Investigating the Prevalence of Contrast-associated Nephropathy and the Related Risk Factors in Patients Undergoing Elective Angioplasty.

Objective: Contrast-associated nephropathy (CAN) is a sudden decrease in kidney function following contrast media administration. Considering the importance of CAN in the patient's outcome and the high prevalence of this complication in cardiac catheterizing centers, this study was designed to investigate the prevalence and the related risk factors of CAN in patients undergoing angioplasty in Chamran Heart Hospital, Isfahan, Iran, from January 2022 to June 2022. Methods: The inclusion criteria were adult patients above 18 admitted for elective percutaneous coronary intervention (PCI). Patient demographic information, underlying diseases and medications, dehydration state, type and amount of contrast media, and serum levels of blood urea nitrogen (BUN) and serum creatinine (SrCr) at 24 and 72 h after contrast injection were all recorded. Findings: Out of 340, 128 patients developed CAN after PCI, giving an incidence of 37.64%. Adjusted analysis showed a significant relation between age over 65, the amount of contrast media administered, and the use of furosemide with the incidence of CAN. However, adjusted logistic regression analysis failed to show any significant relationship between the risk of CAN and the hydration status of the patients at 24 and 48 h after receiving contrast media as diagnosed by BUN/SrCr >20. Conclusion: The prevalence of CAN in this study was higher than in other studies since this high-risk population was under risk factors such as arterial injection of contrast material and a higher amount of contrast material administration. In addition, advanced age, volume of contrast material, and previous or concurrent furosemide administration were associated with an increased risk of CAN.

Lactate Dehydrogenase to Albumin ratio as a Predictive Factor of COVID-19 Patients' Outcome; a Cross-sectional Study.

Introduction:  Despite the increasing vaccination coverage, COVID-19 is still a concern. With the limited health care capacity, early risk stratification is crucial to identify patients who should be prioritized for optimal management. The present study investigates whether on-admission lactate dehydrogenase to albumin ratio (LAR) can be used to predict COVID-19 outcomes. Methods: This retrospective cross-sectional study evaluated hospitalized COVID-19 patients in an academic referral center in Iran from May 2020 to October 2020. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the value of LAR in the prediction of mortality. The Yuden index was used to find the optimal cut-off of LAR to distinguish severity. Patients were classified into three groups (LAR tertiles), first: LAR<101.46, second: 101.46≤LAR< 148.78, and third group: LAR≥148.78. Logistic regression analysis was used to identify the association between tertiles of LAR, as well as the relationship between each one-unit increase in LAR with mortality and ICU admission in three models, based on potential confounding variables. Results: A total of 477 patients were included. Among all patients, 100 patients (21%) died, and 121 patients (25.4%) were admitted to intensive care unit (ICU). In the third group, the risk of mortality and ICU admission increased 7.78 times (OR=7.78, CI: 3.95-15.26; p <0.0001) and 4.49 times (OR=4.49, CI: 2.01-9.04; p <0.0001), respectively, compared to the first group. The AUC of LAR for prediction of mortality was 0.768 (95% CI 0.69- 0.81). LAR ≥ 136, with the sensitivity and specificity of 72% (95%CI: 62.1-80.5) and 70% (95%CI: 64.9-74.4), respectively, was the optimal cut-off value for predicting mortality. Conclusion: High LAR was associated with higher odds of COVID-19 mortality, ICU admission, and length of hospitalization. On-admission LAR levels might help health care workers identify critical patients early on.

High dose melatonin as an adjuvant therapy in intubated patients with COVID-19: A randomized clinical trial.

Objective: In the COVID-19 pandemic, the SARS-CoV-2 virus has infected millions of people worldwide. Mortality primarily results from the inflammation state and its complications. High-dose melatonin has been established as an anti-inflammatory agent. This study evaluated high-dose melatonin as an adjuvant therapy in critically ill patients with SARS-CoV-2 infection. Methods: We conducted a double-blinded, randomized clinical trial of 21 mg of melatonin per day compared with a placebo in 67 patients with COVID-19. We enrolled patients older than 18 years of age with documented SARS-CoV-2 infection, who were admitted to the intensive care unit and underwent invasive mechanical ventilation. Administration of melatonin and placebo through a nasogastric tube continued for 5 days. The main outcomes were mortality rate, duration of mechanical ventilation, changes in oxygenation indices, and C-reactive protein (CRP) levels. Results: No significant differences were observed in mortality and duration of mechanical ventilation between the control and intervention groups. After 5 days of the intervention, the mean (±standard deviation) CRP and platelet count were 47.28 (±38.86) mg/L and 195.73 (±87.13) × 1000/µL, respectively, in the intervention group and 75.52 (±48.02) mg/L and 149.62 (±68.03) × 1000/µL, respectively, in the control group (P < 0.05). Conclusion: High-dose melatonin in intubated patients with COVID-19 was associated with a decrease in CRP levels. However, this treatment did not apparently affect patient outcomes.

Possible effects of melatonin on reperfusion injury following coronary artery bypass graft surgery.

BACKGROUND: Although coronary artery bypass graft (CABG) surgery has been reported to be one of the most effective internentions in terms of myocardial salvage, reperfusion itself can cause additional damage to the myocardium. Since there is strong evidence that free radicals are the principal offender in ischemia-reperfusion (I/R) injury, it has been suggested that treatment with antioxidant agents can be protective. Investigations have shown that melatonin secretion is partially disturbed in CABG patients. The aim of this study was to evaluate the protective effect of melatonin as an antioxidant agent on I/R injury. METHODS: 164 elective CABG candidates participated in this randomized clinical trial during the preoperative period. The candidates were randomized to receive 3 mg of melatonin tablets (physiologic dose) from 3 days before surgery until the day of discharge. Cardiac biomarkers [troponin and creatine kinase myocardial band (CKMB)] were assessed once before surgery (24 hours before surgery), and 8 and 24 hours after surgery. RESULTS: Finally, 130 patients, 65 (50%) patients in the melatonin group and 65 (50%) in the control arm finished our study. Mean age of melatonin and control groups was 59.90 ± 9.59 and 60.80 ± 8.00 years, respectively; moreover, 47 (72.30%) in melatonin and 45 (69.23%) in control group were men. No significant difference was seen in baseline cardiac biomarkers between two groups (P > 0.05). In both groups, cardiac biomarkers (CKMB and troponin) elevated after surgery in comparison to their preoperative values. There was no statistically significant difference between the control and melatonin groups regarding the 8-hour and 24-hour troponin and CKMB when adjusted for interacting factors (P > 0.05). CONCLUSION: Although physiological concentration of melatonin is protective against I/R injury, substitution of endogenous melatonin with the oral supplement which creates physiologic concentration may not prevent I/R injury. In order to have antioxidant effect, pharmacologic doses of melatonin should be employed.

Evaluation of Epithelial Lining Fluid Concentration of Amikacin in Critically Ill Patients With Ventilator-Associated Pneumonia.

INTRODUCTION: Classically, aminoglycosides are known to have low penetration into the lung tissue. So far, no study has been conducted on human adult patients to evaluate amikacin concentration in epithelial lining fluid (ELF) of the alveoli. Therefore, convincing data are not available from the perspective of pharmacokinetics to support the fact that a dosage of 20 mg/kg of amikacin is sufficient to treat patients with ventilator-associated pneumonia (VAP). METHOD: This was a pilot study of amikacin concentration measurement in the alveolar site of action in critically ill adult patients with VAP who required aminoglycoside therapy. A dose of 20 mg/kg of amikacin was administered over a 30-minute infusion. The serum concentrations of amikacin were evaluated in the first, second, fourth, and sixth hours. However, the ELF concentration of amikacin was evaluated in the second hour with the help of bronchoalveolar lavage sampling technique. RESULTS: A total number of 8 patients was included in the study. The mean (SD) administered dose was 20 (0.9) mg/kg. The mean (SD) peak plasma concentration of amikacin was 59.6 (23) mg/L, with the volume of distribution of 0.36 (0.13)L/kg. The amikacin concentration in ELF was successfully measured in 7 patients (6.3) mg/L. The lung tissue penetration of the drug was described as alveolar percentage, proportional to both the first- and second-hour plasma concentrations, with a mean (SD) of 10.1% (8.4%) and 18% (16.7%), respectively. CONCLUSION: To our knowledge, the current study is the first that investigates whether standard doses of amikacin may lead to sufficient alveolar concentration of the drug. The results show that administration of amikacin in doses of 20 mg/kg in critically ill patients with VAP may not provide sufficient concentrations in ELF.

Management of Hypotension and Bradycardia Caused By Spinal Cord Injury. The Usefulness of Midodrine and Methylxanthines.

Spinal cord injury is a devastating chronic condition resulting in temporary or permanent motor, sensory or autonomic dysfunction of the cord. The manifestation of spinal cord injury based on the severity and involved areas could be different. Numerous studies have demonstrated that bradycardia, hypotension, and orthostatic hypotension are present insignificant number of patients after spinal cord injury which peaks at 4th day of injury. Although vasopressors are common drugs that have been used to restore blood pressure and heart rate in patients with neurogenic shock, there is limited data regarding pharmacologic management of bradycardia and hypotension after spinal cord injury. Midodrine is a potent vasopressor approved for the management of symptomatic orthostatic hypotension. Theophylline and aminophylline are methylxanthine derivatives. There are very few case reports concerning the use of midodrine and methylxanthines for treatment of hypotension in patients with spinal cord injury. In this case report and review of the articles we report a 45 year old woman with a diagnosis of spinal cord injury who was successfully managed with midodrine and aminophylline and then we review current case reports. Based on our case report and other available data, midodrine as well as methylxanthines can be suggested as therapeutic options for managing symptoms in spinal cord injury patients.

Melatonin Supplementation May Improve the Outcome of Patients with Hemorrhagic Stroke in the Intensive Care Unit.

OBJECTIVE: Although mechanical ventilation is frequently a life-saving therapy, its use can result in unwanted side effects. It has been well documented that the choice of sedating agent may influence the duration of mechanical ventilation. Melatonin is a sedative and analgesic agent without any respiratory depressant effect which makes it an attractive adjuvant for sedation in the intubated patients. The aim of this study is to evaluate the effect of melatonin on the duration of mechanical ventilation in patients with hemorrhagic stroke. METHODS: Forty adult intubated patients with hemorrhagic stroke, who were admitted to the Intensive Care Unit (ICU) within 24 h of onset, were enrolled in this randomized double-blind study. Subjects in the melatonin group received 30 mg of melatonin every night throughout the nasogastric tube. Length of ICU stay, mortality, and duration of mechanical ventilation were recorded for all patients. FINDINGS: The duration of mechanical ventilation and length of ICU stay were shorter in patients who received melatonin in comparison with the control group, and this difference was statistically significant for the length of ICU stay and marginally significant for the duration of mechanical ventilation. Although not statistically significant, the mortality rate of the control group was 30%, almost double that of the study group (15%). CONCLUSION: Melatonin possesses hypnotic, analgesic, anti-inflammatory, and anti-oxidative properties that distinguish it as an attractive adjuvant in patients under mechanical ventilation. In conclusion, the administration of melatonin may facilitate the weaning process through decreasing the consumption of sedatives with respiratory depressant properties as well as preventing ventilator-associated lung injury.

The Potential Role of Naltrexone in Borderline Personality Disorder.

Objective: Management of borderline personality disorder (BPD) is a difficult challenge due to the complex features of this disorder. This article reviews the use of naltrexone in the treatment of BPD. Method: Published articles and clinical trials were searched in Google Scholar, MedLine, ELSEVIER, and Cochrane database of systematic reviews abstracts in English language between 1990 and 2017. Results: Naltrexone (NTX), a nonspecific competitive opiate antagonist, has been noted to be helpful in controlling self-injurious behavior (SIB) and dissociative symptoms in patients with BPD. Conclusion: Further studies should be conducted on the effects of naltrexone to confirm the role of this medication in the treatment of BPD.

A Novel Practical Equation for Treatment of Emergent Hypernatremia and Dehydration Phase in Infants.

Serum sodium (Na) concentration more than 145 mmol/L is defined as hypernatremia. Hypernatremia carries an acute morbidity and mortality, especially in neonates and infants. Rapid correction of hypernatremia leads to severe cerebral damages, and seizure is the most common neurological complication of hypernatremia. Selection and calculation of an appropriate fluid and its amount is one of the tremendous challenges. It is important to choose the correct amount of suitable fluid and adjust rehydration rate. In this study, we have suggested practical equation to determine the amount of fluid that should be administered to the neonates and infants with hypernatremia. In this equation, the amount of infusate volume will be calculated from changes in serum Na and total body water. However, serum Na and infusate Na will play an important role in equation structure, too. Our suggested equation will help physicians to manage hypernatremic dehydrated patients in a suitable manner with an adjustable rate.

Evaluating the Potential Effect of Melatonin on the post-Cardiac Surgery Sleep Disorder.

BACKGROUND: Postoperative neurological injuries, including cognitive dysfunction, sleep disorder, delirium, and anxiety, are the important consequences of coronary artery bypass graft surgery (CABG). Evidence has shown that postoperative sleep disturbance is partly due to disturbed melatonin secretion in the perioperative period. The aim of this study was to evaluate the effect of melatonin on postoperative sleep disorder in patients undergoing CABG. METHOD: One hundred forty-five elective CABG patients participated in a randomized double-blind study during the preoperative period. The patients were randomized to receive either 3 mg of melatonin or 10 mg of Oxazepam one hour before sleep time. Each group received the medication from 3 days before surgery until the time of discharge. Sleep quality was evaluated using the Groningen Sleep Quality Score (GSQS), and the incidence of delirium was evaluated by nursing records. Sleep quality and anxiety scores were compared before and after surgery through the Wilcoxon signed-rank test. The analysis of covariance (ANCOVA) and independent t-test were used to compare the sleep and anxiety scores between the groups. P values ≤ 0.05 were considered statistically significant. RESULTS: Totally, 137 patients at a mean age of 60 years completed the study (76% male). The analysis of the data showed that sleep was significantly disturbed after surgery in both groups. The patients in the Oxazepam group demonstrated significantly higher disturbance in their mean postoperative GSQS score than did their counterparts in the melatonin group (p value < 0.001). A smaller proportion of the participants experienced delirium in the melatonin group (0.06%) than in the Oxazepam group (0.12%); however, this difference was not statistically significant. CONCLUSION: The result of the present study revealed that melatonin improved sleep in post-cardiac surgery patients more than what was observed with Oxazepam. Therefore, melatonin may be considered an effective alternative for Benzodiazepines in the management of postoperative sleep disorder.

Association between Perioperative Parameters and Cognitive Impairment in Post-Cardiac Surgery Patients.

BACKGROUND: Postoperative cognitive dysfunction (POCD) has been an important complication of cardiac surgery over the years. Neurocognitive dysfunction can affect quality of life and lead to social, functional, emotional, and financial problems in the patient's life. To reduce POCD, we sought to identify the association between cognitive dysfunction and perioperative factors in patients undergoing cardiac surgery. METHODS: One hundred one patients aged between 45 and 75 years undergoing elective cardiac surgery were enrolled in this study. All the surgeries were performed on-pump by the same medical team. A brief Wechsler Memory Test (WMT) was administered before surgery, 3 to 5 days after the surgery, and 3 months after discharge. All related perioperative parameters were collected in order to study the effect of these parameters on the postoperative WMT scores and WMT score change. RESULTS: The study population consisted of 101 patients, comprising 14 (13.8%) females and 87 (86.2%) males aged between 45 and 75 years. In univariate analysis, the baseline WMT score, serum levels of lactate dehydrogenase and T3, cross-clamp time, and preexistence of chronic obstructive pulmonary disease showed significant effects on the postoperative WMT score (p value < 0.05), whereas only the baseline WMT score and chronic obstructive pulmonary disease showed strong effects on the postoperative WMT score in the multiple regression model. In addition, the multiple regression model demonstrated a significant association between the baseline WMT score, serum creatinine level, and nitrate administration and the WMT score change. CONCLUSION: Our study showed that preexisting chronic obstructive pulmonary disease and preoperative high serum creatinine levels negatively affected cognitive function after surgery. In addition, there was a strong relationship between the patients' basic cognition and POCD. Preoperative nitrate administration led to a significant improvement in POCD. It is also concluded that the preoperative administration of specific medicines like nitrates can reduce neurological complications after cardiac surgery.

Clinical evaluation of Nigella sativa seeds for the treatment of hyperlipidemia: a randomized, placebo controlled clinical trial.

BACKGROUND: Natural products are proved to play a good role as an alternative to synthetic chemicals in many clinical conditions. Hypercholesterolemia is the most important risk factor for atherosclerosis. Previous studies showed that Nigella sativa L. has both antioxidant and lipid lowering potentials. THE AIM OF THIS STUDY: To evaluate the efficacy of the seeds of Nigella sativa on the treatment of hyperlipidemia. METHODS: In this randomized, placebo controlled clinical trial which was conducted in Isfahan city (Iran), 88 subjects aged > or =18 years with a total cholesterol concentration >200 mg/dl were included. According to the patients" profiles number, they were randomized to receive either N. sativa capsules or the matching placebo. Each N sativa capsule contained 500 +/- 10 mg N. sativa crushed seeds, and patients had to take 2 g N. sativa per day for 4 weeks. Fasting baseline laboratory values (fasting blood sugar, total cholesterol, low density lipoprotein, high density lipoprotein and triglyceride) were obtained for all parameters on each subject prior to the start of the study and at the end of 4 weeks. RESULTS: In our study a significant decrease was observed in the concentration of total cholesterol (4.78%), Low density lipoprotein (7.6%) and Triglyceride (16.65%), and this decrease was more significant for TG concentration. N. sativa had not any beneficial effects on Fasting blood sugar and High density lipoprotein. CONCLUSION: According to the results of our present study it seems that N. sativa may have some beneficial therapeutic effects in the treatment of hyperlipidemia. However, further investigations with a larger sample size are necessary.