Ketamine-based Sedation Use in Mechanically Ventilated Critically Ill Patients with COVID-19: A Multicenter Cohort Study.

Backgrounds: Ketamine possesses analgesia, anti-inflammation, anticonvulsant, and neuroprotection properties. However, the evidence that supports its use in mechanically ventilated critically ill patients with COVID-19 is insufficient. The study's goal was to assess ketamine's effectiveness and safety in critically ill, mechanically ventilated (MV) patients with COVID-19. Methods: Adult critically ill patients with COVID-19 were included in a multicenter retrospective-prospective cohort study. Patients admitted between March 1, 2020, and July 31, 2021, to five ICUs in Saudi Arabia were included. Eligible patients who required MV within 24 hours of ICU admission were divided into two sub-cohort groups based on their use of ketamine (Control vs. Ketamine). The primary outcome was the length of stay (LOS) in the hospital. P/F ratio differences, lactic acid normalization, MV duration, and mortality were considered secondary outcomes. Propensity score (PS) matching was used (1:2 ratio) based on the selected criteria. Results: In total, 1,130 patients met the eligibility criteria. Among these, 1036 patients (91.7 %) were in the control group, whereas 94 patients (8.3 %) received ketamine. The total number of patients after PS matching, was 264 patients, including 88 patients (33.3 %) who received ketamine. The ketamine group's LOS was significantly lower (beta coefficient (95 % CI): -0.26 (-0.45, -0.07), P = 0.008). Furthermore, the PaO2/FiO2 ratio significantly improved 24 hours after the start of ketamine treatment compared to the pre-treatment period (6 hours) (124.9 (92.1, 184.5) vs. 106 (73.1, 129.3; P = 0.002). Additionally, the ketamine group had a substantially shorter mean time for lactic acid normalization (beta coefficient (95 % CI): -1.55 (-2.42, -0.69), P 0.01). However, there were no significant differences in the duration of MV or mortality. Conclusions: Ketamine-based sedation was associated with lower hospital LOS and faster lactic acid normalization but no mortality benefits in critically ill patients with COVID-19. Thus, larger prospective studies are recommended to assess the safety and effectiveness of ketamine as a sedative in critically ill adult patients.

The predictors and risk factors of two-year rejection in renal transplant patients: A multicenter case-control study.

INTRODUCTION: Kidney transplantation is a definitive treatment for end-stage renal disease. It is associated with improved life expectancy and quality of life. One of the most common complications following kidney transplantation is graft rejection. To our knowledge, no previous study has identified rejection risk factors in kidney transplant recipients in Saudi Arabia. Therefore, the purpose of this study was to determine the specific risk factors of graft rejection. METHODS: A multicenter case-control study was conducted at four transplant centers in Saudi Arabia. All adult patients who underwent a renal transplant in the period between 01/01/2015 and 31/12/2021 were screened for eligibility. Included patients were categorized into two groups (cases and control) based on the occurrence of biopsy-proven rejection within two years. The primary outcome was to determine the risk factors for rejection within the first two years of transplant. Exact matching was utilized using a 1:4 ratio based on patients' age, gender, and transplant year. RESULTS: Out of 1320 screened renal transplant recipients, 816 patients were included. The overall prevalence of two-year rejection was 13.9%. In bivariate analysis, deceased donor status, the presence Donor Specific Antibody (DSA), intraoperative hypotension, serum Chloride levels, Pseudomonas aeruginosa, Candida, and any Infection within two years were linked with increased risk of two-year rejection. However, in the logistic regression analysis, DSA was identified as a significant risk for two-year rejection (Adjusted OR 2.68; 95% CI, 1.10, 6.49, p = 0.03). While, the presence of Panel-reactive antibody (PRA) and higher serum chloride levels one week prior to transplant was associated with lower odds of rejection (Adjusted OR 0.12; 95% CI, 0.03, 0.53, p = 0.005 and Adjusted OR 0.93; 95% CI, 0.86, 0.98, p = 0.02, respectively). Furthermore, blood infection, infected with Pseudomonas aeruginosa or BK virus within two years of transplant was associated with higher odds of two-year rejection (Adjusted OR 3.10; 95% CI, 1.48, 6.48, p = 0.003, Adjusted OR 3.23; 95% CI, 0.87, 11.97, p = 0.08 and Adjusted OR 2.76; 95% CI, 0.89, 8.48, p = 0.07, respectively). CONCLUSION: Our findings emphasize the need for appropriate prevention and management of infections following kidney transplantation to avoid more serious problems, such as rejection, which could significantly raise the likelihood of allograft failure and probably death. Further studies with larger sample size are needed to investigate the impact of serum chloride levels prior to transplant and intraoperative hypotension on the risk of rejection.

Identification of mitogen-activated protein kinase 7 inhibitors from natural products: Combined virtual screening and dynamic simulation studies.

Mitogen-activated protein kinase 7 (MAPK7) is a serine/threonine protein kinase that belongs to the MAPK family and plays a vital role in various cellular processes such as cell proliferation, differentiation, gene transcription, apoptosis, metabolism, and cell survival. The elevated expression of MAPK7 has been associated with the onset and progression of multiple aggressive tumors in humans, underscoring the potential of targeting MAPK7 pathways in therapeutic research. This pursuit holds promise for the advancement of anticancer drug development by developing potential MAPK7 inhibitors. To look for potential MAPK7 inhibitors, we exploited structure-based virtual screening of natural products from the ZINC database. First, the Lipinski rule of five criteria was used to filter a large library of ~90,000 natural compounds, followed by ADMET and pan-assay interference compounds (PAINS) filters. Then, top hits were chosen based on their strong binding affinity as determined by molecular docking. Further, interaction analysis was performed to find effective and specific compounds that can precisely bind to the binding pocket of MAPK7. Consequently, two compounds, ZINC12296700 and ZINC02123081, exhibited significant binding affinity and demonstrated excellent drug-like properties. All-atom molecular dynamics simulations for 200 ns confirmed the stability of MAPK7-ZINC12296700 and MAPK7-ZINC02123081 docked complexes. According to the molecular mechanics Poisson-Boltzmann surface area investigation, the binding affinities of both complexes were considerable. Overall, the result suggests that ZINC12296700 and ZINC02123081 might be used as promising leads to develop novel MAPK7 inhibitors. Since these compounds would interfere with the kinase activity of MAPK7, therefore, may be implemented to control cell growth and proliferation in cancer after required validations.

Resistance Modulation of Individual and Polymicrobial Culture of S. aureus and E. coli through Nanoparticle-Coupled Antibiotics.

Polymicrobial mastitis is now becoming very common in dairy animals, resulting in exaggerated resistance to multiple antibiotics. The current study was executed to find drug responses in individual and mixed Culture of Staphylococcus aureus and Escherichia coli isolated from milk samples, as well as to evaluate the antibacterial potential of tungsten oxide nanoparticles. These isolates (alone and in mixed culture) were further processed for their responses to antibiotics using the disc diffusion method. On the other hand, tungsten oxide WO3 (W) nanoparticles coupled with antibiotics (ampicillin, A, and oxytetracycline, O) were prepared through the chemical method and characterized by X-ray diffraction, scanning electron microscopy (SEM), and UV-visible techniques. The preparations consisting of nanoparticles alone (W) and coupled with ampicillin (WA) and oxytetracycline (WO) were tested against individual and mixed Culture through the well diffusion and broth microdilution methods. The findings of the current study showed the highest resistance in E. coli was against penicillin (60%) and ampicillin (50%), while amikacin, erythromycin, ciprofloxacin, and oxytetracycline were the most effective antibiotics. S. aureus showed the highest resistance against penicillin (50%), oxytetracycline (40%), and ciprofloxacin (40%), while, except for ampicillin, the sensitive strains of S. aureus were in the range of 40-60% against the rest of antibiotics. The highest zones of inhibition (ZOI) against mixed Culture were shown by imipenem and ampicillin, whereas the highest percentage decrease in ZOI was noted in cases of ciprofloxacin (-240%) and gentamicin (-119.4%) in comparison to individual Culture of S. aureus and E. coli. It was noteworthy that the increase in ZOI was not more than 38% against mixed Culture as compared to the individual Culture. On the other hand, there was a significant reduction in the minimum inhibitory concentration (MIC) of nanoparticle-coupled antibiotics compared to nanoparticles alone for individual and mixed-culture bacteria, while MICs in the case of mixed Culture remained consistently high throughout the trial. This study therefore concluded that diverse drug resistance was present in both individual and mixed-culture bacteria, whereas the application of tungsten oxide nanoparticle-coupled antibiotics proved to be an effective candidate in reversing the drug resistance in bacterial strains.

Prevalence of Multidrug-Resistant and ESBL-Producing Bacterial Pathogens in Patients with Chronic Wound Infections and Spinal Cord Injury Admitted to a Tertiary Care Rehabilitation Hospital.

A pressure ulcer is defined as a skin lesion of ischemic origin, a condition that contributes to morbidity and mortality in patients with spinal cord injuries. The most common complication of ulcers is a bacterial infection. Antimicrobial therapy should be selected with caution for spinal cord injury patients since they have a high risk of developing multidrug-resistant (MDR) infections. The aim of this study was to determine the prevalence of different bacterial pathogens in patients with pressure ulcers admitted with spinal cord injuries. This was a retrospective single-center study that included adult patients aged 18 years and above, admitted with chronic pressure wounds after a spinal cord injury requiring hospitalization between 2015 and 2021. A total of 203 spinal cord injury patients with pressure ulcers were included in the study. Ulcers were commonly infected by Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli, and they were mostly located in the sacral and gluteal areas. More than half of the bacteria isolated from patients were sensitive to commonly tested antibiotics, while 10% were either MDR- or pan-drug-resistant organisms. Of the MDR bacterial isolates, 25.61% were methicillin-resistant S. aureus, and 17.73% were extended-spectrum beta-lactamase Enterobacteriaceae. The most prevalent bacteria in pressure ulcers of spinal cord injury patients were S. aureus. Other antibiotic-resistant organisms were also isolated from the wounds.

Azithromycin Treatment for Acne Vulgaris: A Case Report on the Risk of Clostridioides difficile Infection.

BACKGROUND Clostridium difficile (C. difficile) is a gram-positive, anaerobic, spore-forming bacillus. It can lead to pseudomembranous colitis characterized by electrolyte disturbances, toxic megacolon, and septic shock. The risk of C. difficile infection is higher with use of certain classes of antibiotics, or when an antibiotic used for a long time. Azithromycin is a macrolide antibiotic known to be safe, with few adverse effects such as diarrhea, stomach pain, and constipation. Azithromycin is currently used for the treatment of acne, with different dosing regimens for patients who cannot receive traditional treatment based on practice guidelines. CASE REPORT A 41-year-old woman was treated with a course of azithromycin 500 mg by mouth 3 times weekly for 6 weeks for acne vulgaris. This was her second antibiotic course of acne treatment within 10 months. A few days after completion of the second azithromycin course, she presented to the clinic with worsening abdominal pain and frequent soft bloody stool. A complete blood count test, C. difficile toxin test, stool culture, and colonoscopy were ordered. She was diagnosed with C. difficile infection confirmed by C. difficile toxin and symptoms. CONCLUSIONS Despite the safety profile of azithromycin, our patient was predisposed to a non-severe case of C. difficile-associated diarrhea, most likely due to the repeated course of the azithromycin regimen that was used to treat her acne vulgaris. This report highlights the importance of managing patients with acne vulgaris according to current practice guidelines, and to report a link between the use of azithromycin as an acne treatment and the occurrence of C. difficile colitis.

Evaluation of Physicians' Compliance With Secondary Prevention Among Ischemic Stroke Patients: A Retrospective Study.

Background: Stroke is a leading cause of disability and death worldwide. Globally, stroke affects 13.7 million individuals every year. Several studies have shown an increase in the rehospitalization rate among stroke patients caused by non-adherence to secondary prevention as recommended by the American Heart Association/American Stroke Association (AHA/ASA) guideline. The aim of this study was to evaluate physicians' compliance with secondary prevention of stroke upon patients' discharge. Methods: A retrospective chart review study was conducted at King Fahad Medical City. The primary outcome of this study was the number of patients discharged with the recommended medications for the secondary prevention of ischemic stroke (IS). The data were collected from the patient's medical record files and analyzed using the Statistical Package for the Social Sciences (SPSS). Results: Of the 675 patients who were screened for eligibility, 507 were included and 168 were excluded. The mean age of the patients was 59.5 (± 15.6) years. Of the 507 patients, 181 (35.7%) had a history of previous stroke. Overall, 376 (74%) stroke patients were discharged with appropriate secondary prevention recommendation per AHA/ASA guideline. Conclusions: This study stresses the importance of compliance with the AHA/ASA guideline for secondary stroke prevention and highlights the role of pharmacists in the stroke unit in which it is necessary to ensure that all stroke patients are discharged with the recommended medications to reduce recurrent stroke.

The remission rate, metabolic changes, and quality of life assessment among patients with type 2 diabetes post-bariatric surgery in Riyadh, Saudi Arabia: A cross-sectional study.

OBJECTIVES: To assess the remission rate, metabolic changes, and quality of life after bariatric surgery among Saudi patients with type 2 diabetes (T2DM). METHODS: This cross-sectional study was conducted in 2 main centers in the Riyadh, Saudi Arabia. The study included patients with T2DM who underwent either laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB) surgery from 2014 to 2018. The remission rate was defined based on the American Diabetes Association (ADA) and the International Diabetes Federation (IDF) criteria. Quality of life was assessed using the World Health Organization Quality of Life (WHOQOL)-BREF. RESULTS: A total of 232 patients were included with a mean age of 44.3 ± 10.3 years. 93.4% of the patients had LSG, while only 6.6% had RYGB surgery. Among patients who underwent either LSG or RYGB surgery, there was a significant improvement in metabolic and glycemic markers compared to the baseline. According to the ADA criteria, 48.5% of the patients had complete remission, while 18.9% had partial remission. Overall, 7% of the patients met the IDF optimization criteria, while 5.7% met the IDF improvement criteria. The mean score for all the QOL domains exceeded 63 ± 13, with the environmental and physical health domains having the highest scores. CONCLUSION: Among Saudi patients, bariatric surgery was associated with high remission rates and a better quality of life.

Doxycycline's Potential Role in Reducing Thrombosis and Mortality in Critically Ill Patients With COVID-19: A Multicenter Cohort Study.

Doxycycline has revealed potential effects in animal studies to prevent thrombosis and reduce mortality. However, less is known about its antithrombotic role in patients with COVID-19. Our study aimed to evaluate doxycycline's impact on clinical outcomes in critically ill patients with COVID-19. A multicenter retrospective cohort study was conducted between March 1, 2020, and July 31, 2021. Patients who received doxycycline in intensive care units (ICUs) were compared to patients who did not (control). The primary outcome was the composite thrombotic events. The secondary outcomes were 30-day and in-hospital mortality, length of stay, ventilator-free days, and complications during ICU stay. Propensity score (PS) matching was used based on the selected criteria. Logistic, negative binomial, and Cox proportional hazards regression analyses were used as appropriate. After PS (1:3) matching, 664 patients (doxycycline n = 166, control n = 498) were included. The number of thromboembolic events was lower in the doxycycline group (OR: 0.54; 95% CI: 0.26-1.08; P = .08); however, it failed to reach to a statistical significance. Moreover, D-dimer levels and 30-day mortality were lower in the doxycycline group (beta coefficient [95% CI]: -0.22 [-0.46, 0.03; P = .08]; HR: 0.73; 95% CI: 0.52-1.00; P = .05, respectively). In addition, patients who received doxycycline had significantly lower odds of bacterial/fungal pneumonia (OR: 0.65; 95% CI: 0.44-0.94; P = .02). The use of doxycycline as adjunctive therapy in critically ill patients with COVID-19 might may be a desirable therapeutic option for thrombosis reduction and survival benefits.

Severe Neutropenia and Hepatotoxicity After Carbimazole Drug Therapy for Hyperthyroidism in a Pediatric Patient: A Case Report.

BACKGROUND Hyperthyroidism is an overproduction of thyroid hormones. Carbimazole is an anti-thyroid medication used to treat hyperthyroidism in adults and children. It is a thionamide associated with rare adverse effects such as neutropenia, leukopenia, agranulocytosis, and hepatotoxicity. Severe neutropenia is a life-threatening event characterized by a sharp drop in absolute neutrophil count. Severe neutropenia can be treated by discontinuation of the precipitating medication. Administration of granulocyte colony-stimulating factor provides longer protection against neutropenia. Elevated liver enzymes indicate hepatotoxicity, which usually normalize after discontinuation of the offending medication. CASE REPORT A 17-year-old girl was treated with carbimazole since the age of 15 for hyperthyroidism secondary to Graves' disease. She initially received 10 mg of carbimazole orally twice daily. After 3 months, the patient's thyroid function reflected residual hyperthyroidism and was then up-titrated to 15 mg orally in the morning and 10 mg orally in the evening. She presented to the emergency department reporting fever, body aches, headache, nausea, and abdominal pain for 3 days. She was diagnosed with severe neutropenia and hepatotoxicity induced by carbimazole after 18 months of dose modification. CONCLUSIONS In hyperthyroidism, it is important to maintain patients in a euthyroid state for a long period to minimize the autoimmunity and hyperthyroid relapse, which often requires long-term use of carbimazole. However, severe neutropenia and hepatotoxicity are rare and serious adverse effects of carbimazole. Clinicians should be aware of the importance to discontinuation of carbimazole, administration of granulocyte colony-stimulating factors, and supportive treatment to reverse the consequences.

Effect of an antimicrobial stewardship program in the prevention of antibiotic misuse in patients with spinal cord injury undergoing minor urologic procedures: a single-group, quasi-experiment study.

BACKGROUND: Antimicrobial stewardship programs (ASPs) are an internationally recognized strategy for reducing antimicrobial resistance while maintaining patient safety. ASP activities include the restriction of broad-spectrum antibiotics, the establishment of hospital guidelines based on antibiograms, and the promotion of appropriate antibiotic use. This study aimed to determine whether the implementation of antimicrobial stewardship practices improved the effects of a peri-procedure antibiotic prophylaxis prescribed by urologists for patients with spinal cord injury/disease (SCI/D) undergoing minor urological procedures at a tertiary care hospital. METHODS: This single-group, quasi-experiment study included adult patients with SCI/D who required minor urological procedures (cystoscopy, cytobotox, cystolitholapaxy, and urodynamic study) and who were hospitalized between 2012 and 2020. RESULTS: In total, 233 patients were included in each of the pre- and post-ASP implantation groups. There was a significant reduction in antibiotic use among patients who received a pre-procedure antimicrobial prophylaxis in the post- compared to the pre-implementation group (45.9% vs. 24.46%, p < 0.0001), and there was a highly significant reduction in the post- compared to the pre-implementation group in the number who received a post-procedure prophylaxis (16.7% vs. 1.2%, p < 0.0001). CONCLUSION: ASP implementation is a highly effective strategy for reducing the use of peri-procedure antimicrobial prophylaxes in patients with SCI/D injuries undergoing minor urological procedures.

Simulation-Based Education Implementation in Pharmacy Curriculum: A Review of the Current Status.

Simulation-based education (SBE) is a fundamental teaching method that complements traditional teaching modalities. SBE has improved students' knowledge, understanding, and numerous essential skills within undergraduate pharmacy education, similar to traditional teaching methods. However, SBE has become crucial for developing students' teamwork, decision-making, and communication skills. Even though the Accreditation Council for Pharmacy Education (ACPE) has acknowledged the benefit of SBE in interprofessional education (IPE) and the introductory pharmacy practice experience (IPPE). This article provides evidence that SBE can be effective beyond that. This narrative review is focused on the literature related to SBE modalities and the assessment methods of student learning outcomes in the undergraduate pharmacy curriculum. The review illustrates that SBE is an effective teaching method that could be utilized within the pharmacy curriculum. The review also could help pharmacy educators decide on the best modality and placement of integrating patient simulation within the pharmacy curriculum. Combining multiple simulation techniques may be the best way to achieve the desired student learning outcomes.

The safety and effectiveness of tocilizumab in older adult critically ill patients with COVID-19: a multicenter, cohort study.

OBJECTIVES: Evidence supports tocilizumab (TCZ) benefit and safety in adult patients with severe COVID-19. However, its effectiveness in critically ill older adult patients remains questionable. Thus, the study aimed to evaluate the safety and effectiveness of TCZ in older critically ill patients with COVID-19. METHODS: A multicenter, retrospective study for all critically ill older adults (aged ≥65 years) with confirmed COVID-19 infection and admitted to the intensive care units (ICUs). Eligible patients were categorized into two groups based on TCZ use during ICU stay (control vs TCZ). Propensity score (PS) matching was used (1:1 ratio) based on the selected criteria. The primary outcome was the in-hospital mortality. RESULTS: A total of 368 critically ill older adult patients were included in the study. Fifty one patients (13.8%) received TCZ. The in-hospital mortality was lower in the TCZ group (HR 0.41; 95% CI 0.22-0.76, P-value = 0.005). Patients who received TCZ had lower odds of respiratory failure requiring mechanical ventilation (OR [95% CI]: 0.32 [0.10-0.98], P-value = 0.04). No statistically significant differences were found between the two groups for 30-days mortality, ventilator-free days, length of stay, and complications during ICU stay. CONCLUSION: Tocilizumab use in critically ill older adult patients with COVID-19 is associated with lower in-hospital mortality and a similar safety profile.

Distance Education During COVID-19 Pandemic: A College of Pharmacy Experience.

PURPOSE: This study aimed at describing the experience of academic staff and students with distance education, during the COVID-19 pandemic, at a college of pharmacy in Saudi Arabia. METHODS: This study used a mixed-method approach. The first phase implemented a survey that targeted both academic staff and students to evaluate their experiences with distance education during the COVID-19 pandemic. Then, a focus group discussion was conducted to explore, in-depth, their experience. The survey consisted of five domains as follows: readiness for the shift to distance education during the full and partial lockdown, perception towards distance education, barriers against distance education, and the acquisitions due to distance education. A five-point Likert scale was used to assess participants' responses to the different domains (mean score ± standard deviation). RESULTS: Seventy-eight percent of the academic staff and 65% of the students responded to the survey. Participants' views were positive for readiness for the shift to distance education during the full lockdown (3.89±0.42 for academic staff and 3.82±0.50 for students) with almost similar evaluation for the readiness during the blended learning period (3.91±0.44 for staff and 3.83±0.59 for students). The findings showed a generally positive perception towards distance education (3.59± 0.67 for academic staff and 3.47±0.64 for students). The acquisitions due to distance education were also positive (3.95±0.72 for academic staff and 3.78±0.77 for students). Nonetheless, some barriers that affected distance education were raised with an overall neutral view from both academic staff (3.31±0.72) and students (3.31±0.64), with different responses for the individual items. Qualitative findings from the focus group discussions explored the strengths, weaknesses, opportunities, and challenges, with emphasis on the areas for improvement. CONCLUSION: Although the shift for distance education was out of a sudden, participants showed overall positive views about their experience with distance education and highlighted areas for improvement.