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Kayaaslan B, Eser F, Asilturk D, Oktay Z, Hasanoglu I, Kalem AK, Dönertaş G, Kaplan B, Ozkocak Turan I, Erdem D, Bektas H, Guner R. Development and validation of COVID-19 associated candidemia score (CAC-Score) in ICU patients. Mycoses 2022; 66:128-137. [PMID: 36135336 PMCID: PMC9537877 DOI: 10.1111/myc.13531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/02/2022] [Accepted: 09/15/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The development of candidemia is a highly fatal condition in severe COVID-19 infection. OBJECTIVES This study aimed to develop a candidemia prediction score in COVID-19 patient based on the patient's clinical characteristics, and healthcare-related factors during intensive care units (ICU) follow-up. PATIENTS/METHODS Severe COVID-19 patients hospitalised in ICU in Ankara City Hospital during the one-year period (August 15, 2020, and August 15, 2021) were included. After univariate analysis, multivariate analysis was applied using variable selection approach to investigate the effects of variables together and to create a score model for candidemia. Statistically significant factors were included in the development process of candida prediction score. RESULTS Of 1305 COVID-19 ICU patients, 139 had a candidemia episode. According to the final model, four variables, presence of central venous catheter (CVC) (OR 19.07, CI 8.12-44.8, p < .0001), multifocal colonisation (OR 2.28, CI 1.39-3.72, p 0.001), length of ICU stays ≥14 days (OR 3.62, CI 2.42-5.44, p < .0001) and corticosteroids (OR 0.51, CI 0.34-0.76, p 0.0011) were the only statistically significant independent risk factors for candidemia. Score model was demonstrated by a nomogram, and the risk for candidemia was calculated to be high in patients who scored ≥56 points by using the criteria [CVC = 51, multifocal colonisation = 14, prolonged hospitalisation = 23, no steroid use = 12 points]. The AUC of the score is 0.84 (CI 0.81-0.87). CONCLUSION We developed and validated an easy-to-use clinical prediction score for candidemia in severe COVID-19 infection. In COVID-19 ICU patients, the risk of candidemia is high if one of the other risk factors is present together with CVC.
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Affiliation(s)
- Bircan Kayaaslan
- Department of Infectious Disease and Clinical Microbiology, Ankara City HospitalAnkara Yildirim Beyazit UniversityAnkaraTurkey
| | - Fatma Eser
- Department of Infectious Disease and Clinical Microbiology, Ankara City HospitalAnkara Yildirim Beyazit UniversityAnkaraTurkey
| | - Dilek Asilturk
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Zeynep Oktay
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Imran Hasanoglu
- Department of Infectious Disease and Clinical Microbiology, Ankara City HospitalAnkara Yildirim Beyazit UniversityAnkaraTurkey
| | - Ayşe Kaya Kalem
- Department of Infectious Disease and Clinical Microbiology, Ankara City HospitalAnkara Yildirim Beyazit UniversityAnkaraTurkey
| | - Gülen Dönertaş
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Betul Kaplan
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Isıl Ozkocak Turan
- Department of Intensive Care UnitUniversity of Health Sciences Ankara City HospitalAnkaraTurkey
| | - Deniz Erdem
- Department of Intensive Care UnitUniversity of Health Sciences Ankara City HospitalAnkaraTurkey
| | - Hesna Bektas
- Department of Neurology, Ankara City HospitalAnkara Yildirim Beyazit UniversityAnkaraTurkey
| | - Rahmet Guner
- Department of Infectious Disease and Clinical Microbiology, Ankara City HospitalAnkara Yildirim Beyazit UniversityAnkaraTurkey
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Kayaaslan B, Kaya Kalem A, Asilturk D, Kaplan B, Dönertas G, Hasanoglu I, Eser F, Korkmazer R, Oktay Z, Ozkocak Turan I, Erdem D, Bektas H, Guner R. Incidence and risk factors for COVID-19 associated candidemia (CAC) in ICU patients. Mycoses 2022; 65:508-516. [PMID: 35156742 PMCID: PMC9115269 DOI: 10.1111/myc.13431] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Critically ill COVID-19 patients have a high risk for the development of candidemia due to being exposed to both well-defined classical risk factors and COVID-19-specific risk factors in ICU. OBJECTIVES In this study, we investigated the incidence of candidemia in critically COVID-19 patients, and the independent risk factors for candidemia. PATIENTS/METHODS COVID-19 patients hospitalised in ICU during 1-year period (August 2020 to August 2021) were included. Clinical and laboratory characteristics of all COVID-19 patients, applied treatments, and invasive procedures that may predispose to candidemia were recorded. RESULTS Of 1229 COVID-19 patients, 63 developed candidemia. Candidemia incidence rate was 4.4 episodes per 1000 ICU days. The most common species was Candida albicans (52.3%). Only 37 patients (58.7%) received antifungal therapy. The presence of central venous catheter (OR 4.7, 95% CI 1.8-12.2, p < .005), multifocal candida colonisation (OR 2.7, 95% CI 1.4-5.2, p < .005), a prolonged ICU stay (≥14 days) (OR 1.9, 95% CI 1.08-3-37, p < .05), the absence of chronic lung disease (OR 0.4, 95% CI 0.1-0.9, p < .05) and the absence of corticosteroid use (OR 0.3, 95% CI 0.14-0.52, p < .0001) were significantly associated with candidemia. CONCLUSIONS Our study filled the knowledge gap in the literature about the impact of COVID-19-associated risk factors for the development of candidemia. The classical risk factors for candidemia had a significant effect on candidemia, and contrary to expectations, corticosteroids had a protective effect against the development of candidemia. The results of these studies showing interesting effects of corticosteroids in critically ill COVID-19 patients should be confirmed by further studies.
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Affiliation(s)
- Bircan Kayaaslan
- Department of Infectious Disease and Clinical MicrobiologyAnkara Yildirim Beyazit UniversityAnkara City HospitalAnkaraTurkey
| | - Ayşe Kaya Kalem
- Department of Infectious Disease and Clinical MicrobiologyAnkara Yildirim Beyazit UniversityAnkara City HospitalAnkaraTurkey
| | - Dilek Asilturk
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Betul Kaplan
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Gülen Dönertas
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Imran Hasanoglu
- Department of Infectious Disease and Clinical MicrobiologyAnkara Yildirim Beyazit UniversityAnkara City HospitalAnkaraTurkey
| | - Fatma Eser
- Department of Infectious Disease and Clinical MicrobiologyAnkara Yildirim Beyazit UniversityAnkara City HospitalAnkaraTurkey
| | - Ruveyda Korkmazer
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Zeynep Oktay
- Department of Infectious Disease and Clinical MicrobiologyAnkara City HospitalAnkaraTurkey
| | - Isıl Ozkocak Turan
- Department of Intensive Care UnitUniversity of Health Sciences Ankara City HospitalAnkaraTurkey
| | - Deniz Erdem
- Department of Intensive Care UnitUniversity of Health Sciences Ankara City HospitalAnkaraTurkey
| | - Hesna Bektas
- Department of NeurologyAnkara City HospitalAnkara Yildirim Beyazit UniversityAnkaraTurkey
| | - Rahmet Guner
- Department of Infectious Disease and Clinical MicrobiologyAnkara Yildirim Beyazit UniversityAnkara City HospitalAnkaraTurkey
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Kosovali BD, Mutlu NM, Gonen CC, Peker TT, Yavuz A, Soyal OB, Cakır E, Akan B, Gokcinar D, Erdem D, Turan IO. Does hospitalisation of a patient in the intensive care unit cause anxiety and does restriction of visiting cause depression for the relatives of these patients during COVID-19 pandemic? Int J Clin Pract 2021; 75:e14328. [PMID: 33960085 PMCID: PMC8236937 DOI: 10.1111/ijcp.14328] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/03/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES During the pandemic, anxiety and depression may occur increasingly in the whole society. The aim of this study was to evaluate the possible cause, incidence and levels of anxiety and depression in the relatives of the patients in the intensive care unit (ICU) in accordance with the patients' SARS-CoV-2 polymerase chain reaction (PCR) result. MATERIALS AND METHOD The study was prospectively conducted on relatives of patients admitted to tertiary intensive care units during COVID-19 pandemic. Sociodemographic characteristics of the patients and their relatives were recorded. "The Turkish version of the Hospital Anxiety and Depression Scale" was applied twice to the relatives of 120 patients to determine the symptoms of anxiety and depression in accordance with the PCR results of the patients (PCR positive n = 60, PCR negative n = 60). RESULTS The ratios above cut-off values for anxiety and depression among relatives of the patients were 45.8% and 67.5% for the first questionnaire and 46.7% and 62.5% for the second questionnaire, respectively. The anxiety and depression in the relatives of PCR-positive patients was more frequent than the PCR negative (P < .001 for HADS-A and P = .034 for HADS-D). The prevalence of anxiety and depression was significantly higher in female relatives (P = .046 for HADS-A and P = .009 for HADS-A). There was no significant correlation between HADS and age of the patient or education of the participants. The fact that the patients were hospitalised in the ICU during the pandemic was an independent risk factor for anxiety (AUC = 0.746) while restricted visitation in the ICU was an independent risk factor for depression (AUC = 0.703). CONCLUSION Positive PCR and female gender were associated with both anxiety and depression while hospitalisation in the ICU due to COVID-19 was an independent risk factor for anxiety and restricted visitation in the ICU is an independent risk factor for depression.
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Affiliation(s)
| | | | - Canan Cam Gonen
- Department of Critical Care UnitAnkara City HospitalAnkaraTurkey
| | | | - Asiye Yavuz
- Department of Critical Care UnitAnkara City HospitalAnkaraTurkey
| | - Ozlem Balkiz Soyal
- Department of Anesthesiology and ReanimationAnkara City HospitalAnkaraTurkey
| | - Esra Cakır
- Department of Critical Care UnitAnkara City HospitalAnkaraTurkey
| | - Belgin Akan
- Department of Critical Care UnitAnkara City HospitalAnkaraTurkey
| | - Derya Gokcinar
- Department of Critical Care UnitAnkara City HospitalAnkaraTurkey
| | - Deniz Erdem
- Department of Critical Care UnitAnkara City HospitalAnkaraTurkey
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Guner R, Kayaaslan B, Hasanoglu I, Aypak A, Bodur H, Ates I, Akinci E, Erdem D, Eser F, Izdes S, Kalem AK, Bastug A, Karalezli A, Surel AA, Ayhan M, Karaahmetoglu S, Turan IO, Arguder E, Ozdemir B, Mutlu MN, Bilir YA, Sarıcaoglu EM, Gokcinar D, Gunay S, Dinc B, Gemcioglu E, Bilmez R, Aydos O, Asilturk D, Inan O, Buzgan T. Development and validation of nomogram to predict severe illness requiring intensive care follow up in hospitalized COVID-19 cases. BMC Infect Dis 2021; 21:1004. [PMID: 34563117 PMCID: PMC8467006 DOI: 10.1186/s12879-021-06656-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/03/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Early identification of severe COVID-19 patients who will need intensive care unit (ICU) follow-up and providing rapid, aggressive supportive care may reduce mortality and provide optimal use of medical resources. We aimed to develop and validate a nomogram to predict severe COVID-19 cases that would need ICU follow-up based on available and accessible patient values. METHODS Patients hospitalized with laboratory-confirmed COVID-19 between March 15, 2020, and June 15, 2020, were enrolled in this retrospective study with 35 variables obtained upon admission considered. Univariate and multivariable logistic regression models were constructed to select potential predictive parameters using 1000 bootstrap samples. Afterward, a nomogram was developed with 5 variables selected from multivariable analysis. The nomogram model was evaluated by Area Under the Curve (AUC) and bias-corrected Harrell's C-index with 95% confidence interval, Hosmer-Lemeshow Goodness-of-fit test, and calibration curve analysis. RESULTS Out of a total of 1022 patients, 686 cases without missing data were used to construct the nomogram. Of the 686, 104 needed ICU follow-up. The final model includes oxygen saturation, CRP, PCT, LDH, troponin as independent factors for the prediction of need for ICU admission. The model has good predictive power with an AUC of 0.93 (0.902-0.950) and a bias-corrected Harrell's C-index of 0.91 (0.899-0.947). Hosmer-Lemeshow test p-value was 0.826 and the model is well-calibrated (p = 0.1703). CONCLUSION We developed a simple, accessible, easy-to-use nomogram with good distinctive power for severe illness requiring ICU follow-up. Clinicians can easily predict the course of COVID-19 and decide the procedure and facility of further follow-up by using clinical and laboratory values of patients available upon admission.
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Affiliation(s)
- Rahmet Guner
- Department of Infectious Disease and Clinical Microbiology, Ankara Yildirim Beyazit University, Ankara City Hospital, Bilkent Street no:1, Ankara, 06800, Turkey
| | - Bircan Kayaaslan
- Department of Infectious Disease and Clinical Microbiology, Ankara Yildirim Beyazit University, Ankara City Hospital, Bilkent Street no:1, Ankara, 06800, Turkey.
| | - Imran Hasanoglu
- Department of Infectious Disease and Clinical Microbiology, Ankara Yildirim Beyazit University, Ankara City Hospital, Bilkent Street no:1, Ankara, 06800, Turkey
| | - Adalet Aypak
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Hurrem Bodur
- Department of Infectious Disease and Clinical Microbiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Esragul Akinci
- Department of Infectious Disease and Clinical Microbiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Deniz Erdem
- Department of Anesthesiology and Reanimation, Ankara City Hospital, Ankara, Turkey
| | - Fatma Eser
- Department of Infectious Disease and Clinical Microbiology, Ankara Yildirim Beyazit University, Ankara City Hospital, Bilkent Street no:1, Ankara, 06800, Turkey
| | - Seval Izdes
- Department of Anesthesiology and Reanimation and Intensive Care Unıt, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Ayse Kaya Kalem
- Department of Infectious Disease and Clinical Microbiology, Ankara Yildirim Beyazit University, Ankara City Hospital, Bilkent Street no:1, Ankara, 06800, Turkey
| | - Aliye Bastug
- Department of Infectious Disease and Clinical Microbiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Aysegul Karalezli
- Department of Pulmonary Diseases, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Aziz Ahmet Surel
- Department of General Surgery, Ankara City Hospital, Ankara, Turkey
| | - Muge Ayhan
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | | | - Isıl Ozkocak Turan
- Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Emine Arguder
- Department of Anesthesiology and Reanimation and Intensive Care Unıt, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - Burcu Ozdemir
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Mehmet Nevzat Mutlu
- Department of Anesthesiology and Reanimation, Ankara City Hospital, Ankara, Turkey
| | - Yesim Aybar Bilir
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Elif Mukime Sarıcaoglu
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Derya Gokcinar
- Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Sibel Gunay
- Department of Pulmonary Diseases, Ankara City Hospital, Ankara, Turkey
| | - Bedia Dinc
- Department of Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Emin Gemcioglu
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Ruveyda Bilmez
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Omer Aydos
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Dilek Asilturk
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara, Turkey
| | - Osman Inan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Turan Buzgan
- Department of Infectious Disease and Clinical Microbiology, Ankara Yildirim Beyazit University, Ankara City Hospital, Bilkent Street no:1, Ankara, 06800, Turkey
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Bollucuoglu K, Hanci V, Yurtlu S, Okyay D, Ayoglu H, Turan IO. Comparison of propofol-dexmedetomidine, tiopental-dexmedetomidine and etomidate-dexmedetomidine combinations' effects on the tracheal intubation conditions without using muscle relaxants. ACTA ACUST UNITED AC 2014; 114:514-8. [PMID: 24020707 DOI: 10.4149/bll_2013_107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In our study, we aimed to compare the endotracheal intubation conditions without muscle relaxants during induction with the combinations of dexmedotimidine-propofol, dexmedotimidine-thiopenthal and dexmedetomidine-etomidate. METHOD Seventy-six patients, in ASA risk group I-II, between ages 20-60 years, with Mallampati Class 1 were included in the study. All patients were premedicated with midazolam. The patients were randomly divided into three groups as Group P (n=30, dexmedetomidine-propofol), Group T (n=30, dexmedetomidine-thiopenthal), Group E (n=16, dexmedetomidine-etomidate). All patients received dexmedetomidine 1 μg.kg-1 in 10 min. Then, the patients were administered 2.5 mg.kg-1 propofol for Group P, 5 mg.kg-1 thiopental for Group T and 0.3 mg.kg-1 etomidate for Group E during induction. Hemodynamic data of the patients were recorded before induction, after dexmedetomidine administration, immediately after intubation and 3, 5 and 10 minutes after intubation. RESULTS There was no difference between the groups according to hemodynamic data. Sixteen patients in Group P and 10 patients in Group T had acceptable intubation conditions. Muscle relaxant was needed in 14, 20 and 16 patients in Groups P, T and E, respectively (p<0.05). CONCLUSION In conclusion, we determined that best intubation conditions without muscle relaxants were achieved with propofol-dexmedetomidine combination. None of the patients receiving etomidate -dexmedetomidine combination could be intubated without muscle relaxants (Tab. 6, Ref. 29).
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Karakaya K, Hanci V, Bektas S, Can M, Ucan HB, Emre AU, Tascılar O, Turan IO, Comert M, Irkorucu O, Cakmak GK. Mitigation of indomethacin-induced gastric mucosal lesions by a potent specific type V phosphodiesterase inhibitor. World J Gastroenterol 2009; 15:5091-6. [PMID: 19860004 PMCID: PMC2768890 DOI: 10.3748/wjg.15.5091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the gastroprotective effect of vardenafil against indomethacin-induced gastric damage.
METHODS: Forty-eight female Wistar albino rats were randomly divided into 6 groups. Group 1 received saline only. Group 2 (indomethacin) received indomethacin. Rats in group 3 and 4 were pretreated with different doses of famotidine. Group 5 and 6 were pretreated with different doses of vardenafil. Rats in groups 3 to 6 received 25 mg/kg indomethacin 30 min after pretreatment. The animals were sacrificed 6 h later and their stomachs were opened. Gastric lesions were counted and measured. The stomach of each animal was divided in two parts for histopathological examinations and nitric oxide (NO) and malondialdehyde (MDA) assays, respectively.
RESULTS: There were no gastric mucosal lesion in the saline group but all rats in the indomethacin group had gastric mucosal ulcerations (ulcer count; 6.25 ± 3.49, and mean ulcer area; 21.00 ± 12.35). Ulcer counts were diminished with famotidine 5 mg/kg (4.12 ± 2.47, P > 0.05), 20 mg/kg (2.37 ± 4.43, P < 0.05), vardenafil 2 mg/kg (4.37 ± 3.06), and vardenafil 10 mgkg (1.25 ± 1.38, P < 0.05) compared to the indomethacin group. Gastric mucosal lesion areas were diminished with famotidine 5 mg/kg (8.62 ± 2.97, P < 0.001) , famotidine 20 mg/kg (0.94 ± 2.06, P < 0.001), vardenafil 2 mg/kg (6.62 ± 5.87, P < 0.001), and vardenafil 10 mg/kg (0.75 ± 0.88, P < 0.001) compared to the indomethacin group. MDA levels were significantly higher in indomethacin group (28.48 ± 14.51), compared to the famotidine 5 mg/kg (6,21 ± 1.88, P < 0.05), famotidine 20 mg/kg (5.88 ± 1.60. P < 0.05), vardenafil 2 mg/kg (15.87 ± 3.93, P < 0.05), and vardenafil 10 mg/kg (10.97 ± 4.50, P < 0.05). NO concentration in gastric tissues of the famotidine groups were significantly increased (P < 0.05), but the NO increases in the vardenafil groups were not statistically significant. Histopathology revealed diminished gastric damage for pretreatment groups compared to the indomethacin group (P < 0.05).
CONCLUSION: Vardenafil affords a significant dose-dependent protection against indomethacin induced gastric mucosal lesions in rats.
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