PRESS (Propofol, Remifentanil, Electricity/EEG, Setup and Setting) to Start: Introducing a Total Intravenous Anaesthesia Checklist at a Large Teaching Hospital

Total intravenous anaesthesia (TIVA) is becoming more widely used, and as of yet there are few safety checks for the use of TIVA when compared to inhaled anaesthesia. This study aims to assess the feasibility and utility of introducing a TIVA checklist at a large teaching hospital. Methods A survey was sent out to all consultant and trainee anaesthetists at our hospital regarding their use of TIVA and errors in practice related to its use. A checklist was created based on common errors reported in the survey, errors described in NAP5 and our hospital's standard operating procedure. The checklist was introduced, and another survey was distributed a month later to assess compliance and utility and to gain feedback. Results In the first survey, there were 39 responses. A total of 64% had seen an error with the use of TIVA. For those using TIVA 70% of the time or more, 31% had seen an error in the last three months. Twelve per cent of those who had seen errors found that the errors led to patient harm. Only 33% used a method to double-check for errors prior to commencing TIVA. In the follow-up survey, 80% of those who used the checklist had found it useful, and 30% had corrected an error while using the checklist. Eighty-seven per cent felt the checklist would prevent errors from being made. Eighty per cent of respondents said they would use the checklist in their future practice. The checklist was found to be more useful for trainees, and for those who use TIVA less often. Discussion The 'PRESS to start TIVA" checklist has been shown to be a useful tool to prevent errors and a majority of anaesthetists at our hospital plan to use it going forward. Our data suggests that anaesthetists who are less experienced with TIVA benefit more from having a checklist. There was a marked increase in the number of anaesthetists who would use a checklist in the future, compared to those who used one in the initial survey. This shows that introducing a checklist is feasible and is likely to reduce errors going forward.

Management of infusion-related reactions in cancer therapy: strategies and challenges

Several anticancer therapies have the potential to cause infusion-related reactions (IRRs) in the form of adverse events that typically occur within minutes to hours after drug infusion. IRRs can range in severity from mild to severe anaphylaxis-like reactions. Careful monitoring at infusion initiation, prompt recognition, and appropriate clinical assessment of the IRR and its severity, followed by immediate management, are required to ensure patient safety and optimal outcomes. Lack of standardization in the prevention, management, and reporting of IRRs across cancer-treating institutions represents not only a quality and safety gap but also a disparity in cancer care. The present article, supported by recently published data, was developed to standardize these procedures across institutions and provide a useful tool for health care providers in clinical practice to recognize early signs and symptoms of an IRR and promptly and appropriately manage the event.

Dancing in the purple rain: color affinity and oviposition choices in Aedes sierrensis (Diptera: Culicidae)

The western tree hole mosquito, Aedes sierrensis (Ludlow) (Diptera: Clucidae), is a pestiferous mosquito with a range extending over the entire pacific seaboard and into portions of the intermountain west. As a peridomestic heartworm vector, it demands at least some level of surveillance to understand its abundance. However, the species is refractory to a majority of conventional vector surveillance approaches for tracking mosquitoes. To find more options for Aedes sierrensis surveillance, a variety of oviposition attractants were evaluated in arena-style choice assays using colony reared adults. A range of infusion treatments (e.g., alfalfa, oak, and beetroot) were examined and then combined with investigations of liquid color as well as ovicup color and entryway position. These studies revealed that Ae. sierrensis have an affinity for purple coloration, plain water, and larger entryway sizes for oviposition cups. A prototype ovicup was 3D-printed using purple filament and multiple types of entryways, and used to re-test infusion waters. No particular attraction differences were detected after normalizing for purple color. Comparisons to black 3D-printed cups yielded surprising observations that male mosquitoes also aggregated on purple cups while females sheltered, but not necessarily oviposited, in black cups. Although this was only a laboratory-based assessment, these studies provide useful information for future field trials of potential oviposition traps for surveillance of Ae. sierrensis.

Effective remimazolam loading dose for adequate sedation in regional anesthesia

PURPOSE

Remimazolam is a novel ultrashort-acting sedative considered appropriate for continuous infusion during surgical procedures. Nevertheless, information regarding its loading dose for sedation during surgery is limited. We aimed to determine the 90% effective dose (ED90) of the remimazolam loading dose for sedation in patients undergoing limb surgery under regional anesthesia.

METHODS

We included 50 patients aged 19-80 yr undergoing limb surgery under regional anesthesia. After regional anesthesia, remimazolam besylate was administered at the assigned dose. For ten minutes after the initiation of loading, the level of sedation was evaluated using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. The primary outcome was the ED90 based on whether patients reached a MOAA/S score of ≤ 3 points (loss of response to verbal command) within ten minutes. The secondary outcomes were the ED50 and the estimated effect site and plasma concentration at the time of achieving successful sedation.

RESULTS

In total, 49 patients were included in the final analysis, and adequate sedation with the assigned loading dose was successful in 42 patients. The log-logistic function showed that the ED90 and ED50 were 0.617 mg·kg-1·hr-1 (95% confidence interval [CI], 0.511 to 0.722; 98% CI, 0.492 to 0.741) and 0.438 mg·kg-1·hr-1 (95% CI, 0.335 to 0.541; 98% CI, 0.315 to 0.560), respectively.

CONCLUSION

The ED90 of the remimazolam loading dose to achieve adequate sedation in patients undergoing limb surgery under regional anesthesia was 0.617 mg·kg-1·hr-1 (95% CI, 0.511 to 0.722; 98% CI, 0.492 to 0.741).

STUDY REGISTRATION

ClinicalTrials.gov (NCT05340335); first posted 22 April 2022.

Evaluation of oncology infusion pharmacy practices: A nationwide survey

PURPOSE

Oncology care continues to evolve at a rapid pace including provision of infusion-based care. There is currently a lack of robust metrics around oncology infusion centers and pharmacy practice. The workgroup completed a nationwide survey to learn about oncology-based infusion pharmacy services offered. The objective was to highlight consistent, measureable oncology-based infusion pharmacy metrics that will provide a foundation to describe overall productivity including emphasis on high patient-safety standards.

METHODS

A nationwide survey was developed via a workgroup within the Vizient Pharmacy Cancer Care Group beginning in April 2019 and conducted electronically via the Vizient Pharmacy Network from September to November 2020. The survey was designed to capture a number of key metrics related to oncology-based infusion pharmacy services.

RESULTS

Forty-one sites responded to the survey. Responses highlighted hours of operation (median = 11.5), number of infusion chairs (median = 45). Staffing metrics included 7.1 pharmacist full-time equivalent (FTE) and 7.6 technician FTE per week. 80.5% of sites had cleanrooms and 95.1% reported both hazardous and nonhazardous compounding hoods. 68.3% of sites reported using intravenous (IV) technology, 50.0% measured turnaround time, and 31.4% prepared treatment medications in advance.

CONCLUSION

There was variability among oncology infusion pharmacy practices in regard to survey responses among sites. The survey results highlight the need for standardization of established productivity metrics across oncology infusion pharmacies in order to improve efficiency and contain costs in the changing oncology landscape. The survey provides insight into oncology infusion pharmacy practices nationwide and provides information for pharmacy leaders to help guide their practices.

Infusion Inhibits Sugar Uptake and Counteracts Oxidative Stress-Induced Stimulation of Glucose Uptake by Intestinal Epithelial (Caco-2) Cells

Sweet cherry (Prunus avium L.) is among the most valued fruits due to its organoleptic properties and nutritional worth. Cherry stems are rich in bioactive compounds, known for their anti-inflammatory and antioxidant properties. Innumerable studies have indicated that some bioactive compounds can modulate sugar absorption in the small intestine. In this study, the phenolic profile of a cherry stem infusion was investigated, as well as its capacity to modulate intestinal glucose and fructose transport in Caco-2 cells. Long-term (24 h) exposure to cherry stem infusion (25%, v/v) significantly reduced glucose (3H-DG) and fructose (14C-FRU) apical uptake, reduced the apical-to-basolateral Papp to 3H-DG, and decreased mRNA expression levels of the sugar transporters SGLT1, GLUT2 and GLUT5. Oxidative stress (induced by tert-butyl hydroperoxide) caused an increase in 3H-DG uptake, which was abolished by the cherry stem infusion. These findings suggest that cherry stem infusion can reduce the intestinal absorption of both glucose and fructose by decreasing the gene expression of their membrane transporters. Moreover, this infusion also appears to be able to counteract the stimulatory effect of oxidative stress upon glucose intestinal uptake. Therefore, it can be a potentially useful compound for controlling hyperglycemia, especially in the presence of increased intestinal oxidative stress levels.

Traditional Knowledge Evolution over Half of a Century: Local Herbal Resources and Their Changes in the Upper Susa Valley of Northwest Italy

Susa Valley, located in the Italian Western Alps, has served as a meeting point for cultural, spiritual, and commercial exchange for a long period of history. The valley's role as one of the main connecting routes between south and southwestern Europe resulted in its acquisition of a rich traditional ecological knowledge. However, like other Italian mountainous valleys, this valley has suffered from abandonment and depopulation in the past 50 years. Our study aims to investigate the current ethnobotanical medicinal knowledge in the valley and to compare our findings with a study conducted over 50 years ago in the same area. In 2018, we conducted 30 in-depth semi-structured interviews on medicinal plants and food-medicines used in the Susa Valley. We documented 36 species, of which 21 species were used for medical purposes and 15 species were used as food-medicine. The comparison with the previous study on medicinal herbs conducted in 1970 in the valley demonstrated a significant decrease in both the knowledge and use of medicinal plants, which could be attributed to socioeconomic, cultural, and possibly environmental changes that occurred in the past half-century. Our study highlights several promising species for future use as nutraceuticals, food, and medicinal products, such as Taraxacum officinale, Urtica dioica, and Artemisia genipi.

Effect of vertical pump position on start-up fluid delivery of syringe pumps used for microinfusion

BACKGROUND

Connection and opening a syringe infusion pump to a central venous line can lead to acute anterograde or retrograde fluid shifts depending on the level of central venous pressure. This may lead to bolus events or to prolonged lag times of intravenous drug delivery, being particularly relevant when administering vasoactive or inotropic drugs in critically ill patients using microinfusion. The aim of this study was to assess the effect of syringe pump positioning at different vertical heights on start-up fluid delivery before versus after purging and connection the pump to the central venous catheter.

METHODS

This in vitro study measured ante- and retrograde infusion volumes delivered to the central venous line after starting the syringe pump at a set infusion rate of 1 mL/h. In setup one, the pump was first positioned to vertical levels of +43 cm or -43 cm and then purged and connected to a central venous catheter. In setup two, the pump was first purged and connected at zero level and secondarily positioned to a vertical level of +43 cm or -43 cm. Central venous pressure was adjusted to 10 mmHg in both setups.

RESULTS

Positioning of the pump prior to purging and connection to the central venous catheter resulted in a better start-up performance with delivered fluid closer to programmed and expected infusion volumes when compared to the pump first purged, connected, and then positioned. Significant backflow volumes were observed with the pump purged and connected first and then positioned below zero level. No backflow was measured with the pump positioned first below zero level and then purged and connected.

CONCLUSIONS

Syringe infusion pump assemblies should be positioned prior to purging and connection to a central venous catheter line when starting a new drug, particularly when administering highly concentrated vasoactive or inotropic drugs delivered at low flow rates.

Hypophosphatemia related to intravenous iron therapy with ferric carboxymaltose: A case series

OBJECTIVES

This case series would like to highlight hypophosphatemia related to ferric carboxymaltose and its adverse clinical consequences.

BACKGROUND

Intravenous iron supplementation is a good alternative to oral iron replacement in iron deficiency anaemia due to its ability to correct iron deficit with minimal infusions without incurring the gastrointestinal side effects of oral iron replacement. Ferric carboxymaltose is one common formula for intravenous iron supplementation. However, an increasingly recognised adverse side-effect of intravenous ferric carboxymaltose is hypophosphatemia. There has been increasing reports and studies highlighting hypophosphatemia related to intra-venous iron therapy. Though initially thought to be transient and asymptomatic, recent studies have shown that persistent hypophosphatemia in iron therapy can result in debilitating disease including myopathy, fractures and osteomalacia.

METHODS

A retrospective analysis of all patients who had ferric carboxymaltose was performed.

RESULTS

We highlight 3 cases where hyposphatemia affected the clinical outcomes.

CONCLUSION

With the increased use of IV iron it is important to be aware of the high potential for hypophosphatemia secondary to ferric carboxymaltose.

Vascular effects of Fragaria vesca L. in human arteries

Fragaria vesca L. (wild strawberry) is traditionally used for its anti-inflammatory activity and for gastrointestinal, cardiovascular and urinary disorders. A previous study with the rat aorta showed that its leaves extract elicits endothelium-dependent vasorelaxation. Our aim was to investigate the clinical application of Fragaria vesca in vascular disease, by assessing the vascular effects of an infusion and hydroalcoholic extract in internal thoracic arteries from patients with coronary artery disease. The extracts elicited no effects on basal vascular tone and did not induce any vasorelaxation. At low concentration (0.02 mg/mL), the infusion potentiated the noradrenaline-induced contraction, while the other concentrations did not elicit significant changes in efficacy or potency. Differences between our findings and the previous report on rat aorta may result from methodological differences, e.g. vascular bed, method of extraction and extract composition. The clinical applicability of extracts of Fragaria vesca in patients with cardiovascular disease remains to be fully validated.

Practical Clinical Guidelines for Natalizumab Treatment in Patients With Relapsing Multiple Sclerosis

Natalizumab (TYSABRI®) was the first high-efficacy monoclonal antibody disease-modifying therapy (DMT) approved as a monotherapy for the treatment of adults with relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting MS, and active secondary progressive MS. Because natalizumab is administered by intravenous infusion, infusion nurses play a key role in the care of natalizumab-treated patients. In the 16 years since approval, substantial data have been gathered on the long-term, real-world effectiveness and safety of natalizumab. This article provides a synopsis of this data, as well as practical information for optimizing patient care. This includes information on strategies to mitigate the risk of progressive multifocal leukoencephalopathy in natalizumab-treated patients, natalizumab use during pregnancy, and use with vaccines. It also includes guidance on the preparation and administration of natalizumab and monitoring of natalizumab-treated patients.

When the Going Gets Tough: A Case Report and Review of Calcinosis Cutis in an Infant with Pseudo-Hypoaldosteronism

Calcium gluconate solutions are an essential part of the intensive care medication armamentarium. Calcium-related extravasations are not an infrequent occurrence. However, occult extravasation presenting solely as an isolated mass lesion with no preceding cutaneous manifestation is rare. Calcinosis cutis is an extraosseous collection of calcium deposits in the skin and subcutaneous tissues. Multiple etiopathogenetic factors play a role in its manifestations. We illustrate a case of a seven-week-old infant diagnosed with pseudo-hypoaldosteronism with a mysterious swelling on the left leg during the third week of hospitalization, which was attributed to occult iatrogenic calcinosis cutis.

Neutropenic Rat Thigh Infection Model for Evaluation of the Pharmacokinetics/Pharmacodynamics of Anti-Infectives

The neutropenic mouse infection model is extensively used to characterize the pharmacokinetics/pharmacodynamics (PK/PD) of anti-infective agents. However, it is difficult to evaluate agents following intravenous (i.v.) infusions using this model. Furthermore, in many drug discovery programs, lead identification and optimization is performed in rats, and pharmacology is performed in mice. Alternative models of infection are needed for robust predictions of PK/PD in humans. The rat is an alternative model of infection which can overcome the shortcomings of the mouse model. However, the rat neutropenic thigh infection (NTI) model has not been adequately characterized for evaluation of the PK/PD of anti-infectives. The aim of this study was to characterize the PK/PD of ciprofloxacin against bacterial pathogens in a rat NTI model. We studied the PK/PD relationships of ciprofloxacin against wild-type Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae in neutropenic Wistar rats following administration of 10, 30, and 100 mg/kg as single intravenous boluses and 30- and 60-min infusions. The PK/PD of ciprofloxacin against all four pathogens was AUC/MIC dependent and independent of the duration of administration at 10, 30, and 100 mg/kg. At human-equivalent rat doses, the PK/PD targets of ciprofloxacin achieved in rats for microbiological cure were similar to those reported in human patients. The neutropenic rat thigh infection model can be used to evaluate anti-infective agents intended to be administered as infusions in the clinic, and it complements the mouse model, increasing the robustness of PK/PD predictions in humans. IMPORTANCE Many antibiotics are administered as intravenous infusions in the clinic, especially in intensive care units. Anti-infective drug discovery companies develop clinical candidates that are intended to be administered as i.v. infusions in the clinic. However, there are no well-characterized models with which they can evaluate the PK/PD of the candidates following i.v. infusions. The neutropenic rat thigh infection model reported in this study helps in evaluating anti-infective agents that are intended to be administered as i.v. infusions in the clinic. The rat model is useful for simulating the clinical conditions for i.v. infusions for treatment of infections, such as acute bacterial skin and skin structure, lung, and urinary tract infections. This model is predictive of efficacy in humans and can serve as an additional confirmatory model, along with the mouse model, for determining the proof of concept and for making robust predictions of efficacy in humans.

Extraction Methods, Chemical Characterization, and In Vitro Biological Activities of Plinia cauliflora (Mart.) Kausel Peels

Plinia cauliflora (Mart.) Kausel, popularly known as jabuticaba, possesses bioactive compounds such as flavonoids, tannins, and phenolic acids, known for their antioxidant, antibacterial, wound healing, and cardioprotective effects. Therefore, this study aimed to standardize the P. cauliflora fruit peel extraction method, maximize phenolic constituents, and evaluate their antioxidative and antimicrobial effects. Various extraction methods, including vortex extraction with and without precipitation at 25, 40, and 80 °C, and infusion extraction with and without precipitation, were performed using a completely randomized design. Extraction without precipitation (E - P) showed the highest yield (57.9%). However, the precipitated extraction (E + P) method displayed a yield of 45.9%, higher levels of phenolic derivatives, and enhanced antioxidant capacity. Major compounds, such as D-psicose, D-glucose, and citric acid, were identified through gas chromatography-mass spectrometry (GC-MS) analysis. Ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis identified citric acid, hexose, flavonoids, tannins, and quercetin as the major compounds in the extracts. Furthermore, the extracts exhibited inhibitory effects against Bacillus subtilis, Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli bacteria. In conclusion, the E + P method efficiently obtained extracts with high content of bioactive compounds showing antioxidant and antimicrobial capacities with potential application as a dietary supplement.

Evaluation of Strategies for Reducing Vancomycin-Piperacillin/Tazobactam Incompatibility

BACKGROUND

Drug incompatibility is defined as a physical-chemical reaction between two or more injectable drugs and that results mainly in precipitation or insolubility. Several strategies for reducing incompatibilities have been implemented empirically in intensive care units. However, these strategies have never been compared directly (and particularly in terms of the particulate load and drug mass flow rate) under standardized conditions. The objective of the present in vitro study was to evaluate the impact of various strategies for preventing incompatibility between simultaneously infused vancomycin and piperacillin/tazobactam.

METHODS

An in-line filter, a dilute vancomycin solution (5 mg/mL), and an alternative saline administration line were evaluated separately. The infusion line outlet was connected to a dynamic particle counter. The antibiotic concentration was measured in an HPLC-UV assay.

RESULT

The use of an in-line filter and an alternative saline administration route did not significantly reduce the particulate load caused by vancomycin-piperacillin/tazobactam incompatibility. Dilution of the vancomycin solution was associated with a significantly lower particulate load and maintenance of the vancomycin mass flow rate.

DISCUSSION

It is important to systematically compare the efficacy of strategies for preventing drug incompatibility. The use of diluted vancomycin solution gave the best results in the case of vancomycin-piperacillin/tazobactam incompatibility.

Case Report: Extended Duration Andexanet Alfa Infusion in a Surgical Trauma Patient

Background: Andexanet alfa (andexanet) is the only FDA-approved medication for reversal of apixaban and rivaroxaban anticoagulation for life-threatening or uncontrolled bleeding. Infusion modifications may be required in surgical patients undergoing prolonged operative intervention but have not previously been described. Case Report: A 78-year-old woman on rivaroxaban for atrial fibrillation was admitted to the trauma service for a mechanical fall, sustaining a T4 burst fracture with severe canal stenosis and spinal cord edema resulting in loss of strength and sensation in her legs. Clinically relevant rivaroxaban activity was verified with an elevated low molecular weight heparin anti-factor Xa assay, and laboratory confirmed coagulopathy was demonstrated by a prolonged prothrombin time, thromboelastography (TEG) R-time, and activated clotting time (ACT). The patient required urgent surgical intervention for spinal fixation. Given the expected prolonged duration of the procedure, standard dose andexanet was initiated with a prolonged infusion at half the standard rate during the operation. The procedure was successful and intraoperative TEGs demonstrated normalization of R-time and ACT throughout the procedure. The patient did not experience any complications postoperatively and successfully discharged to inpatient rehabilitation. Conclusion: Modifications to the andexanet infusion may be required in surgical patients requiring rivaroxaban reversal for a prolonged procedure. Further data are needed to determine the optimal approach to infusion modification.

Pesticide residues in herbs and their transfer for infusions

In this work, a cost-effective gas chromatography-mass spectrometry method was validated for the analysis of twenty-five pesticide residues in herbs and infusions using a quick, easy, cheap, effective, rugged, and safe procedure or a dispersive liquid-liquid microextraction method, respectively. Figures of merit of the method showed good accordance with current guidelines. From the 58 herb samples studied (pertaining to 20 different species), 80% presented at least one detectable pesticide, with 62% of them above the maximum residual level. Results showed that pesticide residues from naturally contaminated herbs were not transferred at a significant rate to the herbal infusions. When a control assay was conducted by spiking a blank herb sample with a large amount of each pesticide (7 mg/L) 15 analytes were detected below the limit of quantification in the infusion.

The vascular role of CGRP: a systematic review of human studies

Intravenous infusion of human alpha calcitonin gene-related peptide (h-α-CGRP) has been applied to explore migraine pathogenesis and cerebral hemodynamics during the past three decades. Cumulative data implicate h-α-CGRP in regulating the vascular tone. In this systematic review, we searched PubMed and EMBASE for clinical studies investigating the vascular changes upon intravenous infusion of h-α-CGRP in humans. A total of 386 studies were screened by title and abstract. Of these, 11 studies with 61 healthy participants and 177 participants diagnosed with migraine were included. Several studies reported hemodynamic effects including flushing, palpitation, warm sensation, heart rate (HR), mean arterial blood pressure (MABP), mean blood flow velocity of middle cerebral artery (mean V_MCA), and diameter of superficial temporal artery (STA). Upon the start of h-α-CGRP infusion, 163 of 165 (99%) participants had flushing, 98 of 155 (63%) participants reported palpitation, and 160 of 165 (97%) participants reported warm sensation. HR increased with 14%-58% and MABP decreased with 7%-12%. The mean V_MCA was decreased with 9.5%-21%, and the diameter of the STA was dilated with 41%-43%. The vascular changes lasted from 20 to >120 min. Intravenous infusion of h-α-CGRP caused a universal vasodilation without any serious adverse events. The involvement of CGRP in the systemic hemodynamic raises concerns regarding long-term blockade of CGRP in migraine patients with and without cardiovascular complications.

Comparative Phytochemical Analyses of Flowers from Primula veris subsp. veris Growing Wild and from Ex Situ Cultivation in Greece

In the last decades, Primula veris subsp. veris (roots and flowers) has been over harvested through legal and illegal ways in Greece, due to its extremely high commercial demand, as it is used in industry because of its well-known therapeutic properties. As ex situ cultures of the plant have been already developed, in the current comparative study, the herbal teas (infusions) from both flowers of cowslip growing wild in the Prespa Lake Park (NW Greece), and from ex situ propagated and cultivated plant material, have been investigated, with the ultimate goal of assessing them qualitatively. Furthermore, through classic phytochemical studies, the ten most abundant metabolites, belonging to the chemical categories of flavonol-glycosides and methoxy flavones, have been identified and structurally determined. The chemical profile of both infusions has been further analyzed through UHPLC-HRMS, showing that they show only light differences. The total phenolic content (TPC) of both studied samples (wild and ex situ cultivation), was determined by the Folin-Ciocalteau method, followed by an antioxidant activity assay though DPPH where, in both cases, wild plants exerted higher phenolic load and stronger antioxidative properties. According to the reported results, it could be proposed that the ex situ cultivated plant material could facilitate the mass production of plants and the sustainable cultivation of cowslip in the Greek mountains.

A systematic review and meta-regression of exogenous ketone infusion rates and resulting ketosis-A tool for clinicians and researchers

Introduction: Ketone bodies such as beta-hydroxybutyrate (BHB) have pleiotropic functional benefits as fuel and signaling metabolites and may have multiple clinical applications. An alternative to inducing ketosis by dietary modification is intravenous delivery of exogenous sources of ketones. It is unknown whether there is a strong relationship between BHB infusion rate and blood BHB concentrations in the published literature; this information is vital for clinical studies investigating therapeutic effects of ketosis. This systematic review aimed to aggregate available data and address this gap. Methods: The PubMed and EMBASE databases were searched, and data were extracted from 23 manuscripts where BHB was infused and maximum and/or steady state BHB levels assessed. Infusion rate was adjusted when racemic BHB was infused but only D-BHB was measured. Results: Using a random effects meta-regression, strong linear relationships between BHB infusion rate and maximal (y = 0.060 + 0.870x, R ² = 87.2%, p < 0.0001) and steady state (y = -0.022 + 0.849x, R ² = 86.9%, p < 0.0001) blood BHB concentrations were found. Sensitivity analysis found this relationship was stronger when studies in non-healthy populations were excluded (y = 0.059 + 0.831x, R ² = 96.3%, p < 0.0001). Conclusion: There is a strong relationship between BHB infusion rate and blood BHB concentrations; the regressions described here can be used by clinicians or researchers to determine ketone delivery required for a target blood concentration.

Oviposition Preferences of Aedes aegypti in Msambweni, Kwale County, Kenya

Aedes aegypti is the primary vector of dengue fever virus (DENV) worldwide. Infusions made from organic materials have been shown to act as oviposition attractants for Ae. aegypti; however, studies on locally suitable infusion materials are lacking. The current study assessed the suitability of 4 locally available materials as oviposition infusions for use in surveillance and control of Ae. aegypti in Kwale County, Kenya. Oviposition infusion preferences were assessed in laboratory, semifield, and field conditions, using 4 infusions made from banana, grass, neem, and coconut. In addition, ovitrapping in wall, grass, bush, and banana microhabitats was done in 10 houses each in urban and rural coastal households to determine suitable oviposition microhabitats. Overall, the highest oviposition responses were observed for banana infusion, followed by neem and grass infusions, which were comparable. Coconut infusion resulted in the lowest oviposition response. Although female Ae. aegypti did not show preference for any microhabitat, the oviposition activity across all the microhabitats was highly enhanced by use of the organic infusions. Banana, neem, and grass infusions could be used to attract gravid mosquitoes to oviposition sites laced with insecticide to kill eggs. Additionally, banana plantings could be important targets for integrated vector control programs.

Ethnobotany, Biological Activities and Phytochemical Compounds of Some Species of the Genus Eryngium (Apiaceae), from the Central-Western Region of Mexico

There are approximately 250 species of Eryngium L. distributed throughout the world, with North America and South America being centers of diversity on this continent. In the central-western region of Mexico there may be around 28 species of this genus. Some Eryngium species are cultivated as leafy vegetables, ornamental, and medicinal plants. In traditional medicine they are used to treat respiratory and gastrointestinal conditions, diabetes, and dyslipidemia, among others. This review addresses the phytochemistry and biological activities, as well as traditional uses, distribution, and characteristics of the eight species of Eryngium reported as medicinal in the central-western region of Mexico: E. cymosum, E. longifolium, E. fluitans (or mexicanum), E. beecheyanum, E. carlinae, E. comosum, E. heterophyllum, and E. nasturtiifolium. The extracts of the different Eryngium spp. have shown biological activities such as hypoglycemic, hypocholesterolemic, renoprotective, anti-inflammatory, antibacterial, and antioxidant, among others. E. carlinae is the most studied species, and phytochemical analyses, performed mainly by high-performance liquid chromatography (HPLC) and gas chromatography coupled with mass spectrometry (GC-MS), have shown its content of terpenoids, fatty acids, organic acids, phenolic acids, flavonoids, sterols, saccharides, polyalcohols, and aromatic and aliphatic aldehydes. According to the results of this review on Eryngium spp., they constitute a relevant alternative as a source of bioactive compounds for pharmaceutical, food, and other industries. However, there is a lot of research to be conducted regarding phytochemistry, biological activities, cultivation, and propagation, in those species with few or no reports.

Evaluation of the Biological Properties of an Optimized Extract of Polygonum cuspidatum Using Ultrasonic-Assisted Extraction

Phytochemicals are natural compounds found in plants that have potential health benefits such as antioxidants, anti-inflammatory and anti-cancer properties, and immune reinforcement. Polygonum cuspidatum Sieb. et Zucc. is a source rich in resveratrol, traditionally consumed as an infusion. In this study, P. cuspidatum root extraction conditions were optimized to increase antioxidant capacity (DPPH, ABTS+), extraction yield, resveratrol concentration, and total polyphenolic compounds (TPC) via ultrasonic-assisted extraction using a Box-Behnken design (BBD). The biological activities of the optimized extract and the infusion were compared. The optimized extract was obtained using a solvent/root powder ratio of 4, 60% ethanol concentration, and 60% ultrasonic power. The optimized extract showed higher biological activities than the infusion. The optimized extract contained 16.6 mg mL^-1 resveratrol, high antioxidant activities (135.1 µg TE mL^-1 for DPPH, and 230.4 µg TE mL^-1 for ABTS+), TPC (33.2 mg GAE mL^-1), and extraction yield of 12.4%. The EC₅₀ value (effective concentration 50) of the optimized extract was 0.194 µg mL^-1, which revealed high cytotoxic activity against the Caco-2 cell line. The optimized extract could be used to develop functional beverages with high antioxidant capacity, antioxidants for edible oils, functional foods, and cosmetics.

Implementation of 2D Barcode Medication Labels and Smart Pumps in Pediatric Acute Care: Lessons Learned

BACKGROUND

In pediatric intensive care, prescription, administration, and interpretation of drug doses are weight dependent. The use of standardized concentrations simplifies the preparation of drugs and increases safety. For safe administration as well as easy interpretation of intravenous drug dosing regimens with standardized concentrations, the display of weight-related dose rates on the infusion device is of pivotal significance.

OBJECTIVES

We report on challenges in the implementation of a new information technology-supported medication workflow. The workflow was introduced on eight beds in the pediatric heart surgery intensive care unit as well as in the pediatric anesthesia at the University of Bonn Medical Center. The proposed workflow utilizes medication labels generated from prescription data from the electronic health record. The generated labels include a two-dimensional barcode to transfer data to the infusion devices.

METHODS

Clinical and technical processes were agilely developed. The reliability of the system under real-life conditions was monitored. User satisfaction and potential for improvement were assessed. In addition, a structured survey among the nursing staff was performed. The questionnaire addressed usability as well as the end-users' perception of the effects on patient safety.

RESULTS

The workflow has been applied 44,111 times during the pilot phase. A total of 114 known failures in the technical infrastructure were observed. The survey showed good ratings for usability and safety (median "school grade" 2 or B for patient safety, intelligibility, patient identification, and handling). The medical management of the involved acute care facilities rated the process as clearly beneficial regarding patient safety, suggesting a rollout to all pediatric intensive care areas.

CONCLUSION

A medical information technology-supported medication workflow can increase user satisfaction and patient safety as perceived by the clinical end-users in pediatric acute care. The successful implementation benefits from an interdisciplinary team, active investigation of possible associated risks, and technical redundancy.

Antioxidant properties and antibacterial activity of water extracts from Sambucus nigra L. under different conditions

INTRODUCTION

In folk medicine, dried white flowers of Sambucus nigra L. are used to make infusions, decoctions, and juices.

AIM

The present article aims to study and compare the antioxidant activity of aqueous solutions of leaves and flowers of Sambucus nigra L obtained at different exposure times and assess the antibacterial activity of these solutions against Escherichia coli ATCC 8739, Salmonella NCTC 6017, Listeria monocytogenes NCTC 11994, and Staphylococcus aureus ATCC 25093.

MATERIALS AND METHODS

We studied the physicochemical properties of aqueous extracts of leaves (fresh) and flowers (fresh and dry) of Sambucus nigra L collected from the Rhodope region of Bulgaria. The samples from Sambucus nigra L were analyzed to determine their total phenolic content (TPC), total flavonoid content (TFC), and antioxidant activity using 1,1-diphenyl-2-picrylhydrazyl (DPPH) and ferric reducing antioxidant power (FRAP). The diameters (in millimeters) of the growth inhibition zones of four pathogens were measured, and a comparative assessment of their antibacterial activity was made.

RESULTS

The infusions of fresh blossoms and fresh leaves of Sambucus nigra L had the highest antioxidant activity at the total contact time of 30 minutes (82.7 mmol TE/100 ml) and 35 minutes (36.5 mmol TE/100 ml), respectively. The phenol-richest infusions were those made from dried flowers of Sambucus nigra L after a 30-minute contact time (86.7 mg GAE/ml). Of the four pathogens we studied, we found that the extracts affected partially only the pathogenic bacteria of Salmonella.

CONCLUSIONS

The highest content of bioactive components was obtained from dried blossoms of Sambucus nigra L. for infusions with a total contact time of 30 minutes and for decoctions at a contact time of 45 minutes.

Pharmacokinetics of buprenorphine and its metabolite norbuprenorphine in neutered male cats anesthetized with isoflurane

OBJECTIVE

To characterize the pharmacokinetics of buprenorphine and norbuprenorphine in isoflurane-anesthetized cats.

STUDY DESIGN

Prospective experimental study.

ANIMALS

A group of six healthy adult male neutered cats.

METHODS

Cats were anesthetized with isoflurane in oxygen. Catheters were placed in a jugular vein for blood sampling and in a medial saphenous vein for buprenorphine and lactated Ringer's solution administration. Buprenorphine hydrochloride (40 μg kg^-1 over 5 minutes) was administered intravenously. Blood samples were collected before buprenorphine administration and at various times up to 12 hours after administration. Plasma buprenorphine and norbuprenorphine concentrations were measured using liquid chromatography/tandem mass spectrometry. Compartment models were fitted to the time-concentration data using nonlinear mixed effect (population) modeling.

RESULTS

A five-compartment model (three compartments for buprenorphine and two compartments for norbuprenorphine) best fitted the data. Typical value (% interindividual variability) for the three buprenorphine volumes of distribution, and the metabolic clearance to norbuprenorphine, the remaining metabolic clearance and the two distribution clearances were 157 (33), 759 (34) and 1432 (43) mL kg^-1, and 5.3 (33), 16.4 (11), 58.7 (27) and 6.0 (not estimated) mL minute^-1 kg^-1, respectively. Typical values (% interindividual variability) for the two norbuprenorphine volumes of distribution, and the norbuprenorphine metabolic and distribution clearances were 1437 (30) and 8428 (not estimated) mL kg^-1 and 48.4 (68) and 235.9 (not estimated) mL minute^-1 kg^-1, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

The pharmacokinetics of buprenorphine in isoflurane-anesthetized cats were characterized by a medium clearance.

Extended Stability of Vasopressin Injection in Polyvinyl Chloride Bags and Polypropylene Syringes and Its Impact on Critically Ill Patient Care and Medication Waste

Background. Vasopressin is frequently utilized for a variety of shock states in critically ill patients. Short stability (≤24 hours) after intravenous admixture with current manufacturer labeling requires just in time preparation and may lead to delays in therapy and increased medication waste. We aimed to evaluate vasopressin stability in 0.9% sodium chloride stored in polyvinyl chloride bags and polypropylene syringes for up to 90 days. Additionally, we evaluated the impact of extended stability on the time to administration and cost savings from reduced medical waste at an academic medical center. Methods. Dilutions of vasopressin to concentrations of 0.4 and 1.0 unit/mL were performed under aseptic conditions. The bags and syringes were stored at room temperature (23°C-25°C) or under refrigeration (3°C-5°C). Three samples of each preparation and storage environment were analyzed on days 0, 2, 14, 30, 45, 60, and 90. Physical stability was performed by visual examination. The pH was assessed at each point and upon final degradation evaluation. Sterility of the samples was not assessed. Chemical stability of vasopressin was evaluated using liquid chromatography with tandem mass spectrometry. Samples were considered stable if there was <10% degradation of the initial concentration. Results. Vasopressin diluted to 0.4 and 1.0 unit/mL with 0.9% sodium chloride injection was physically stable throughout the study. No precipitation was observed. At days 2, 14, 30, 45, 60, and 90 all bags and syringes diluted to 0.4 units/mL had <10% degradation. Vasopressin diluted to 1 unit/mL and stored under refrigeration had <10% degradation at all measured days, but when stored under room temperature was found to have >10% degradation at day 30. Implementation of a batching process resulted in reduced waste ($185 300) and improved time to administration (26 vs 4 minutes). Conclusion. Vasopressin diluted to a concentration of 0.4 units/mL with 0.9% sodium chloride injection is stable for 90 days at room temperature and under refrigeration. When diluted to 1.0 unit/mL with 0.9% sodium chloride injection it is stable for 90 days under refrigeration. Use of extended stability and sterility testing to batch prepare infusions may lead to improved time to administration and cost savings from reduced medication waste.

The mammalian insulin antagonist S961 does not exhibit insulin receptor antagonism in rainbow trout in vivo

Due to their reported 'glucose-intolerant' phenotype, rainbow trout have been the focus of comparative studies probing underlying endocrine mechanisms at the organismal, tissue and molecular level. A particular focus has been placed on the investigation of the comparative role of insulin, an important glucoregulatory hormone, and its interaction with macronutrients. A limiting factor in the comparative investigation of insulin is the current lack of reliable assays to quantify circulating mature and thus bioactive insulin. To circumvent this limitation, tissue-specific responsiveness to postprandial or exogenous insulin has been quantified at the level of post-translational modifications of cell signalling proteins. These studies revealed that the insulin responsiveness of these proteins and their post-translational modifications are evolutionarily highly conserved and thus provide useful and quantifiable proxy indices to investigate insulin function in rainbow trout. While the involvement of specific branches of the intracellular insulin signalling pathway (e.g., mTor) in rainbow trout glucoregulation have been successfully probed through pharmacological approaches, it would be useful to have a functionally validated insulin receptor antagonist to characterize the glucoregulatory role of the insulin receptor pathway in its entirety for this species. Here, we report two separate in vivo experiments to test the ability of the mammalian insulin receptor antagonist, S961, to efficiently block insulin signalling in liver and muscle in response to endogenously released insulin and to exogenously infused bovine insulin. We found that, irrespective of the experimental treatment or dose, activation of the insulin pathway in liver and muscle was not inhibited by S961, showing that its antagonistic effect does not extend to rainbow trout.

Influence of Aloe vera (Aloe barbadensis M.) as an alternative to antibiotics on the growth performance, carcass characteristics and haemato-biochemical indices of broiler chickens

BACKGROUND

Medicinal herbs as classes of additives to poultry feeds have proven to be beneficial due to their antioxidant, antimicrobial and antifungal properties.

OBJECTIVE

A 6-week study was conducted to assess the effects of Aloe vera (Aloe barbadensis M.) as an alternative to antibiotics on the growth performance, carcass traits and haemato-biochemical parameters of broiler chickens.

METHODS

A total of 240 unsexed commercial broiler chickens, 2 weeks old, were randomly allocated to four treatments: T1 (negative control), T2 (positive control, 1 g/L oxytetracycline), T3 (0.5% Aloe vera gel extract) and T4 (1% Aloe vera gel extract) in a completely randomised design (CRD), with six replicates of 10 birds per replicate. The Aloe vera gel extract was administered in fresh drinking water.

RESULTS

The results revealed across all the treatment groups, no significant (p > 0.05) differences were found in terms of growth performance and carcass traits. However, the mortality rate was significantly lower (p < 0.05) in the positive control and the Aloe vera groups compared to the negative control. Total cholesterol, total glucose, and high-density lipoprotein values for the experimental groups (T3 and T4) were significantly (p < 0.05) lower than those of the control groups. The values for red blood cell count, haemoglobin content, mean corpuscular haemoglobin and mean corpuscular haemoglobin concentration for the birds treated with Aloe vera gel were significantly (p < 0.05) higher than those of the control groups.

CONCLUSIONS

It is therefore concluded that the addition of Aloe vera gel extracts up to 1% in the drinking water could replace antibiotics in broiler chickens without any adverse effects on the health status and the performance of birds.

Combining topical dermal infused exosomes with injected calcium hydroxylapatite for enhanced tissue biostimulation

BACKGROUND

Exosome research continues to flourish. Subsequent knowledge surrounding indications, dose-response, safety, efficacy, and the ability to combine exosome treatment as a "skin primer"-for biostimulation modalities such as calcium hydroxylapatite (CaHA), platelet-rich plasma (PRP), and platelet-rich fibrin matrix (PRFM) is growing rapidly. The objective of this study was to develop safe, reproducible methods of improving topical exosome absorption to enhance the quality of skin either by themselves, or in combination with injectable CaHA.

METHODS

Under IRB Approval (International Cell Surgical Society: ICSS-2022-007), 40 patients were enrolled in this study. Twenty patients underwent facial biostimulatory dermal infusion alone, to determine if this method allowed adequate exosome absorption. Five patients underwent facial biostimulatory infusion followed immediately by Dilute CaHA injection (1:1 dilution) to the face. Five patients underwent exosome biostimulatory dermal infusion followed immediately by hyperdilute CaHA (dilution 1:4) injection to the neck. Five patients underwent Facial Dilute CaHA injection (1:1 dilution) alone, without dermal infusion. Five patients underwent neck hyperdilute CaHA injection (1:4 dilution) alone, without dermal infusion. All patients had pretreatment Quantificare 3-D photo-documentation and skin analysis (Quantificare, France). In all patients, the skin was first cleansed with a gentle glycolic acid facial wash (Gregory MD). To induce a "homing inflammatory environment" for the exosomes, sea salt exfoliation was performed (SaltFacial®, SaltMed, Cardiff, CA). A nitric oxide-generating serum (N101 Pneuma Nitric Oxide, Austin, TX) was then applied to act as an enhanced vehicle for absorption. A 3 MHz ultrasound (SaltFacial®, SaltMed, Cardiff, CA) was then utilized to further deepen the absorption of the nitric oxide serum. A topical emulsion containing equal volumes (1.0 cc containing 1 million) of exosomes (Kimera Labs, Miramar, FL), 25 units of botulinum toxin (Xeomin, Merz Aesthetics, Raleigh, NC) and hyaluronic acid (Belatero, Merz Aesthetics, Raleigh, NC) was mixed via back-and-forth propulsion in a 3-cc syringe. When adequately mixed, the emulsion was then applied to the treatment areas. The cavitating ultrasound was then used to aid in the absorption of the emulsion. The patients were then treated with high-intensity LED therapy (SaltFacial®, SaltMed, Cardiff, CA), utilizing the collagen restoration preset program of combination red (660 nm) near-infrared (930 nm) wavelength for 20 min. Post-treatment Quantificare analysis was performed at 15 and 30 days after treatment.

RESULTS

Without exception, all dermal infusion alone and CaHA injection alone patients showed an improvement in the tone, quality, and texture of their skin. Quantificare results showed consistent improvement in wrinkles, pores, skin evenness, improved vascularity, and a reduction in oiliness and unwanted pigment. When employed as a skin primer prior to injections (CaHA), enhanced and more rapid results were seen.

CONCLUSIONS

Biostimulatory dermal infusion can be achieved utilizing topical placental mesenchymal stem cell-derived exosomes. These exosomes can be used alone, or mixed with ancillary ingredients such as botulinum toxin, hyaluronic acid dermal filler, and CaHA to customize and personalize treatments based upon individual patient needs. Topical absorption is enhanced with sea salt exfoliation, a topical nitric oxide-generating serum, and 3 MHz cavitating ultrasound. Post-absorption activity is enhanced with high-intensity LED treatment. The addition of CaHA injections after the topical exosome "priming of the skin" yielded enhanced skin quality faster than exosomes or CaHA alone.

Metrology in health: challenges and solutions in infusion therapy and diagnostics

The significance of Metrology in infusion therapy and diagnostics, both critical in health care safety and quality, is discussed in this article. Although infusion therapy is the most used form of drug administration, infusion errors are often made with reported dramatic effects in different applications, especially in neonatology. Adverse incidents, morbidity, and mortality have often been traced back to poor or inaccurate dosing. For critical infusion applications to vulnerable patients, well-controlled medication administration might be accomplished by improved dosing accuracy, traceable measurement of volume, flow, and pressure in existing drug delivery devices and in-line sensors operating at very low flow rates. To this end, the contribution of recently upgraded metrological infrastructures in European Metrology Institutes to a safer infusion therapy in health care is described in detail. Diagnostics, on the other hand is a sector characterized by rapid developments further triggered recently by the necessity for the management and prevention of infectious diseases like COVID-19. In this context, the impact of metrology in future large-scale commercialization of next generation diagnostics (e.g., point-of-care) is highlighted. Moreover, the latest contributions of Metrology in the development of traceable testing methods and protocols to ensure the sensitivity and accuracy of these devices are described.

Unexpected dosing errors due to air bubbles in infusion lines with and without air filters

The effect of the presence of an air bubble, inside an infusion line, on the time (Tnew) needed for a new medication to reach the patient after a syringe exchange was studied in this paper. If an air bubble escapes through an air filter, then a sudden drop in pressure occurs, causing a relaxation of the compressible part of the syringe, followed by a gradual restoration of the flow rate in the line. We modeled this phenomenon mathematically and measured it experimentally in vitro. In an example with a pump flow rate of 5 mL/h and an air bubble of 1 cm length inside an infusion line (diameter 1 mm) with an air filter, both theory and experiment yield an additional increase of at least 600% in delay time if a naive estimate (based on the size of the bubble alone) is replaced by a more realistic estimate incorporating compressibility. Furthermore, we show that an air bubble in a line without air filter may increase Tnew by a factor 2, depending on the initial position of the air bubble. We conclude that an air bubble in an infusion line causes delays that may not be expected by health care professionals.

Pushing the agenda for intravenous push administration in outpatient parenteral antimicrobial therapy

Intravenous push (IVP) antimicrobial administration refers to rapid bolus infusion of medication. This drug delivery method offers improved patient convenience, superior patient and nursing satisfaction, and cost savings when used in outpatient parenteral antimicrobial therapy (OPAT). Antimicrobial agents must demonstrate optimal physiochemical and pharmacologic characteristics, as well as sufficient syringe stability, to be administered in this manner. Additionally, impacts on medication tolerability, patient safety, and effectiveness must be considered. This narrative review summarizes the available data and practical implications of IVP administration of antimicrobials in the OPAT setting.

The role of flumazenil in generalised anxiety disorder: a pilot naturalistic open-label study with a focus on treatment resistance

Background

Anxiety disorders are highly prevalent and chronic disorders with treatment resistance to current pharmacotherapies occurring in approximately one in three patients. It has been postulated that flumazenil (FMZ) is efficacious in the management of anxiety disorders via the removal of α₄β2δ gamma-aminobutyric acid A receptors.

Objective

To assess the safety and feasibility of continuous low-dose FMZ infusions for the management of generalised anxiety disorder (GAD) and collect preliminary efficacy data.

Design

Uncontrolled, open-label pilot study.

Method

Participants had a primary diagnosis of generalised anxiety disorder (GAD) and received two consecutive subcutaneous continuous low-dose FMZ infusions. Each infusion contained 16 mg of FMZ and was delivered over 96 ± 19.2 h. The total dose of FMZ delivered was 32 mg over approximately 8 days. Sodium valproate was given to participants at risk of seizure. The primary outcome was the change in stress and anxiety subscale scores on the Depression Anxiety Stress Scale-21 between baseline, day 8, and day 28.

Results

Nine participants with a primary diagnosis of GAD were treated with subcutaneous continuous low-dose FMZ infusions; seven participants met the criteria for treatment resistance. There was a significant decrease in anxiety and stress between baseline and day 8 and baseline and day 28. There was also a significant improvement in subjective sleep quality from baseline to day 28 measured by the Jenkins Sleep Scale. No serious adverse events occurred.

Conclusion

This study presents preliminary results for subcutaneous continuous low-dose FMZ's effectiveness and safety in GAD. The findings suggest that it is a safe, well-tolerated, and feasible treatment option in this group of patients. Future randomised control trials are needed in this field to determine the efficacy of this treatment.

Intermittent urethral infusion of dimethylsulfoxide for urethral amyloidosis: a case report and literature review

Urethral amyloidosis (UA) is a very rare condition. We here report the case of a 63-year-old male patient who was admitted to our outpatient department due to aggravating dysuria, frequent urination, pain during intercourse, and a gradually enlarging mass at the ostium of his urethra, which he first notice one year earlier. Pathological tissue biopsy of urethral ostium mass confirmed UA. Intermittent urethra infusion of dimethyl sulfoxide was performed and the treatment effect is satisfactory.

Infusions and Essential Oils - Biological Evaluation, Statistical Principal Component and Hierarchial Cluster Analyses

Origanum onites L. of Lamiaceae, is used as a culinary spice and herbal tea; also for its antioxidant, antimicrobial effects among other activities and effects. This research aims to examine the in vitro antimicrobial and antioxidant activities of the infusions and the essential oils (EOs) obtained using different conditions from the aerial parts of the processed and raw of O. onites herbal material. The EOs from O. onites were distilled at different times and characterized both by GC-FID and GC/MS systems. The resulting main compounds were identified as carvacrol (65.5-91 %), linalool (0.3-17.9 %), γ-terpinene (2.8-4.6 %), and thymol (0.5-1.5 %), respectively. In addition, Origanum infusions were prepared at four different time intervals, where the volatile compounds of the infusions were analysed using the HS-SPME-GC/MS system. Statistical Principal Component (PCA) and Hierarchical Cluster Analyses (HCA) tools were used to demonstrate the composition variations on different times for O. onites infusion and EO samples.

Is there an association between 30-day mortality and adrenaline infusion rates in post-ROSC patients? A retrospective observational analysis

Introduction

Revised guidelines for the management of cardiac arrest have placed greater emphasis on early defibrillation and closed chest compressions; subsequently there has been a significant rise in the number of patients gaining a return of spontaneous circulation (ROSC). As a consequence, emergency medical services have realised the importance of therapies delivered during this phase of care. In some Trusts this includes the use of inotropic agents to augment the cardiovascular system and maintain adequate cerebral and coronary perfusion pressures to mitigate the effects of post-cardiac arrest syndrome. Currently, limited evidence exists with regards to the efficacy of such treatments in the pre-hospital phase.

Methods

Retrospective observational analysis of out-of-hospital cardiac arrest patients who received an adrenaline infusion by critical care paramedics. Infusion rates, time of call (ToC) to ROSC and 30-day mortality were compared.

Results

Over a 2-year period, 202 patients were recorded as having an adrenaline infusion commenced. Of these, 25 were excluded as they did not meet criteria or had incomplete data and 22 were excluded as the infusion was stopped at scene; 155 patients were admitted to hospital. There were no survivors in the non-shockable group and three survivors in the shockable group at 30 days. A rare events analysis found no relationship between infusion rate, ToC to ROSC and 30-day mortality (Wald chi2, 1.37).

Conclusion

Commencement of adrenaline infusions in post-ROSC was associated with significant 30-day mortality, especially in non-shockable rhythms. Further research is needed to elucidate whether this intervention has any benefit in the post-ROSC patient.

Pancreatic intra-arterial infusion chemotherapy for the treatment of patients with advanced pancreatic carcinoma: A pilot study

Objective

To preliminarily evaluate the efficacy and safety of pancreatic intra-arterial infusion chemotherapy (PAIC) with nab-paclitaxel in patients with advanced pancreatic carcinoma.

Methods

Fifteen patients with advanced pancreatic carcinoma received monthly, inpatient, 3-h, continuous PAIC of nab-paclitaxel at 180 mg/m², combined with 60 mg oral tegafur gimeracil oteracil potassium capsule for 2 weeks. The therapeutic courses were repeated every 4 weeks. All patients had a preliminary diagnosis based on clinical symptoms, imaging data (computed tomography or magnetic resonance imaging or positron emission tomography/computed tomography), and tumor markers. The adverse effects, clinical benefit response (CBR), objective response rate (ORR), median progression free survival (mPFS), and median overall survival (mOS) were monitored.

Results

Fifteen patients with advanced pancreatic carcinoma were enrolled in this study, including 10 male and 5 female patients. The mean age at the time of treatment was 66.3 years (53-84 years). A total of 49 cycles of PAIC (mean = 3.27 cycles/patient) were performed. The most common treatment-related toxicities were alopecia, diarrhea, and nausea/vomiting. No procedure-related complications were observed. The longest overall survival observed was 22 months and the maximum number of treatments for the same patient was six cycles. PAIC contributed a high rate (13/15 [86.67%]) and fast (10/15 [66.67%]) easement of pain, with apparent symptom relief within 24 h, especially local pain symptom. The pain anesis rate was 13 (86.67%). CBR was achieved in 13 (86.67%) patients (95%CI [59.54,98.34]). ORR was achieved in four (26.67%) patients (95%CI [7.79,55.10]). Disease Control Rate was achieved in 14 (93.33%) patients. The mPFS was 5.22 months (interquartile range [IQR], 4.27-7.85 months). The mOS was 8.97 months (IQR, 5.65-13.70 months).

Conclusions

In this study, the dose of the chemotherapeutics and the schedule of the transcatheter pancreatic arterial chemotherapy perfusion were shown to be safe, well-tolerated, and effective for the relief of clinical symptoms and CBR. These advantages can quickly establish the treatment belief and improve patient quality of life. This regimen requires further investigation in patients with advanced pancreatic carcinoma.

Volatile Fingerprinting and Sensory Profiles of Coffee Cascara Teas Produced in Latin American Countries

Coffee is one of the most produced and consumed food products worldwide. Its production generates a large amount of byproducts with bioactive potential, like the fruit skin and pulp, popularly called cascara. This study aimed to evaluate the volatile and sensory profiles and the consumption potential of commercial Coffea arabica cascara teas by Rio de Janeiro consumers. Analyses of volatile organic compounds in unfermented (n = 2) and fermented (n = 4) cascara tea infusions were performed by GC-MS. RATA and acceptance sensory tests were performed with untrained assessors (n = 100). Fifty-three volatile organic compounds distributed in 9 classes were identified in different samples. Aldehydes, acids, alcohols, esters, and ketones prevailed in order of abundance. With mild intensity, the most cited aroma and flavor attributes were sweet, herbal, woody, prune, fruity, honey, toasted maté and black tea for unfermented teas. For the fermented teas, sweet, woody, black tea, prune, herbal, citric, fruity, honey, raisin, peach, toasted maté, tamarind, and hibiscus were rated as intense. A good association between the attributes selected by the assessors and the volatile compounds was observed. Unfermented teas, with a mild flavor and traditional characteristics, showed better mean acceptance (6.0−5.9 points) when compared to fermented teas (6.0−5.3 points), with exotic and complex attributes. These were well accepted (>8.0 points) by only about 20% of the assessors, a niche of consumers that appreciate gourmet foods.

Same Day Infusion of Iron Therapy Is Associated With No Increased Risk for Adverse Events Among Patients Receiving Biological Infusions for Inflammatory Bowel Disease

GOALS

The goal of this study was to compare the relative safety of administering iron infusions on the same day as intravenous (IV) biological therapy to the administration of these treatments on different days in patients with inflammatory bowel disease (IBD).

BACKGROUND

IV iron therapy is often required in patients with IBD. Many patients with IBD who receive IV iron therapy in the outpatient setting also receive biological infusion therapy for treatment of their IBD.

STUDY

Patients with IBD who received IV iron therapy at a single infusion center were included. We compared documented infusion-related reactions in patients with patients receiving an iron infusion on the same day as their biological infusion to those who received their iron infusion on a different day.

RESULTS

Among 481 patients, 129 received an iron infusion on the same day as a biologic infusion. There was no significant difference in the incidence of infusion reaction when comparing patients who received biological infusion therapy in the same session as the iron infusion to those patients who received a biological infusion on a different day (5% vs. 7%, P =0.246) or any IBD-related therapy (5% vs. 8%, P =0.206).

CONCLUSIONS

The frequency and type of infusion reactions in patients receiving IV iron therapy on the same day after IV therapy with biologics was not increased compared with patients who received a biological infusion on a different day. A sequential infusion of biological therapy followed by IV iron therapy may be a safe and cost-effective approach.

Novel isochoric impregnation to develop high-quality and nutritionally fortified plant materials (apples and sweet potatoes)

Isochoric impregnation was explored as a novel pressure-assisted infusion technique to fortify plant materials with bioactive compounds. Apple and potato cylinders were impregnated with a sucrose solution containing 4% ascorbic acid (AA) while freezing under isochoric conditions. Isochoric impregnation resulted in greater infusion of AA compared to infusion at atmospheric pressure, which demonstrated the feasibility of this impregnation technology. Processing temperatures (-3°C and -5°C) and processing times (1, 3, and 5 h) significantly affected the AA infusion. The AA content values ranged from 446 to 516 mg/100 g for apples and 322 to 831 mg/100 g for sweet potatoes under isochoric conditions. For both plant materials, isochoric impregnation at -3°C did not cause major changes in texture and microstructure of the biological tissues. These results indicated that isochoric impregnation of solid foods could be a feasible technology for infusion of bioactive compounds without significantly altering their matrix. PRACTICAL APPLICATION: The findings of this study showed that the use of isochoric impregnation as a fortification technique is a promising way to develop fresh-like and value-added products with improved nutrition during preservation at subfreezing temperatures.

Are Opioid Infusions Used Inappropriately at End of Life? Results From a Quality/Safety Project

CONTEXT

Opioid continuous infusions are commonly used for end-of-life (EOL) symptoms in hospital settings. However, prescribing practices vary, and even the recent literature contains conflicting protocols and guidelines for best practice.

OBJECTIVES

To determine the prevalence of potentially inappropriate opioid infusion use for EOL comfort care at an academic medical center, and determine if inappropriate use is associated with distress.

METHODS

Through literature review and iterative interdisciplinary discussion, we defined three criteria for "potentially inappropriate" infusion use. We conducted a retrospective, observational study of inpatients who died over six months, abstracting demographics, opioid use patterns, survival time, palliative care (PC) involvement, and evidence of patient/caregiver/staff distress from the electronic medical record.

RESULTS

We identified 193 decedents who received opioid infusions for EOL comfort care. Forty-four percent received opioid infusions that were classified as "potentially inappropriate." Insufficient use of as-needed intravenous opioid boluses and use of opioid infusions in opioid-naïve patients were the most common problems observed. Potentially inappropriate infusions were associated with more frequent patient (24% vs. 2%; P < 0.001) and staff distress (10% vs. 2%; P = 0.02) and were less common when PC provided medication recommendations (20% vs. 50%; P < 0.001).

CONCLUSION

Potentially inappropriate opioid infusions are prevalent at our hospital, an academic medical center with an active PC team and existing contracts for in-hospital hospice care. Furthermore, potentially inappropriate opioid infusions are associated with increased patient and staff distress. We are developing an interdisciplinary intervention to address this safety issue.

Pharmacokinetics of Levonorgestrel in Rat and Minipig and Pharmacokinetics of Etonogestrel in Rat Following Various Administration Routes

1. The objective of these studies was to determine the pharmacokinetics of levonorgestrel and etonogestrel in Sprague-Dawley rat or Göttingen minipig following various administration routes.2. Four sequential crossover studies were conducted: Study 1 administered levonorgestrel 30 µg intravenously and intradermally in four minipigs; Study 2 administered levonorgestrel 30 µg intravenously in 12 rats; Study 3 administered levonorgestrel 60 µg intravenously and subcutaneously in 12 rats; and Study 4 administered etonogestrel 30 µg intravenously in 12 rats. Samples were quantified using liquid chromatography-tandem mass spectrometry and pharmacokinetic parameters were estimated via noncompartmental analysis.3. C_max and AUC_inf for etonogestrel and levonorgestrel were similar following 30 µg intravenous bolus in rat, suggesting comparable pharmacokinetics. Levonorgestrel exposure was dose-proportional in rats, based on two-fold higher AUC_inf following levonorgestrel 60 versus 30 µg. Bioavailability of intradermal and subcutaneous levonorgestrel was 97.7% (Study 1) and 90.3% (Study 3), respectively. The minipig levonorgestrel clearance was 21.5 L/hr, which was about 10-fold higher than both the rat levonorgestrel (range: 0.985 to 1.45 L/hr) and etonogestrel clearance (range: 0.803 to 0.968 L/hr).4. These studies contribute to the gap in knowledge of nonclinical levonorgestrel and etonogestrel pharmacokinetics, which is necessary for ongoing development of long-acting reversible contraceptives.

Cardiac events among patients with sarcoma treated with doxorubicin by method of infusion: A real-world database study

BACKGROUND

Administration of doxorubicin by continuous intravenous (CIV) infusion, versus bolus (BOL) administration, has been proposed to mitigate the risk of cardiac events. This study used real-world data to explore the association between mode of doxorubicin administration and duration of treatment, time-to-treatment failure (TTF), and cardiac events.

METHODS

Occurrence of cardiac events after initiation of BOL versus CIV doxorubicin for sarcoma in the International Business Machines MarketScan claims database were compared. Duration of doxorubicin treatment, TTF, and time-to-first-cardiac event (TCE) were evaluated using Kaplan-Meier method and unadjusted and adjusted Cox regression models.

RESULTS

A total of 196 patients were included in the BOL group and 399 in the CIV group. In unadjusted analyses, there were significant differences between BOL versus CIV for duration of doxorubicin treatment (median 1.4 vs. 2.1 months, p = .002), TTF (median 8.8 vs. 5.6 months, p = .002), and TCE (medians not reached, p = .03). Adjusting for baseline covariates, only TTF remained significant (hazard ratio: 0.71, 95% confidence interval 0.59-0.86, p = .0004), favoring BOL.

CONCLUSIONS

While the risk of cardiac complications was higher with BOL in unadjusted analysis, the risk was no longer present in the adjusted analysis. While we cannot draw causal inferences due to the retrospective, nonrandomized study design, these data suggest that replacing BOL with prolonged CIV administration has not been effective as a strategy to mitigate cardiac events, given community standards of oncologic practice.

Evaluation of a Proportional-Integral-Derivative Controller for Hemorrhage Resuscitation Using a Hardware-in-Loop Test Platform

Hemorrhage is a leading cause of preventable death in trauma, which can often be avoided with proper fluid resuscitation. Fluid administration can be cognitive-demanding for medical personnel as the rates and volumes must be personalized to the trauma due to variations in injury severity and overall fluid responsiveness. Thus, automated fluid administration systems are ideal to simplify hemorrhagic shock resuscitation if properly designed for a wide range of hemorrhage scenarios. Here, we highlight the development of a proportional–integral–derivative (PID) controller using a hardware-in-loop test platform. The controller relies only on an input data stream of arterial pressure and a target pressure; the PID controller then outputs infusion rates to stabilize the subject. To evaluate PID controller performance with more than 10 controller metrics, the hardware-in-loop platform allowed for 11 different trauma-relevant hemorrhage scenarios for the controller to resuscitate against. Overall, the two controller configurations performed uniquely for the scenarios, with one reaching the target quicker but often overshooting, while the other rarely overshot the target but failed to reach the target during severe hemorrhage. In conclusion, PID controllers have the potential to simplify hemorrhage resuscitation if properly designed and evaluated, which can be accomplished with the test platform shown here.

Diuretic response to Ringer's solution is normal shortly after awakening from general anaesthesia: a retrospective kinetic analysis

Background

The elimination of Ringer's solution is severely depressed during general anaesthesia, but the degree to which this continues postoperatively is poorly established.

Methods

An intravenous infusion of Ringer's acetate solution 20 ml kg-1 was administered over 60 min in 12 patients undergoing laparoscopic cholecystectomy. Population kinetic analysis was performed based on repeated measurements of blood haemoglobin concentration and urinary excretion over 240 min regardless of when the operations were finished. The analysis contrasted the periods before and after awakening from general anaesthesia and compared them with data from 18 volunteers who received the same fluid at the same rate.

Results

Patients were monitored for approximately 2 h after awakening from general anaesthesia. The rate constant for redistribution of fluid from the extravascular space to the plasma (k21) and the rate constant for urinary excretion (k10) were significantly higher postoperatively than during the surgical period. Computer simulations indicated that urinary excretion after surgery was almost restored to the rate found in the volunteers. In contrast, the redistribution of fluid from the extravascular space to the plasma, which was almost nil during the surgery, showed only limited recovery during the postoperative phase, and was only approximately 10% of the flow rate found in the volunteers. The combination of nearly normalised urinary excretion and lack of adequate return of distributed fluid to the plasma promoted postoperative hypovolaemia.

Conclusion

The kinetic analysis indicates that plasma volume support should be given during the first 2 h after laparoscopic cholecystectomy.

Advancements in Interventional Oncology of the Chest: Transarterial Chemoembolization and Related Therapies

While embolization therapy has been used for many years in the treatment of nonmalignant diseases of the chest, such as pulmonary arteriovenous malformation treatment and bronchial artery embolization for hemorrhage, the application of transarterial techniques to the treatment of chest neoplasms is relatively uncommon. Extrapolating from transarterial chemoembolization techniques used for liver malignancy, investigators have recently sought to expand the indications for transarterial techniques from the control of symptoms such as bleeding to the control of disease progression and potentially survival benefit in patients with malignancies in the chest. This article provides an overview of the current embolotherapy techniques used in the treatment of patients with thoracic malignancies.

[Comparison of the characteristics of NK cells after two different methods of expansion and observation of the clinical efficacy in patients who relapsed post allogeneic hematopoietic stem cell transplantation]

Objective: To explore the differences in the biological effects of different expansion systems on natural killer (NK) cells, as well as the safety and preliminary clinical efficacy in the treatment of patients with recurrence after allogeneic hematopoietic stem cell transplantation (allo-HSCT) . Methods: Peripheral blood cells from healthy donors were stimulated with either CD3 combined with CD52 or K562 feeder cells loaded with IL-21/4-1BB to induce NK cell expansion. Changes in the NK cell phenotype, cytokine secretion, and cytotoxicity before and after expansion were detected. We also evaluated the safety and clinical efficacy of two different expansion strategies for patients received NK infusion. Results: Compared with the CD3/CD52 monoclonal antibody amplification system, the feeder cell expansion group had a higher purity of NK cells and higher expression ratios of NK cell surface activation receptors such as DNAM-1 and NKp30, while inhibitory receptor CTLA-4 expression was low and NKG2D/CD25/CD69/ Trail/PD-1/TIM-3/TIGIT had no statistically significant differences between the groups. Further functional results showed that the expression level of KI67 in NK cells after expansion in the two groups increased significantly, especially in the feeder cell expansion group. Simultaneously, the perforin and granzyme B levels of NK cells in the feeder cell expansion group were significantly higher than in the CD3/CD52 expansion group. A retrospective analysis of eight patients who received monoclonal antibody-expanded NK cell reinfusion and nine patients with trophoblast cell-expanded NK cell reinfusion was done. The disease characteristics of the two groups were comparable, NK cell reinfusion was safe, and there were no obvious adverse reactions. Clinical prognostic results showed that in the CD3/CD52 monoclonal antibody amplification group, the MRD conversion rate was 50% (2/4) , and the feeder cell expansion group was 50% (3/6) . After 5 years of follow-up from allo-HSCT, three patients in the monoclonal antibody expansion group had long-term survival without leukemia, and the remaining five patients had died; two patients died in the feeder cell expansion group, and the other six patients had long-term survival. Six cases had GVHD before NK cell reinfusion, and GVHD did not aggravate or even relieved after NK cell reinfusion. Conclusions: Preliminary results show that the biological characteristics of NK cells with diverse expansion strategies are significantly different, which may affect the clinical prognosis of patients with recurrence or persistent minimal residual disease after HSCT. The two groups of patients treated with NK cells from different expansion strategies had no obvious adverse reactions after NK cell infusion, but efficacy still needs to be further confirmed.

Platelet reactivity and platelet count in women with iron deficiency treated with intravenous iron

Background

Iron deficiency anemia (IDA) and heavy menstrual bleeding are prevalent, interrelated issues impacting over 300 million premenopausal women worldwide. IDA is generally associated with increased platelet counts; however, the effects of IDA and its correction on platelet function in premenopausal women remain unknown.

Objectives

We sought to determine how IDA and intravenous iron affect platelet count and platelet function in premenopausal women.

Methods

Hematologic indices were assessed in a multicenter, retrospective cohort of 231 women repleted with intravenous iron. Pre- and postinfusion blood samples were then obtained from a prospective cohort of 13 women to analyze the effect of intravenous iron on hematologic parameters as well as platelet function with flow cytometry and platelet aggregation assays under physiologic shear.

Results

Following iron replacement, anemia improved, and mean platelet counts decreased by 26.5 and 16.0 K/mm³ in the retrospective and prospective cohorts, respectively. Replacement reduced baseline platelet surface P-selectin levels while enhancing platelet secretory responses to agonists, including collagen-related peptide and ADP. Platelet adhesion and aggregation on collagen under physiologic shear also significantly increased following repletion.

Conclusion

We find that intravenous iron improves anemia while restoring platelet counts and platelet secretory responses in premenopausal women with iron deficiency. Our results suggest that iron deficiency as well as iron replacement can have a range of effects on platelet production and function. Consequently, platelet reactivity profiles should be further examined in women and other groups with IDA where replacement offers a promising means to improve anemia as well as quality of life.