was no significant difference between the mortality rate, the need for ICU (Intensive Care Unit) admission, and the severity of the disease between the two groups (p> 0.05). Conclusion: Since the patients studied in this article did not receive any of the Covid-19 vaccines; Therefore, the effect of influenza vaccination on the clinical course of Covid-19 can be evaluated using the results of this study. A longer length of hospital stay was observed in the unvaccinated patients in our study, which may suggest the possible protective effect of the influenza vaccine against COVID-19. 

Possible effects of melatonin on reperfusion injury following coronary artery bypass graft surgery

BACKGROUND

Although coronary artery bypass graft (CABG) surgery has been reported to be one of the most effective internentions in terms of myocardial salvage, reperfusion itself can cause additional damage to the myocardium. Since there is strong evidence that free radicals are the principal offender in ischemia-reperfusion (I/R) injury, it has been suggested that treatment with antioxidant agents can be protective. Investigations have shown that melatonin secretion is partially disturbed in CABG patients. The aim of this study was to evaluate the protective effect of melatonin as an antioxidant agent on I/R injury.

METHODS

164 elective CABG candidates participated in this randomized clinical trial during the preoperative period. The candidates were randomized to receive 3 mg of melatonin tablets (physiologic dose) from 3 days before surgery until the day of discharge. Cardiac biomarkers [troponin and creatine kinase myocardial band (CKMB)] were assessed once before surgery (24 hours before surgery), and 8 and 24 hours after surgery.

RESULTS

Finally, 130 patients, 65 (50%) patients in the melatonin group and 65 (50%) in the control arm finished our study. Mean age of melatonin and control groups was 59.90 ± 9.59 and 60.80 ± 8.00 years, respectively; moreover, 47 (72.30%) in melatonin and 45 (69.23%) in control group were men. No significant difference was seen in baseline cardiac biomarkers between two groups (P > 0.05). In both groups, cardiac biomarkers (CKMB and troponin) elevated after surgery in comparison to their preoperative values. There was no statistically significant difference between the control and melatonin groups regarding the 8-hour and 24-hour troponin and CKMB when adjusted for interacting factors (P > 0.05).

CONCLUSION

Although physiological concentration of melatonin is protective against I/R injury, substitution of endogenous melatonin with the oral supplement which creates physiologic concentration may not prevent I/R injury. In order to have antioxidant effect, pharmacologic doses of melatonin should be employed.

A Rare Case of Aluminum Phosphide Induced Thrombotic Thrombocytopenic Purpura

Aluminum phosphide (AlP) has remained a chemical cause of completed suicides in some developing countries. ALP toxicity can cause multi-system damage. As far as we know, this is the first case of ALP-induced Thrombotic Thrombocytopenic Purpura (TTP) and its successful management. A 34-year-old man, who had attempted suicide with ALP was admitted to our hospital. On the 3rd day of admission, the patient developed hematuria, hemolysis, and thrombocytopenia. Based upon available evidence, TTP was diagnosed. Following a complete patient evaluation, ALP was recognized as the probable cause of TTP. Following the treatment using prednisolone and therapeutic plasma exchange, the patient substantially improved. Finally, he was discharged on the 22nd day. Toxin-induced intravascular hemolysis should be considered for patients presenting with ALP toxicity. As reported in this patient, TTP is another manageable consequence of ALP poisoning.

Metronidazole induced anaphylactic shock: a case report

Metronidazole induced anaphylactic shock is an extremely rare drug reaction. We reported a 39-year-old man with severe anaphylactic shock caused by Metronidazole. He denied history of food or drugs allergy. Severe cardiovascular collapse suddenly occurred after receiving intravenous Metronidazole. The patient was successfully managed as a case of anaphylactic shock and finally discharge.

Oral Substitution of Melatonin in Critical Care: A Pharmacokinetic Study in Patients with Intracranial Hemorrhage

Background: Intracranial hemorrhage (ICH) is a devastating condition with a high mortality and morbidity rate. Neuroprotective agents protect surrounding brain tissue from the toxic effects of hematoma and can result in better outcomes. There is evidence demonstrating the neuroprotective benefits of melatonin in experimental animal models of ICH. Reduced melatonin levels have been reported in the intensive care unit (ICU) patients. The aim of this study was to evaluate baseline melatonin levels and pharmacokinetic profile of melatonin in ICH patients. Methods: This was a randomized clinical trial in which 24 patients with non-traumatic ICH were divided into melatonin and control groups. Subjects in the melatonin group received 30 mg of melatonin for 5 days. Another group of 12 healthy volunteers also were recruited for the study. Baseline serum melatonin levels were measured for all groups. For the pharmacokinetic study, sampling intervals were 0.25, 0.5, 0.75, 1.5, 3, 6 and 10 hours after melatonin administration. Samples were analyzed using an HPLC system with fluorescence detection. Results: Serum melatonin concentrations found to be decreased in all patients. Patients showed a significant increase in levels by the third day but still lower than healthy volunteers. By day 5, the melatonin group reaches melatonin levels, statistically similar to healthy volunteers, but the control group didn't reach normal levels even on the seventh day of study. Conclusion: Our study suggests that monitoring melatonin levels and supplementing with exogenous melatonin can correct the reduced levels. Further studies focused on melatonin administration in ICH patients can be helpful in evaluating clinical outcomes in these patients. J Pharm Care 2020; 8(1): 3-10.

Evaluation of Epithelial Lining Fluid Concentration of Amikacin in Critically Ill Patients With Ventilator-Associated Pneumonia

INTRODUCTION

Classically, aminoglycosides are known to have low penetration into the lung tissue. So far, no study has been conducted on human adult patients to evaluate amikacin concentration in epithelial lining fluid (ELF) of the alveoli. Therefore, convincing data are not available from the perspective of pharmacokinetics to support the fact that a dosage of 20 mg/kg of amikacin is sufficient to treat patients with ventilator-associated pneumonia (VAP).

METHOD

This was a pilot study of amikacin concentration measurement in the alveolar site of action in critically ill adult patients with VAP who required aminoglycoside therapy. A dose of 20 mg/kg of amikacin was administered over a 30-minute infusion. The serum concentrations of amikacin were evaluated in the first, second, fourth, and sixth hours. However, the ELF concentration of amikacin was evaluated in the second hour with the help of bronchoalveolar lavage sampling technique.

RESULTS

A total number of 8 patients was included in the study. The mean (SD) administered dose was 20 (0.9) mg/kg. The mean (SD) peak plasma concentration of amikacin was 59.6 (23) mg/L, with the volume of distribution of 0.36 (0.13)L/kg. The amikacin concentration in ELF was successfully measured in 7 patients (6.3) mg/L. The lung tissue penetration of the drug was described as alveolar percentage, proportional to both the first- and second-hour plasma concentrations, with a mean (SD) of 10.1% (8.4%) and 18% (16.7%), respectively.

CONCLUSION

To our knowledge, the current study is the first that investigates whether standard doses of amikacin may lead to sufficient alveolar concentration of the drug. The results show that administration of amikacin in doses of 20 mg/kg in critically ill patients with VAP may not provide sufficient concentrations in ELF.

A Novel Practical Equation for Treatment of Emergent Hypernatremia and Dehydration Phase in Infants

Serum sodium (Na) concentration more than 145 mmol/L is defined as hypernatremia. Hypernatremia carries an acute morbidity and mortality, especially in neonates and infants. Rapid correction of hypernatremia leads to severe cerebral damages, and seizure is the most common neurological complication of hypernatremia. Selection and calculation of an appropriate fluid and its amount is one of the tremendous challenges. It is important to choose the correct amount of suitable fluid and adjust rehydration rate. In this study, we have suggested practical equation to determine the amount of fluid that should be administered to the neonates and infants with hypernatremia. In this equation, the amount of infusate volume will be calculated from changes in serum Na and total body water. However, serum Na and infusate Na will play an important role in equation structure, too. Our suggested equation will help physicians to manage hypernatremic dehydrated patients in a suitable manner with an adjustable rate.

Melatonin Supplementation May Improve the Outcome of Patients with Hemorrhagic Stroke in the Intensive Care Unit

Objective:

Although mechanical ventilation is frequently a life-saving therapy, its use can result in unwanted side effects. It has been well documented that the choice of sedating agent may influence the duration of mechanical ventilation. Melatonin is a sedative and analgesic agent without any respiratory depressant effect which makes it an attractive adjuvant for sedation in the intubated patients. The aim of this study is to evaluate the effect of melatonin on the duration of mechanical ventilation in patients with hemorrhagic stroke.

Methods:

Forty adult intubated patients with hemorrhagic stroke, who were admitted to the Intensive Care Unit (ICU) within 24 h of onset, were enrolled in this randomized double-blind study. Subjects in the melatonin group received 30 mg of melatonin every night throughout the nasogastric tube. Length of ICU stay, mortality, and duration of mechanical ventilation were recorded for all patients.

Findings:

The duration of mechanical ventilation and length of ICU stay were shorter in patients who received melatonin in comparison with the control group, and this difference was statistically significant for the length of ICU stay and marginally significant for the duration of mechanical ventilation. Although not statistically significant, the mortality rate of the control group was 30%, almost double that of the study group (15%).

Conclusion:

Melatonin possesses hypnotic, analgesic, anti-inflammatory, and anti-oxidative properties that distinguish it as an attractive adjuvant in patients under mechanical ventilation. In conclusion, the administration of melatonin may facilitate the weaning process through decreasing the consumption of sedatives with respiratory depressant properties as well as preventing ventilator-associated lung injury.

Evaluating the Potential Effect of Melatonin on the post-Cardiac Surgery Sleep Disorder

BACKGROUND

Postoperative neurological injuries, including cognitive dysfunction, sleep disorder, delirium, and anxiety, are the important consequences of coronary artery bypass graft surgery (CABG). Evidence has shown that postoperative sleep disturbance is partly due to disturbed melatonin secretion in the perioperative period. The aim of this study was to evaluate the effect of melatonin on postoperative sleep disorder in patients undergoing CABG.

METHOD

One hundred forty-five elective CABG patients participated in a randomized double-blind study during the preoperative period. The patients were randomized to receive either 3 mg of melatonin or 10 mg of Oxazepam one hour before sleep time. Each group received the medication from 3 days before surgery until the time of discharge. Sleep quality was evaluated using the Groningen Sleep Quality Score (GSQS), and the incidence of delirium was evaluated by nursing records. Sleep quality and anxiety scores were compared before and after surgery through the Wilcoxon signed-rank test. The analysis of covariance (ANCOVA) and independent t-test were used to compare the sleep and anxiety scores between the groups. P values ≤ 0.05 were considered statistically significant.

RESULTS

Totally, 137 patients at a mean age of 60 years completed the study (76% male). The analysis of the data showed that sleep was significantly disturbed after surgery in both groups. The patients in the Oxazepam group demonstrated significantly higher disturbance in their mean postoperative GSQS score than did their counterparts in the melatonin group (p value < 0.001). A smaller proportion of the participants experienced delirium in the melatonin group (0.06%) than in the Oxazepam group (0.12%); however, this difference was not statistically significant.

CONCLUSION

The result of the present study revealed that melatonin improved sleep in post-cardiac surgery patients more than what was observed with Oxazepam. Therefore, melatonin may be considered an effective alternative for Benzodiazepines in the management of postoperative sleep disorder.

Association between Perioperative Parameters and Cognitive Impairment in Post-Cardiac Surgery Patients

BACKGROUND

Postoperative cognitive dysfunction (POCD) has been an important complication of cardiac surgery over the years. Neurocognitive dysfunction can affect quality of life and lead to social, functional, emotional, and financial problems in the patient's life. To reduce POCD, we sought to identify the association between cognitive dysfunction and perioperative factors in patients undergoing cardiac surgery.

METHODS

One hundred one patients aged between 45 and 75 years undergoing elective cardiac surgery were enrolled in this study. All the surgeries were performed on-pump by the same medical team. A brief Wechsler Memory Test (WMT) was administered before surgery, 3 to 5 days after the surgery, and 3 months after discharge. All related perioperative parameters were collected in order to study the effect of these parameters on the postoperative WMT scores and WMT score change.

RESULTS

The study population consisted of 101 patients, comprising 14 (13.8%) females and 87 (86.2%) males aged between 45 and 75 years. In univariate analysis, the baseline WMT score, serum levels of lactate dehydrogenase and T3, cross-clamp time, and preexistence of chronic obstructive pulmonary disease showed significant effects on the postoperative WMT score (p value < 0.05), whereas only the baseline WMT score and chronic obstructive pulmonary disease showed strong effects on the postoperative WMT score in the multiple regression model. In addition, the multiple regression model demonstrated a significant association between the baseline WMT score, serum creatinine level, and nitrate administration and the WMT score change.

CONCLUSION

Our study showed that preexisting chronic obstructive pulmonary disease and preoperative high serum creatinine levels negatively affected cognitive function after surgery. In addition, there was a strong relationship between the patients' basic cognition and POCD. Preoperative nitrate administration led to a significant improvement in POCD. It is also concluded that the preoperative administration of specific medicines like nitrates can reduce neurological complications after cardiac surgery.

Clinical evaluation of Nigella sativa seeds for the treatment of hyperlipidemia: a randomized, placebo controlled clinical trial

BACKGROUND

Natural products are proved to play a good role as an alternative to synthetic chemicals in many clinical conditions. Hypercholesterolemia is the most important risk factor for atherosclerosis. Previous studies showed that Nigella sativa L. has both antioxidant and lipid lowering potentials.

THE AIM OF THIS STUDY

To evaluate the efficacy of the seeds of Nigella sativa on the treatment of hyperlipidemia.

METHODS

In this randomized, placebo controlled clinical trial which was conducted in Isfahan city (Iran), 88 subjects aged > or =18 years with a total cholesterol concentration >200 mg/dl were included. According to the patients" profiles number, they were randomized to receive either N. sativa capsules or the matching placebo. Each N sativa capsule contained 500 +/- 10 mg N. sativa crushed seeds, and patients had to take 2 g N. sativa per day for 4 weeks. Fasting baseline laboratory values (fasting blood sugar, total cholesterol, low density lipoprotein, high density lipoprotein and triglyceride) were obtained for all parameters on each subject prior to the start of the study and at the end of 4 weeks.

RESULTS

In our study a significant decrease was observed in the concentration of total cholesterol (4.78%), Low density lipoprotein (7.6%) and Triglyceride (16.65%), and this decrease was more significant for TG concentration. N. sativa had not any beneficial effects on Fasting blood sugar and High density lipoprotein.

CONCLUSION

According to the results of our present study it seems that N. sativa may have some beneficial therapeutic effects in the treatment of hyperlipidemia. However, further investigations with a larger sample size are necessary.