Predicting severe disease in patients diagnosed with seasonal influenza in the emergency department.

Objectives: We sought to develop an evidence-based tool to risk stratify patients diagnosed with seasonal influenza in the emergency department (ED). Methods: We performed a single-center retrospective cohort study of all adult patients diagnosed with influenza in a large tertiary care ED between 2008 and 2018. We evaluated demographics, triage vital signs, chest x-ray and laboratory results obtained in the ED. We used univariate and multivariate statistics to examine the composite primary outcome of death or need for intubation. We validated our findings in patients diagnosed between 2018 and 2020. Results: We collected data from 3128 subjects; 2196 in the derivation cohort and 932 in the validation cohort. Medical comorbidities, multifocal opacities or pleural effusion on chest radiography, older age, elevated respiratory rate, hypoxia, elevated blood urea nitrogen, blood glucose, blood lactate, and red blood cell distribution width were factors associated with intubation or death. We developed the Predicting Intubation in seasonal Influenza Patients diagnosed in the ED (PIIPED) risk-stratification tool from these factors. The PIIPED tool predicted intubation or death with an area under the receiver operating characteristic curve (AUC) of 0.899 in the derivation cohort and 0.895 in the validation cohort. A version of the tool including only factors available at ED triage, before laboratory or radiographic evaluation, exhibited AUC of 0.852 in the derivation cohort and 0.823 in the validation cohort. Conclusion: Clinical findings during an ED visit predict severe outcomes in patients with seasonal influenza. The PIIPED risk stratification tool shows promise but requires prospective validation.

The Epidemiology and Pathogenesis and Treatment of Pseudomonas aeruginosa Infections: An Update.

Pseudomonas aeruginosa is a Gram-negative bacterial pathogen that is a common cause of nosocomial infections, particularly pneumonia, infection in immunocompromised hosts, and in those with structural lung disease such as cystic fibrosis. Epidemiological studies have identified increasing trends of antimicrobial resistance, including multi-drug resistant (MDR) isolates in recent years. P. aeruginosa has several virulence mechanisms that increase its ability to cause severe infections, such as secreted toxins, quorum sensing and biofilm formation. Management of P. aeruginosa infections focuses on prevention when possible, obtaining cultures, and prompt initiation of antimicrobial therapy, occasionally with combination therapy depending on the clinical scenario to ensure activity against P. aeruginosa. Newer anti-pseudomonal antibiotics are available and are increasingly being used in the management of MDR P. aeruginosa.

Decreased Hospital Length of Stay With Early Administration of Oseltamivir in Patients Hospitalized With Influenza.

OBJECTIVE: To evaluate the effects of timely oseltamivir administration in patients hospitalized with seasonal influenza. PATIENTS AND METHODS: We performed a single-center retrospective cohort study for hospitalized patients who tested positive for influenza between December 1, 2010, and July 1, 2014. We compared outcomes for patients who received antivirals within 48 hours of symptoms to those of patients who either received oseltamivir after 48 hours or never received oseltamivir. Hospital length of stay (LOS) and 90-day mortality were compared using Cox regression models. Antiviral administration was analyzed as a time-varying covariate. RESULTS: During the study period, 433 patients were hospitalized with laboratory-confirmed influenza. Of these patients, 146 (33.7%) received oseltamivir within 48 hours of symptoms, 202 (46.7%) received oseltamivir after 48 hours of symptoms, and 85 (19.6%) did not receive antivirals. Baseline characteristics were similar among these patient groups. Receiving oseltamivir within 48 hours was associated with shorter hospital LOS (5.9 days vs 7.2 days; P=.03) but no significant difference in 90-day mortality (13.7% vs 11.5%; P=.51). In a Cox regression analysis, patients who received antivirals within 48 hours had a 50% higher chance of being discharged (hazard ratio, 1.50; 95% CI, 1.14-1.98) on any given day during hospital stay. CONCLUSION: In patients hospitalized with laboratory-confirmed influenza, timely administration of oseltamivir was associated with shorter hospital LOS.

The Degradation Chemistry of Farglitazar and Elucidation of the Oxidative Degradation Mechanisms.

The chemical degradation of farglitazar (1) was investigated using a series of controlled stress testing experiments. Farglitazar drug substance was stressed under acidic, natural pH, basic, and oxidative conditions in solution. In the solid state, the drug substance was stressed with heat, high humidity, and light. Farglitazar was found to be most labile toward oxidative stress. A series of mechanistic experiments are described in which the use of 18O-labelled oxygen demonstrated that oxidative degradation of farglitazar is caused primarily by singlet oxygen formed under thermal conditions. Major degradation products were isolated and fully characterized. Mechanisms for the formation of degradation products are proposed. Drug product tablets were also stressed in the solid state with heat, high humidity, and light. Stressed tablets afforded many of the same degradation products observed during drug substance stress testing, with oxidation again being the predominant degradation pathway. Evidence for the activity of singlet oxygen, formed during thermal stress testing of the solid oral dosage form, is presented. The degradation pathways observed during stress testing matched those observed during long-term stability trials of the drug product.

In silico prediction of pharmaceutical degradation pathways: a benchmarking study.

Zeneth is a new software application capable of predicting degradation products derived from small molecule active pharmaceutical ingredients. This study was aimed at understanding the current status of Zeneth's predictive capabilities and assessing gaps in predictivity. Using data from 27 small molecule drug substances from five pharmaceutical companies, the evolution of Zeneth predictions through knowledge base development since 2009 was evaluated. The experimentally observed degradation products from forced degradation, accelerated, and long-term stability studies were compared to Zeneth predictions. Steady progress in predictive performance was observed as the knowledge bases grew and were refined. Over the course of the development covered within this evaluation, the ability of Zeneth to predict experimentally observed degradants increased from 31% to 54%. In particular, gaps in predictivity were noted in the areas of epimerizations, N-dealkylation of N-alkylheteroaromatic compounds, photochemical decarboxylations, and electrocyclic reactions. The results of this study show that knowledge base development efforts have increased the ability of Zeneth to predict relevant degradation products and aid pharmaceutical research. This study has also provided valuable information to help guide further improvements to Zeneth and its knowledge base.

Power and limitations of daily prognostications of death in the medical ICU for outcomes in the following 6 months.

OBJECTIVES: We tested the power of clinicians' predictions that a medical ICU patient would "die before hospital discharge" for both survival to discharge and for outcomes at 6 months. DESIGN: We restricted our analyses to patients who had been in the medical ICU at least 72 hours and for whom we had follow-up at 6 months after medical ICU admission. For 350 medical ICU patients, on each medical ICU day, we asked their attending physician, fellow, resident, and primary nurse one question-"do you think this patient will die in hospital or survive to be discharged"? We correlated these responses with 6-month outcomes (death and/or Barthel score for survivors). RESULTS: We obtained over 6,000 predictions on 2,271 medical ICU patient-days. Of 350 medical ICU patients who stayed more than 72 hours, 143 patients (41%) had discordant predictions-that is, on the same medical ICU day, at least one provider predicted survival, whereas another predicted death before discharge. As we have shown previously, predictions of "death before discharge" were imperfect-only 104 of 187 of patients with a prediction of death (56%) actually died in hospital. However, this is the central finding of our study, and predictions of death before discharge were much more accurate for 6-month outcomes. Of 120 patients with a corroborated prediction of death before discharge (93%), 112 patients had died within 6 months of medical ICU discharge, and only 4% were functioning with a Barthel score more than 70. In contrast, 67 of 163 patients who did not have any prediction of death before discharge (41%) were alive with Barthel score more than 70 at 6 months. CONCLUSIONS: Fewer than 4% of medical ICU patients who required 72 hours of medical ICU care and had a corroborated prediction of death before discharge were alive at 6 months and functioning with a Barthel score more than 70.

The use of N-methylpyrrolidone as a cosolvent and oxidant in pharmaceutical stress testing.

The use of N-methylpyrrolidone (NMP) as an oxidant and cosolvent in pharmaceutical stress testing (forced degradation) is examined. Various active pharmaceutical ingredients were heated in NMP-water solutions under nitrogen, air, and oxygen and then analyzed by high-performance liquid chromatography, usually with ultraviolet diode array detection and mass spectrometry detection. In some cases, degradation products were isolated and characterized by nuclear magnetic resonance. The NMP-water-air-heat system provided oxidative and hydrolytic degradation products. The observed oxidation products were consistent with products expected from free radical autoxidation, reactions with hydroperoxides, and possibly singlet oxygen. Oxidative and hydrolytic pathways could be distinguished by comparison of the reactions carried out under air/oxygen and nitrogen. In many cases, the oxidation products observed during stress testing were also observed during formal stability studies of drug products. The NMP-water-air-heat stress condition facilitates various oxidative degradation pathways, which are often relevant to drug product on stability. This approach facilitates stability-indicating method development and helps elucidate degradation pathways.

Myth, marula, and elephant: an assessment of voluntary ethanol intoxication of the African elephant (Loxodonta africana) following feeding on the fruit of the marula tree (Sclerocarya birrea).

Africa can stir wild and fanciful notions in the casual visitor; one of these is the tale of inebriated wild elephants. The suggestion that the African elephant (Loxodonta africana) becomes intoxicated from eating the fruit of the marula tree (Sclerocarya birrea) is an attractive, established, and persistent tale. This idea now permeates the African tourist industry, historical travelogues, the popular press, and even scholastic works. Accounts of ethanol inebriation in animals under natural conditions appear mired in folklore. Elephants are attracted to alcohol, but there is no clear evidence of inebriation in the field. Extrapolating from human physiology, a 3,000-kg elephant would require the ingestion of between 10 and 27 L of 7% ethanol in a short period to overtly affect behavior, which is unlikely in the wild. Interpolating from ecological circumstances and assuming rather unrealistically that marula fruit contain 3% ethanol, an elephant feeding normally might attain an ethanol dose of 0.3 g kg(-1), about half that required. Physiological issues to resolve include alcohol dehydrogenase activity and ethanol clearance rates in elephants, as well as values for marula fruit alcohol content. These models were highly biased in favor of inebriation but even so failed to show that elephants can ordinarily become drunk. Such tales, it seems, may result from "humanizing" elephant behavior.