Low plasma vitamin D is associated with increased 28-day mortality and worse clinical outcomes in critically ill patients.

BACKGROUND & OBJECTIVE: Patients in the intensive care unit have a high prevalence of vitamin D deficiency (VDD). In the present study, clinical outcomes in the ICU were analyzed with vitamin D status. MATERIALS AND METHODS: In this prospective, multicenter study, sampling was conducted on seven ICUs in three hospitals. Within the first 24 h of ICU admission, patient's serum vitamin D levels were measured, and their disease severity was monitored using the scores of acute physiologic assessment and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), and the modified Nutrition Risk in Critically ill (mNUTRIC) score. RESULTS: A total of 236 patients were enrolled in this study, of which 163 (69.1%) had lower vitamin D levels than 20 ng/ml upon ICU admission. The patients with VDD had higher APACHE II scores)P = 0.02), SOFA scores (P < 0.001), and mNUTRIC scores (P = 0.01). Patients with sufficient levels of vitamin D (> 30 ng/ml) had a shorter stay at ICU (P < 0.001). VDD was independently associated with 28-day mortality (OR: 4.83; 95% CI: 1.63-14.27; P = 0.004). CONCLUSION: The data showed that VDD was common among the critically ill and was related to a more severe course of illness and a higher mortality rate.

The effect of threshold inspiratory muscle training on the duration of weaning in intensive care unit-admitted patients: A randomized clinical trial.

Background: The purpose of this study was to evaluate the effect of threshold inspiratory muscle training (IMT) on the duration of weaning in intensive care unit (ICU)-admitted patients. Materials and Methods: This randomized clinical trial enrolled 79 ICU-admitted, mechanically ventilated patients in 2020-2021 in Imam Reza Hospital, Mashhad. Patients were randomly divided into intervention (n = 40) and control (n = 39) groups. The intervention group received threshold IMT and conventional chest physiotherapy, while the control group only received conventional chest physiotherapy once a day. Before and after the end of the intervention, the strength of inspiratory muscles and the duration of weaning were measured in both the groups. Results: The duration of weaning was shorter in the intervention group (8.4 ± 1.1 days) versus the control group (11.2 ± 0.6 days) (P < 0.001). The rapid shallow breathing index decreased by 46.5% in the intervention group and by 27.3% in the control group after the intervention (both P < 0.001), and the between-group comparison showed a significantly higher reduction in the intervention group than control group (P < 0.001). The patients' compliance after the intervention compared to the 1st day increased to 16.2 ± 6.6 in the intervention group and 9.6 ± 6.8 in the control group (both P < 0.001), and the between-group comparison showed a significantly higher increase in the intervention group than control group. The maximum inspiratory pressure increased by 13.7 ± 6.1 in the intervention group and by 9.1 ± 6.0 in the control group (P < 0.001). Furthermore, the weaning success was 54% more probable in the intervention group than control group (P < 0.05). Conclusion: The results of this study showed the positive effect of IMT with threshold IMT trainer on increased strength of respiratory muscles and reduced weaning duration.

Molecular and cellular mechanisms of the effects of Propolis in inflammation, oxidative stress and glycemic control in chronic diseases.

Propolis is a sticky, resinous material gather from plants and is blended with wax and other constituents. It is reported to have anti-inflammatory, anti-oxidative and blood glucose-lowering properties. This review aims to summarise evidences for the cellular and molecular mechanism of Propolis in inflammation, oxidative stress, and glycemic control. Propolis stimulate the production and secretion of anti-inflammatory cytokines and to inhibit the production of inflammatory cytokines and due to its various antioxidant and poly-phenolic compounds may has a role in control and treating some of the chronic diseases. Most studies have shown that Propolis may affect metabolic factors including plasma insulin levels, and it has proposed that it could be used in the prevention and treatment of T2D Mellitus. In general, to demonstrate the definite effects of Propolis on chronic diseases, more studies are required using larger sample sizes and various doses of Propolis, using better characterized and standardized agents.

Application of methylene blue -vitamin C -N-acetyl cysteine for treatment of critically ill COVID-19 patients, report of a phase-I clinical trial.

COVID-19 is a global catastrophic event that causes severe acute respiratory syndrome. The mechanism of the disease remains unclear, and hypoxia is one of the main complications. There is no currently approved protocol for treatment. The microbial threat as induced by COVID-19 causes the activation of macrophages to produce a huge amount of inflammatory molecules and nitric oxide (NO). Activation of macrophages population into a pro-inflammatory phenotype induces a self-reinforcing cycle. Oxidative stress and NO contribute to this cycle, establishing a cascade inflammatory state that can kill the patient. Interrupting this vicious cycle by a simple remedy may save critical patients' lives. Nitrite, nitrate (the metabolites of NO), methemoglobin, and prooxidant-antioxidant-balance levels were measured in 25 ICU COVID-19 patients and 25 healthy individuals. As the last therapeutic option, five patients were administered methylene blue-vitamin C-N-acetyl Cysteine (MCN). Nitrite, nitrate, methemoglobin, and oxidative stress were significantly increased in patients in comparison to healthy individuals. Four of the five patients responded well to treatment. In conclusion, NO, methemoglobin and oxidative stress may play a central role in the pathogenesis of critical COVID-19 disease. MCN treatment seems to increase the survival rate of these patients. Considering the vicious cycle of macrophage activation leading to deadly NO, oxidative stress, and cytokine cascade syndrome; the therapeutic effect of MCN seems to be reasonable. Accordingly, a wider clinical trial has been designed. It should be noted that the protocol is using the low-cost drugs which the FDA approved for other diseases. TRIAL REGISTRATION NUMBER: NCT04370288.

Family participation in the care of older adult patients admitted to the intensive care unit: A scoping review.

BACKGROUND: Family members' participation in care is internationally advocated as a way to improve patient outcomes admitted to the intensive care unit (ICU). OBJECTIVE: to provide an overview of current understandings about family participation in the care of older adult patients admitted to ICU. DESIGN, DATA SOURCES, AND METHODS: The Arksey and O'Malley's framework for scoping review was used. We searched PubMed, CINAHL, EmBase, Scopus, and Cochrane from their inception until 10 October 2019 to answer this question: What are the dimensions, prerequisites, facilitators, barriers, and consequences of family member's participation in the care of older adult patient admitted to ICU? RESULTS: Of 3410 search results, 33 articles were included (10 descriptive; 3 interventional or quality improvement project; 12 qualitative; 5 reviews; 1 expert opinion; 1 evidence-practice recommendation and 1 clinical guideline). The included studies were conducted internationally (n = 7), USA (n = 8), Canada (n = 3), France (n = 2), Britannia, Australia (n = 6), (n = 2), and Sweden (n = 5). No article from Asian and African countries was retrieved. The supporting level of evidence for most studies (28 out of 33) was low. CONCLUSIONS: This review showed that family members could participate in the provision of physical and non-physical care (emotional, mental, cognitive, and psychosocial) to older adult patients admitted to ICU. Their participation in ICU care has the potential to improve the physical, emotional, psychological and psychological outcomes of older adult patients and their family members as well as reduce the burden of the healthcare system. The barriers were grouped into patient-related factors, ICU staff-related factors, family-related factors, and ICU setting-related factors. In addition, several facilitators of participation in ICU care were discussed. THE IMPLICATION FOR FUTURE RESEARCH: This review showed a lack of experimental studies on the effectiveness of family members' participation in ICU care for the patient, family, and care system. This provides an opportunity for future research to develop and test interventions based on the multiple dimensions described in this paper.

Allopurinol and Loss of Consciousness in a 78-old Year Man Suffering from Gout.

Allopurinol is an FDA -Approved xanthine oxidase inhibitor, which is effective in the treatment of gout, hyperuricemia and uremic kidney stones in patients with an increased level of uric acid excretion. Xanthine oxidase acts by converting hypoxanthine and xanthine into uric acid, and therefore its inhibition results in decreased production of uric acid. The most common side effects of this medication are as follows: maculopapular rashes, hives, itching, headache, dizziness, abnormal hair loss, fever and hypersensitivity reaction. Case Presentation: This report represents a case of drug-induced meningitis of a senile man who ended up in the ICU due to the remarkably reduced state of consciousness.

Challenges and Barriers to Providing Care to Older Adult Patients in the Intensive Care Unit: A Qualitative Research.

BACKGROUND: Enhancing the quality of care for elderly patients needs an understanding of the challenges and obstacles experienced by the intensive care unit (ICU) staff in providing care. AIM: To explore the most challenging issues experienced by ICU staff, in particular, nurses, in the care of elderly patients in the general adult ICU. DESIGN: A qualitative research design was employed. The Standards for Reporting Qualitative Research (SRQR) were followed. METHODS: Based on theoretical sampling, we carried out 34 in-depth semi-structured interviews from two medical adult ICUs. Data analysis was carried out using qualitative conventional content analysis. RESULTS: Data analysis led to the identification of three interrelated categories and 12 subcategories. Three main categories were factors related to nurses' attitude in elderly care, factors related to the system of care, and factors related to the models of patient care delivery. These categories came under the main theme of "Inappropriate and unfair system for elderly care". CONCLUSION: The findings of this study increase scholarly understanding of challenges and barriers to providing care to elderly patients in the general adult ICU. We found that the provision of care to elderly patients is inappropriate and unfair. Various obstacles must be overcome to improve the care of these patients. For example, negative attitudes toward elder care, inappropriate environments, lack of resources, lack of knowledge and skills, a specialized model of care delivery, respect for humanity, care without considering patient age, and separating professional conflicts from patient care. These findings may be used by ICU's caregivers and managers to improve the quality of care. IMPLICATIONS FOR PRACTICE: Various obstacles were documented that need to be overcome by hospital administrators, nursing managers, clinical nurses, nursing educators, nursing researchers to improve the care of elderly patients admitted to ICU.

A Healthy Young Woman with Acute Respiratory Distress Syndrome: an unfamiliar face of a familiar disease.

The presented case features a rare manifestation of pulmonary tuberculosis in a previously healthy young woman who had acute presentation of tuberculous pneumonia complicated by acute respiratory distress syndrome. In developing countries, mycobacterium tuberculosis is an important cause of community-acquired pneumonia (CAP). TB can present as an acute process and should be included in the differential diagnosis of CAP. This case is special in its manifestation from several clinical perspectives, including the lack of an underlying medical condition or immune defect and the development of acute respiratory distress syndrome (ARDS) in non-miliary and non-disseminated tuberculosis. In conclusion, the diagnosis of TB should be considered in all patients who present with CAP in endemic regions.

A cadaver study of the structures and positions of the anterior cruciate ligament in humans.

BACKGROUND: The anterior cruciate ligament (ACL) is one of the major knee structures. It consists of anteromedial bundle (AMB) and posterolateral bundle (PLB). Rupture of the ACL is one of the most prevalent traumas among athletes. There are two ways to reconstruct the rupture; Single-bundle and double-bundle (DB) reconstruction. Precise study on bundles anatomy, the exact number of attachments and knee flexion angle with an appropriate place of bundles and also choosing the best angle for the grafts are so important in successful reconstructing of the bundles. In this research, the general attempt was to assess anatomy and the act of the ACL is and bundles in Iranian population. METHODS: We obtained twelve fresh-frozen cadaver knees (two females, ten males). The average age of them was 30 years; they were mostly between 27 and 34 years old. Initially, skin, muscles, and patellar and articular capsule were removed. Then, bundle attachments, knee movements in flexion angle, extension and stiffness of both bundles were evaluated. Thereafter, on 0, 30, 60, 90, 120, and 180° angle knee flexion the bundles degree stiffness evaluated in different directions. During the process, to measure bundles size, digital camera for photography, oblique for measuring the angles, and micrometer were utilized. From all next of kin written consent testimonial form was obtained. RESULTS: In all knees, two bundles were identified as distinct. AMB attachment location in the anterior region observed as semi-lunate and in one case, it was rounded. In all cases, two bundles of full knee extension were paralleled, and the AMB was anterior to the PLB; with increasing flexion angle, femoral attachment location of AMB was in back direction and femoral attachment location of PLB moved toward the front direction. Two bundles were in the most amount of cross state, which the angle was 90°. From the stiffness point of view in all 6 samples, the PLB had the most tension in extension state, and the AMB had the most tension in 120° flexion. CONCLUSION: In the current study, we realized that the ACL is a DB ligament in Iranian population. The AMB in full extension has the least stiffness and in 90° flexion has the most; the PLB also in full knee extension and in 160° flexion has the most and least stiffness, respectively.

Timing of Anterior Cruciate Ligament Reconstruction and Incidence of Meniscal and Chondral Injury within the Knee.

BACKGROUND: To review a single-surgeon series of 616 athletic patients with anterior cruciate ligament reconstructions in order to evaluate the relationship between the timing of the reconstruction and the incidence of meniscal and chondral injuries. METHODS: SIX GROUP OF PATIENTS WERE CATEGORIZED BASED ON THE TIME INTERVAL FROM THEIR INJURY TO SURGERY IN THE FOLLOWING MANNER: <3 months, 3-6 months, 6-9 months, 9-18 months, 18-36 months, and >36 months. The presence of meniscal tears was documented and chondral pathology was scored based on the Outerbridge classification. RESULTS: Incidence of medial meniscus tear was significantly higher in patients undergoing reconstruction after 3 months from their injury (P = 0.032). The opportunity of patients with chondral pathology was recorded to be significantly higher in the groups operated on after 6 months from their injuries time (P = 0.008). CONCLUSIONS: Considering the effect of time on the rate of having meniscus injury and chondral pathology, reducing the time between the injury and surgery could improve the long-term health outcomes in this population.