Adrenal Insufficiency in Septic Patients Admitted to Intensive Care Unit: Prevalence and Associated Factors.

Background: Adrenal insufficiency (AI) is associated with an increase in the risk of mortality in ICU-admitted septic patients. It should be suspected not only in patients with septic shock but also in those with sepsis. The aim of this study was to investigate the prevalence of AI in the spectrum of septic patients and determine the main predictors of this condition. Methods: This study included 99 patients with the diagnosis of sepsis, severe sepsis, or septic shock. Patients with basal cortisol < 10 µg/dl or those with ∆ cortisol < 9 µg/dl after the cosyntropin test were considered as having AI. Appropriate statistical tests were used for comparing the variables between the two groups. A logistic regression model was applied to determine the predictors of AI. The P-value <0.05 was considered as a significant level. Results: AI was found in 25 (25.3%) of these patients. There was no significant difference in the occurrence of AI in patients with sepsis, severe sepsis, or septic shock. Patients with positive blood culture (OR (95% CI); 7.8 (3.5-9.1); p=0.021) or those with CRP≥ 3+ (OR (95% CI); 14.1 8 (5.7-16.2); p<0.001) were more likely to develop AI. Conclusion AI is prevalent among ICU admitted septic patients even in the absence of septic shock. The main predictors of AI are high levels of CRP and positive blood culture.

Frequency and outcome of olfactory impairment and sinonasal involvement in hospitalized patients with COVID-19.

BACKGROUND: Olfactory dysfunction has shown to accompany COVID-19. There are varying data regarding the exact frequency in the various study population. The outcome of the olfactory impairment is also not clearly defined. OBJECTIVE: To find the frequency of olfactory impairment and its outcome in hospitalized patients with positive swab test for COVID-19. METHODS: This is a prospective descriptive study of 100 hospitalized COVID-19 patients, randomly sampled, from February to March 2020. Demographics, comorbidities, and laboratory findings were analyzed according to the olfactory loss or sinonasal symptoms. The olfactory impairment and sinonasal symptoms were evaluated by 9 Likert scale questions asked from the patients. RESULTS: Ninety-two patients completed the follow-up (means 20.1 (± 7.42) days). Twenty-two (23.91%) patients complained of olfactory loss and in 6 (6.52%) patients olfactory loss was the first symptom of the disease. The olfactory loss was reported to be completely resolved in all but one patient. Thirty-nine (42.39%) patients had notable sinonasal symptoms while rhinorrhea was the first symptom in 3 (3.26%). Fifteen patients (16.3%) had a taste impairment. Patients with sinonasal symptoms had a lower age (p = 0.01). There was no significant relation between olfactory loss and sinonasal symptoms (p = 0.07). CONCLUSIONS: Sudden olfactory dysfunction and sinonasal symptoms have a considerable prevalence in patients with COVID-19. No significant association was noted between the sinonasal symptoms and the olfactory loss, which may suggest that other mechanisms beyond upper respiratory tract involvement are responsible for the olfactory loss.

A randomized controlled trial of pegylated interferon-alpha with tenofovir disoproxil fumarate for hepatitis B e antigen-negative chronic hepatitis B: A 48-week follow-up study.

BACKGROUND: Recent studies report incongruent finds regarding the addition of pegylated interferon -alpha (Peg- IFNα) to nucleos(t)ide analogues. This study was designed to compare the efficacy of Peg- IFNα and tenofovir disoproxil fumarate (TDF) combination therapy with each of the treatments separately. METHODS: In this open-label, randomized clinical trial, treatment-naive hepatitis B e antigen (HBeAg)-negative patients were randomly assigned to three treatment groups: Group A: Peg- IFNα (180 mcg/week) with TDF (300 mg/day); Group B: TDF (300 mg/day); and Group C: Peg- IFNα (180 mcg/week). The intervention spanned 48 weeks and patients were followed up every 12 weeks. The primary end-point was HBV DNA load <20 IU/mL. RESULTS: Groups A, B and C each comprised of 22, 23 and 22 patients, respectively. The number of patients with HBV DNA suppression in group A was significantly higher compared to groups B and C (P = 0.034). No significant difference was observed in the normalization trends of serum ALT levels between the three groups (P = 0.082). At week 48, combination therapy was significantly more effective in suppressing HBV DNA concentration to below the level of detection than TDF monotherapy (OR = 2.1, 95%CI: 1.18-4.15; P = 0.034). Furthermore, a comparison between monotherapy arms revealed that both interventions had similar effects on the overall outcome (OR = 1.24, 95%CI: 1.02-5.8; P = 0.062). CONCLUSION: A Peg- IFNα and TDF combination therapy resulted in improved virologic response and was safe in HBeAg negative patients. Monotherapy with Peg-IFNα or TDF procured limited benefits in comparison. TRIAL REGISTRATION: This study was registered in the Iranian Registry of Clinical Trials (IRCT20181113041635N1).

Determination of antimicotic susceptibility pattern of Candida species isolated from patients with symptomatic candiduria.

BACKGROUND: The present study was conducted to determine antimicotic susceptibility of Candida species (sp.) from patients with symptomatic candiduria. MATERIALS AND METHODS: Identification of Candida sp. and determination of efficacy of most routine antifungals were done using polymerase chain reaction-restriction fragment length polymorphism method and E-test, respectively. RESULTS: The results from susceptibility test reveal that caspofungin and amphotericin B have high antifungal activity against both albicans (100% and 96%, respectively) and nonalbicans (95.11% and 72.72%, respectively) isolates. CONCLUSION: The present study suggests that caspofungin and amphotericin B have the excellent ability to eradicate both Candida groups that showed decreased susceptibility to other compounds.

Extraction, Chemical Composition, Antioxidant Property, and In-vitro Anticancer Activity of Silymarin from Silybum marianum on Kb and A549 Cell Lines.

INTRODUCTION: This study aimed to evaluate the antioxidant property of Silymarin (SM) extracted from the seed of Silybum marianum and its anticancer activity on KB and A549 cell lines following 24, 48, and 72 h of treatment. METHODS: Ten grams of powdered S. marianum seeds were defatted using n-hexane for 6 hours and then extracted by methanol. The Silymarin extracted of extraction components. The extracted components of Silymarin were measured by spectrophotometric assay and HPLC analysis. 2, 2- diphenyl-1-picrylhydrazyl (DPPH) radical scavenging, phenol content, total flavonoid content, and total antioxidant capacity were measured to detect the antioxidant properties of SM. The anticancer activity of the SM on cell lines evaluated by MTT. RESULTS: In HPLC analysis, more than 50% of the peaks were related to silybin A and B. SM was reduced DPPH (the stable free radical) with a 50% inhibitory concentration (IC50) of 6.56 µg/ ml in comparison with butylated hydroxyl toluene (BHT), which indicated an IC50 of ~3.9 µg/ ml. The cytotoxicity effect of SM on the cell lines was studied by MTT assay. The cytotoxicity effect of the extracted Silymarin on KB and A549 cell lines was observed up to 80 and 70% at 156 and 78 µg/ml, respectively. The IC50 value of the extracted SM on KB and A549 cell lines after 24 hours of treatment was seen at 555 and 511 µg/ml, respectively. CONCLUSION: Due to the good antioxidant and anticancer properties of the isolated Silymarin, its use as an anticancer drug is suggested.

Effects of synthetic silymarin-PLGA nanoparticles on M2 polarization and inflammatory cytokines in LPS-treated murine peritoneal macrophages.

OBJECTIVES: Silymarin (SM) is a natural antioxidant compound with good anti-inflammatory effects, but its poor water solubility restricts its usage. Today, nanomaterial compounds (such as PLGA Poly D, L-lactic-co-glycolic acid) can provide a proper drug delivery system and help improve the accessibility of bioactive compounds to cells and tissues. MATERIALS AND METHODS: In this study, PLGA nanoparticles (NPs) containing SM (SM-PLGA) were synthesized and characterized and their biological effects were evaluated on M2 macrophage polarization to regulate inflammation. SM-PLGA NPs were fabricated by the oil in water emulsion (O/W) method. Macrophages (MQs) were isolated from mouse peritoneum by the cold RPMI lavage protocol. Primary mouse MQ cells were treated by SM and SM-PLGA NPs and then stimulated with lipopolysaccharide (LPS). M2 polarization was evaluated by measurements of cytokine secretion levels (TNF-α, IL1-ß, and IL-10), flow cytometry markers (F4/80, CD11b, CD38, and CD206), and the expression of specific proteins (M2 Ym1 and Fizz1). RESULTS: SM-PLGA characterization showed that NPs were fabricated in the desired form. SM and SM-PLGA decreased pro-inflammatory cytokines (TNF-α and IL1-ß) and increased IL10 as an anti-inflammatory cytokine. On the other hand, the M2-associated markers and proteins increased following treatment with SM and SM-PLGA. Post-hoc analysis indicated that these changes were more pronounced in the SM-PLGA group. CONCLUSION: This study revealed that SM-PLGA could markedly promote M2 polarization, thereby providing a valuable medical approach against sepsis and septic shock.

Varicella Zoster antibodies among health care workers in a university hospital, Teheran, Iran.

OBJECTIVES: This study was designed to evaluate the immune status of health care workers against varicella zoster in a university hospital in Teheran, Iran, and to compare the history of chickenpox infection with the presence of varicella antibodies in this population. METHODS: Serologic testing for varicella was performed for 405 health care workers with different job categories and at different age. The enzyme immunoassay was used for determining IgG antibodies against varicella zoster virus. RESULTS: A total of 405 health care workers, aged 19-50 years (median: 29 years), were examined. Of these, 289 (71.4%) were found to be seropositive. No statistically significant differences were observed between gender, age, or occupation, and seropositivity (p = 0.09, 0.75, 0.54. respectively). Statistical analysis revealed that the correlation between chickenpox history and seropositivity showed a 62.3% sensitivity, 72.4% specificity, 84.9% positive predictive value, and 43.5% negative predictive value. CONCLUSIONS: Serologic screening of health care workers is essential to determine their immunity to varicella, regardless of the age, occupation and history of infection. This population is recommended to be considered a target group for future immunization programs in Iran.

Comparison of WBC, ESR, CRP and PCT serum levels in septic and non-septic burn cases.

Diagnosis of sepsis is difficult, particularly in cases of burn where signs of sepsis may be present in the absence of a real infection. This study compared serum levels of procalcitonin (PCT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and white blood cell (WBC) among 60 burned people with and without infection, in order to assess the value of the information for diagnosis of sepsis. A significantly higher PCT level was observed in the septic group compared to those without sepsis (8.45+/-7.8 vs. 0.5+/-1.0, respectively, p<0.001); no significant differences were found in CRP or WBC levels, neutrophil count or ESR. The area under the receiver operating characteristics curve in the diagnosis of sepsis was 0.97 for PCT (p<0.001) with sensitivity of 100% and specificity of 89.3%. Non-survivors had a mean PCT level significantly higher than that of survivors. Thus the serum PCT level was a highly efficient laboratory parameter for the diagnosis of severe infectious complications after burn, but WBC, neutrophil, ESR and CRP levels were of little value.

Effect of sticky mat usage in control of nosocomial infection in Motahary Burn Hospital.

BACKGROUND AND OBJECTIVES: Infection is the most common cause of death among burnt patients and infection control decrease the rate of mortality. The use of sticky mat can control contamination by preventing the entrance microorganisms into the hospital wards. This study was designed to evaluate the sticky mats effect in reduction of microorganism's entry by personnel shoes to burn intensive care unit (BICU). MATERIALS AND METHODS: This is a simple cross sectional study. We tested outer soles of personnel's shoes with swap and cultured them before and after sticky mat contact in the entrance of BICU. Results were analyzed with IBM SPSS version 22 software. McNemar and Wilcoxon Signed Ranks tests were used. RESULTS: We analyzed 60 outer soles of the shoes before and after contact with sticky mats. Coagulase negative Staphylococci, Gram positive bacilli, Staphylococcus aureus, Aspergillus fumigatus, Pseudomonas aeruginosa and Acinetobacter baumannii were isolated before contact from 57 (95%), 32 (53%), 4 (6.7%) and 3 (5%) cases, respectively. Coagulase negative Staphylococci, Gram positive bacilli, Staphylococcus aureus, Aspergillus fumigatus, Pseudomonas aeruginosa were isolated after contact from 36 (60%), 30 (50%), 16 (26.6%), 2 (3.3%) and 3 (5%) cases, respectively. No Acinetobacter was isolated after contact with sticky mat. Total isolated colonies before and after contact with sticky mats were 2573 and 830, respectively. There were significant statistically differences between the colony counts of coagulase ngative staphylococci, Gram positive bacilli, and Staphylococci aureus before and after contact with sticky mats (P. < 0.001). CONCLUSION: Regarding to statistical analysis, the effect of mat in removing the microorganisms was 56%. It confirms the effectiveness of sticky mat controlling the infection and reducing the amount of hospital contamination.

Hospital acquired diarrhea in a burn center of Tehran.

BACKGROUND AND OBJECTIVES: Incidence of hospital-acquired diarrhea has increased rapidly and burn patients are at high risk of getting it. Infection with C. difficile is the most common cause of antibiotic associated diarrhea. The aim of this study was to determine the baseline characteristics and clinical presentation of hospital-acquired diarrhea and compare C. difficile and non-C. difficile diarrhea in burn patients treated at a burn center. MATERIALS AND METHODS: During a 1-year study all patients with hospital-acquired diarrhea at Motahari Burn Hospital, Tehran, Iran enrolled in this study. We compared patients with a stool sample positive for C. difficile toxin or tracing the antigen in patients who were negative for detection of toxin in their stool sample specimens. RESULTS: Diarrhea developed in 37 patients out of 3200 admitted patients with a mean burn size of 34.8 ±20.1%. Among them, 8 patients had a positive result for C. difficile. The mean time between antibiotic therapy and occurrence of diarrhea was 9.5 ± 6.2 days. Nine (23.7%) patients died in the 7.8± 4.2 days, mostly due to co-morbidities. The mean duration of diarrhea was 3.6 ± 2 days. Twenty two (57.9%) patients were treated with oral metronidazol and eleven (28.9%) patients were treated with combination of metronidazole and vancomycin, higher rate of combination therapy was seen in Clostridium difficile CDI. CONCLUSION: Overall, the prevalence of hospital-acquired diarrhea was 120/10,000 and 21% of them caused by infection with C. difficile. Presence of peripheral leukocytosis and colitis were the alarm sign for diagnosis of C. difficile infection.

Th1 and Th2 cytokine gene expression in atopic and nonatopic patients with nasal polyposis.

The pathogenesis of nasal polyps has been debated for many years. The lymphocytes that infiltrate nasal polyps have been identified as predominantly memory T cells in an activated state, and these cells produce a mixed cytokine pattern of T1 helper (Th1) and T2 helper (Th2) cells. We conducted a prospective study to compare the expression levels of some Th1 and Th2 cytokines in atopic and nonatopic patients. Our study population consisted of 75 adults-42 men and 33 women (mean age: 38 yr)-with nasal polyposis. Patients with an allergy were distinguished from those without an allergy on the basis of the history, the results of skin-prick testing, and measurement of total IgE serum concentrations. Based on these criteria, patients were divided into two groups: atopic (n = 38) and nonatopic (n = 37). Levels of cytokine gene expression in the atopic patients were compared with those of the nonatopic patients by real-time polymerase chain reaction. Statistical analysis found no significant differences in the rate of interleukin (IL) 10 and IL-12 gene expression between the allergic and nonallergic patients. On the other hand, rates of interferon gamma and IL-4 gene expression were significantly higher in the atopic patients (p = 0.03 and p = 0.02, respectively). Our research suggests that an imbalance of Th1 and Th2 cells plays an important role in the pathophysiology of nasal polyps. Although nasal polyposis is a multifactorial disease associated with several different etiologic factors, chronic persistent inflammation is undoubtedly a major factor, regardless of the specific etiology.

Serum inflammatory markers in the elderly: are they useful in differentiating sepsis from SIRS?

Differentiating sepsis from other noninfectious causes of systemic inflammation is often difficult in the elderly. The aim of this study was to evaluate the ability of C-reactive protein (CRP), Erythrocyte Sedimentation Rate (ESR), procalcitonin (PCT), and Interleukin-6 (IL-6) to identify elderly patients with sepsis. In this single center prospective observational study, we included all consecutive elderly patients admitted with suspected sepsis and systemic inflammatory response syndrome (SIRS) in an emergency department. Blood samples for measuring CRP, PCT, IL-6, ESR and white blood cells (WBC) count were taken at first day of admission. Sensitivity, specificity, positive and negative predictive values were calculated for each inflammatory markers being studied. A total of 150 elderly patients aged 65 and older, 50 with sepsis and 50 with SIRS, and fifty individuals in a normal health status were included. CRP exhibited the greatest sensitivity (98%) and negative predictive value (98.6%) and performed best in differentiating patients with sepsis from those with SIRS. In a receiver operating characteristic curve analysis, IL-6 performed best in distinguishing between SIRS and the control group (AUC 0.75, 95% CI). On the other hand, both CRP and ESR appeared to be a more accurate diagnostic parameter for differentiating sepsis from SIRS among elderly patients.

Soluble triggering receptor expressed on myeloid cells 1 and the diagnosis of sepsis.

PURPOSE: Early diagnosis and assessment of the systemic inflammatory response to infection are difficult with usual markers (fever, leukocytosis, C-reactive protein [CRP]). Triggering receptor expressed on myeloid cells-1 (TREM-1) expression on phagocytes is up-regulated by microbial products. We studied the ability of soluble TREM-1 (sTREM-1) to identify patients with sepsis. MATERIALS AND METHODS: Plasma samples were obtained on intensive care unit admission from patients with systemic inflammatory response syndrome for sTREM-1 measurement. RESULTS: Soluble TREM-1, CRP concentrations and erythrocyte sedimentation rate (ESR) were higher in the sepsis group (n = 52) than in the non-infectious systemic inflammatory response syndrome group (n = 43; P = .00, .02, and .001, respectively). Soluble TREM-1, CRP concentrations, white blood cell count and ESR were higher in the sepsis group than in the non SIRS group (n = 37; P = .04, .00, .01, and .00, respectively). In a receiver-operating characteristic curve analysis, ESR, CRP and sTREM-1 had an area under the curve larger than 0.65 (P = .00), in distinguishing between septic and non-infectious SIRS patients. CRP, ESR, sTREM-1 had a sensitivity of 60%, 70% and 70% and a specificity of 60%, 69% and, 60% respectively in diagnosing infection in SIRS. CONCLUSION: C-reactive protein and ESR performed better than sTREM-1 and white blood cell count in diagnosing infection.