A Retrospective Chart Review to Determine Hypophosphatemia Incidence and Phosphorus Supplementation Requirements in Patients With Severe Thermal Cutaneous Injuries Receiving High-Volume Hemofiltration.

Patients with severe thermal injuries have increased metabolic demands necessitating frequent phosphate supplementation. Patients with acute renal failure may have less requirements, due to reduced elimination. However, patients being supported with renal replacement therapy have varying degree of requirements. Little published evidence depicts the incidence of hypophosphatemia and repletion requirements in patients with severe thermal injuries treated with high-volume hemofiltration (HVHF) and a high-flux membrane. The objective of this retrospective chart review was to determine the incidence of hypophosphatemia and characterize repletion requirements and response in this population. Enrolled patients had at least 20% TBSA thermal injuries and required continuous hemofiltration with prefilter replacement fluid doses ≥35 mL/kg IBW/hr. A randomly selected cohort without acute kidney injury (AKI) and matched based on age and extent of TBSA was used to compare phosphorus requirements over an initial 14-day period. Demographics, diet, and variables affecting phosphorus concentrations were collected. Sixteen patients were included in the retrospective HVHF group and 16 patients in a case-control cohort to better depict the impact of HVHF. The average age was 60.2 ± 15.1 years and median TBSA was 30% (23.4, 56.3) in the HVHF group, compared to 53.3 ± 16.4 years (P = .22) and TBSA 29% (26.4, 33.9; P = .73). All patients in the HVHF group were started on HVHF with a 1.6 m2 polyethersulfone membrane for AKI. As expected, the HVHF group exhibited statistically higher than normal baseline potassium and phosphorous laboratory values. The HVHF group experienced more days with hypophosphatemia (49.6 ± 12.4% vs 29.3 ± 16.3%, P = .012), despite 0.75 mmol/kg/day phosphorous supplementation (compared to 0.66 mmol/kg/day for the control group, P = .45). Patients with longer durations of HVHF therapy experienced increasing risk of hypophosphatemia, reaching 100% by the end of the study period. This study demonstrates severe thermally injured patients receiving HVHF for AKI are at increased risk for hypophosphatemia, and require high phosphate supplementation.

Spatial Association of Environmental and Dietary Factors with COPD Deaths.

Introduction: Chronic obstructive pulmonary disease (COPD) remains a significant health concern globally and spatiotemporal investigations on the etiology and progression of COPD are needed to develop more effective and timely preventive measures. To address this continuing need, we explored the association of air-quality and meteorological markers, fruit and vegetable consumption and drinking water source trajectories with COPD death rate. Methods: For 81 provinces of Turkey, we extracted and merged data in four dimensions: provincial COPD deaths, provincial annual meteorological and air-quality markers, drinking water source data covering rivers, dams, wells, and springs, and annual provincial fruits and vegetables consumption. To investigate the association of these markers with COPD deaths, we used a spatial modelling approach accounting for the spatial autocorrelation. Results: Controlling for household expenditure on cigarette and alcohol and elderly population size, our models suggest that provinces with higher consumption of lemon and higher temperature reported lower level of COPD deaths and provinces high in Nitrogen Dioxide concentration reported higher COPD deaths on average. Conclusion: Therefore, provinces with such profiles need to develop closer screening and follow-up of patients with COPD and encourage healthier diets and lifestyles.

Analysis of Ceftazidime/Avibactam Use for Treating Carbapenem-Resistant Infections in Critically Ill Patients With Thermal or Inhalation Injuries.

Rising antimicrobial resistance is a pressing public health concern. An increase in carbapenem-resistant organisms has led to increased use of novel antibiotics, such as ceftazidime/avibactam (CZ/AV). However, recent studies have shown increasing treatment failures and resistance rates associated with ceftazidime/avibactam use. The efficacy of CZ/AV has not been studied in patients with thermal or inhalation injuries, where pharmacokinetic derangements are common and patients are often subject to longer lengths of stay and several antimicrobial courses that may lead to higher resistance rates. The objective of this study was to evaluate the outcomes of patients with thermal and inhalation injuries including clinical success, the frequency of adverse effects, and emergence of resistance. In the 17 courses of CZ/AV evaluated, clinical success occurred in 71% (12/17) of courses. Enterobacter cloacae was the most commonly treated pathogen. Resistance developed in 18% (3/17) of courses, but follow-up sensitivities were not evaluable for every case. Although lower than desired, clinical success rates in this sample were similar to other reported populations treated with CZ/AV. However, the emergence of resistance occurred more frequently and was likely underreported in this sample. Although limited by its small sample size, this study emphasizes the concern of growing antimicrobial resistance among even novel antibiotics. Resistance can develop during the initial course, stressing the importance of infection prevention and antimicrobial stewardship. Furthermore, attention and resources should be given to proper pharmacokinetic analysis of medications given in severely ill, hypermetabolic populations.

A non-inferiority study comparing efficacy of preoperative prophylactic antibiotics for preventing infectious complications in patients with less severe burns.

While international burn injury guidelines discourage prophylactic antibiotics on admission, current surgery guidelines focusing on antimicrobial prophylaxis place thermal injury under a general plastics procedure umbrella, and require significant evidential extrapolation. The purpose of this study was to determine if withholding systemic antibiotics in patients with <20% total body surface area (TBSA) burns without invasive wound infections and undergo wound excision is non-inferior to patients that receive preoperative antibiotics. Success was defined as lack of graft loss, bacteremia, or surgical site infection. One-thousand and eighty-three patients were screened and 100 patients undergoing 133 operations remained after exclusions. Seventy-four percent were male. Median age and %TBSA was 41 years (30, 55) and 5 (1.5, 8.3), respectively. We found no differences in demographics between patients that did and did not receive preoperative antibiotics. The success rates were 81.7% and 84.3%, respectively. There was one clinically significant bacteremia in each group. Withholding preoperative antibiotics was non-inferior with a percent difference of 2.6 (95% CI; -10.4, 15.6). Patients that did not receive antibiotics were no more likely to incur infection-related complications. In patients with <20% TBSA burns and without active wound infections, withholding preoperative systemic antibiotics will preserve unneeded antimicrobial exposure without increasing risk of infection-related complications.

Simplified Approach to Incorporating Glycemic Response Within a Continuous Insulin Infusion Algorithm to Improve the Incidence of Hypoglycemia in a Single Burn Center.

Attaining adequate glycemic control in burn patients has been shown to reduce infection-related mortality. Previous internal evaluation of continuous insulin infusion (CII) use revealed a hypoglycemia rate of 0.6% and an average time within goal glycemic range (70-149 mg/dl) of 13.8 h/day. A new algorithm, designed to adjust dosage based on glycemic response, underwent six iterations over 2 years before the final version was implemented. The purpose of this retrospective study was to assess the post-implementation performance of the newly developed CII algorithm. The current study was powered to detect a 50% reduction in hypoglycemic events, as compared to a pre-implementation historical control. The cohort was 62% male with a mean age of 54.5 ± 17.4. Sixty-five percent had thermal injuries with a median 23.5 (11-45) %TBSA. There were no differences in demographics between groups. Among the 20 records reviewed, 5239 point-of-care glucose values were assessed. Post-implementation, hypoglycemia rates were significantly lower (0.6% vs 0.2%; P < .001). There was no difference in median blood glucose between groups (149.9 vs 146.5 mg/dl; P = .56). Time spent within goal glycemic range was not significantly different (13.8 vs 14.7 h/day; P = 0.23). There were no differences in infection, length of stay, or survival. The consolidation, education, and implementation of a single, dynamic CII algorithm reduced the incidence of hypoglycemia. The authors expect that education and diligence with follow-up glucose monitoring will further improve time within goal glycemic range by preventing rebound hyperglycemia.

Effect of Leadership Support, Work Conditions and Job Security on Job Satisfaction in a Medical College.

BACKGROUND: Faculty members are crucial elements of an educational institution, and their job satisfaction is likely essential for success of the educational process. Leadership support, work conditions and perceived job security could be factors affecting academic job satisfaction. OBJECTIVE: The aim of the study was to investigate the effect of leadership support, work conditions and perceived job security on the overall academic job satisfaction of faculty. MATERIALS AND METHODS: A cross-sectional survey, using a structured questionnaire, was conducted to determine the effect of leadership support, work conditions and perceived job security on academic job satisfaction among faculty and teaching staff at the College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. Multiple regression analysis was performed to examine the significance of these relationships at 95% confidence interval and P < 0.05 level of significance. RESULTS: Leadership support (ß = 0.187, t = 2.714, P = 0.007), work conditions (ß = 0.199, t = 2.628, P= 0.009) and perceived job security (ß = 0.264, t = 3.369, P = 0.001) were found to be significantly associated with overall academic job satisfaction. CONCLUSION: The results of this study support the hypothesis that faculty and teaching staff working with supportive leaders and favorable work conditions as well as having an optimized sense of perceived job security demonstrate significantly higher levels of overall academic job satisfaction. These findings provide input for policymakers, and their implementation could enhance an institution's vitality and performance, and thus enable it to fulfill its goals.

Unattended Sleep Studies in a VA Population: Initial Evaluation by Chart Review Versus Clinic Visit by a Midlevel Provider.

OBJECTIVES: Obstructive sleep apnea (OSA) is a prevalent disorder that is associated with multiple medical consequences. Although in-laboratory polysomnography is the gold standard for the diagnosis of OSA, portable monitors have been developed and studied to help increase efficiency and ease of diagnosis. We aimed to assess the adequacy of a midlevel provider specializing in sleep medicine to risk-stratify patients for OSA based on a chart review versus a comprehensive clinic evaluation before scheduling an unattended sleep study. METHODS: This study was an observational, nonrandomized, retrospective data collection by chart review of patients accrued prospectively who underwent an unattended sleep study at the Sleep Health Center at the Memphis Veterans Affairs Medical Center during the first 13 months of the program (May 1, 2011-May 31, 2012). A total of 205 patients were included in the data analysis. RESULTS: Analysis showed no statistically significant differences between chart review and clinic visit groups (P = 0.54) in terms of OSA diagnosis. Although not statistically significant, the analysis shows a trend toward higher mean age (50.3 vs 47.4 years; P = 0.10) and lower mean body mass index (34.4 vs 36.0; P = 0.08) in individuals who were evaluated during a comprehensive clinic visit. A statistically significant difference is seen in terms of the pretest clinical probability of OSA being moderate or high in 62.2% of patients in the clinic visit group and 95.7% in the chart review group, with a χ2P ≤ 0.0001. CONCLUSIONS: In the Veterans Health Administration's system, the assessment of pretest probability may be determined by a midlevel provider using chart review with equal efficacy to a comprehensive face-to-face evaluation in terms of OSA diagnosis via unattended sleep studies.

Profile of non-communicable disease risk factors among employees at a Saudi university.

BACKGROUND: There is paucity of studies defining the prevalence of non-communicable disease (NCD) risk factors in Saudi Arabia despite the surging epidemic of obesity, change in dietary habits and sedentary lifestyle. OBJECTIVES: This cross-sectional study aimed to assess the prevalence of NCDs risk factors among employees at King Faisal University in Al Hassa, Saudi Arabia and to determine the possible correlates for clustering of NCDs risk factors among them. MATERIALS AND METHODS: All employees were invited to participate; the World Health Organization STEPwise approach was used for data collection which consisted of a personal interview to collect socio-demographic characteristics, NCD history, tobacco use, vegetables and fruit consumption, and physical activity (PA), followed by anthropometric measurements namely weight, height and waist circumference and blood pressure measurements, subjects were finally subjected to biochemical tests with determination of fasting plasma glucose, serum triglycerides, cholesterol and high density lipoproteins. RESULTS: Of the surveyed employees (n=691), daily current smokers accounted for 22.7%. 94.9%, 95.1% and 86% consumed < 5 servings per day of vegetables, fruits and both fruits and vegetables respectively, 73% were physically inactive, 64% were overweight or obese, 22.1% had hypertension, and 21.5% were diabetics. Elevated cholesterol levels were found in 36.6%, low high density lipoproteins in 36.8%, and elevated triglycerides in 36.1%. Only 3% had no NCD risk factors, and 57.6% had ≥3 factors. Multivariate logistic regression showed that gender (being male, adjusted odds ratio 'aOR'=1.51), aged ≥ 50 years (aOR=3.06), < college education (aOR=1.75), current smokers (aOR=2.37), being obese (aOR=6.96) and having a low PA level (aOR=4.59) were the significant positive predictors for clustering of NCD risk factors. CONCLUSIONS: Over fifty percent of the studied university's employees had multiple (≥3) NCD risk factors. Screening and health promotion initiatives should be launched at least targeting the modifiable factors to avert the excessive risk for cardiovascular disease, diabetes mellitus and several types of cancers.

Surgical biopsy prevented with PET/CT scan in a young female with intrathoracic lymphadenopathy.

Intrathoracic lymphadenopathy is a common clinical problem encountered in Histoplasma endemic zones. It is challenging for clinicians to distinguish the infectious lesions from the neoplastic ones. Bronchoscopy with or without lung sampling and transbronchial needle aspiration (TBNA) is commonly the first diagnostic procedure employed. If non-diagnostic, the next step is usually surgical biopsy. In our experience, a significant number of patients who go for surgical biopsy are diagnosed with histoplasmosis. A positron emission tomography (PET) scan with dual-time imaging may help us distinguish benign from malignant lesions, thus obviating the need for surgical sampling. We report a case of a young female who presented with progressively increasing intrathoracic lymphadenopathy and was treated successfully based on dual-time PET scan results, without proceeding to surgical lung biopsy.

Coenzyme Q10 counteracts testicular injury induced by sodium arsenite in rats.

The protective effect of coenzyme Q10 against testicular toxicity induced by sodium arsenite (10mg/kg/day, orally for two consecutive days) was investigated in rats. Coenzyme Q10 treatment (10mg/kg/day, i.p.) was applied for five consecutive days, starting three days before arsenite administration. Coenzyme Q10 significantly increased serum testosterone level which was reduced by sodium arsenite. Coenzyme Q10 significantly suppressed lipid peroxidation, restored the depleted antioxidant defenses, and attenuated the increases of tumor necrosis factor-α and nitric oxide resulted from arsenic administration. Also, the elevation of arsenic ion, and the reductions of selenium and zinc ions in testicular tissue were mitigated by coenzyme Q10. Histopathological examination showed that testicular injury mediated by arsenic was ameliorated by coenzyme Q10 treatment. Immunohistochemical analysis revealed that coenzyme Q10 significantly decreased the arsenic-induced expression of inducible nitric oxide synthase, nuclear factor-κB, Fas ligand and caspase-3 in testicular tissue. It was concluded that coenzyme Q10 represents a potential therapeutic option to protect the testicular tissue from the detrimental effects of arsenic intoxication.

Coenzyme Q10 treatment ameliorates acute cisplatin nephrotoxicity in mice.

The nephroprotective effect of coenzyme Q10 was investigated in mice with acute renal injury induced by a single i.p. injection of cisplatin (5 mg/kg). Coenzyme Q10 treatment (10 mg/kg/day, i.p.) was applied for 6 consecutive days, starting 1 day before cisplatin administration. Coenzyme Q10 significantly reduced blood urea nitrogen and serum creatinine levels which were increased by cisplatin. Coenzyme Q10 significantly compensated deficits in the antioxidant defense mechanisms (reduced glutathione level and superoxide dismutase activity), suppressed lipid peroxidation, decreased the elevations of tumor necrosis factor-alpha, nitric oxide and platinum ion concentration, and attenuated the reductions of selenium and zinc ions in renal tissue resulted from cisplatin administration. Also, histopathological renal tissue damage mediated by cisplatin was ameliorated by coenzyme Q10 treatment. Immunohistochemical analysis revealed that coenzyme Q10 significantly decreased the cisplatin-induced overexpression of inducible nitric oxide synthase, nuclear factor-kappaB, caspase-3 and p53 in renal tissue. It was concluded that coenzyme Q10 represents a potential therapeutic option to protect against acute cisplatin nephrotoxicity commonly encountered in clinical practice.

Ameliorative effects of telmisartan in diabetic rats with indomethacin-induced gastric ulceration.

The protective effects of telmisartan, the angiotensin II-receptor antagonist, were investigated in rats with type 2 diabetes mellitus exposed to acute gastric ulceration. Following successful induction of diabetes, telmisartan treatment (1 mg/kg/day, orally) was started and continued for 8 weeks, after which acute gastric ulceration was induced by indomethacin. Telmisartan significantly attenuated the hyperglycemia and hypoinsulinemia in diabetic rats. Also, telmisartan significantly reduced the elevations of total gastric acid output, pepsin activity, gastric ulcer index and gastric mucosal tumor necrosis factor-alpha, nitric oxide, malondialdehyde and caspase-3 activity, and restored the depleted antioxidant defenses (reduced glutathione level, and superoxide dismutase and catalase activities) caused by indomethacin administration in diabetic rats. Histopathological gastric tissue damage induced by indomethacin in diabetic rats was ameliorated by telmisartan treatment. Immunohistochemical analysis revealed that telmisartan markedly attenuated the reduction in insulin content of pancreatic islet beta-cells, and prevented the indomethacin-induced overexpression of inducible nitric oxide synthase and nuclear factor-kappaB in gastric mucosa of diabetic rats. It was concluded that telmisartan represents a potential therapeutic option to reduce the risk of gastric ulceration induced by nonsteroidal anti-inflammatory drugs in type 2 diabetic patients.

Nephroprotective effect of telmisartan in rats with ischemia/reperfusion renal injury.

We investigated the protective effect of telmisartan, an angiotensin II receptor antagonist, against ischemia/reperfusion renal injury in rats. Bilateral ischemia was induced by clamping both renal vascular pedicles for 45 min followed by reperfusion for 3 h. Untreated rats exposed to ischemia/reperfusion showed significant elevations in blood urea nitrogen and serum creatinine levels, renal tissue levels of malondialdehyde, tumor necrosis factor-alpha and nitric oxide, and caspase-3 activity. This was associated with significant decreases in renal reduced glutathione level, catalase and superoxide dismutase activities. Also, significant increases in serum and renal tissue levels of homocysteine were detected following ischemia/reperfusion. Pre-ischemic treatment with telmisartan (0.3 mg/kg/day, i.p.) for 7 consecutive days significantly attenuated the increases in blood urea nitrogen, serum creatinine, renal malondialdehyde, tumor necrosis factor-alpha, nitric oxide, caspase-3 activity, and serum and renal homocysteine levels, and significantly restored the renal antioxidant defenses. In addition, light and electron microscopic examinations revealed that telmisartan pre-treatment markedly ameliorated ischemia/reperfusion-induced renal tissue damage. It was concluded that telmisartan, through its antioxidant, anti-inflammatory and antiapoptotic effects, can be considered a potential candidate to protect against acute ischemia/reperfusion renal injury.

Protective effect of hemin against cadmium-induced testicular damage in rats.

The protective effect of hemin, the heme oxygenase-1 inducer, was investigated in rats with cadmium induced-testicular injury, in which oxidative stress and inflammation play a major role. Testicular damage was induced by a single i.p. injection of cadmium chloride (2mg/kg). Hemin was given for three consecutive days (40 micromol/kg/day, s.c.), starting 1 day before cadmium administration. Hemin treatment significantly increased serum testosterone level that was reduced by cadmium. Hemin compensated deficits in the antioxidant defense mechanisms (reduced glutathione, and catalase and superoxide dismutase activities), and suppressed lipid peroxidation in testicular tissue resulted from cadmium administration. Also, hemin attenuated the cadmium-induced elevations in testicular tumor necrosis factor-alpha and nitric oxide levels, and caspase-3 activity. Additionally, hemin ameliorated cadmium-induced testicular tissue damage observed by light and electron microscopic examinations. The protective effect afforded by hemin was abolished by prior administration of zinc protoporphyrin-IX, the heme oxygenase-1 inhibitor. It was concluded that hemin, through its antioxidant, anti-inflammatory and antiapoptotic effects, represents a potential therapeutic option to protect the testicular tissue from the detrimental effects of cadmium.

Overweight and obesity and their relation to dietary habits and socio-demographic characteristics among male primary school children in Al-Hassa, Kingdom of Saudi Arabia.

BACKGROUND: Several studies were carried out to study the prevalence of overweight and obesity among Saudi children, but those assessed the association between eating habits, socio-demographic differentials and obesity in these children are scarce. OBJECTIVES: To assess the magnitude of obesity and overweight among male primary schoolchildren and to find the possible association between obesity/overweight with dietary habits and socio-demographic differentials among them. STUDY DESIGN AND METHODS: A cross-sectional descriptive study including 1,139 Saudi male enrolled in the fifth and sixth grades in public primary schools in Al Hassa, KSA, through a multistage random sampling technique, submitted to interview using Youth and Adolescent Food Frequency Questionnaire, gathering data regarding dietary intake, some dietary habits, followed by anthropometric measurements with calculation of body mass index, the interpretation of which was based on using Cole's tables for standard definition of overweight and obesity. Socio-demographics data were collected through parental questionnaire form. Data analysis was carried out using SPSS 12 (SPSS Inc. Chicago, IL, USA), univariate as well as multivariate analyses were conducted. RESULTS: The age ranged from 10 to 14 years. The prevalence of overweight among the included subjects was 14.2% while obesity was 9.7%, more in urban, older age students, mothers of obese and overweight were less educated, more working. Missing and or infrequent intake of breakfast at home, frequent consumption of fast foods, low servings of fruits, vegetables, milk and dairy product per day, with frequent consumption of sweets/candy and carbonated drinks were all predictors of obesity and overweight among the included male schoolchildren. CONCLUSION: The prevalence of childhood obesity is escalating and approaching figures reported in the developed countries. Less healthy dietary habits and poor food choices may be responsible for this high prevalence.

Assessment of the relationship of hepatic enzymes with obesity and insulin resistance in adults in saudi arabia.

OBJECTIVES: This study was conducted to assess the relationship of hepatic enzymes and serum albumin to obesity and insulin resistance in adults in Saudi Arabia. METHODS: A comparative study of 136 Saudi adults, comprising of 68 obese and 68 non-obese was conducted. Anthropometric measurements, hepatic enzymes, serum albumin, blood glucose, serum insulin, lipid profile, and homeostasis model assessment of insulin resistance (HOMA IR) were measured. RESULTS: The study showed significantly higher levels of gamma glutamyl transpeptidase (GGT), alkaline phosphatase, fasting glucose, serum insulin, and HOMA IR p < 0.001, <0.004 < 0.005, <0.0001, <0.0001, among obese subjects. Hepatic enzymes correlated with both anthropometric measures (body mass index (BMI), and waist to hip ratio) and markers of insulin resistance (HOMA IR, insulin, and fasting glucose). However, the study found that GGT had the strongest associations. Significant inverse correlation was found between serum albumin and BMI, HOMA IR, and serum insulin, p< 0.01, <0.05, <0.01, respectively. CONCLUSION: Deranged liver functions, especially GGT, had the strongest correlations with obesity and HOMA IR. GGT might be a better marker of hepatic pathology associated with obesity and insulin resistance in Saudi adults with restricted alcohol intake. The results also propose that albumin metabolism might be altered in obesity.

Overweight and Obesity and their Association with Dietary Habits, and Sociodemographic Characteristics Among Male Primary School Children in Al-Hassa, Kingdom of Saudi Arabia.

OBJECTIVES: To assess the magnitude of obesity and overweight among male primary school children, and to find the possible association between obesity/overweight and dietary habits and sociodemographic differentials among them. STUDY DESIGN AND METHODS: A cross-sectional descriptive study, including 1139 Saudi male children enrolled in the 5(th) and 6(th) grades in public primary schools in Al Hassa, Kingdom of Saudi Arabia (KSA), was conducted. The test included a multistage random sampling technique, based on interview using Youth and Adolescent Food Frequency Questionnaire, gathering data regarding dietary intake, dietary habits, followed by anthropometric measurements with the calculation of body mass index (BMI), the interpretation of which was based on Cole's tables for the standard definition of overweight and obesity. Sociodemographic data were collected through a parental questionnaire from. Data analysis was performed using the SPSS 12 software (SPSS Inc. Chicago, IL, USA); both univariate and multivariate analyses were performed. RESULTS: The age of the school children ranged from 10-14 years. The prevalence of overweight among the subjects was 14.2%, while that of obesity was 9.7%; the prevalence was more in the urban, older age students. The mothers of obese and overweight children were less educated and more working. Missing and or infrequent intake of breakfast at home, frequent consumption of fast foods, low servings per day of fruits, vegetables, milk and dairy products, with frequent consumption of sweets/candy and carbonated drinks were all predictors of obesity and overweight among the schoolchildren studied. CONCLUSION: The prevalence of childhood obesity is escalating and approaching figures that have been reported till now from the developed countries. Less healthy dietary habits and poor selection of food may be responsible for this high prevalence.