Effects of N-acetylcysteine on the expressions of UCP1 and factors related to thyroid function in visceral adipose tissue of obese adults: a randomized, double-blind clinical trial

BACKGROUND

Evidences have shown that obesity is influenced by various factors, including various hormones such as thyroid hormones and the body's metabolism rate. It seems that practical solutions such as weight loss diets and common drugs can affect these potential disorders. In this study, we investigate one of these common drugs, N-Acetylcysteine (NAC), on expressions of UCP1 and factors related to thyroid function in adults with obesity.

METHODS AND ANALYSIS

The current investigation was carried out as a randomized clinical trial (RCT) including 43 adults with obesity who were potential candidates for bariatric surgery. These individuals were randomly divided into two groups: 600 mg of NAC (n = 22) or placebo (n = 21) for a duration of 8 weeks. Visceral adipose tissue was utilized in the context of bariatric surgery to investigate the gene expression of UCP1 and thyroid function. Polymerase chain reaction (PCR) was performed in duplicate for UCP1, DIO2, DIO3, THRα and β, and 18s RNA (as an internal control) using the provided instructions to investigate the expression of the respective genes.

RESULTS

Our findings revealed that after 8 weeks compared to placebo, NAC caused a significant decrease in the expression of the DIO3 gene as one of the genes related to thyroid function and metabolism. However, regarding other related genes, no statistically significant was found (despite the increase in UCP1, DIO2, and THRα expression and decrease in THRβ expression). In addition, after adjustment of possible confounders, no significant effect was observed on anthropometric factors and serum levels of thyroid hormones.

CONCLUSION

The results of this study indicate that, following an 8-week period, NAC effectively decreases the expression of the DIO3 gene in the visceral fat tissue, in comparison to the placebo.

Locoregional therapy containing surgery in metastatic breast cancer: Systematic review and meta-analysis

INTRODUCTION

The role of locoregional therapy (LRT) containing surgery and systematic therapy in metastatic breast cancer patients remains controversial. This study investigated the effect of LRT in patients who were initially diagnosed with metastatic breast cancer (MBC) on overall survival (OS), locoregional progression-free survival (PFS), and distant systemic PFS.

METHODS

The related keywords were searched in MEDLINE/PubMed, SCOPUS, and Web of Science databases up to August 15th, 2022. Hazard ratios (HR) with 95% confidence intervals (CIs) were pooled by the random-effects model.

RESULTS

Seven articles with 1626 participants compared LRT with only systemic therapy (ST) for patients with de novo MBC. LRT did not improve (p = 0.28) OS compared to ST (HR: 0.83, 95% CI: 0.60, 1.16). LRT significantly improved locoregional PFS outcomes compared to ST (HR: 0.31, 95% CI: 0.15, 0.60, p = 0.001). LRT significantly (p = 0.001) improved OS in patients with solitary bone metastases (HR: 0.48; 95% CI: 0.35-0.67).

CONCLUSION

LRT improves locoregional PFS. Furthermore, LRT improves OS in patients with solitary bone metastases.

The effect of anamorelin (ONO-7643) on cachexia in cancer patients: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cachexia is associated with increased morbidity and mortality rates in patients with cancer. This meta-analysis aims to explore the effect of anamorelin on cancer cachexia markers.

METHODS

We searched MEDLINE/PubMed, SCOPUS, and WOS from their inception until 5 June 2022. A systematic search was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We included trials investigating the effect of anamorelin on body weight, lean body mass, fat mass, insulin-like growth factor 1 (IGF-1), handgrip, quality of life insulin-like growth factor-binding protein 3 (IGFBP-3), and in patients with cancer. A random-effects model was run to pooled results.

RESULTS

Five articles providing 1331 participants were analyzed in this study. Pooled analysis revealed a significant increase in body weight (weighted mean difference (WMD): 1.56 kg, 95% confidence interval (CI): 1.20, 1.92; I2= 0%), lean body mass (WMD: 1.36 kg, 95% CI: 0.85, 1.86; I2= 53.1%), fat mass (WMD: 1.02 kg, 95% CI: 0.51, 1.53; I2= 60.7%), IGF-1 (WMD: 51.16 ng/mL, 95% CI: 41.42, 60.90, I2= 0%), and IGFBP-3 (WMD: 0.43 μg/mL, 95% CI: 0.17, 0.68, I2= 98.6%). Results showed no significant increase in appetite when analysis run on all studies without considering different doses 0.29 (95% CI: -0.30, 0.89, I2= 73.8%), however, there was a significant increase in appetite without heterogeneity and inconsistency 0.59 (95% CI: 0.32, 0.86; I2= 0%) in the 100 mg/day group compared to anamorelin non-user.

CONCLUSIONS

Patients with cancer who receive anamorelin as a treatment for cachexia showed a significant increase in body weight, lean body mass, fat mass, IGF-1, and IGFBP-3.

Tamoxifen use and risk of endometrial cancer in breast cancer patients: A systematic review and dose-response meta-analysis

BACKGROUND

Worse prognosis of endometrial cancers (EC) in tamoxifen-treated women compared to non-tamoxifen-treated women been proposed. The relationship between tamoxifen treatment of breast cancer (BC) and the risk of EC is controversial and there is no agreement between publication results on this issue (the answer to all comments provided in the page 2 of manuscript). The aim of this study is investigation the association between tamoxifen treatment and the risk of EC in patients with BC.

METHODS AND RESULTS

We conducted a comprehensive search with related keywords in MEDLINE/PubMed, SCOPUS, and Web of Science databases until April 16, 2022. Random-effects model (DerSimonian and Laird) was used to pool risk ratios (RRs) with 95% confidence intervals (CIs) of EC. Dose, cumulative dose, and duration-response analysis were performed in linear and non-linear states. Twenty-six studies reported a relation between tamoxifen treatment and risk of EC in patients with BC. Results showed a direct relationship between tamoxifen use and EC (RR: 2.03, 95% CI: 1.68-2.45; I2:76%). By increase the age of participants, the risk of EC was decrease (coef = -.0206), although this was not statistically significant (p = .37). Linear dose-response model indicated a direct significant association between dose and duration use of tamoxifen and EC (dose: exe(b) = 1.019, p = .001; duration: exe(b) = 1.014, p = .001). Non-linear dose-response analysis confirmed linear analysis.

CONCLUSION

This study highlights that tamoxifen use is a significant risk factor related to the incidence of EC in patients with BC.

Prognostic Value of Platelet to Lymphocyte Ratio (PLR) and Neutrophil to Lymphocyte Ratio (NLR) in Patients with Pulmonary Hypertension

Background

Pulmonary hypertension (PH) is a hemodynamic and pathophysiological disease defined by a mean pulmonary artery pressure of ≥20 mm Hg. Pulmonary hypertension severity and prognosis play an essential role in the management of these patients. The aim of this study was to evaluate the prognostic value of platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) in patients with PH referred to Masih Daneshvari Hospital, Tehran, Iran.

Materials and Methods

A total of 61 patients with PH referred to Masih Daneshvari Hospital in Tehran were enrolled. Patients' information such as age, sex, type of PH, echocardiographic data, and blood cell count, including platelet, lymphocyte, and neutrophil count, hemoglobin, and RDW, were collected in each follow-up.

Results

Out of 61 patients with PH, 27 (44.3%) were male, and 34 (55.7%) were female. The mean age of the patients was 43.19 ± 2.25 years. Our results showed that during hospitalization, PLR decreased from 13.2 to 9.7, and NLR also decreased from 4.49 to 3.08. Neither PLR nor NLR was associated with gender. However, both PLR and NLR showed a significant difference between deceased vs. discharged patients and were significantly lower in the patients who died.

Conclusion

Both PLR and NLR decreased during hospitalization in patients with PH, and this decrease was greater in the patients who died, suggesting these indicators as potential prognostic markers for the disease.

Association of vitamin D deficiency with COVID-19 severity and mortality in Iranian people: a prospective observational study

Background

As the coronavirus disease 2019 (COVID-19) pandemic continues to escalate, it is important to identify the prognostic factors related to increased mortality and disease severity. To assess the possible associations of vitamin D level with disease severity and survival, we studied 248 hospitalized COVID-19 patients in a single center in a prospective observational study from October 2020 to May 2021 in Tehran, Iran.

Methods

Patients who had a record of their 25-hydroxyvitamin D level measured in the previous year before testing positive with COVID-19 were included. Serum 25-hydroxyvitamin D level was measured upon admission in COVID-19 patients. The associations between clinical outcomes of patients and 25-hydroxyvitamin D level were assessed by adjusting for potential confounders and estimating a multivariate logistic regression model.

Results

The median (interquartile range) age of patients was 60 years (44–74 years), and 53% were male. The median serum 25-hydroxyvitamin D level prior to admission decreased with increasing COVID-19 severity (P=0.009). Similar findings were obtained when comparing median serum 25-hydroxyvitamin D on admission between moderate and severe patients (P=0.014). A univariate logistic regression model showed that vitamin D deficiency prior to COVID-19 was associated with a significant increase in the odds of mortality (odds ratio, 2.01; P=0.041). The multivariate Cox model showed that vitamin D deficiency on admission was associated with a significant increase in risk for mortality (hazard ratio, 2.35; P=0.019).

Conclusions:

Based on our results, it is likely that deficient vitamin D status is associated with increased mortality in COVID-19 patients. Thus, evaluating vitamin D level in COVID-19 patients is warranted.

Vascular Endothelial Growth Factor as a Predictive and Prognostic Biomarker for Multiple Sclerosis

BACKGROUND

Growing bodies of evidence suggest that angiogenesis plays a crucial role in the development and progression of multiple sclerosis (MS). Vascular endothelial growth factor (VEGF) is one of the key factors involved in angiogenesis. Because of this importance, we investigated the serum levels of VEGF in MS patients according to their clinical phase and subtype of MS in this study.

MATERIAL AND METHODS

This case-control study was done on 47 definite MS patients with the first clinical attack and 47 randomly selected individuals without any underlying inflammatory and autoimmune disease as the control group. The total serum VEGF level was measured from the subject's peripheral blood sample by ELISA during the first and second attacks of MS and 6 months after the first attack in the remission phase as well as the control group. In addition, the correlation between these variables and the influence of gender, age, and duration of the remission phase on such associations was evaluated by using the independent t test and Pearson's correlation coefficient.

RESULTS

There was an increase in the serum level of VEGF in all phases of MS compared with non-MS individuals (p value <0.0001) and a significant correlation between the serum level of VEGF and the interval between first and second attacks (r = -720, p < 0.0001). A higher serum level of VEGF in the first attack leads to higher VEGF levels in the second and sixth mount of remission phases.

CONCLUSION

Rise in the serum VEGF level may be involved in MS's relapsing phases and a shorter remission phase. Therefore, it could be used as a prognostic and predictive biomarker for MS disease.

Associations between systemic inflammation and intestinal permeability with Onodera's prognostic nutritional index in critically ill patients

Background

Malnutrition is a serious condition in critically ill patients. The aim of this study is to evaluate the relationships between the Onodera’s prognostic nutritional index (OPNI) and intestinal permeability and between OPNI and systemic inflammation in critically ill patients.

Methods

This was a cross-sectional study conducted in the general intensive care unit (ICU) of a university-affiliated hospital. A total of 162 patients admitted between May 2018 and December 2019, was included in the study. The OPNI was calculated at admission and categorized as ≤40 or >40. We assessed plasma endotoxin and zonulin concentrations as markers of intestinal permeability as well as serum interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP) as markers of systemic inflammation upon admission under stringent conditions. The relationships between these markers and OPNI were assessed after adjusting for potential confounders through estimation of a binary logistic regression model.

Results

Median (interquartile range) hs-CRP, IL-6 zonulin, and endotoxin were significantly greater in the low OPNI subgroup than in the high OPNI subgroup (all P<0.05). Multivariate analyses showed significant association between serum IL-6 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.64–0.96), serum hs-CRP (OR, 0.77; 95% CI, 0.53–0.92), plasma endotoxin (OR, 0.81; 95% CI, 0.72–0.93), and plasma zonulin (OR, 0.83; 95% CI, 0.75–0.98) levels with OPNI in the overall population.

Conclusions

Our results provide evidence that higher plasma endotoxin, zonulin, IL-6, and hs-CRP levels are associated with progressively lower OPNI in mixed ICU populations, particularly in surgical ICU patients.

Effects of curcuminoids on inflammatory and oxidative stress biomarkers and clinical outcomes in critically ill patients: A randomized double-blind placebo-controlled trial

Experimental studies have suggested the beneficial effects of curcuminoids as natural polyphenols against traumatic brain injury (TBI). The aim of this study was to investigate the effects of supplementation with curcuminoids on inflammatory and oxidative stress biomarkers, clinical outcomes and nutritional status in critically ill patients with TBI. A total of 62 ICU-admitted adult patients with TBI were randomly allocated to receive either a daily dose of 500 mg curcuminoids or matched placebo via enteral nutrition for 7 consecutive days based on stratified block randomization by age and sex. Inflammatory and oxidative stress as well as clinical outcomes and nutritional status of the patients were measured at baseline and at the end of the study. There were no overall group effects regarding to all dependent variables. Compared with baseline, serum levels of IL-6, TNF-α, MCP-1 and CRP were significantly reduced in patients receiving curcuminoids (p < .05) without any significant changes in placebo group; however, changes in the activities of GPx and SOD in serum were not significant between two groups. Moreover, APACHEII and NUTRIC score were significantly improved following curcuminoids consumption in comparison with placebo (p < .05). The findings of this study suggest that short-term supplementation with curcuminoids may have beneficial effects on inflammation, clinical outcomes and nutritional status of critically ill patients with TBI.

Translation and adaptation of the modified NUTRIC score for critically ill patients

BACKGROUND & AIMS

Some critically ill patients are at high nutritional risk, and early identification of these patients is needed to reduce morbidity and mortality related to underfeeding. The Modified NUTrition Risk in Critically ill (mNUTRIC) score is the first nutritional risk assessment tool developed and validated specifically for ICU patients. This study aims to translate and adapt the Modified NUTRIC (mNUTRIC) Score into Persian to facilitate use in Iranian Intensive Care Units and assess its efficiency in a pilot sample.

METHOD

The translation process followed standardized steps: initial translation, synthesis of translations, back -translation to the English language, revision and cultural adaptation of the tool by language specialist and expert committee. A pilot study was conducted on the application of the tool in 46 critically ill patients from three ICUs in Iran hospitals.

RESULTS

The translation and adaptation process generated a feasible version of the mNUTRIC Score in the Persian language.The translated version was easily introduced into Iranian ICUs. The prevalence of patients with a mNUTRIC score of five or more was 43% (n = 46).

CONCLUSION

Translation of mNUTRIC Score from English into Persian, following internationally accepted methodology, has provided the ICU care in Iran with a comprehensive and useful instrument.

Comparison of Modified NUTRIC, NRS-2002, and MUST Scores in Iranian Critically Ill Patients Admitted to Intensive Care Units: A Prospective Cohort Study

BACKGROUND

There are no data on the validity of the modified Nutrition Risk in the Critically Ill (m-NUTRIC)-score and Nutritional Risk Screening 2002 (NRS-2002)-score in Iranian intensive care unit (ICU) patients. The Malnutrition Universal Screening Tool (MUST) is still used in most Iranian ICUs. Our goal was to test the validity of these tools in the Iranian ICU population.

METHODS

The association between nutrition risk scores and outcomes (longer length of stay [LOS], prolonged mechanical ventilation [MV], and 28-day mortality) was assessed using the multivariable logistic regression. The performance of nutrition risk tools to predict 28-day mortality was assessed using the receiver operating characteristic curve. A logistic regression model was used to test the interaction between nutrition risk category, energy adequacy, and 28-day mortality.

RESULTS

Four hundred forty patients were included. Both the m-NUTRIC and NRS-2002 scores were significantly associated with all 3 outcomes (all P < .001). However, no significant association was identified between the MUST and all 3 outcomes (P > .05). The area under the curve for predicting 28-day mortality was 0.806 (95% CI, 0.756-0.851), 0.695 (95% CI, 0.632-0.752), and 0.551 (95% CI, 0.483-0.612) for m-NUTRIC, NRS-2002, and MUST, respectively. Greater energy adequacy was associated with a lower 28-day mortality rate in patients with high m-NUTRIC but not in those with low m-NUTRIC score (P interaction = .015).

CONCLUSION

In the Iranian ICU population, the m-NUTRIC score may be a valid tool for identifying patients who would benefit from more aggressive nutrition therapy.

Relationship Between "Simulated Patient Scenarios and Role-Playing" Method and OSCE Performance in Senior Anesthesiology Residents: A Correlation Assessment Study

BACKGROUND

"Simulated-patient scenarios and role-playing" and OSCE are among the many non-traditional education methods with variable results in different clinical settings.

OBJECTIVES

This cross-sectional study was performed to assess the correlation between the results of these two methods in senior anesthesiology residents, with a special focus on four of the six ACGME core competencies.

METHODS

During two years, senior anesthesiology residents were subject to "simulated patient scenario and role-playing" sessions. Two faculty members took the role of the patient and one of the relatives. An objective checklist with 15 items was prepared to be rated by other department faculty members. Meanwhile, an ordered pattern of OSCE was prepared to cover four core competencies that were more related to this academic process (from a total of six core competencies). The mean and standard deviation of the score of each of the 15 items in the checklist were calculated. The correlation between cumulative checklist scoring results and OSCE exam results was assessed. A P value of less than 0.05 was considered significant.

RESULTS

A total of 40 senior anesthesiology residents, with 344 assessments by faculty members in 40 sessions, were enrolled in the study. The questionnaire's Cronbach's alpha reliability was 0.74. No statistically significant disparity was detected between the results of the two assessment methods, while the results of the two assessments had a significant correlation (two-tailed correlation coefficient = 0.886; P value < 0.001).

CONCLUSIONS

There was an objective relationship between the results of "simulated patient scenario and role-playing" strategies and the results of OSCE exams using an observer-based rating method. Thus, they could be used as surrogates in the assessment of core clinical competencies of senior anesthesiology residents.

Therapeutic effects of supplementation with Curcuminoids in critically ill patients receiving enteral nutrition: a randomized controlled trial protocol

Background

Curcuminoids are dietary polyphenols that can improve health indices through different mechanisms such as anti-inflammatory, antioxidant and immunoregulatory properties. Due to the lack of evidences on the efficacy of curcuminoids in critically ill patients, this study was designed to investigate the effects of short-term curcuminoids supplementation on inflammatory, oxidative stress and adipokine indices as well as nutritional and clinical status in Traumatic Brain Injury (TBI) patients admitted in the Intensive Care Unit (ICU).

Methods

The present trial will be performed in the ICU of Sina and Shohadaye Tajrish hospitals of Tehran, Iran. Sixty-two critically ill patients with TBI will be enrolled based on the eligibility criteria. The patients will be randomly assigned into two groups. For 7 days, they will received either 500 mg curcuminoids in combination with 5 mg piperine or matched placebo. A general questionnaire, consent form as well as NUTRIC, SOFA and APACHEII scoring system and anthropometrics will be assessed at baseline. The inflammatory markers including TNF-α, IL-6, MCP-1 and CRP, oxidative stress indices (GPx and SOD) and adipokines (leptin and adiponetctin) will be measured at baseline and at the end of the study. In addition, dietary intake, concomitant drugs and laboratory tests will be recorded daily.

Discussion

To the best of our knowledge, this is the first clinical trial investigating the effect of curcuminoids supplementation in critically ill patient with TBI. The findings of the present study will provide evidence on the efficacy and safety of curcuminoids in these patients.

Trial registration number

(http://www.irct.ir, identifier: IRCT20180619040151N1), Registration date:18.09.2018.

Coenzyme Q10 supplementation and oxidative stress parameters: a systematic review and meta-analysis of clinical trials

PURPOSE

Oxidative stress (OS) is associated with several chronic complications and diseases. The use of coenzyme Q10 (CoQ10) as an adjuvant treatment with routine clinical therapy against metabolic diseases has shown to be beneficial. However, the impact of CoQ10 as a preventive agent against OS has not been systematically investigated.

METHODS

A systematic literature search was performed using the PubMed, SCOPUS, EMBASE, and Cochrane Library databases to identify randomized clinical trials evaluating the efficacy of CoQ10 supplementation on OS parameters. Standard mean differences and 95% confidence intervals were calculated for net changes in OS parameters using a random-effects model.

RESULTS

Seventeen randomized clinical trials met the eligibility criteria to be included in the meta-analysis. Overall, CoQ10 supplementation was associated with a statistically significant decrease in malondialdehyde (MDA) (SMD - 0.94; 95% CI - 1.46, - 0.41; I² = 87.7%) and a significant increase in total antioxidant capacity (TAC) (SMD 0.67; 95% CI 0.28, 1.07; I² = 74.9%) and superoxide dismutase (SOD) activity (SMD 0.40; 95% CI 1.12, 0.67; I² = 9.6%). The meta-analysis found no statistically significant impact of CoQ10 supplementation on nitric oxide (NO) (SMD - 1.40; 95% CI - 0.12, 1.93; I² = 92.6%), glutathione (GSH) levels (SMD 0.41; 95% CI - 0.09, 0.91; I² = 70.0%), catalase (CAT) activity (SMD 0.36; 95% CI - 0.46, 1.18; I² = 90.0%), or glutathione peroxidase (GPx) activities (SMD - 1.40; 95% CI: - 0.12, 1.93; I² = 92.6%).

CONCLUSION

CoQ10 supplementation, in the tested range of doses, was shown to reduce MDA concentrations, and increase TAC and antioxidant defense system enzymes. However, there were no significant effects of CoQ10 on NO, GSH concentrations, or CAT activity.

Nutritional adequacy in critically ill patients: Result of PNSI study

BACKGROUND & AIMS

Critically ill patients are provided with the intensive care medicine to prevent further complications, including malnutrition, disease progression, and even death. This study was intended to assess nutritional support and its' efficacy in the Intensive Care Units (ICUs) of Iran.

METHODS

This cross-sectional study assessed 50 ICU's patients out of 25 hospitals in the 10 major regions of Iran's health system and was performed using the multistage cluster sampling design. The data were collected from patient's medical records, ICU nursing sheets, patients or their relatives from 2017 to 2018. Nutritional status was investigated by modified NUTRIC score and food frequency checklist.

RESULTS

This study included 1321 ICU patients with the mean age of 54.8 ± 19.97 years, mean mNUTRIC score of 3.4 ± 2.14, and malnutrition rate of 32.6%. The mean time of first feeding was the second day and most of patients (66%) received nutrition support, mainly through enteral (57.2%) or oral (37%) route during ICU stay. The patients received 59.2 ± 37.78 percent of required calorie and 55.5 ± 30.04 percent of required protein. Adequate intake of energy and protein was provided for 16.2% and 10.7% of the patients, respectively. The result of regression analysis showed that the odds ratio of mNUTRIC score was 0.85 (95% confidence interval [CI] = 0.74-0.98) and APACHE II was 0.92 (95%CI = 0.89-0.95) for the prediction of energy deficiency. Nutrition intake was significantly different from patient's nutritional requirements both in terms of energy (p < 0.001) and protein (p < 0.001). Also, mean mNUTRIC score varied notably (p = 0.011) with changing in energy intake, defined as underfeeding, adequate feeding, and overfeeding.

CONCLUSION

The present findings shown that, provided nutritional care for ICU patients is not adequate for their requirements and nutritional status.

Effects of supplementation with curcuminoids on serum adipokines in critically ill patients: a randomized double-blind placebo-controlled trial

Previous studies have shown a beneficial effect of curcuminoids supplementation on serum concentrations of adipokines; however, there are no published studies that have examined this effect among critically ill patients. We aimed to assess the effects of supplementation with curcuminoids on serum concentrations of leptin and adiponectin in critically ill patients with traumatic brain injury (TBI). In this trial, 62 critically ill patients with TBI, aged 18-65 years, were randomly allocated to receive either 500 mg/day curcuminoids (co-administered with 5 mg/day piperine) or matched placebo for 7 days. Patients in both intervention groups received routine treatments for TBI as well as enteral nutrition. Serum concentrations of leptin and adiponectin were measured at baseline and at the end of trial. We found a significant reduction in serum levels of leptin in both curcuminoids (47.1%) and placebo (22.8%) groups; though the magnitude of reduction was greater in the former (p < .05). Supplementation with curcumioinds was not found to alter serum concentrations of adiponectin (p > .05). Supplementation with curcumioinds significantly reduced serum levels of leptin but had no significant effect on adiponectin levels in critically ill patients with TBI. Further clinical trials, particularly those with a long-term period, are needed to confirm our findings.

Effect of Calcium and Vitamin D Co-supplementation on Blood Pressure: A Systematic Review and Meta-Analysis

PURPOSE

Vitamin D and calcium insufficiency has been related to elevated blood pressure (BP) and cardiovascular complications. This systematic review and meta-analysis investigates the effect of calcium and vitamin D co-supplementation on BP.

METHODS

A systematic search was conducted of electronic databases, including Web of Sciences, MEDLINE, Scopus, EMBASE, and the Cochrane Library, along with searches of gray literature and reference lists from included trials. There were no language restrictions, and the databases were searched from inception to October 2019. Randomized controlled trials, using calcium and vitamin D co-supplementation and reporting mean systolic BP and/or diastolic BP (DBP) with SDs, were included in the systematic review. Articles were evaluated independently by 2 researchers based on inclusion and exclusion criteria. A random effects model was conducted to synthesize the data.

FINDINGS

Eight trials were included in the meta-analysis. Meta-analysis of these 8 trials indicated a nonsignificant reduction in systolic BP in the calcium and vitamin D co-supplementation group compared with control (standardized mean difference, -0.23; 95% CI, -0.52 to 0.06). Conversely, there was a statistically significant decrease in DBP (standardized mean difference, -0.29; 95% CI, -0.55 to -0.02). Subgroup analysis suggested that young adults achieve a greater reduction in DBP than other age groups.

IMPLICATIONS

Calcium and vitamin D co-supplementation can modulate DBP and should be investigated more specifically in large, well-designed trials of hypertensive populations. (Clin Ther. 2020;42:XXX-XXX) © 2020 Elsevier HS Journals, Inc.

The Effects of Open and Closed Suction Methods on Occurrence of Ventilator Associated Pneumonia; a Comparative Study

INTRODUCTION

Endotracheal suctioning is a method commonly used to clean airway secretions in patients under mechanical ventilation (MV). This study aimed to compare the effects of open and closed suction methods on the occurrence of ventilator associated pneumonia (VAP).

METHODS

This comparative study was carried out on adult intensive care unit (ICU) patients in need of MV for more than 48 hours, from October 2018 to January 2019. Patients were randomly allocated to either closed tracheal suction system (CTSS) group or open tracheal suction system (OTSS) group. Patients were monitored for developing VAP within 72 hours of intubation and the findings were compared between groups.

RESULTS

120 cases with the mean age of 57.91±19.9 years were randomly divided into two groups (56.7% male). The two groups were similar regarding age (p = 0.492) and sex (p = 0.713) distribution. 22 (18.3%) cases developed VAP (12 (20%) in OSST group and 10 (16.7%) in CSST; p = 0.637). The most prevalent bacterial causes of VAP were Acinetobacter_Baumannii (72.7%), Klebsiella pneumoniae (18.2%), and Methicillin-Resistant Staphylococcus aureus (9.1%), respectively. There was not any significant difference between groups regarding the mean duration of remaining under MV (p = 0.623), mean duration of hospitalization (p = 0.219), frequency of VAP (p = 0.637), and mortality (p = 0.99).

CONCLUSION

It seems that type of endotracheal suction system (OSST vs. CSST) had no effect on occurrence of VAP and other outcomes such as duration of need for MV and ICU stay as well as mortality.

Association of intestinal permeability with admission vitamin D deficiency in patients who are critically ill

Emerging data have led to the hypothesis that vitamin D plays a role in promoting epithelial barrier dysfunction. Therefore, intestinal permeability becomes a significant determiner in the future of patients hospitalized in intensive care unit (ICU). The relationship between vitamin D and intestinal permeability remains unclear in patients who are critically ill. The aim of the study is to document the relationship between the admission vitamin D deficiency and markers of intestinal permeability in the critical care setting. This was a single-center, observational, prospective study in the general ICU of a university-affiliated hospital. A sample of 144 ICU-hospitalized adult patients was recruited between January and May 2018. The admission serum 25-hydroxyvitamin D levels were measured and categorized as <20 and ≥20 ng/dL, respectively. Moreover, the admission plasma endotoxin and zonulin concentrations as markers of intestinal permeability were determined in stringent conditions. The association between markers of intestinal permeability and 25-hydroxyvitamin D levels was assessed adjusting for potential confounders through an estimation of a binary logistic regression model. Our results showed that median plasma endotoxin and zonulin decreased with increasing serum levels of vitamin D categories (p=0.001) in the overall study population. Multivariate binary logistic regression analyses showed a significant association between the plasma endotoxin (OR 0.12, 95% CI 0.03 to 0.52) and zonulin (OR 0.91, 95% CI 0.87 to 0.99) levels with serum levels of vitamin D categories in the overall population. Our finding suggests a relationship between vitamin D deficiency and early alterations in intestinal permeability. Thus, evaluating vitamin D levels in patients who are critically ill may be warranted.

Early diagnosis of skin cancer by ultrasound frequency analysis

The diagnosis of cancer by modern computer tools, at the very first stages of the incident, is a very important issue that has involved many researchers. In the meantime, skin cancer is a great deal of research because many people are involved with it. The purpose of this paper is to introduce an innovative method based on tissue frequency analyzes to obtain the accurate and real-time evaluation of skin cancers. According to the Biological resonance theory, body cells have natural and unique frequencies based on their biological fluctuations, which, if the structure, profile and cellular status change, its frequency also varies. This concept and theory is considered as the basis for analyzing skin tissue health in the proposed method. Reflected ultrasound waves from tissue have been processed and studied based on frequency analysis as a new method for early detection and diagnosis of accurate location and type of skin diseases. The developed algorithm was approved through 400 patients from CRED; its ability to evaluate benign and malignant skin lesions was shown (AUC = 0.959), with comparable clinical precision; as for the selected threshold, sensitivity, and specificity were 93.8% and 97.3%, respectively. Therefore, this method can detect skin malignancy with an accurate, noninvasive and real-time procedure.

Molecular detection of ALS1, ALS3, HWP1 and SAP4 genes in Candida Genus isolated from hospitalized patients in Intensive Care Unit, Tehran, Iran

Candida species are considered as one of the important cause of nosocomial and community infections. Candidacies are fourth caused by septicemia in some countries and possess extra cost to the health care system. The aim of this study was survey the presence of virulence factors associated with various candida geniuses in samples which have been collected from the intensive care unit. In this cross-sectional study, various clinical specimens have been collected from patients which hospitalized in the Intensive Care Unit (ICU) of Milad hospital, Tehran, Iran. The species of candida has been determined by CHROM agar. Finally, adherence factors genes and proteinase gene have been detected by PCR. In this research, 100 samples have been collected from patients that colonized with candida. C. albicans (63%) and C.glabrata (19.4%) are the most identified species, respectively. The species of four specimens have been not detected according to the color of CHROM agar candida medium and two different genus of candida has been isolated from 7 patients. The frequency of Als1, Als3, HWP1 and SAP1 genes among C. albicans was (92%), (94%), (95%) and (88%), respectively. The most detected virulence factor was HWP1 and SAP4 was the lowest one. At least two virulence factors have been detected in 95% of different Candida species that can cause invasive fungal properties. These results are important for infection control committee in the hospital because invasive fungal diseases can make a serious problem for patients that hospitalized in ICU. 

Molecular detection of ALS1, ALS3, HWP1 and SAP4 genes in Candida Genus isolated from hospitalized patients in Intensive Care Unit, Tehran, Iran

Candida species are considered as one of the important cause of nosocomial and community infections. Candidacies are fourth caused by septicemia in some countries and possess extra cost to the health care system. The aim of this study was survey the presence of virulence factors associated with various candida geniuses in samples which have been collected from the intensive care unit. In this cross-sectional study, various clinical specimens have been collected from patients which hospitalized in the Intensive Care Unit (ICU) of Milad hospital, Tehran, Iran. The species of candida has been determined by CHROM agar. Finally, adherence factors genes and proteinase gene have been detected by PCR. In this research, 100 samples have been collected from patients that colonized with candida. C. albicans (63%) and C.glabrata (19.4%) are the most identified species, respectively. The species of four specimens have been not detected according to the color of CHROM agar candida medium and two different genus of candida has been isolated from 7 patients. The frequency of Als1, Als3, HWP1 and SAP1 genes among C. albicans was (92%), (94%), (95%) and (88%), respectively. The most detected virulence factor was HWP1 and SAP4 was the lowest one. At least two virulence factors have been detected in 95% of different Candida species that can cause invasive fungal properties. These results are important for infection control committee in the hospital because invasive fungal diseases can make a serious problem for patients that hospitalized in ICU.

Effects of Early Enteral Glutamine Supplementation on Intestinal Permeability in Critically Ill Patients

Background and aims

Enteral administration of glutamine has been proposed as an effective recovery of intestinal barrier function. This amino acid has a modulating effect on the reducing bacterial translocation, which can influence immune functions of the intestine. The objective was to evaluate the effects of early enteral glutamine supplementation on intestinal permeability in critically ill patients.

Materials and methods

A total of 80 critically ill patients older than 18 years were randomly assigned to one of two groups according to the stratified blocked randomization by age and admission category. Consecutive participants took enteral formula plus 0.3 g/kg/day glutamine powder or enteral formula plus maltodextrin during the ICU stay for a maximum of 10 days. Plasma glutamine, endotoxin, zonulin, and antiendotoxin immunoglobulin (Ig)G/IgM concentrations were measured on days 5 and 10 of intervention.

Results

Out of 80 participants, 36 patients in the glutamine group and 34 patients in the control group were included in the analysis of the outcomes. Enteral glutamine significantly reduced plasma zonulin concentration up to 40% during 10 days. This reduction was significantly greater compared with that of the placebo group (p<0.001). Endotoxin concentration decreased in both groups; this reduction was significantly greater in the glutamine group (p = 0.014). The antiendotoxin IgM and IgG antibody levels increased in the glutamine group but decreased in the control group (p <0.001). There were no significant differences in clinical outcomes between two groups.

Conclusion

Early enteral glutamine supplementation led to a declined intestinal permeability in critically ill patients.

How to cite this article

Shariatpanahi ZV, Eslamian G, Ardehali SH, Baghestani AR. Effects of Early Enteral Glutamine Supplementation on Intestinal Permeability in Critically Ill Patients. Indian J Crit Care Med 2019;23(8):356-362.

Effects of early enteral bovine colostrum supplementation on intestinal permeability in critically ill patients: A randomized, double-blind, placebo-controlled study

OBJECTIVES

In this study we sought to investigate the effect of early enteral bovine colostrum supplementation on intestinal permeability in intensive care unit (ICU)-hospitalized patients.

METHODS

A total of 70 ICU-hospitalized adult patients were randomly assigned to receive a bovine colostrum supplement or placebo according to the stratified blocked randomization by age and admission category. Plasma endotoxin and zonulin concentrations were measured on days 5 and 10 of intervention.

RESULTS

Out of 70 participants, 32 patients in the colostrum group and 30 patients in the control group were included in the final analysis of the outcomes. Plasma endotoxin concentration decreased significantly in the colostrum group on the 10th day (P < 0.05). Furthermore, plasma levels of zonulin reduced in the colostrum group significantly compared with the placebo group (P < 0.001).The incidence of diarrhea was significantly lower in the colostrum group than in the control group (P = 0.02).

CONCLUSIONS

Our results provide evidence that bovine colostrum supplementation may have beneficial effects on intestinal permeability and gastrointestinal complications in ICU-hospitalized patients. Further studies are needed to investigate the exact mechanism of action of these effects.

Modeling of diffuse reflectance of light in heterogeneous biological tissue to analysis of the effects of multiple scattering on reflectance pulse oximetry

Fingertip-type pulse oximeters are popular, but their inconvenience for long-term monitoring in daily life means that other types of wearable pulse oximeters, such as reflectance pulse oximeters, need to be developed. For the purpose of developing reflection pulse oximetry, we have analyzed the light propagation in tissue to calculate and estimate the measured intensities of reflected light using the analytical and numerical solutions of the diffusion approximation equation. The reflectance of light from the biological tissue is investigated from theoretical and experimental perspectives, for light in the visible and near-infrared wavelengths. To establish the model, the calculated curves were compared with the analytical solution (AS) of the diffusion approximation equation in biological tissue. The results validated that the diffusion approximation equation could resolve the heterogeneous advanced tissue and the finite element method (FEM) could offer the simulation with higher efficiency and accuracy. Our aim has been to demonstrate the power of the FEM and AS in modeling of the steady-state diffusion approximation in a heterogeneous medium. Also, experimental data and the Monte Carlo model as a gold standard were used to verify the effectiveness of these methods.

Effect of Vitamin D Supplementation on Procalcitonin as Prognostic Biomarker in Patients with Ventilator Associated Pneumonia Complicated with Vitamin D Deficiency

Ventilator-associated pneumonia (VAP) is a common and serious problem that develops after more than 48 h of mechanical ventilation. Improving the activity of immune system with vitamin D, and its consequent impact on prognostic biomarkers of VAP was studied in the current study. A randomized double blind placebo controlled clinical trial was designed. A total of 46 patients with VAP, who were suffering from vitamin D deficiency, were randomly allocated into the study groups of placebo (n=22) and treatment (n=24) The treatment group received 300,000 units of intramuscular vitamin D. Serum levels of procalcitonin and vitamin D along with SOFA and CPIS scores were determined at baseline and on day 7 after intervention. The mortality rate of patients was also monitored for the succeeding 28 days after the injection. The administration of vitamin D significantly enhanced its levels (P<0.0001) in the treated patients (12.28 ± 8.26) in comparison to placebo group (1.15 ± 1.50). The levels of PCT were significantly decreased (p=0.001) in the treatment group (- 0.02 ± 0.59 ng/mL) compared to that of placebo group (0.68 ± 1.03 ng/mL). However, changes in (SOFA) and CPIS scores were not significantly different between study groups (p=0.63 and p=0.32, respectively). Interestingly, the mortality rate of patients in the treatment group (5/24) was significantly lower (p=0.04) than that of the placebo group (11/22). In conclusion, our results indicate that vitamin D supplementation can significantly reduce the procalcitonin in (VAP) patients, and must be considered as a preventive and/or therapeutic strategy.

Role of Transcranial Doppler Sonography in Diagnosis of Brain Death: A Single Center Study

BACKGROUND

Diagnosis of brain death relies on clinical and electroencephalographic (EEG) criteria. Waiting for 24 hours is mandatory to make definitive diagnosis of the condition in the Iranian protocol. Although it has been previously shown that oscillatory or spiked systolic or reversed diastolic flow patterns in transcranial Doppler sonography (TCD) are associated with faster brain death confirmation, it has not yet been approved in our protocol. Thus, the aim of this study was to assess the applicability of this method to our organ donation system.

MATERIALS AND METHODS

This study was performed in Masih Daneshvari Organ Procurement Unit from July to December 2009. TCD from the middle cerebral and basilar arteries was attempted in 35 patients who fulfilled the clinical and EEG criteria for brain death. Extensive skull defects and hypotension (blood pressure < 80 mmHg) were the exclusion criteria. Examinations were made for about 30 minutes via temporal and occipital windows as soon as possible after diagnosis of brain death.

RESULTS

The mean age of cases was 31.9±14.78 years and 18 (51.4%) were males. The most prevalent cause of brain death was trauma (in 19 or 54.2% of cases). We were unable to detect any intracranial artery in 2 (5.7%) cases. There were no false negative or false positive results in the remaining ones. Detected ultrasonic patterns of cerebral vascular flow were systolic spike and oscillating signal in 29 (87.9%) and 4 (12.1%) donors, respectively.

CONCLUSION

Our study showed that TCD results in brain dead cases were concordant with clinical and EEG criteria. Therefore, TCD, as a confirmatory test, can be applied for rapid diagnosis of brain death.

Stress Among Iranian Nurses in Critical Wards

BACKGROUND

Stress has been recognized as a significant psychosocial and physiologic component in educational and practical processes.

OBJECTIVES

The purpose of present study was to survey stress among Iranian nurses in critical wards.

PATIENTS AND METHODS

In this cross-sectional study, 3643 anonymous questionnaires were disseminated among nurses in different hospitals in Tehran, Iran, by utilizing multistage random sampling. The questionnaire consisted of two sections: demographic characteristics and a 22-item list on a five-point Likert scale. The association of variables with stress was evaluated using hierarchical logistic regression.

RESULTS

A total of 3043 completed questionnaires were completed and returned (response rate, 83.53%). Age (> 33 years, 1571 (51.63%); < 33 years old, 1472 (48.37%)), marital status (single, 188 (6.18%); married, 2685 (88.24%); and widow, 170 (5.59%)), working shift (morning, 605 (19.88%); evening, 631 (20.74%); night, 603 (19.82%); and rotation, 1204 (39.57%)), and the years of experience of nurses (1 - 5 years, 413 (13.57%); 6 - 10 years, 589 (19.36%); 11 - 15 years, 832 (27.34%); 16 - 20 years, 758 (24.91%); and 21-25 years, 451 (14.82%)) had significant association with the level of stress (P < 0.05 for all parameters). However, sex (male, 937 (30.79%); and female, 2106 (69.21%)), education (associate, 444 (14.59%); baccalaureate, 2250 (73.94%); and master, 349 (11.47%)), and body mass index (> 24.6 kg/m(2), 2514 (49.75%); and < 24.6 kg/m(2), 1529 (50.25%)) showed no significant association with the level of stress (P > 0.05 for all parameters).

CONCLUSIONS

Considering the personal and background characteristics of personnel and understanding their association with stress and stressful situations encompasses the ability to persevere and adapt to contextual stressors.

Use of Bispectral Index Score for Interventional Bronchoscopy Procedures

BACKGROUND

Interventional bronchoscopic procedures are novel diagnostic and therapeutic methods in pulmonology, which may be unpleasant and dangerous to the patients; therefore, sedation and in some cases general anaesthesia are recommended. But adjusting the level of sedation is a challenge. In this study we intended to define a range of bispectral index (BIS) score suitable for these procedures.

MATERIALS AND METHODS

All patients referred to our interventional bronchoscopy unit were enrolled in the study. Sedation was induced using midazolam, sufentanil, and propofol with the patient breathing spontaneously. The target level of sedation was to reach a Ramsay sedation score of 3 and patient tolerance in performing the procedure. The BIS score was recorded at baseline and every five minutes thereafter. Correlation between different BIS values, propofol dosage, duration of procedure, and awakening time was evaluated.

RESULTS

A total of 70 patients were enrolled in this study with a mean age of 50± 16 years and 34 (48.6%) of them were males. The mean baseline BIS was 96±3.7, and the mean time to reach "stable BIS" ("stable time") was 7.9±6 minutes. The mean "stable BIS" was 52±13.5 and 70% of patients had stable BIS between 40 and 60.

CONCLUSION

BIS is a useful objective tool for evaluation of sedation, which can guide us through bronchoscopy and related procedures. According to our observational study, reaching the mean BIS level of 52±13.5 is required to prevent complications and ensure feasibility of the procedure.

Invasive candidiasis in intensive care unit; consensus statement from an Iranian panel of experts, July 2013

Invasive candidiasis (IC) is associated with high mortality in intensive care unit (ICU) patients. Timely diagnosis of this potentially fatal condition remains a challenge; on the other hand, the criteria for initiating empirical antifungal therapy in critically ill patients are not well defined in different patient population and ICU settings. Alongside the international guidelines, reaching regional and local consensus on diagnosis and management of IC in ICU setting is essential. This report summarizes our present status of IC management in ICU, considered by a group of Iranian experts in the fields of intensive care and infectious diseases. A round table of 17 experts was held to review the available data and discuss the optimal treatment strategies for IC in critical care setting. Comparative published data on the management of IC were analytically reviewed and the commonly asked questions about the management of IC in ICU were isolated. These questions were interactively discussed by the panel and audience responses were taken to consolidate point-to-point agreement with the panel arriving at consensus in many instances. The responses indicated that patients’ risk stratification, clinical discretion, fungal diagnostic techniques and the empirical therapy for IC are likely to save more patients. Treatment options were recommended to be based on the disease severity, prior azole exposure, and the presence of suspected azole-resistant Candida species. This report was reviewed, edited and discussed by all participants to include further evidence-based insights. The panel expects such endorsed recommendations to be soon formulated for implementation across the country.