Retrobulbar hemorrhage with orbital compartment syndrome: A rare sight-threatening emergency during air medical evacuation

Traumatic retrobulbar hemorrhage may be rapidly progressive, converts to a sight-threatening emergency with potentially devastating complications. Assisted-escape systems in fast jet aircraft can lead to the pilot's facial/orbital injuries at any stage of the ejection sequences, which may result in retrobulbar hemorrhage. Orbital traumas are common and rarely result in retrobulbar hemorrhage and orbital compartment syndrome. However, early diagnosis and urgent out-of-the-hospital lateral canthotomy with cantholysis were recommended to save the patient's vision.

Dexmedetomidine versus sufentanil as adjuvants to bupivacaine for brachial plexus block during upper extremity surgery: a randomized clinical trial

BACKGROUND

Brachial plexus block (BPB) has been accepted as a reliable alternative for general anesthesia in upper limb surgeries. Adding adjuvant drugs like dexmedetomidine and sufentanil has been shown to have clinical and pharmacologic advantages. In this randomized parallel clinical trial, we aim to compare the effects of these two adjuvants for bupivacaine in BPB.

METHODS

In this double-blinded study, by using computer-assisted block randomization, 40 patients ranged from 20 to 65 years old and scheduled for elective upper limb surgeries were assigned to two equal study groups (n = 20), receiving 1 mL of 5 ..g.mL-1 sufentanil (group S) or 1 mL of 100 ..g.mL-1 dexmedetomidine (group D) in adjunction to 30 mL of 0.5% bupivacaine for supraclavicular BPB under the guidance of ultrasonography. Characteristics of local anesthesia and postoperative analgesia were evaluated (n = 40).

RESULTS

The duration of blocks significantly improved in group S (sensory: estimated median difference (EMD) [95%CI] = 100.0 [70.0...130.0], p < 0.001; motor: EMD [95%CI] = 120.0 [100.0...130.0], p < 0.001). Group S also had significantly longer postoperative analgesia and lower opioid consumption within 24 hours after the surgery (EMD [95%CI] = 4.0 [3.0...7.0], p < 0.001; EMD [95%CI] = -5.0 [-5.0...-5.0], p < 0.001; respectively). None of the patients showed adverse effects concerning vital signs, nausea, or vomiting.

CONCLUSION

Our study showed that during ultrasound-guided supraclavicular BPB, sufentanil is a fairly better choice than dexmedetomidine as an adjuvant for bupivacaine and can provide preferable sensory and motor blocks. No significant side effects were seen in either of the study groups.

Oleanolic acid increases the anticancer potency of doxorubicin in pancreatic cancer cells

Combination therapy is a novel cancer therapy approach that combines two or more chemotherapy drugs. This treatment modality enhances the efficacy of chemotherapy by targeting key pathways in an additive or synergistic manner. Therefore, we investigated the efficacy of combination therapy by widely used chemotherapy drug doxorubicin (DOX) and oleanolic acid (OA) to induction of apoptosis for pancreatic cancer (PC) therapy. The effects of DOX, OA, and their combination (DOX-OA) were investigated on proliferation and viability of PC cell line (PANC-1) by MTT assay. Moreover, migration and invasion of the cancer cells were evaluated by trans-well migration assay and wound healing assay. Flow cytometry and DAPI (4',6-diamidino-2-phenylindole) staining were employed to investigate apoptosis quantification and qualification of the treated cancer cells. Finally, mRNA expression of apoptosis-related genes was assessed by quantitative real-time polymerase chain reaction. Our results demonstrated that the proliferation and metastasis potential of PC cells significantly decreased after treatment by DOX, OA, and DOX-OA. Moreover, we observed an increase in apoptosis percentage in the treated cancer cells. The apoptosis-related gene expression was modified to increase the apoptosis rate in all of the treatment groups. However, the anticancer potency of DOX-OA combination was significantly more than that of DOX and OA treatments alone. Our study suggested that DOX-OA combination exerts more profound anticancer effects against PC cell lines than DOX or OA monotherapy. This approach may increase the efficiency of chemotherapy and reduce unintended side effects by lowering the prescribed dose of DOX.

Cardio-Pulmonary Histopathology with Clinical Correlations of Deceased Patients with COVID-19: A Case Series in Tehran, Iran

BACKGROUND

SARS-CoV-2 may affect vital organs. The present study investigated the histopathology of pulmonary and cardiac tissues with clinical correlation in deceased patients with COVID-19.

METHODS

We obtained pulmonary and cardiac tissues from 30 deceased patients with COVID-19 in Tehran, Iran, from January to May 2021. Sampling was performed through a percutaneous needle biopsy. After slide preparation, two expert pathologists studied them. We assessed the correlation between clinical and pathological data by Fisher's exact test.

RESULTS

The mean age of the patients was 73.8±13.4 years, and the male-to-female ratio was 23/7. The most common underlying disease was hypertension (HTN) in 25 patients (83%). Fifty-five tissue samples were achieved, including 28 pulmonary and 27 cardiac samples. Our results showed that all patients (100%) developed diffuse alveolar damage (DAD), and 26 (93%) developed hyaline membrane formation. The most common phase of DAD was the exudative-proliferative phase in 16 (57.1%). Three cardiac samples (11%) revealed myocarditis, and seven (26%) showed cardiomyocyte hypertrophy. In univariate analysis using Fischer's exact test, myocarditis had significant relationships with C-reactive protein (CRP) levels higher than 80 mg/dL (P=0.008) and elevated cardiac troponin levels higher than two-fold (P=0.01).

CONCLUSION

COVID-19 can affect the major vital organs. However, only myocarditis had a significant relationship with the circulating levels of inflammatory factors.

The effect of l-carnitine supplementation on mortality and clinical outcomes in ventilator-dependent critically ill patients with obesity and COVID-19: Protocol for a randomized double-blind placebo-controlled trial

Background

Coronavirus disease 2019 (COVID-19) still remains a pandemic accounting for at least 15% of intensive care unit (ICU) admissions. Recently, it has been observed that l-carnitine levels, which play an important role in fatty acid metabolism, have an inverse association with the severity of COVID-19 and its complications, hence a potential role for supplementing with this nutraceutical has been suggested. The current protocol describes a trial aiming to an evaluation of the effect of l-carnitine intervention on mortality and clinical outcomes in ICU-admitted patients with COVID-19.

Methods

This parallel-group, randomized, placebo-controlled, and double-blind clinical trial involves 50 participants and will be performed at the ICU of Artesh (AJA) Hospital, Mashhad, IRAN. Eligible participants will be randomized into two groups: 1) the intervention group will receive 1000 mg l-carnitine capsules 3 times a day, and 2) the placebo group will receive 1000 mg placebo capsules 3 times a day. Assessments will be performed at baseline, 7 and 28 days after study initiation. The primary outcome includes changes in serum levels of C-reactive protein (CRP). Secondary outcomes include the length of stay in the ICU, ICU mortality, hospital mortality, 28-day mortality, duration of mechanical ventilation (MV), and the neutrophil-lymphocyte ratio (NLR).

Conclusion

Based on previous evidence, l-carnitine may reduce inflammation and oxidation stress and improve respiratory function. However, the effects of l-carnitine on ventilator-dependent COVID-19 critically ill patients have not been assessed yet, justifying the necessity to conduct a clinical study in this field. c.

DNA methylation alterations in systemic lupus erythematosus: A systematic review of case-control studies

BACKGROUND

Traditionally, the diagnosis and monitoring of disease activity in systemic lupus erythematosus (SLE) are contingent upon clinical manifestations and serological markers. However, researchers are struggling to find biomarkers with higher sensitivity and specificity. DNA methylation has been the most studied epigenetic feature in SLE. So, in this study, we performed a systematic review of studies about DNA methylation alterations in SLE patients compared to healthy controls.

METHODS

By searching PubMed, Scopus, and Google Scholar up to July 2022, all case-control studies in which DNA methylation of specific genes was assessed by a non-high-throughput technique and passed the quality of bias assessment were included.

RESULTS

In total, 44 eligible studies underwent a data extraction process. In all, 3471 SLE patients and 1028 healthy individuals were included. Among the studies that reported the patients' gender (n = 2853), 89.41% were female and 10.59% were male. Forty studies have been conducted on adult patients. The number of works on fractionated and unfractionated blood cells was almost equal. In this regard, 22 studies were conducted on whole blood or peripheral blood mononuclear cells and two studies on unfractionated white blood cells. Sorted blood cells were biological sources in 20 studies. The most investigated gene was IFI44L. Sensitivity, specificity, and diagnostic power of methylation levels were only reported for IFI44L in five studies. The most employed methylation profiling method was bisulfite sequencing polymerase chain reaction. The correlation between methylation patterns and clinical parameters was explored in 22 studies, which of them 16 publications displayed a remarkable association between DNA methylation status and clinical indices.

CONCLUSIONS

The methylation status of some genes especially IFI44L, FOXP3, and MX1 has been suggested as promising SLE biomarkers. However, given the conflicting findings between studies because of potential confounders such as different sample types, methylation profiling methods, and ethnicity as well as shared DNA methylation patterns of SLE and other autoimmune diseases, DNA methylation biomarkers are currently not reliable diagnostic biomarkers and do not represent surrogate markers of SLE disease activity. Future investigations on a larger scale with the discarding of limitations of previous studies would probably lead to a consensus.

An overview on role of nutrition on COVID-19 immunity: Accumulative review from available studies

The novel coronavirus infection (COVID-19) conveys a serious global threat to health and economy. A common predisposing factor for development to serious progressive disease is presence of a low-grade inflammation, e.g., as seen in diabetes, metabolic syndrome, and heart failure. Micronutrient deficiencies may also contribute to the development of this state. Therefore, the aim of the present study is to explore the role of the nutrition to relieve progression of COVID-19. According PRISMA protocol, we conducted an online databases search including Scopus, PubMed, Google Scholar and web of science for published literatures in the era of COVID-19 Outbreak regarding to the status of nutrition and COVID-19 until December 2021. There were available studies (80 studies) providing direct evidence regarding the associations between the status of nutrition and COVID-19 infection. Adequate nutritional supply is essential for resistance against other viral infections and also for improvement of immune function and reduction of inflammation. Hence, it is suggested that nutritional intervention which secures an adequate status might protect against the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - coronavirus-2) and mitigate its course. We also recommend initiation of adequate nutritional supplementation in high-risk areas and/or soon after the time of suspected infection with SARS-CoV-2. Subjects in high-risk groups should have high priority for applying this nutritive adjuvant therapy that should be started prior to administration of specific and supportive medical measures.

The Effect of L-Citrulline Supplementation on Outcomes of Critically Ill Patients under Mechanical Ventilation; a Double-Blind Randomized Controlled Trial

Introduction

Effective parenteral and enteral amino acid replacement is crucial for critically ill patients with altered amino acid metabolism. This study aimed to assess the effects of l-citrulline supplementation on the clinical and laboratory outcomes in critically patients.

Methods

This was a double-blind placebo-controlled randomized clinical trial. 82 critically ill patients who were expected to receive mechanical ventilation for more than 72 hours were selected. The patients were assigned to either a placebo or an intervention group. The patients in the placebo group received 10 gr of microcrystalline cellulose and the ones in the intervention group were given l-citrulline daily for 7 days. Serum levels of fasting blood sugar (FBS), lipid profile, hepatic enzymes, serum electrolytes, urea nitrogen, creatinine, and C-reactive protein (CRP) were evaluated before and after the intervention. Duration of invasive ventilation, intensive care unit (ICU) length of stay, ventilator-free days, and 28-day mortality rate were recorded and compared between groups.

Results

Eighty-two patients completed the trial. No statistically significant differences were observed between the two groups in terms of age (p = 0.46), sex (p = 0.49), body mass index (BMI) (p = 0.41), Sequential Organ Failure Assessment (SOFA) Score (p = 0.08), Clinical Pulmonary Infection Score (CPIS) score (p = 0.76), Acute Physiology and Chronic Health Evaluation (APACHE II) score (p = 0.58), risk factors (p = 0.13), ICU stay before randomization (p = 0.32), and reason of admission (p = 0.50) before the intervention. Citrulline group had a notable reduction in FBS (p = 0.04), total cholesterol (TC) (p = 0.02), low density lipoprotein (LDL-C) (p <0.001) and high-sensitivity CRP (hs-CRP) (p <0.001). Also, a significant increase in lactate dehydrogenase (LDH) concentration (p <0.001) was observed in the intervention group at the end of the trial. Total duration of invasive ventilation and the mean SOFA score on 7th day were significantly lower in the citrulline group compared to the control group. Moreover, a significant increase in days alive and ventilator-free days within 28 days after admission was found in the citrulline group at the end of the trial. Also, there were no significant differences between the groups in terms of mortality rate during intervention, serious adverse events, endotracheal intubation, the use of tracheotomy or non-invasive ventilation after extubation, length of ICU stay, ICU-free days at 28 days, and CPIS and APACHE II scores. For mortality, in the citrulline group, there was two deaths compared to eight deaths in the control group. This resulted in an absolute risk reduction (ARR) of 14.05% (95% CI: 0.39-27.71%) and a number needed to treat (NNT) of 7.1 (95% CI: 3.6-29.5), regarding mortality.

Conclusions

The results of the present study demonstrated the probable positive effects of citrulline supplementation on lipid profile, hs-CRP levels, duration of invasive ventilation, and SOFA score. Also, l-citrulline consumption may increase the probability of survival without mechanical ventilation.

Importance of STAT3 Polymorphisms on the Risk and Clinical Characteristics of Rheumatoid Arthritis

Signal transducer and activator of transcription 3 (STAT3) has been introduced as one of the critical genetic factors in the pathogenesis of rheumatoid arthritis (RA). Single nucleotide polymorphisms (SNPs) in microRNA binding sites, known as miRSNPs, are a class of common variants in the 3' untranslated regions of genes targeted by miRNAs. miRSNPs unbalance gene expression by disrupting the binding regions of microRNAs. In this study, we intended to evaluate the association of two miRSNPs with the risk of RA development and its clinical features. We studied 120 Iranian patients with RA and 125 non-RA subjects as controls. The genotypes and alleles of rs1053005 and rs1053023 in each individual were assessed by the high-resolution melting method. The distribution of STAT3 variants did not differ markedly in RA patients compared to healthy controls. Stratification analysis revealed that rs1053005 was linked with a higher concentration of C-reactive protein and an increased erythrocyte sedimentation rate, two indicators of inflammation and disease activity in RA patients. The rs1053023 variant was correlated with higher levels of creatinine as an indicator of renal involvement. Our data demonstrate an association between STAT3 variants and clinical characteristics of RA, such as disease activity and probably kidney impairment.  However, we did not observe a significant relationship between the two targeted variants and a predisposition to RA.

Thalamic hemi-chorea: a rare complication after receiving the adenoviral vector-based COVID-19 vaccine: a case report

Lacunar strokes occur when a branch of a large cerebral artery is blocked. The thalamus is often affected, causing uncontrollable motions. A 72-year-old previously healthy man presented with involuntary motions in the right limbs, which were present at rest, and exacerbated during voluntary actions. He had received the first dose of the adenoviral vector-based coronavirus disease 2019 vaccine (ChAdOx1 nCoV-19) 9 days ago. Severe thrombocytopenia and elevated levels of lactate dehydrogenase, ferritin, C-reactive protein, and D-dimer were found, without any evidence of connective tissue disease. Electromyography demonstrated typical choreiform movements, and the brain magnetic resonance imaging indicated a small high signal lesion on the left side of the thalamus. Detection of the immunoglobulin G antibodies against platelet factor 4 in the blood, negative heparin-induced platelet activation (HIPA) test, and positive modified HIPA test confirmed the thalamic stroke due to the vaccine-induced prothrombotic immune thrombocytopenia (VIPIT). He was admitted to the intensive care unit and received nadroparin, sodium ozagrel, edaravone, methylprednisolone, and haloperidol. His hemi-chorea improved gradually over 2 weeks, and he was discharged after 21 days with rehabilitation advice. VIPIT due to the ChAdOx1 nCoV-19 is a novel immune-mediated response that needs clinicians' awareness and further investigations.

The effect of ginger supplementation on metabolic profiles in patients with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

There is some evidence regarding the positive effects of ginger supplementation on metabolic profile in patients with type 2 diabetes (T2DM). However, they are conflicting. The present systematic review and meta-analysis aimed to summarize earlier findings for the effect of ginger supplementation on metabolic profile in patients with T2DM.

METHODS

Scopus, PubMed and Google Scholar databases were systematically searched up until September 2021 to collect all randomized clinical trials that evaluated the effect of ginger supplementation on FBS, HbA1c, TC, TG, LDL, HDL, SBP and DBP in patients with T2DM. We conducted our study according to the 2020 PRISMA guidelines. We included only English language publications. Pooled effect sizes were measured using a random-effects model and were reported as the weighted mean difference (WMD) and 95% CI. In addition, the Cochrane Collaboration's risk of bias tool was used to evaluate quality of the trials.

RESULTS

In overall, 10 articles were included in this systematic review and meta-analysis. Our pooled meta-analysis indicated a significant reduction in FBS following ginger supplementation by polling 8 effect sizes [weighted mean difference (WMD): - 18.81; 95% CI: - 28.70, - 8.92), I2 = 77.4%] and in HbA1C through 7 effect sizes (WMD: -0.57; 95% CI: -0.93, -0.20, I2 =88.6%). Pooling 5 effect sizes, we found a significant reduction in SBP (WMD: -4.20; 95% CI: -7.64, -0.77, I2 =97%) and DBP [WMD: - 1.61; 95% CI: - 3.04, - 0.18), I2 = 93.2%] after supplementation with ginger. However, our pooled meta-analysis indicated that ginger supplementation had no significant influence on lipid profile involving TG, TC, LDL and HDL.

CONCLUSIONS

We found significant reductions in FBS, HbA1C, SBP and DBP after supplementation with ginger in patients with T2DM compared to control group, with no significant changes in serum lipids. Further large RCTs are required to shed light on this issue.

The effect of Nigella sativa oil on vascular dysfunction assessed by flow-mediated dilation and vascular-related biomarkers in subject with cardiovascular disease risk factors: A randomized controlled trial

Cardiovascular diseases (CVD) are the leading causes of mortality worldwide. Flow-mediated dilation (FMD) is a marker of vascular function. Beneficial cardiometabolic effects of Nigella sativa (N. sativa) have been observed. We evaluated the effect of N. sativa oil on FMD, plasma nitrite, and nitrate (NOx) as nitric oxide (NO) metabolites, and inflammatory markers in subjects with CVD risk factors. Fifty participants were randomly assigned to either the N. sativa (two capsules of 500 mg N. sativa oil) or the placebo group (two capsules of 500 mg mineral oil), for 2 months. The brachial FMD, plasma NOx, vascular cellular adhesion molecule-1 (VCAM-1), and intracellular adhesion molecule-1 (ICAM-1) were measured. FMD and plasma NOx levels was significantly increased in the N. sativa group compared to the placebo group (changes: 2.97 ± 2.11% vs. 0.71 ± 3.19%, p < 0.001 for FMD and 4.73 ± 7.25 μmol/L vs. 0.99 ± 5.37 μmol/L, p = 0.036 for plasma NOx). However, there was no significant difference in ICAM-1 and VCAM-1 levels between groups. Therefore, N. sativa oil improves vascular NO and FMD in subjects with cardiovascular risk factors. However, more studies are warranted to confirm the beneficial impacts of the N. sativa oil on vascular inflammation.

Effect of Dexmedetomidine infusion during hip fracture surgery on hemodynamic parameters and blood loss: A triple-blinded Randomized Clinical Trial

Introduction In this study, we aim to assess the intra-operative effect of dexmedetomidine administration on the hemodynamic parameters and bleeding volume during hip fracture surgery. Patients and methods we designed and implemented a triple-blinded randomized clinical trial to objectively compare the effects of 0.5 µg/kg/h infusion of dexmedetomidine with placebo (equal amount of normal saline) during hip fracture surgery. All included cases were between 30 and 70 years old and underwent surgery for fixation of a proximal femur fracture from September 26, 2020 until February 15, 2021. They were all ASA class I or II with preoperative hemoglobin levels of 10 mg/dL or higher. Surgical blood loss and hemodynamic parameters were documented. Results 76 patients were enrolled. There were no significant differences in baseline patient characteristics. The bleeding rate was 620 ± 190.0 mL for the normal saline group and 476 ± 177.98 mL in the dexmedetomidine group (P = 0.04). No significant effect on hemodynamic parameters was observed. Conclusion Based on the current study, intravenous infusion of dexmedetomidine during hip fracture surgery under general anesthesia reduced the amount of intraoperative bleeding without causing any significant hemodynamic disturbances. Registration number IRCT20191222045857N1 (Iranian Registry of Clinical Trials).

Evaluation of anesthesia quality with three methods: "propofol + fentanyl" vs. "propofol + fentanyl + lidocaine" vs. "propofol + fentanyl + lidocaine + ketamine" in patients referred to the scoping ward

Introduction:

Toleration of the complexity and pain of interventions such as endoscopy and colonoscopy is highly difficult for patients. Considering the disagreement on the method of injection of propofol, this study was performed to evaluate the quality of anesthesia using the three methods of propofol + fentanyl, propofol + fentanyl + lidocaine, and propofol + fentanyl + lidocaine + ketamine.

Methods:

This one-way blind clinical trial study included 99 patients who were admitted in three groups by block randomization method. In a group of patients that were sedated with propofol + fentanyl + lidocaine + ketamine, the dose of all drugs is reduced by half the amount of the other groups. Variables included age, sex, frequency of cough, apnea, need for jaw thrust maneuver, O₂ saturation, duration of recovery, and procedural satisfaction. Data were analyzed using SPSS version 20.0. P value of < 0.05 was considered to be significant.

Results:

The three groups were similar in terms of demographic characteristics. The effects of the three sedation protocols on the variables showed that patient’s apnea, cough, O₂ saturation, and also proceduralist satisfaction in the group of the patient that sedated with four drugs was significantly higher (P < 0.05) than other groups. But there was no significant difference between the three groups when comparing the recovery time and need for jaw thrust during the procedure.

Conclusion:

The findings of the present study showed that the use of combination of “propofol + fentanyl + lidocaine + ketamine” with lower doses, significantly results in higher quality sedation compared with higher doses of “propofol + fentanyl + lidocaine” or “propofol + fentanyl” for scoping procedures.

The effect of IGF-1 plasma concentration on COVID-19 severity

BACKGROUND

The severity and fatality of Coronavirus disease 2019 (COVID-19) infection are not the same in the infected population. The host immune response and Immune-stimulating factors appear to play a role in COVID-19 infection outcome. insulin-like growth factor-1 (IGF-1) affects the immune system by controlling the endocrine system. Recently, the effect of IGF-1 levels on COVID-19 prognosis has been considered.

OBJECTIVE

To investigate the difference between circulating IGF-1 and inflammatory cytokines concentration among COVID-19 patients, infected patients admitted to the Intensive Care Unit (ICU) (n = 40; 35 ± 5 y) and patients with mild cases of COVID-19 (n = 40; 35 ± 5 y) were screened prior to participation in the study. There was no significant difference between the groups in terms of gender and preexisting inflammatory state. Collected samples were evaluated by ELISA for IGF-1 and IL-6.

RESULTS

The study outcomes included a significant decrease in IGF-1 and an increase in IL-6 serum concentration, as an inflammatory marker, for infected patients admitted to the Intensive Care Unit (ICU) (P ≤ 0.001). Finally, there was a significant increase in the IGF-1 and a decrease in the IL-6 serum concentration of hospitalized patients.

DISCUSSION

it appears that inflammatory cytokines (IL-6) serum concentration in the severe form of corona virus-based infections causes reduced defenses because of suppressed IGF-1.

CONCLUSIONS

Our findings show that lower IGF-1 concentrations are associated with a Severe form of COVID-19 disease. It seems, IGF-1 supplementation or anti-inflammatory treatment rescued the severe form of COVID-19 infection. Further studies are required to determine how to design COVID-19 therapeutic strategies targeting the IGF-1 pathway.

Efficacy and safety of acetylcysteine for the prevention of liver injury in COVID-19 intensive care unit patients under treatment with remdesivir

AIM

The present double-blinded placebo-controlled randomized clinical trial evaluated prophylactic use of acetylcysteine for the prevention of liver injury in patients with severe COVID-19 pneumonia under treatment with remdesivir.

BACKGROUND

Liver injury is reportedly common in patients with severe COVID-19 pneumonia and can occur not only as a result of disease progression, but as an iatrogenic reaction to remdesivir.

METHODS

A total of 83 adult patients with severe COVID-19 pneumonia were randomly assigned in parallel groups to receive either acetylcysteine or placebo. All the patients received standard care according to institutional protocols, including remdesivir for a total of five days. One gram acetylcysteine was administered intravenously every 12 hours for 42 patients, and 41 patients received the same volume of 0.9% sodium chloride as placebo (Trial Registration: www.irct.ir identifier, IRCT20210726051995N1).

RESULTS

After 5 days, median aspartate transaminase (AST) and alanine transaminase (ALT) levels were significantly lower in the acetylcysteine than in the placebo group. Of those who received the placebo, 30 (73.2%), 4 (9.7%), and 3 (7.3%) patients had serum AST levels elevated between 1-2.5, 2.5-5, and over 5 times the upper limit of normal (ULN), respectively; while in the acetylcysteine group, 33 (78.6%) and 0 patients had AST levels between 1-2.5 and over 2.5 times ULN, respectively (p-value=0.037). In the acetylcysteine group, 23 (54.8%), 1 (2.4%), and 1 (2.4%) patient had serum ALT levels elevated between 1-2.5, 2.5-5, and over 5 times ULN, respectively; in the placebo group, however, 24 (58.5%), 7 (17.1%), and 1 (2.4%) patient had serum ALT levels between 1-2.5, 2.5-5, and over 5 times ULN, respectively (p-value=0.073).

CONCLUSION

Intravenous administration of acetylcysteine significantly prevents liver transaminases elevation and liver injury in seriously ill COVID-19 patients treated with remdesivir.

Acute vestibular neuritis: A rare complication after the adenoviral vector-based COVID-19 vaccine

Vestibular neuritis was first reported in 1952 by Dix and Hallpike, and 30% of patients reporting a flu-like symptom before acquiring the disorder. The most common causes are viral infections, often resulting from systemic viral infections or bacterial labyrinthitis. Here we presented a rare case of acute vestibular neuritis after the adenoviral vector-based COVID-19 vaccination. A 51-year-old male pilot awoke early in the morning with severe vertigo, nausea, and vomiting after receiving the first dose of the ChAdOx1 nCoV-19 vaccine 11 days ago. Nasopharyngeal SARS-CoV-2 RT-PCR test and chest CT scan were inconclusive for COVID-19 pneumonia. Significant findings were a severe spontaneous and constant true-whirling vertigo which worsened with head movement, horizontal-torsional spontaneous nystagmus, abnormal caloric test, positive bedside head impulse tests, and inability to tolerate head-thrust test. PTA, MRI of the brain and internal auditory canal, and cerebral CT arteriography were normal. According to the clinical, imaging, and laboratory findings, he was admitted to the neurology ward and received treatment for vestibular neuritis. His vertigo increased gradually over 6-8 h, peaking on the first day, and gradually subsided over 7 days. Ten days later, the symptoms became tolerable; the patient was discharged with advice for home-based vestibular rehabilitation exercises. Despite the proper treatment and rehabilitation, signs of dynamic vestibular imbalances persisted after 1 year. Based on the Federal Aviation Administration (FAA) regulations, the Air Medical Council (AMC) suspended him from flight duties until receiving full recovery. Several cases of vestibular neuritis have been reported in the COVID-19 patients and after the COVID-19 vaccination. This is the first case report of acute vestibular neuritis after the ChAdOx1 nCoV-19 vaccination in a healthy pilot without past medical history. However, the authors believe that this is a primary clinical suspicion that must be considered and confirmed after complete investigations.

Abdominal Compartment Syndrome: A Life-Threatening Condition in Air Medical Transportation of Multiple Trauma Patients

A 41-year-old male farmer was injured in a land mine explosion. After initial resuscitation, the emergency physician coordinated with the hospital and air medical crew for the patient's evacuation. The evacuation was started by a Bell 214C helicopter, and the patient's clinical condition deteriorated during flight with increased abdominal pain and distension, tachycardia, tachypnea, hypotension, and loss of consciousness. Intra-abdominal (vesical) pressure of 23 mm Hg, findings of in-flight bedside ultrasound, and echocardiography indicated intra-abdominal hypertension with abdominal compartment syndrome. The emergency physician started medical management quickly based on the World Society of Abdominal Compartment Syndrome, but after 15 minutes the intra-abdominal pressure was still > 20 mm Hg. Despite the in-flight difficult condition, the risk of vascular or neural damages, and infection, the emergency physician performed a midline decompression laparotomy and, when the intra-abdominal pressure reached about 11 mm Hg, temporarily covered the wound with a Bogota bag. After the patient's intra-abdominal pressure stabilized, permanent abdominal wound repair was performed by the surgeon, and he was discharged from the hospital.

Weaning of septic patients from the ventilator in the intensive care unit by attention approach to common antibiotic regimens

Background:

Sepsis is a chronic blood infection that is more common in patients with ventilatory and disability. This study aimed to evaluate the effect of common antibiotic regimens on weaning sepsis patients from mechanical ventilator.

Methods:

In this prospective cross-sectional study, we classified 70 sepsis patients under mechanical ventilation which sedates with midazolam and do not take muscle relaxants into two groups: meropenem and levofloxacin versus meropenem, levofloxacin, and clindamycin. The duration of intubation and the number of patients who needed re-intubation (and their duration of extubation) were recorded. Data were analyzed using SPSS software.

Results:

In the present study, 68.6% were male and 31.4% were female. The mean age was calculated to be 37.98. The mean duration of mechanical ventilation and stay in the ICU in the group of two drugs (meropenem + levofloxacin) showed a significant decrease compared to the group of three drugs (P < 0.05). But no significant difference was observed in terms of ventilator connection time (P < 0.05).

Conclusion:

The differences in terms of mean duration of mechanical ventilation and ICU stay between the groups indicate that the two-drug regimen (meropenem + levofloxacin) is more efficient in bringing [sepsis] patients back to recovery.

A randomized clinical trial study on the efficacy and safety of adalimumab and methylprednisolone pulse therapy in the treatment of COVID-19 patients with acute respiratory distress syndrome

Introduction: Adalimumab reduces the expression of the angiotensin-converting enzyme (ACE2) receptor at the cell surface, therefore it is thought to be effective in treating patients with COVID-19. Objectives: The present study was conducted to evaluate the effectiveness of adalimumab and pulsed corticosteroids in treating patients with severe acute respiratory failure due to COVID-19. Patients and Methods: The present double-blind clinical trial study was carried out on patients with COVID-19 referred to Imam Reza hospital, Tehran. Patients were randomly divided into two groups of intervention (patients under standard treatment according to the national protocol of Iran + methylprednisolone + adalimumab) and control (patients under standard treatment according to the national protocol of Iran + methylprednisolone). Results: The patients’ hospitalization information shows that the duration of patients’ hospitalization in the intervention group was significantly shorter than their counterparts in the control group (P=0.041). Serum levels of total bilirubin on the ninth day (P=0.043) and GCS (Glasgow coma scale) on the ninth day (P=0.041) and tenth (P=0.039) in the adalimumab group were significantly increased compared to the control group. However, the direct bilirubin value on the eighth day (P=0.031), serum creatinine on the 8th (P=0.047), 9th (P=0.047) and 10th (P=0.047) days and also PEEF (pericarditis/pericardial effusion) on the tenth day were significantly lower in the intervention group than the control group. Conclusion: The administration of adalimumab significantly increases the GCS of COVID-19 patients and reduces the length of hospital stay. Trial Registration: This study is designed as a double-blind clinical trial (identifier: IRCT20200406046963N2, https://www.irct.ir/trial/55011), and has been approved by the ethics committee in biomedical research of AJA University of Medical Sciences (#IR.AJAUMS.REC.1400.032).

Vitamin D Insufficiency in Disease Severity and Prognosis of the Patients With SARS Corona Virus-2 Infection

The global crisis caused by the SARS Corona virus-2 infection is continuing through 2021, with more than 3.5 million deaths. Several risk factors for this virus’s severity and death were documented, including diabetes, hypertension, and ischemic heart disease. To evaluate the relation between serum vitamin D3 level, the disease severity, and prognosis of the patients with SARS Corona virus-2 infection. Patients with COVID-19 were evaluated for serum vitamin D levels and laboratory data. Correlation between vitamin D levels and laboratory data with disease severity and prognosis was assessed. Cox and logistic regression tests, as well as ROC curves, were used for data analysis. Ninety-eight patients with Corona virus-2 disease (COVID-19), which consisted of sixty patients with moderate COVID-19 in the general wards, and thirty-eight patients with severe COVID-19 in the intensive care unit (ICU), were evaluated. The mean age in the general wards was lower than in ICU (60.96±14.86 compared to 67.94±16.46, P=0.001), and the mean serum vitamin D level in the patients admitted in the general wards was higher than in the ICU (31 ng/mL compared to 20.57 ng/mL, P=0.003). Furthermore, vitamin D deficiency (25 (OH) D <25 ng/ml) significantly increased the risk of severe disease. (odds ratio=2.91, P=0.019) and mortality (odds ratio=3.64, P=0.026). Vitamin D deficiency is a risk factor for disease severity and poor prognosis in COVID-19. Vitamin D levels of 25 ng/mL can be used as a cut-off value for predicting severity and prognosis.

Blunt Thoracic Aortic Injury: A Life-Threatening Emergency on Air Medical Transportation

A 54-year-old male driver was injured in a car crash in which his front-side passenger died at the scene. The initial assessment indicated that he was conscious and able to recall the accident. His vital signs included blood pressure of 155/95 mm Hg, heart rate of 112 beats/min, and respiratory rate of 21 breaths/min, and he complained of stabbing retrosternal pain. A palpable sternal fracture with a tender contusion, a discrepancy between the blood pressures between the arms, and diminished femoral pulses were other findings. With a thoracic aortic pseudoaneurysm suspicion, the emergency physician maintained the patient's systolic blood pressure around 100 mm Hg and his heart rate less than 100 beats/min. Because of the need for urgent medical interventions, the emergency physician decided to transport him by air to the nearest advanced trauma center. After accordance with the trauma center and the air medical crew, the air transportation began. The patient subsequently decompensated with bradycardia and hypotension to cardiac arrest, for which 30 minutes of cardiopulmonary resuscitation unfortunately proved unsuccessful. The forensic report indicated an aortic pseudoaneurysm rupture of the proximal descending aorta with a massive hematoma that was a possible cause of death.

Frequency of HLA Alleles in a Group of Severe COVID-19 Iranian Patients

Background:

Human Leukocyte Antigen (HLA) system composed of a group of related proteins with important functions in the immune system. Several studies have reported that there is a significant association between specific HLA alleles and the susceptibility to different infectious diseases. This study aimed to detect the specific HLA alleles that cause higher susceptibility to COVID-19, we analyzed the HLA allele frequency distribution in Iranian patients with a severe form of COVID-19.

Methods:

Overall, 48 severe cases of COVID-19 that were hospitalized and required intensive care unit (ICU) admission between Oct and Dec 2020 were included in this study. Genomic DNA was extracted from the peripheral blood samples and HLA typing (Locus A, B, and DR) was performed for the patients.

Results:

After analyzing and comparing the results with a reference group of 500 Iranian individuals, a significant association was found for HLA-B*38, HLA-A*68, HLA-A*24, and HLA-DRB1*01.

Conclusion:

These results may be valuable for studying the potential association of specific HLA alleles with susceptibility to COVID-19 and mortality due to the disease.

Risk factors of developing critical conditions in Iranian patients with COVID-19

COVID-19 due to novel Coronavirus was first reported in Wuhan, China. Nowadays, the Islamic Republic of Iran stands among countries with high COVID-19 prevalence and high burden of disease. Since the medical resources are limited, we aimed to identify the risk factors for patients developing critical conditions. This can help to improve resource management and treatment outcomes. In this retrospective study, we included 12,677 patients who were from 26 hospitals, supervised by Tehran University of Medical Sciences with signs and symptoms of COVID-19, until April 12. University integrated IT system was adopted to collect the data. We performed Logistic regression to evaluate the association between death in COVID-19 positive patients and other variables. Cough, respiratory distress and fever were the most common symptoms in our patients, respectively. Cancer, chronic lung diseases and chronic neurologic diseases were the strongest risk factors for death in COVID-19 patients.

Use of Azelastine and Sodium Chloride Spray for Prevention of Sinusitis in ICU Admitted Patients: A Randomized Clinical Trial

Background:

Nosocomial sinusitis is a common and less attended complication in patients admitted to intensive care units (ICU). It can cause several problems, such as prolongation of hospitalization, comorbidity, and mortality in patients. The present study aimed to evaluate the effect of azelastine (second-generation antihistamine) and sodium chloride spray on sinusitis prevention in ICU admitted patients.

Methods:

In this randomized, open-label, and parallel clinical trial a total of 126 patients were enrolled (63 patients per arm). Finally, 121 patients (61 patients in the control group and 60 patients in the treatment group) completed the study, and 120 patients entered the final analysis. In the treatment group, during 24 h after the insertion of nasogastric tube azelastine and sodium chloride sprays were administered (one puff from each spray every 12 h) while no intervention was conducted in the control group. Primary and secondary end-points were evaluated within 10 days of the study period.

Results:

The incidence of sinusitis and pneumonia (18.3% and 16.6% in the control group compared to 8.3% and 3.3% in the treatment group, respectively) in the treatment group showed a decreasing trend; however, only the difference of pneumonia was statistically significant between groups (P = 0.03). In addition to the clinical pulmonary infection score, nasal and tracheal secretions were significantly improved in the treatment group (P = 0.03, P < 0.001, and P = 0.01, respectively).

Conclusions:

The findings of the present study offer an inexpensive, low-risk, and efficacious intervention for the prevention of upper respiratory tract infections in ICU patients.

Effect on analgesia duration and pain intensity of adding dexamethasone to lidocaine in digital nerve block in patients with finger trauma

Digital nerve block is one of the multimodal analgesia methods used in finger trauma cases. According to some studies, dexamethasone needs further investigation before being used routinely. We therefore investigated dexamethasone's effect on the parameters of digital nerve block. In this double-blind clinical study, 60 patients were allocated to two groups: lidocaine alone and lidocaine + dexamethasone. Groups were compared for pain intensity, analgesia duration and demographic characteristics. Patients in the intervention group received 3 cc 2% lidocaine + 1 cc (equivalent to 4 mg) dexamethasone and patients in the control group received 3 cc lidocaine 2% + 1 cc normal saline. The two groups were comparable for age and gender. In the lidocaine + dexamethasone group, postoperative pain severity was significantly lower and the pain-free period was longer (P < 0.05). Dexamethasone as an adjuvant in digital nerve block after trauma reduced the severity of postoperative pain and increased the pain-free period.

Explaining the experiences of nursing administrators, educators, and students about education process in the COVID-19 pandemic: a qualitative study

BACKGROUND

The coronavirus disease 2019 (COVID-19) has severely influenced various aspects of human life, particularly education. This study aimed to explain the impact of the COVID-19 pandemic on nursing education from administrators, educators, and students' perspectives.

METHODS

This qualitative study with a conventional content analysis approach was conducted from June to October 2020 at a nursing school in Tehran. Thirteen participants were enrolled using purposive sampling. Data collection was through in-depth and semi-structured interviews and continued until reaching data saturation. Nursing administrators, educators, and students constructed interviews to understand nursing education changes during the pandemic. All interviews were recorded, transcribed, reviewed, coded, and analyzed using the Graneheim and Lundman methods.

RESULTS

Interviewed respondents included administrators and professors (n = 6) and nursing students (n = 7). The respondents reported five main topic areas: (1) safe management in ambiguous situations; (2) perceived situations; (3) adaptive coping; (4) educational facilitators and challenges, and (5) continuing education in an uncertain context. The central theme was "close conflict of education with COVID-19".

CONCLUSIONS

The current study noted instability and challenges placed on nursing education during the pandemic. Opportunities were addressed during the pandemic to improve the nursing training process using planning, scientific management, emerging technology, innovative educational opportunities, and comprehensive support from institutional stakeholders. Clear guidelines and recommendations are needed to ensure medical education safety during the pandemic.

Acute transverse myelitis after SARS-CoV-2 infection: a rare complicated case of rapid onset paraplegia

A 63-year-old Caucasian male, known case of controlled type 2 diabetes, chronic renal failure, and ischemic heart disease, was presented with weakness and loss of movement in lower limbs, an absent sensation from the chest below, constipation, and urinary retention. About 4 days before these symptoms, he experienced a flu-like syndrome. Suspicious for COVID-19, his nasopharyngeal specimen’s reverse transcription-polymerase chain reaction (RT-PCR) resulted positive. Chest X-ray and HRCT demonstrated severe pulmonary involvement. Immediately, he was admitted to the emergency ward, and the treatment was started according to the national COVID-19 treatment protocol. Subsequently, diagnostic measures were taken to investigate the patient’s non-heterogeneous peripheral (spinal) neuromuscular manifestations. Brain CT scan and MRI were normal, but spinal MRI with gadolinium contrast showed extensive increased T2 signal involving central gray matter and dorsal columns, extended from C7 to T12 with linear enhancement in the sagittal plane, posteriorly within the mid and lower thoracic cord. The CSF specimen demonstrated pleocytosis, positive RT-PCR for SARS-CoV-2, and elevated IgG index. Clinical presentation, MRI, CSF, and laboratory findings prioritized the acute transverse myelitis (ATM) as a probable complication of COVID-19 infection over other differential diagnoses. Intravenous methylprednisolone and, subsequently, IV human immunoglobulin were added to the treatment regimen. In the end, the complete resolution of dysesthesia, urinary retention, and constipation were achieved. After continuous and extended respiratory and motor rehabilitation programs, he was discharged asymptomatic.

Cardiac Complications in COVID-19: A Systematic Review and Meta-analysis

BACKGROUND

The newly emerged coronavirus disease 2019 (COVID-19) seems to involve different organs, including the cardiovascular system. We systematically reviewed COVID-19 cardiac complications and calculated their pooled incidences. Secondarily, we compared the cardiac troponin I (cTnI) level between the surviving and expired patients.

METHODS

A systematic search was conducted for manuscripts published from December 1, 2019 to April 16, 2020. Cardiovascular complications, along with the levels of cTnI, creatine kinase (CK), and creatine kinase MB (CK-MB) in hospitalized PCR-confirmed COVID-19 patients were extracted. The pooled incidences of the extracted data were calculated, and the unadjusted cTnI level was compared between the surviving and expired patients.

RESULTS

Out of 1094 obtained records, 22 studies on a total of 4,157 patients were included. The pooled incidence rate of arrhythmia was 10.11%. Furthermore, myocardial injury had a pooled incidence of 17.85%, and finally, the pooled incidence for heart failure was 22.34%. The pooled incidence rates of cTnI, CK-MB, and CK elevations were also reported at 15.16%, 10.92%, and 12.99%, respectively. Moreover, the pooled level of unadjusted cTnI was significantly higher in expired cases compared with the surviving (mean difference = 31.818, 95% CI = 17.923-45.713, P value <0.001).

CONCLUSION

COVID-19 can affect different parts of the heart; however, the myocardium is more involved.

The Incidence and Risk Factors of Ventilator-Associated Pneumonia in ICU

Considering the importance of ventilator-associated pneumonia (VAP) and the high mortality rate among patients diagnosed with VAP, the aim of the current study was to evaluate the incidence of VAP, and its related risk factors in patients admitted to the intensive care unit (ICU). A total of 197 patients undergoing mechanical ventilation in the ICU diagnosed with VAP was enrolled in this study. Among these patients, 59 (53.6%) cases were male, and 51 (46.4%) were female with the mean age of 69.86±14.62 years. The most common cause of ICU admission was CVA, followed by colorectal cancer, lung cancer, sepsis, and cirrhosis. Our results showed that 110 individuals (55.8%) were diagnosed with VAP. The most common bacteria were Klebsiella, which was found in 20.3% of cases. (47.7%) of patients had diabetes, 21.8% had chronic kidney disease, and 51.8% had cardiovascular disease. 32.7% of patients were bedridden before intubation. The mortality rate due to VAP was estimated at about 20%. In conclusion, the incidence of VAP in ICU is relatively high (55.8%), with a mortality rate of 20%. Among the risk factors, the presence of diabetes, bedridden, reduction in consciousness, and the time duration of mechanical ventilation are relative to this type of infection.

Survival Percentile and Predictors of Difference in Survival among Hemodialysis Patients and Their Additive Interaction Using Laplace Regression

Background: Identifying survival modifiable factors and additive interaction between them could help in prioritizing the clinical care of Hemodialysis (HD) patients. We aimed to examine the survival rate and its predictors in HD patients; and explore the additive interaction between survival modifiable factors.

Study design: A retrospective cohort study.

Methods: The present study was performed on 1142 HD patients in Hamadan Province, western Iran from 2007 to 2017. Data were collected through a researcher-made checklist on hospital records. Laplace regression was used to evaluate differences in 40^th survival percentiles in different levels of predictors as well as exploring the pairwise additive interactions between variables.

Results: We observed significantly higher survival in nonsmoker patients (40^th percentile difference = 5.34 months, 95% CI: 2.06, 8.61). Survival was shorter by more than 3 years in CRP positive patients (40^th percentile difference=36.9 months, 95% CI: 32.37, 41.42). Patients with normal albumin (40^th percentile difference =24.92, 95% CI: 18.04, 31.80) and hemoglobin (40^th percentile difference = 18.65, 95% CI: 12.43, 24.86) had significantly higher survival (P<0.001). There was super-additive interaction between being CRP negative and nonsmoker (β₃ = 9.42 months, 95% CI: 3.35, 15.49 (P=0.002)).

Conclusion: High CRP and low serum albumin and hemoglobin were associated with the increased risk of death in HD patients. The results of this study support the presence of super-additive interaction between CRP status with serum hemoglobin and also CRP status with smoking, resulting in excess survival in HD patients.

Intensive Care Unit Risk Assessment: A Systematic Review

Background:

It is of paramount importance to reduce the probability of clinical risks to improve the quality of health care services, make the relationship between service providers and patients more effective, enhance patient satisfaction, and decrease the rate of complaints regarding medical errors in hospitals. This study aimed at detecting potential and unacceptable risks occurring in the hospital ICUs.

Methods:

In this systematic review, all studies examining the risk assessment of ICUs in hospitals using Failure Mode and Effect Analysis method were reviewed. Google scholar, PubMed, Scopus, SID, Magiran and Web of Science databases were searched to find relevant articles published from 1980 to 2019.

Results:

The most frequent failures detected in the reviewed articles consisted of high risk of infection inwards for medical and nursing operations, high infection rates inwards for medical devices’ operation within the unit, and early discharge. Moreover, the processes through which potential high-risk Failures were examined in these studies were injection or prescription process, suction process, the process of inserting or removing endotracheal tubes, the process of transferring patients from the operation room to the unit or vice versa, pressure ulcers, and processes related to the medical devices’ operation.

Conclusion:

There are many possible reasons for failure occurring throughout these processes, and the failure modes occurring in these processes are more probable to cause serious damages to patients, have high repeatability with low probability of failure detection as the failures cannot be discovered by the personnel.

Determinants of Hospital Inpatient Costs in the Iranian Elderly: A Micro-costing Analysis

Objectives

Aging is assumed to be accompanied by greater health care expenditures. The objective of this retrospective, bottom-up micro-costing study was to identify and analyze the variables related to increased health care costs for the elderly from the provider’s perspective.

Methods

The analysis included all elderly inpatients who were admitted in 2017 to a hospital in Tehran, Iran. In total, 1288 patients were included. The Mann-Whitney and Kruskal-Wallis tests were used.

Results

Slightly more than half (51.1%) of patients were males, and 81.9% had a partial recovery. The 60-64 age group had the highest costs. Cancer and joint/orthopedic diseases accounted for the highest proportion of costs, while joint/orthopedic diseases had the highest total costs. The surgery ward had the highest overall cost among the hospital departments, while the intensive care unit had the highest mean cost. No statistically significant relationships were found between inpatient costs and sex or age group, while significant associations (p<0.05) were observed between inpatient costs and the type of ward, length of stay, type of disease, and final status. Regarding final status, costs for patients who died were 3.9 times higher than costs for patients who experienced a partial recovery.

Conclusions

Sex and age group did not affect hospital costs. Instead, the most important factors associated with costs were type of disease (especially chronic diseases, such as joint and orthopedic conditions), length of stay, final status, and type of ward. Surgical services and medicine were the most important cost items.

Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? A Review Article

Several therapeutic approaches such as holmium laser enucleation of the prostate (HoLEP) have been introduced to relieve bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). Compared with other techniques including the transurethral resection of the prostate (TURP) and simple open prostatectomy, HoLEP results in a shorter hospital stay and catheterization time and fewer blood loss and transfusions. HoLEP is a size-independent treatment option for BPH with average gland size from 36 g to 170 g. HoLEP is a safe procedure in patients receiving an anticoagulant and has no significant influence on the hemoglobin level. Also, HoLEP is an easy and safe technique in patients with a prior history of prostate surgery and a need for retreatment because of adenoma regrowth. The postoperative erectile dysfunction rate of patients treated with HoLEP is similar to TURP or open prostatectomy and about 77% of these patients experience loss of ejaculation. Patients with transitional zone volume less than 30 mL may suffer from persistent stress urinary incontinence following HoLEP so other surgical techniques like bipolar TURP are a good choice for these patients. In young patients, considering HoLEP with high prostate-specific antigen density and a negative standard template prostate biopsy, multiparametric MRI needs to be considered to exclude prostate cancer.

Targeting of oxidative stress and inflammation through ROS/NF-kappaB pathway in phosphine-induced hepatotoxicity mitigation

AIMS

Poisoning with aluminium phosphide (AlP) commonly has a high rate of mortality and morbidities. Phosphine gas is the main cause of AlP poisoning that has deleterious effect on multi-organs especially heart, kidney, and liver. Furthermore, several studies reported that resveratrol has cytoprotective effects through its pleiotropic property. The purpose of this study was to estimate the dose-dependent role of resveratrol on phosphine induced acute hepatic toxicity in rat model.

MAIN METHODS

The rats have been exposed to LD₅₀ of AlP (12 mg/kg) by gavage, and resveratrol doses (20, 40, and 80 mg/kg) were injected 30 min after intoxication. After 24 h, the serum and liver tissue were collected for present study.

KEY FINDINGS

The results indicated that phosphine causes an alteration in oxidative stress markers including elevation of ROS, and GSH level, MPO activity, reduction in SOD, catalase and G6PD activity as well as reduction in SOD1 and catalase expression. Furthermore, phosphine significantly induced phosphorylation of IkappaB, NF-kappaB and up-regulation of TNF-α, IL-1β, IL-6, and ICAM-1 expression. Also, phosphine induces markedly reduced hepatocytes lives cell and elevated apoptosis and necrosis. Co-treatment of resveratrol in a dose-dependent manner reversed aforementioned alterations. All in all, histological analysis indicated a deleterious effect of phosphine on the liver, which is mitigated by resveratrol administration.

SIGNIFICANCE

The results of the present study suggest targeting ROS/NF-kappaB signalling pathway by resveratrol may have a significant effect on the improvement of hepatic injury induced by phosphine. It also may be a possible candidate for the treatment of phosphine-poisoning.

High-dose amikacin for achieving serum target levels in critically ill elderly patients

Introduction

To achieve target concentrations, the application of higher-than-standard doses of amikacin is proposed for the treatment of sepsis due to an increase in volume of distribution and clearance, but little data are available on aminoglycoside administration in critically ill elderly patients.

Patients and methods

Forty critically ill elderly patients (aged over 65 years) who required amikacin therapy due to severe documented, or suspected gram-negative infections, were randomly assigned to two treatment groups. Group A (20 patients) received 15 mg/kg amikacin and Group B (20 patients) received 25 mg/kg amikacin per day as a single daily dose. All the patients were monitored for renal damage by the daily monitoring of serum creatinine. The amikacin peak (C_max) and trough (C_min) serum concentrations were measured on Days 3 and 7 postadministration.

Results

Data from 18 patients in Group A and 15 patients in Group B were finally analyzed. On Day 3, the amikacin mean C_max levels in the standard and high-dose treatment groups were 30.4±11 and 52.3±16.1 µg/mL (P<0.001), and the C_min levels were 3.2±2.1 and 5.2±2.8 µg/mL, respectively (P=0.035). On Day 7, the C_max levels in the standard and high-dose groups were 33±7.3 and 60.0±17.6 µg/mL (P=0.001), and the C_min levels were 3.2±2.9 and 9.3±5.6 µg/mL, respectively (P=0.002). In only six (40%) of the patients in the high-dose groups and none of the patients in the standard-dose group, amikacin C_max reached the target levels (>64 µg/mL), whereas the amikacin mean C_min levels in the high-dose group were above the threshold of toxicity (5 µg/mL).

Conclusion

Our results suggest that the optimum dose of amikacin should be determined for elderly critically ill patients. It seems that higher-than-standard doses of amikacin with more extended intervals might be more appropriate than standard once-daily dosing in the elderly critically ill patients.

Subclinical hypothyroidism and diabetic nephropathy in Iranian patients with type 2 diabetes

PURPOSE

Association of subclinical hypothyroidism with type 2 diabetes and its complications has been previously documented. These reports were, however, inconclusive and mainly gathered from Chinese and East Asian populations. In this study, we aimed to determine the prevalence of subclinical hypothyroidism and its relationship with diabetic nephropathy in Iranian individuals with type 2 diabetes, drawn from a white Middle Eastern population with an increasing prevalence of diabetes.

METHODS

In this cross-sectional study, 255 Iranian participants with type 2 diabetes and without history of thyroid disorders were included. Patients with TSH > 4.2 mIU/L and normal T4 were classified as having subclinical hypothyroidism. Diabetic nephropathy was diagnosed based on abnormal 24-h urinary albumin or protein measurements (24-h urinary albumin ≥30 mg/day or 24-h urinary protein ≥150 mg/day). Multivariate logistic regression was employed to obtain the OR for the relationship between subclinical hypothyroidism and diabetic nephropathy.

RESULTS

We found that subclinical hypothyroidism and diabetic nephropathy were as prevalent as 18.1 and 41.2 %, respectively, among the participants. We also found that subclinical hypothyroidism was independently associated with higher rates of diabetic nephropathy, after multivariable adjustment (OR [95 % CI] 3.23 [1.42-7.37], p = 0.005).

CONCLUSIONS

We found that the prevalence of subclinical hypothyroidism in Iranian diabetic population was among the highest rates reported to date. Our data supported the independent association of subclinical hypothyroidism with diabetic nephropathy, calling for further investigations to evaluate their longitudinal associations.

Rapidly changing tachyarrhythmia in acute stroke

INTRODUCTION

We report a 56-year-olds female with supraventricular arrhythmia due acute ischemic stroke without structural heart disease.

CASE DESCRIPTION

A patient presented with sudden onset of lethargy, right hemiplegia, and global aphasia. There was previous history of stroke 1 year ago presented with left hemiplegia that recovered completely during 10 days. There was no history of comorbid illness. The brain CT revealed extensive hypodensity in left temporoparietal region suggestive of infarct without midline shift. General examination revealed hypotension and bradycardia that treated with dopamine that gradually recovered during 5 days thus infusion of dopamine discontinued, and muscular power in paretic limbs and aphasia was recovered. In 6th day of admission electrocardiographic monitoring of patient showed a rapidly changing tachyarrhythmia including sinus tachycardia, atrial fibrillation, and atrial flutter that quickly interchanged to another, without hemodynamic instability and alteration in mental status. Laboratory tests and TEE study were normal. During 48 hour arrhythmia relived spontaneously.

DISCUSSION

Stroke can cause any type of cardiac arrhythmias that may not be constant.

The keloidal diathesis, a resistant state to malignancies?

We report clinical observations and immunological and laboratory studies whcih suggest that the tendency toward skin malignancies and the keloid diathesis may be two opposing conditions. We conclude that it is quite possible that a keloidal person, armed with a hypersensitive cell-mediated immune response condition and an overactive enzyme system, has a safeguard against acquiring skin malignancies.