Evaluation of a Phenobarbital-Based Protocol for Severe Alcohol Withdrawal in Critically Ill Patients

2020 ◽  
pp. 001857872093146
Author(s):  
Melanie Goodberlet ◽  
Kevin Dube ◽  
Mary Kovacevic ◽  
Paul Szumita ◽  
Jeremy DeGrado
Keyword(s):  
Alcohol Withdrawal ◽  
Primary Outcome ◽  
Guideline Implementation ◽  
Severity Of Illness ◽  
Future Research ◽  
Apache Ii Score ◽  
Efficacy And Safety ◽  
Safety And Efficacy ◽  
Baseline Severity ◽  
Icu Length Of Stay

Background: Phenobarbital offers several possible advantages to benzodiazepines including a longer half-life and anti-glutamate activity, and is an alternative for the treatment of alcohol withdrawal. The objective of this analysis was to evaluate the safety and efficacy of a phenobarbital protocol for alcohol withdrawal newly implemented at our institution. Methods: This was a single-center, retrospective analysis of adult patients admitted to the medical/surgical/burn/trauma intensive care unit (ICU) with or at risk of severe alcohol withdrawal. Patients who were admitted prior to guideline implementation and received scheduled benzodiazepines (PRE) were compared to those who received phenobarbital post guideline update (POST). The primary outcome was ICU length of stay (LOS). Results: Upon analysis, 68 patients in the PRE and 64 patients in the POST were identified for inclusion. The median APACHE II score was significantly higher in the POST (4.5 [3:9] vs 10 [5:13], P < 0.001). ICU (2 [1:2] vs 2 [2:5], P = 0.002) and hospital (4.5 [3:6] vs 8 [6:12], P < 0.001) LOS were significantly longer in the POST. There was no difference in mortality or duration of mechanical ventilation. More patients required propofol or dexmedetomidine on day one in the POST ( P < 0.001). Conclusion: Patients in the POST had significantly longer ICU and hospital LOS, and had a higher baseline severity of illness. Future research is needed to evaluate the efficacy and safety of phenobarbital compared to benzodiazepines for severe alcohol withdrawal.

scholarly journals Relationship between availability of physiotherapy services and ICU costs

2018 ◽  
Vol 44 (3) ◽  
pp. 184-189 ◽  
Author(s):  
Bruna Peruzzo Rotta ◽  
Janete Maria da Silva ◽  
Carolina Fu ◽  
Juliana Barbosa Goulardins ◽  
Ruy de Camargo Pires-Neto ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Length Of Stay ◽  
Invasive Mechanical Ventilation ◽  
Severity Of Illness ◽  
Apache Ii Score ◽  
Health Evaluation ◽  
Icu Length Of Stay ◽  
Tertiary Teaching ◽  
Tertiary Teaching Hospital ◽  
First Time

ABSTRACT Objective: To determine whether 24-h availability of physiotherapy services decreases ICU costs in comparison with the standard 12 h/day availability among patients admitted to the ICU for the first time. Methods: This was an observational prevalence study involving 815 patients ≥ 18 years of age who had been on invasive mechanical ventilation (IMV) for ≥ 24 h and were discharged from an ICU to a ward at a tertiary teaching hospital in Brazil. The patients were divided into two groups according to h/day availability of physiotherapy services in the ICU: 24 h (PT-24; n = 332); and 12 h (PT-12; n = 483). The data collected included the reasons for hospital and ICU admissions; Acute Physiology and Chronic Health Evaluation II (APACHE II) score; IMV duration, ICU length of stay (ICU-LOS); and Omega score. Results: The severity of illness was similar in both groups. Round-the-clock availability of physiotherapy services was associated with shorter IMV durations and ICU-LOS, as well as with lower total, medical, and staff costs, in comparison with the standard 12 h/day availability. Conclusions: In the population studied, total costs and staff costs were lower in the PT-24 group than in the PT-12 group. The h/day availability of physiotherapy services was found to be a significant predictor of ICU costs.

A Symptom-Triggered Benzodiazepine Protocol Utilizing SAS and CIWA-Ar Scoring for the Treatment of Alcohol Withdrawal Syndrome in the Critically Ill

2016 ◽  
Vol 51 (2) ◽  
pp. 101-110 ◽  
Author(s):  
Soumitra Sen ◽  
Philip Grgurich ◽  
Amanda Tulolo ◽  
Andrew Smith-Freedman ◽  
Yuxiu Lei ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Critically Ill ◽  
Alcohol Withdrawal ◽  
Withdrawal Syndrome ◽  
Alcohol Withdrawal Syndrome ◽  
Limited Data ◽  
Safety And Efficacy ◽  
Icu Length Of Stay ◽  
Before And After ◽  
Before And After Study

Background: There are limited data on the efficacy of symptom-triggered therapy for alcohol withdrawal syndrome (AWS) in the intensive care unit (ICU). Objective: To evaluate the safety and efficacy of a symptom-triggered benzodiazepine protocol utilizing Riker Sedation Agitation Scale (SAS) scoring for the treatment of AWS in the ICU. Methods: We performed a before-and-after study in a medical ICU. A protocol incorporating SAS scoring and symptom-triggered benzodiazepine dosing was implemented in place of a protocol that utilized the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale and fixed benzodiazepine dosing. Results: We enrolled 167 patients (135 in the preintervention and 32 in the postintervention group). The median duration of AWS was shorter in the postintervention (5, interquartile range [IQR] = 4-8 days) than in the preintervention group (8, IQR = 5-12 days; P < 0.01). Need for mechanical ventilation (31% vs 57%, P = 0.01), median ICU length of stay (LOS; 4, IQR = 2-7, vs 7, IQR = 4-11 days, P = 0.02), and hospital LOS (9, IQR = 6-13, vs 13, IQR = 9-18 days; P = 0.01) were less in the postintervention group. There was a reduction in mean total benzodiazepine exposure (74 ± 159 vs 450 ± 701 mg lorazepam; P < 0.01) in the postintervention group. Conclusion: A symptom-triggered benzodiazepine protocol utilizing SAS in critically ill patients is associated with a reduction in the duration of AWS treatment, benzodiazepine exposure, need for mechanical ventilation, and ICU and hospital LOS compared with a CIWA-Ar–based protocol using fixed benzodiazepine dosing.

scholarly journals Not All Critically Ill Obese Patients Are the Same: The Influence of Prior Comorbidities

ISRN Obesity ◽  
2012 ◽  
Vol 2012 ◽  
pp. 1-7 ◽  
Author(s):  
Adam Rahman ◽  
Renee D. Stapleton ◽  
Daren K. Heyland
Keyword(s):  
Critically Ill ◽  
Prospective Observational Study ◽  
Primary Outcome ◽  
Admission Diagnosis ◽  
Apache Ii Score ◽  
Obese Patients ◽  
Icu Length Of Stay ◽  
Improved Outcomes ◽  
Severely Obese ◽  
Secondary Outcomes

Purpose. Data suggest that obesity in critical illness is associated with improved outcomes. We postulate that these findings may be influenced by preillness comorbidities. We sought to determine if critically ill obese patients without significant comorbidity had improved mortality compared to obese patients with multiple comorbidities. Materials and Methods. We analyzed data from a prospective observational study conducted in 3 tertiary ICUs. Severely obese (body mass index ≥30) adults in the ICU for ≥24 hours were identified and classified into limited comorbid illnesses (0-1) or multiple comorbidities (≥2). The primary outcome was the odds ratio (OR) of mortality at day 28. Important secondary outcomes were ICU length of stay and ICU free days in the first 28 days. Results. 598 patients were enrolled; 183 had BMI ≥30. Of these, 38 had limited comorbidities and 145 had multiple comorbidities. In unadjusted analyses, obese patients with multiple comorbidities were 4.70 times (95% CI 1.07–20.6) as likely to die by day 28 compared to patients with limited comorbidities (P=0.04). After stratifying by admission diagnosis and adjusting for APACHE II score, the influence of comorbidities remained large and trended toward significance (OR 4.28, 95% CI 0.92–20.02, P=0.06). In adjusted analyses, obese patients with multiple comorbidities tended to have longer ICU duration (3.06 days, SE 2.28, P=0.18) and had significantly fewer ICU free days in the first 28 days (−3.92 days, SE 1.83, P=0.03). Conclusions. Not all critically ill obese patients are the same. Those with less comorbidity may have better outcomes than those with multiple comorbidities. This may be important when considering prognosis and discussing care with patients and families.

scholarly journals Identifying organ dysfunction trajectory-based subphenotypes in critically ill patients with COVID-19

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Chang Su ◽  
Zhenxing Xu ◽  
Katherine Hoffman ◽  
Parag Goyal ◽  
Monika M. Safford ◽  
...  
Keyword(s):  
New York ◽  
Respiratory Failure ◽  
Sofa Score ◽  
Severity Of Illness ◽  
Agglomerative Clustering ◽  
Baseline Severity ◽  
Organ Systems ◽  
Hierarchical Agglomerative Clustering ◽  
Dynamic Time ◽  
Post Intubation

AbstractCOVID-19-associated respiratory failure offers the unprecedented opportunity to evaluate the differential host response to a uniform pathogenic insult. Understanding whether there are distinct subphenotypes of severe COVID-19 may offer insight into its pathophysiology. Sequential Organ Failure Assessment (SOFA) score is an objective and comprehensive measurement that measures dysfunction severity of six organ systems, i.e., cardiovascular, central nervous system, coagulation, liver, renal, and respiration. Our aim was to identify and characterize distinct subphenotypes of COVID-19 critical illness defined by the post-intubation trajectory of SOFA score. Intubated COVID-19 patients at two hospitals in New York city were leveraged as development and validation cohorts. Patients were grouped into mild, intermediate, and severe strata by their baseline post-intubation SOFA. Hierarchical agglomerative clustering was performed within each stratum to detect subphenotypes based on similarities amongst SOFA score trajectories evaluated by Dynamic Time Warping. Distinct worsening and recovering subphenotypes were identified within each stratum, which had distinct 7-day post-intubation SOFA progression trends. Patients in the worsening suphenotypes had a higher mortality than those in the recovering subphenotypes within each stratum (mild stratum, 29.7% vs. 10.3%, p = 0.033; intermediate stratum, 29.3% vs. 8.0%, p = 0.002; severe stratum, 53.7% vs. 22.2%, p < 0.001). Pathophysiologic biomarkers associated with progression were distinct at each stratum, including findings suggestive of inflammation in low baseline severity of illness versus hemophagocytic lymphohistiocytosis in higher baseline severity of illness. The findings suggest that there are clear worsening and recovering subphenotypes of COVID-19 respiratory failure after intubation, which are more predictive of outcomes than baseline severity of illness. Distinct progression biomarkers at differential baseline severity of illness suggests a heterogeneous pathobiology in the progression of COVID-19 respiratory failure.

scholarly journals Efficacy and safety of Si-Jun-Zi-Tang-based therapies for functional (non-ulcer) dyspepsia: a meta-analysis of randomized controlled trials

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Yaping Wang ◽  
Bin Liu ◽  
Xiuqiong Fu ◽  
Tiejun Tong ◽  
Zhiling Yu
Keyword(s):  
Relapse Rate ◽  
Large Scale ◽  
Primary Outcome ◽  
Response Rate ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Efficacy And Safety ◽  
History Of ◽  
Non Ulcer Dyspepsia

Abstract Background The traditional Chinese medicine formula Si-Jun-Zi-Tang (SJZT) has a long history of application in the treatment of functional dyspepsia (non-ulcer dyspepsia, FD)-like symptoms. SJZT-based therapies have been claimed to be beneficial in managing FD. This study aimed to assess the efficacy and safety of SJZT-based therapies in treating FD by meta-analysis. Methods Systematic searches for RCTs were conducted in seven databases (up to February 2019) without language restrictions. Data were analyzed using Cochrane RevMan software version 5.3.0 and Stata software version 13.1, and reported as relative risk (RR) or odds ratio (OR) with 95% confidence intervals (CIs). The primary outcome was response rate and the secondary outcomes were gastric emptying, quality of life, adverse effects and relapse rate. The quality of evidence was evaluated according to criteria from the Cochrane risk of bias. Results A total of 341 potentially relevant publications were identified, and 12 RCTs were eligible for inclusion. For the response rate, there was a statically significant benefit in favor of SJZT-based therapies (RR = 1.23; 95% CI 1.17 to 1.30). However, the benefit was limited to modified SJZT (MSJZT). The relapse rate of FD patients received SJZT-based therapies was lower than that of patients who received conventional medicines (OR = 0.23; 95% CI 0.10 to 0.51). No SJZT-based therapies-related adverse effect was reported. Conclusion SJZT-based prescriptions may be effective in treating FD and no serious side-effects were identified, but the effect on response rate appeared to be limited to MSJZT. The results should be interpreted with caution as all the included studies were considered at a high risk of bias. Standardized, large-scale and strictly designed RCTs are needed to further validate the benefits of SJZT-based therapies for FD management. Trial registration Systematic review registration: [PROSPERO registration: CRD42019139136].

scholarly journals “Nanomaterials of curcumin-hyaluronic acid”: their various methods of formulations, clinical and therapeutic applications, present gap, and future directions

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Tanzeel Rehman Charan ◽  
Muhammad Aqeel Bhutto ◽  
Mihr Ali Bhutto ◽  
Azhar Ali Tunio ◽  
Ghulam Murtaza Khuhro ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Hyaluronic Acid ◽  
Future Research ◽  
Main Body ◽  
Future Directions ◽  
Research Directions ◽  
Safety And Efficacy ◽  
Therapeutic Applications ◽  
Future Research Directions ◽  
Neural Disorders

Abstract Background Nanomaterials of curcumin with hyaluronic acid have gained a lot of attention for potential therapeutic applications of curcumin and hyaluronic acid with or without other additional drugs. Overall studies of curcumin and hyaluronic acid show that nanomaterials of curcumin with hyaluronic acid accelerate the efficacy of curcumin in the treatment of various disorders like arthritis, cancer, hepatic fibrosis, neural disorders, wound healing, and skin regeneration, it is largely due to the combined effect of hyaluronic acid and curcumin. However, due to limited clinical trials and experiments on humans and animals, there is a substantial gap in research for the safety and efficacy of nanomaterials of curcumin-hyaluronic acid in the treatment of curcumin and hyaluronic acid targeted diseases and disorders. Main body of the abstract In this current review, we have first described various reported synthetic nanomaterials of curcumin-hyaluronic acid, then in the next section, we have described various fields, disorders, and diseases where these are being applied and in the final section of this review, we discussed the research gap, and future research directions needed to propose the fabricated nanocurcumin-hyaluronic acid biomaterials. Short conclusion There are substantial gaps in research for the safety and efficacy of nanomaterials of curcumin with hyaluronic acid due to limited available data of clinical trials and experiments of nanocurcumin-hyaluronic acid biomaterials on humans and animals. So, it entirely requires serious and committed efforts through the well-organized system of practical and clinical trials which provide results, data, and detections that lead to the formulation of the best drug from curcumin with hyaluronic acid for the treatment of curcumin and hyaluronic acid targeted diseases and disorders.

Fascial treatment versus manual therapy (HVLA) in patients with chronic neck pain: A randomized controlled trial

2021 ◽  
pp. 1-10
Author(s):  
Katrin Brück ◽  
Kirsten Jacobi ◽  
Tobias Schmidt
Keyword(s):  
Neck Pain ◽  
Manual Therapy ◽  
Repeated Measures ◽  
Primary Outcome ◽  
Controlled Trial ◽  
Severity Of Illness ◽  
Chronic Neck Pain ◽  
Secondary Outcome ◽  
Control Group ◽  
Industrialized Nations

BACKGROUND: Chronic neck pain (CNP) is a common health problem in western industrialized nations. In recent years, the fascial tissue has attracted the attention of therapists, and a treatment of the fasciae promises to be a meaningful approach in the therapy of patients with CNP. OBJECTIVE: The aim of this study was to investigate the effectiveness of a fascial treatment (FT) compared to manual therapy (MT) and to no intervention (control group, CG) in patients with CNP. METHODS: Sixty participants with CNP were randomized into three groups. Primary outcome parameters were pain intensity as measured by the visual analogue scale (VAS), and severity of illness as measured by the Neck Pain and Disability Scale (NPAD). Secondary outcome parameter was the range of motion (ROM) of the cervical spine. RESULTS: Repeated measures t-tests demonstrated significant decreases with medium to large effect sizes for the FT (VAS: dR⁢M= 1.14; NPAD: dR⁢M= 0.51) and for the MT (VAS: dR⁢M= 1.15; NPAD: dR⁢M= 0.72). CONCLUSION: Our results confirmed the effectiveness of MT on pain and severity of illness in the treatment of patients suffering from CNP. Furthermore, the results demonstrated the effectiveness and clinical relevance of FT for this population.

scholarly journals Randomized comparison between dexmedetomidine–remifentanil and midazolam–fentanyl for deep sedation during catheter ablation of atrial fibrillation

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Young Choi ◽  
Sung-Hwan Kim ◽  
Ju Youn Kim ◽  
Youmi Hwang ◽  
Tae-Seok Kim ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Positive Pressure ◽  
Efficacy And Safety ◽  
Af Ablation ◽  
Hemodynamic Compromise ◽  
3D Mapping System ◽  
Sedative Agents

Abstract Background and objectives The efficacy of dexmedetomidine for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) has not been well established. We evaluated the efficacy and safety of sedation using dexmedetomidine with remifentanil compared to conventional sedative agents during RFCA for AF. Subjects and methods A total of 240 patients undergoing RFCA for AF were randomized to either the dexmedetomidine (DEX) group (continuous infusion of dexmedetomidine and remifentanil) or the midazolam (MID) group (intermittent injections of midazolam and fentanyl) according to sedative agents. Non-invasive positive pressure ventilation was applied to all patients during the procedure. The primary outcome was patient movement during the procedure resulting in a 3D mapping system discordance, and the secondary outcome was adverse events including respiratory or hemodynamic compromise. Results During AF ablation, the incidence of the primary outcome was significantly reduced for the DEX group (18.2% vs. 39.5% in the DEX and the MID groups, respectively, p < 0.001). The frequency of a desaturation event (oxygen saturation < 90%) did not significantly differ between the two groups (6.6% vs. 1.7%, p = 0.056). However, the incidences of hypotension not owing to cardiac tamponade (systolic blood pressure < 80 mmHg, 19.8% vs. 8.4%, p = 0.011) and bradycardia (HR < 50 beats/min: 39.7% vs. 21.8%, p = 0.003) were higher in the DEX group. All efficacy and safety results were consistent within the predefined subgroups. Conclusion The combined use of dexmedetomidine and remifentanil provides higher stability sedation during AF ablation, but can lead to more frequent hemodynamic compromise compared to midazolam and fentanyl.

Novel agents for myelodysplastic syndromes

2021 ◽  
pp. 107815522110379
Author(s):  
Katie Xu ◽  
Elizabeth Hansen
Keyword(s):  
Drug Administration ◽  
Myelodysplastic Syndromes ◽  
Primary Outcome ◽  
Food And Drug Administration ◽  
Review Article ◽  
Phase Iii ◽  
Phase Iii Trial ◽  
Safety And Efficacy ◽  
Transfusion Independence ◽  
The Us

Review objective There have been several advances in the field of myelodysplastic syndromes over the past year, yielding two new US Food and Drug Administration drug approvals. The pharmacology, pharmacokinetics, clinical trials, therapeutic use, adverse effects, clinical use controversies, product description, and upcoming trials for myelodysplastic syndromes novel agents luspatercept-aamt and decitabine/cedazuridine are reviewed. Data sources This review article utilized primary information obtained from both the published studies involved in the approval of luspatercept-aamt and decitabine/cedazuridine and package inserts for the respective medications. This review article utilized secondary information obtained from National Comprehensive Cancer Network guidelines using filters and keywords to sustain information relevancy as well as key studies using the keywords, “luspatercept-aamt, myelodysplastic syndromes, decitabine, cedazuridine, hypomethylating agent, ASTX727” from scholarly journal database PubMed. Data summary Myelodysplastic syndromes consist of myeloid clonal hemopathies with a diverse range of presentation. Until recently, there have been relatively few new therapies in the myelodysplastic syndromes treatment landscape. On April 3, 2020 the US Food and Drug Administration approved Reblozyl®(luspatercept-aamt), then on July 7, 2020, the US Food and Drug Administration approved INQOVI® (decitabine and cedazuridine). Luspatercept-aamt acts as a erythroid maturation agent through differentiation of late-stage erythroid precursors. The safety and efficacy of luspatercept-aamt was demonstrated in the MEDALIST trial, a phase III trial in patients with very low-intermediate risk refractory myelodysplastic syndromes and ring sideroblasts. Luspatercept-aamt met both primary and secondary endpoints of transfusion independence of 8 weeks or longer and transfusion independence of 12 weeks or longer, respectively. Decitabine/cedazuridine has a unique mechanism of action in which decitabine acts as a nucleoside metabolic inhibitor promoting DNA hypomethylation and cedazuridine then prevents degradation of decitabine. The safety and efficacy of decitabine/cedazuridine was shown in the ASCERTAIN study, a phase III trial in patients with intermediate or high risk myelodysplastic syndromes or chronic myelomonocytic leukemia. The primary outcome evaluated was 5-day cumulative area under the curve between decitabine/cedazuridine and IV decitabine as well as additional outcomes including safety. Decitabine/cedazuridine met primary outcome and had a similar safety profile to IV decitabine. Conclusion The novel myelodysplastic syndromes agents luspatercept-aamt and decitabine/cedazuridine provide a clinical benefit in the studied populations.

Examination of the Effectiveness of Direct Oral Anticoagulants in Comparison to Warfarin in an Obese Population

2021 ◽  
pp. 875512252110641
Author(s):  
Rachel M. Watson ◽  
Carmen B. Smith ◽  
Erica F. Crannage ◽  
Laura M. Challen
Keyword(s):  
Primary Outcome ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Efficacy And Safety ◽  
Class Iii ◽  
Vein Thrombosis ◽  
Class Iii Obesity ◽  
Recurrent Vte ◽  
The Individual ◽  
Deep Vein

Background: While commonly prescribed today, direct oral anticoagulants (DOACs) have historically been avoided in patients with class III obesity or a weight >120 kg due to limited literature regarding the efficacy and safety in this population. Objective: The overall objective was to examine the effectiveness of DOACs compared to warfarin in a population with obesity. Methods: Patients with a diagnosis of venous thromboembolism (VTE) or atrial fibrillation and a body mass index (BMI) ≥35 kg/m2 from August 1, 2015, to August 1, 2020, were included in this retrospective cohort study. Patients receiving a DOAC were matched in a 1:2 ratio to warfarin. The primary outcome was a composite of stroke or recurrent VTE. Secondary outcomes included the individual components of the primary outcome, hospitalization for bleed, and the primary outcome in patients with a BMI ≥40 kg/m2. Results: A total of 162 patients were included, with 54 and 108 in the DOAC and warfarin groups, respectively. Baseline BMI was similar between groups (45.7 kg/m2 for DOACs vs 43.8 kg/m2 for warfarin), with approximately 70% of patients having a BMI ≥40 kg/m2. The primary outcome occurred in 1 patient (1.9%) in the DOAC group and 2 patients (1.9%) in the warfarin group. The DOAC group had a higher, nonsignificant incidence of bleeding (5.6% vs 0.9%, P = 0.11). There was no difference between groups in incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), or stroke in patients with a BMI ≥40 kg/m2. Conclusion: DOACs may be as efficacious as warfarin in the prevention of stroke or recurrent VTE in patients with a BMI of ≥35 kg/m2. Prospective, randomized trials are warranted to further assess the efficacy and safety of DOACs in this population.

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