Factors associated with pneumonia in post–cardiac arrest patients receiving therapeutic hypothermia

Aim

The aim of this study is to investigate risk factors associated with the development of pneumonia during the first 7 days of admission in survivors of cardiac arrest receiving therapeutic hypothermia.

Methods

A total of 123 patients receiving therapeutic hypothermia after out-of-hospital cardiac arrest between January 2008 and December 2010 were enrolled. Study populations were categorized as “pneumonia present” [P (+)] and “pneumonia absent” [P (−)] contingent upon the development of pneumonia during the first 7 days of admission. Risk factors and outcomes related to development of pneumonia were determined.

Results

Fifty-nine patients (48.0 %) developed pneumonia, and P (+) patients had lower Acute Physiology and Chronic Health Evaluation II score (22 vs 26); longer durations of central venous catheter (8.9 vs 5.1 days), nasogastric tube (11.1 vs 3.8 days), mechanical ventilation (MV) (9.3 vs 3.7 days), and intensive care unit stay (10.0 vs 5.0 days); and higher rates of nasogastric feeding (66.1% vs 35.9 %), tracheostomy (52.5% vs 17.2 %), and postanoxic seizure (62.7% vs 39.1 %). In multivariate analyses, the occurrence of postanoxic seizure (odds ratio, 2.75; 95% confidence interval, 1.06-7.14; P = .04) and the length of MV (odds ratio, 1.33; 95% confidence interval, 1.15-1.52; P < .001) were independently associated with the development of pneumonia. The development of pneumonia had no significant association with survival (log-rank test, P = .15).

Conclusion

Postanoxic seizure and prolonged duration of MV are independently associated with development of pneumonia. It may be helpful that we give more attention to the development of pneumonia in patients with postanoxic seizure and provide prompt diagnosis and treatment of postanoxic seizure.     

Drug–drug interactions in HIV positive cancer patients

Clinically relevant drug–drug interactions (DDIs) refer to the pharmacological or clinical response to the administration or co-exposure of a drug with another drug that modifies the patient's response. Treatment regimens, which include agents that are involved in the cytochrome P450 (CYP450) enzyme system and transporter systems, such as P-glycoprotein may be associated with higher risk of clinically significant drug interactions. In addition, potential DDIs increase with the increasing number of concomitant drugs. HIV positive cancer patients who receive concomitant chemotherapy and combination antiretroviral therapy (cART) may achieve better response rates and higher rates of survival than those who receive chemotherapy alone, but they may be at increased risk of drug interactions. DDIs in HIV positive cancer patients receiving concomitant chemotherapy and cART may increase or decrease antineoplastic drug concentrations, potentially resulting in life threatening interactions, increased toxicity or loss of efficacy. Avoiding and managing potential interactions between cART and antineoplastic agents is an increasingly important challenge. Based on the current literature, more safety and pharmacokinetic studies are needed with the aim to document a clear survival benefit for patients undergoing chemotherapy and concomitant or sequential administration of cART.     

Potential of chemotherapy–herb interactions in adult cancer patients

Goals of work The purpose of this study was to examine the specific herbs or vitamins (HV) used by patients receiving chemotherapy. Specifically, the following aspects were investigated: (1) HV use among adult cancer patients receiving chemotherapy, (2) the frequency of potential chemotherapy–HV interactions, (3) communication patterns between oncologists and their cancer patients taking HV, and (4) patients reactions to two hypothetical scenarios of chemotherapy–HV interactions.Patients and methods Adult cancer patients receiving chemotherapy at a university-based outpatient clinic over a 1-month period were sent a validated eight-page questionnaire regarding the use of complementary/alternative medicine, focusing on HV use. A total of 76 patients participated; relevant medical information was obtained from study participants charts. The chemotherapy received was compared with HV use to assess for potentially detrimental chemotherapy–HV interactions.Results HV use in patients receiving chemotherapy was common (78%), with 27% of the study participants being at risk of a detrimental chemotherapy–HV interaction. Most patients (>85%) would discontinue their HV or ask their medical oncologist for advice if a detrimental chemotherapy–HV interaction was suspected. Although most patients discussed HV use with their oncologist, the majority also relied on their friends and naturopathic physician for information regarding HV.Conclusions Considerable potential exists for detrimental chemotherapy–HV interactions. Methods to improve communication of HV use between cancer patients receiving chemotherapy and health-care practitioners are necessary to identify and minimize the risk of these interactions.This work was supported by University of Washington Undergraduate Research Training and University of Washington School of Pharmacy.     

High prevalence of the risk factors for QT interval prolongation and associated drug–drug interactions in coronary care units

Objectives: Patients admitted in coronary care units are susceptible to QT interval prolongation due to numerous risk factors. The purpose of this study was to identify the prevalence of risk factors for QT interval prolongation; QT prolonging medications; drug–drug interactions; their predictors; and torsades de pointes risks of drugs.

Methods: After obtaining approval, this cross-sectional study was carried out during one-year period in coronary care units of two major tertiary care hospitals of Khyber Pakhtunkhwa, Pakistan. The Arizona Center for Education and Research on Therapeutics QT drugs lists and Micromedex DrugReax® were used to identify the QT prolonging medications and QT prolonging drug–drug interactions.

Results: Total 649 patients were included in this study. The most frequent QT prolonging risk factors included use of ≥ 1 QT prolonging drugs (74.9%) and myocardial infarction (61.3%). Total 181 patients were presented with 361 QT prolonging drug–drug interactions. There was significant association of the occurrence of QT prolonging drug–drug interactions with female gender (p = 0.01), 9–10 prescribed medications (p = 0.001), and > 10 prescribed medications (p < 0.001).

Conclusions: The majority of patients presented with multiple risk factors for QT prolongation in coronary care units which may precipitate lethal outcomes.     

Predicting 30 – Day outcomes in emergency department patients discharged with COVID-19

IntroductionDetermining disposition for COVID-19 patients can be difficult for emergency medicine clinicians. Previous studies have demonstrated risk factors which predict severe infection and mortality however little is known about which risk factors are associated with failure of outpatient management and subsequent admission for COVID-19 patients.MethodsWe conducted a retrospective observational chart review of patients who had a confirmed positive COVID-19 test collected during an ED visit between March 1, 2020 and October 11, 2020. Patients were divided into two groups based on presence or absence of a subsequent 30-day hospitalization. Clinical and demographic information were collected including chief complaint, triage vital signs and comorbid medical conditions.Results1038 patients were seen and discharged from a network ED with a positive SARS-CoV-2 PCR test. 94 patients (9.1%) were admitted to a hospital within 30 days of the index ED visit while 944 (90.9%) were not admitted to a network hospital within 30 days. Patients that were admitted were more likely to be older (aOR = 1.04 (95% CI 1.03–1.06)), hypoxic (aOR = 2.16 (95% CI 1.14–4.10)) and tachycardic (aOR = 2.13 (95% CI 1.34–3.38)) on initial ED presentation. Preexisting hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease and malignancy were all highly significant risk factors for 30-day hospital admission following initial ED discharge (p < 0.0001).ConclusionEmergency Department providers should consider age, chief complaint, vital signs and comorbid medical conditions when determining disposition for patients diagnosed with COVID-19.     

Mortality associated with early changes in ARDS severity in COVID–19 patients – Insights from the PRoVENT–COVID study

PurposeWe investigated changes in ARDS severity and associations with outcome in COVID–19 ARDS patients.MethodsWe compared outcomes in patients with ARDS classified as ‘mild’, ‘moderate’ or ‘severe’ at calendar day 1, and after reclassification at calendar day 2. The primary endpoint was 28–day mortality. We also identified which ventilatory parameters had an association with presence of severe ARDS at day 2. We repeated the analysis for reclassification at calendar day 4.ResultsOf 895 patients, 8.5%, 60.1% and 31.4% had mild, moderate and severe ARDS at day 1. These proportions were 13.5%, 72.6% and 13.9% at day 2. 28–day mortality was 25.3%, 31.3% and 32.0% in patients with mild, moderate and severe ARDS at day 1 (p = 0.537), compared to 28.6%, 29.2% and 44.3% in patients reclassified at day 2 (p = 0.005). No ventilatory parameter had an independent association with presence of severe ARDS at day 2. Findings were not different reclassifying at day 4.ConclusionsIn this cohort of COVID–19 patients, ARDS severity and mortality between severity classes changed substantially over the first 4 days of ventilation. These findings are important, as reclassification could help identify target patients that may benefit from alternative approaches.     

Effect of hyperbaric oxygen in combination with drugs for treatment of sudden deafness

Background:Suddendeafnessalsoknownasessentialdeafnessischaracterizedbyhearingdisorderwithoutdefinitecauses,andwithsuddenonset.Objective:Toobserveeffectofhyperbaricoxygenonsuddendeafness.Unit:ChildrenHospitalofQuanzhouCity.Subjects:53patientswithsignificantlyunilateraldeafnesswereadoptedinourstudy.ABRshowedabnormaldiagnosisresults.Thesepatientsincluded24menand29womenaged7-61years.Theywererandomlydividedintotwogroups,comprehensivegroupcomprisingof16menand17womenaged7-56years(meanage:31±4)wi…     

Outcome of patients with injection drug use–associated endocarditis admitted to an intensive care unit

Purpose

The purpose of this study was to study the outcome of patients with injection drug use–associated infective endocarditis (IDU-IE) admitted to an intensive care unit (ICU).

Material and Methods

A retrospective review of medical records of 33 consecutive patients with IDU-IE admitted to ICU was conducted.

Results

Main indications for admission to ICU were as follows: severe sepsis or septic shock (36%), respiratory failure (33%), and neurologic deterioration (18%). Staphylococcus aureus was found in 94% of patients, and 15% had polymicrobial infection. Fifteen (45%) patients had septic emboli to 1 or more organs, including 12 (36%) to lungs and 7 (21%) to central nervous system. In-hospital mortality was 27%, and in univariate analysis, previous history of endocarditis (odds ratio [OR], 11.2; P = .03), respiratory failure (OR, 7; P = .03), neurologic failure (OR, 6.25; P = .03), and high Acute Physiology and Chronic Health Evaluation II (OR, 1.21; P = .016) and Sequential Organ Failure Assessment scores (OR, 1.25; P = .01) increased risk of death. By multivariate logistic regression analysis, previous history of endocarditis and high Acute Physiology and Chronic Health Evaluation II score were independently associated with poor survival.

Conclusions

Complicated IDU-IE necessitating admission to ICU is associated with high mortality. In addition to consequences of sepsis, septic embolization to central nervous system and lungs contributes to development of organ failure. Increased severity of illness and prior history of endocarditis are associated with poor outcome.     

Recent advances in delivery of drug–nucleic acid combinations for cancer treatment

Cancer treatment that uses a combination of approaches with the ability to affect multiple disease pathways has been proven highly effective in the treatment of many cancers. Combination therapy can include multiple chemotherapeutics or combinations of chemotherapeutics with other treatment modalities like surgery or radiation. However, despite the widespread clinical use of combination therapies, relatively little attention has been given to the potential of modern nanocarrier delivery methods, like liposomes, micelles, and nanoparticles, to enhance the efficacy of combination treatments. This lack of knowledge is particularly notable in the limited success of vectors for the delivery of combinations of nucleic acids with traditional small molecule drugs. The delivery of drug–nucleic acid combinations is particularly challenging due to differences in the physicochemical properties of the two types of agents. This review discusses recent advances in the development of delivery methods using combinations of small molecule drugs and nucleic acid therapeutics to treat cancer. This review primarily focuses on the rationale used for selecting appropriate drug–nucleic acid combinations as well as progress in the development of nanocarriers suitable for simultaneous delivery of drug–nucleic acid combinations.     

Is positivity for hepatitis C virus antibody predictive of lower risk of death in COVID-19 patients with cirrhosis?

Liver injury has been reported in coronavirus disease 2019 (COVID-19) cases but the impact of pre-existing liver damage and related etiology have not been completely elucidated. Our research interests include the potential reciprocal influence of COVID-19 and pre-existing liver damage related to hepatitis C virus (HCV) infection, in particular. To this end, we have evaluated three cohorts of patients admitted at three Italian hospitals during the coronavirus pandemic; these included 332 patients with COVID-19 and 1527 patients with HCV who were from established real-world antiviral treatment study cohorts (sofosbuvir/velpatasvir), with either liver disease (various severities; n = 1319) or cirrhosis (n = 208). Among the COVID-19 patients, 10 had cirrhosis (3%), including 7 of metabolic origin and 3 of viral origin. Mortality among the COVID-19 patients was 27.1%, with 70% of those with cirrhosis of metabolic etiology having died. Cirrhosis, older age, low white blood cell count and lymphocyte count being identified as risk predictors of death [odds ratio (OR) = 13.7, 95% confidence interval (CI): 2.59-83.01, P = 0.006; OR = 1.05, 95%CI: 1.03-1.08, P = 0.0001; OR = 1.09, 95%CI: 1.36-1.16, P = 0.001; OR = 0.61, 95%CI: 0.39-0.93, P = 0.023, respectively]. In the two cohorts of HCV patients, COVID-19 diagnosis was made in 0.07% of those with liver disease and 1% of those with cirrhosis. Thus, the prevalence of HCV antibodies among COVID-19-infected patients was comparable to that currently reported for the general population in Italy. Amongst the COVID-19 patients, pre-existing metabolic cirrhosis appears to be associated with higher mortality, while HCV antibodies may be suggestive of “protection” against COVID-19.     

Certain bio-psychosocial–spiritual problems associated with dyspnea among advanced cancer patients in Taiwan

Purpose

Dyspnea is a multidimensional phenomenon among advanced cancer patients. We aim to explore the association between bio-psychosocial–spiritual problems and dyspnea among advanced cancer patients in Taiwan.

Methods

We retrospectively analyzed advanced cancer patients admitted to the hospice palliative ward in a tertiary hospital in Taiwan from 2002 to 2005. A total of 687 consecutive advanced cancer patients were enrolled. Physical, psychosocial, and spiritual problems for each patient were collected. Multiple logistic regression analyses were used to evaluate the association between dyspnea and other physical, psychosocial, and spiritual problems.

Results

The top four primary sites of cancer among these patients are the liver/biliary tract (19.9%), lung (15.6%), colon/rectum (12.8%), and head/neck (9.9%). During admission period, 260 (37.8%) patients experienced dyspnea. For primary cancer types and metastatic locations, subjects with dyspnea tended to have lung cancer, lung metastasis, or brain metastasis. The clinical symptoms/signs related to dyspnea are pain, anorexia, constipation, nausea/vomiting, coughing, pleural effusion, edema, anxiety, and propriety preparation problem, that is, arranging one’s will, feelings of isolation, fear of death, and survival. After further adjustments for potential confounders, subjects with problems of propriety preparation were found to be strongly associated with dyspnea. The adjusted odds ratio of having dyspnea caused by the problem of propriety preparation was 1.91 (95% confidence interval, 1.15–3.19).

Conclusions

Advanced cancer patients with certain psychosocial and spiritual problems, such as, the problem of propriety preparation, fear of death, and anxiety, tended to have dyspnea. Among these factors, propriety preparation plays an important role among dyspnea patients. Advanced cancer patients with dyspnea have greater needs for propriety preparation.     

Lipid profile changes in patients with rheumatic diseases receiving a treatment with TNF-α blockers: A meta-analysis of prospective studies

Abstract

Background. Some studies showed an anti-atherogenic effect of TNF-α blockers on lipid profile, but these data have been challenged.

Objective. To perform a meta-analysis on lipid profile changes induced by TNF-α blocker treatment.

Methods. Prospective studies on rheumatic patients receiving TNF-α blockers and providing before-and-after treatment values of triglycerides (TGs), total cholesterol (TC), HDL-cholesterol (HDLc), LDL-cholesterol (LDLc), and atherogenic index (AI) were included. Standardized mean differences (SMD) in lipid profile were analyzed at short-term (2–12 weeks), middle-term (13–24 weeks), and long-term (25–52 weeks) assessments.

Results. Thirty articles (1707 patients) were included. TNF-α blockers determined an increase in TC at short-term, middle-term, and long-term assessments (SMD: 0.20 mmol/L [95% CI: 0.04, 0.35]; SMD: 0.27 mmol/L [95% CI: 0.08, 0.46]; SMD: 0.22 mmol/L [95% CI: 0.01, 0.43]). HDLc increased only at the short-term assessment (SMD: 0.19 mmol/L [95% CI: 0.10, 0.28]), and TGs achieved a significant increase at the long-term assessment (SMD: 0.19 mmol/L [95% CI: 0.04, 0.34]). LDLc and AI were not affected by TNF-α blocker treatment.

Conclusions. Slight but significant increases in TC occurred without any significant change in LDLc and AI. Changes in HDLc and TGs were not consistent among the different time point assessments. These quantitative changes in lipid profile do not seem to be able to explain cardiovascular risk improvement reported in patients receiving TNF-α blockers. Further studies on other mechanisms are needed to address this issue.     

“Rapid Counseling” as a new breakthrough: An alternative approach for patients with COVID-19

In this paper, I report on/show that the important of “rapid counseling” for patients with COVID-19 during this pandemic. These matters are studied based on the latest theory and research results, which are related to the current situation, namely the COVID-19 outbreak.     

Convalescent plasma therapy in B-cell-depleted and B-cell sufficient patients with life-threatening COVID-19 – A case series

ObjectiveTo investigate the effect of convalescent plasma therapy (CPT) on clinical courses of B-cell-sufficient and B-cell-depleted patients with life-threatening COVID-19.Patients and MethodsIn this case series, we retrospectively analysed clinical, laboratory and cardiopulmonary parameters of six patients with life-threatening COVID-19 receiving convalescent plasma (CP) as rescue therapy between April 11, 2020 to October 10, 2020. Clinical and laboratory parameters before and after transfusion were compared in two B-cell-depleted patients and four B-cell sufficient patients (control group).ResultsBoth B-cell-depleted patients cleared SARS-CoV-2 virus and survived, while all other patients died within 14 days from intervention despite maximal therapeutic efforts. D-dimer levels increased in both cohorts subsequent to CPT. In control patients, mean Interleukin-6 increased and platelet levels decreased as opposed to decreasing and stable levels in B-cell-depleted patients, respectively. Control patients required increased doses of vasopressor compared to decreasing doses in B-cell depleted patients subsequent to CPT. PO₂/FiO₂ decrease was more pronounced and respiratory deterioration required postinterventional extracorporeal membrane oxygenation in two control patients. Transpulmonary thermodilution revealed a further increase of the Extravascular Lung Water Index upon CPT in control patients.ConclusionUse of CP in late stages of life-threatening COVID-19 should be used with caution but may be beneficial in B-cell-depleted patients. Further studies are necessary to assess factors predicting potential therapeutic benefits as well as possible hazards.     

Time for considering other blood pressure target values in elderly patients with type 2 diabetes?

Although blood pressure control has undoubtedly proven its benefits in reducing the high cardiovascular risk in patients with type 2 diabetes mellitus (T2DM), it still remains unclear whether intensive antihypertensive treatment in old age (> 75 years) is beneficial. Many of the current guidelines recommend a systolic blood pressure (SBP) < 140 mmHg or lower, unless patients are at high risk for possible adverse events such as postural hypotension (1,2). This perspective aims to get a discussion started on the appropriate target SBP value for patients with T2DM aged older than 75 years.We would like to propose the less stringent value of< 160 mmHg in this specific population.