mojtaba mojtahedzadeh

This study aimed to investigate mortality risk factors among severe COVID-19 patients admitted to the intensive care unit (ICU) to inform better management strategies and reduce mortality rates.

A descriptive-analytical, cross-sectional, and retrospective study was conducted between March 2022 and April 2023 at the intensive care unit of Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. The study included patients admitted to the ICU with severe COVID-19. The main variables were demographic factors (age, gender), pre-existing medical conditions (smoking, diabetes, hypertension), disease severity markers (CT-scan scores, inflammatory and coagulation parameters), and mortality outcomes.

The study included 395 eligible patients. The mortality rate was 57.72%, with no significant difference in hospital stay duration between deceased and survived patients. Smoking, diabetes mellitus, and hypertension were significantly associated with higher mortality. Males exhibited a higher mortality rate, although not statistically significant. Patients over 65 years old had significantly higher mortality. Winter showed a significant increase in mortality, likely due to the Omicron subvariant. Higher CT scan scores and elevated inflammatory/coagulation markers correlated with increased mortality risk.

Pre-existing conditions, demographic factors, and disease severity markers are crucial predictors of mortality in severe COVID-19 patients. Tailored interventions targeting these risk factors are essential to improve outcomes.

Obsessive-Compulsive Disorder (OCD) is one of the most common mental disorders that causes many problems in the occupational and social functioning of the patient. In this review article, we have tried to provide a comprehensive study of various areas of this disease, including pathophysiology, diagnosis, and especially OCD treatment strategies. It seems that the optimal treatment option for this disease is drug therapy, and among these, selective serotonin reuptake inhibitors (SSRIs) are of special importance. However, when the severity of the disease is low or moderate, non-pharmacological strategies such as behavioral therapy and sports intervention therapy may be desirable.

According to the American Association of Poison Control Centers (AAPCC), 761 single exposures to the pharmaceutical warfarin were reported in 2021, accounting for more than 10 percent of anticoagulant cases. The cost and mortality caused by warfarin toxicity are very high and usually incurable and fatal. The most important action in the field of warfarin toxicity is to prevent its occurrence. To emphasize how warfarin toxicity occurs, a case is introduced in this regard. A 61-year-old man is found unconscious with a seizure on the street and transported to the hospital by Emergency Medical Services (EMS). In the emergency car, he received a diazepam injection for generalized seizures. His vital signs in the postictal state were as follows: blood pressure 82/44 mmHg, pulse rate 91 bpm, and oxygen saturation (SaO2) 93%. His past medical history includes an ischemic stroke and a myocardial infarction 12 years ago. He underwent Mitral valve repair 11 years ago and a mechanical-type Mitral valve replacement 2 years ago. After undergoing mitral valve replacement surgery, he continued taking warfarin and aspirin for 2 years without consulting a cardiologist or undergoing PT and INR tests. As a result, he suffered a massive intracerebral hemorrhage when his INR level rose above 6. It's important to note that he has no history of depression or suicide attempts. After experiencing decreased consciousness and seizures, he was quickly intubated. A brain CT scan revealed extensive evidence of intracerebral hemorrhage, and he was then transferred to the operating room for craniotomy. To manage the bleeding and because Prothrombin complex concentrate (PCC) was not available, the patient received two grams of fibrinogen, two units of Fresh Frozen Plasma (FFP), 10 mg of vitamin K, and one unit of Packed Red Blood Cells. Unfortunately, after a month-long stay in the ICU, the patient passed away as a result of Ventilator-associated pneumonia (VAP) and sepsis.

Anticoagulation is the cornerstone of preventing thrombosis. Following the aging of society and the greater use of anticoagulant drugs, we see more serious complications in this group. The reduced occurrence of significant bleeding represents a notable benefit of direct oral anticoagulants (DOACs) in comparison to vitamin K antagonists. However, the unavailability of Andexanet alfa and Idarucizumab complicates the management of bleeding associated with DOACs. This case describes a 69-year-old man who presented with massive gastrointestinal bleeding, hemorrhagic shock, and loss of conciseness. He has been taking apixaban 2.5 mg twice a day, aspirin 80 mg once a day, and diltiazem 60 mg three times daily. Bleeding was controlled through transfusion of two units of fresh frozen plasma, five units of packed cell, four units of platelet, and tranexamic acid injection. Although hemorrhagic shock was successfully managed, he unfortunately passed away after three weeks of hospitalization following Ventilator-associated pneumonia and sepsis. In this case, we discuss the importance of the drug interaction of apixaban, diltiazem, and aspirin.

Myasthenic crisis can affect the respiratory muscles in a life-limiting way that requires intubation and mechanical ventilation. This is a case report of a myasthenic crisis in a 61-year-old woman that became complicated following a lack of response to plasmapheresis, intravenous immunoglobulin (IVIG) therapy, and the development of septic shock. The co-occurrence of myasthenic crisis and sepsis is a challenging condition. Many antibiotics cause flare-ups of myasthenia gravis. Infection and sepsis can exacerbate myasthenia. We discuss the successful management of certain unique challenges. To treat sepsis, drugs that may cause deterioration of myasthenia gravis, such as amikacin, ciprofloxacin, colistin, vancomycin, amphotericin B, and voriconazole were prescribed, but eventually the sepsis was cured. After eradicating the infections and stabilizing the patient's hemodynamic, she received rituximab. After 3 weeks of treatment, she responded well to the rituximab, the respiratory failure recovered, and she was extubated and discharged from the ICU after 3 months of hospitalization. This report demonstrates that when the myasthenic patient is under mechanical ventilation, can use even cautionary drugs.

Magnesium is a vital element in the body involved in biochemical and physiological processes. Magnesium deficiency can lead to serious consequences including cardiac, neurological, muscular disorders, and other clinical manifestations. In our country, commonly, magnesium measurement is done by measuring serum magnesium levels. This paper discusses the prevalence and consequences of magnesium deficiency in patients hospitalized in the ICU and emphasizes the importance of diagnosis and treating hypomagnesemia.

Diagnosis of hypomagnesemia is done by measuring serum magnesium, urine magnesium, and magnesium in RBCs. We conducted a prospective study on 30 critically ill patients (14 male, and 16 female) who were admitted to the ICU to examine the prevalence of magnesium deficiency. In eligible patients, after measuring serum and RBC magnesium levels, 7.5 grams of magnesium sulfate in 1000 ml isotonic saline was infused over 8 hours at a rate of 125 ml/hour and urine was collected for 24 hours from the start of the infusion.

The mean age was 71. There was a significant difference between the levels of serum Mg and RBC Mg (U statistic = 266 and P<0.05). The results showed a significant difference between the levels of serum Mg and urinary Mg (U statistic was almost 0 and P<0.05). The results indicated a significant difference between the levels of urinary Mg and RBC Mg (U statistic was almost 0 and P<0.05).

There is no correlation between serum magnesium and the body’s magnesium requirement in patients, and serum magnesium does not reflect the actual status of patients in the ICU. Therefore, measuring the level of magnesium in red blood cells is preferable to urinary magnesium and serum magnesium to investigate hypomagnesemia in the ICU. Additionally, there is no correlation between age, gender, APACHE II score, and the percentage of infused magnesium absorption in patients.

Intracranial pressure (ICP) elevation leading to cerebral edema is a critical condition that should be identified and treated immediately. In this study, we systematically reviewed the articles investigating the role of hypertonic sodium lactate (HSL) in patients with traumatic brain injury (TBI). 

PubMed, Scopus, Embase, and Web of Science were searched to find published articles on the effects of HSL on ICP in patients with a TBI until December 2020. Animal studies, case reports, and studies, including patients with liver and renal failure, cardiac dysfunction, or hypovolemic shock, were excluded. The Newcastle-Ottawa scale checklist was used to assess the methodological quality of eligible articles. Information obtained was classified based on the following criteria: demographic data, methods, intervention, and outcomes. 

Our initial search with the predefined search strategy proceeded with 113 studies. Finally, 7 studies were eligible for systematic review, and 3 of them were eligible for meta-analysis. A random meta-analysis of 3 articles comparing ICP before and after the infusion of HSL showed a reduced ICP following the use of HSL in traumatic brain injuries (P=0.015). 

Our study demonstrated the undeniable role of HSL in managing increased ICP in patients with brain injury. Nevertheless, conducting more clinical studies to assess the possible side effects of HSL seems crucial.

Familial hypokalemic periodic paralysis is a rare disorder that manifests manifests with the sudden onset of flaccid paralysis that is triggered by low levels of blood potassium, which can be caused by various factors such as, rest after intense exercise, or high-carbohydrate foods. This report presents cases of hypokalemic periodic paralysis attack triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A 29-year-old male patient was admitted with quadriparesis, fever, shortness of breath, and sever hypokalemia. The patient had a history of three episodes of Familial hypokalemic periodic paralysis (HPP). Diagnostic tests, such as chest computed tomography scan and polymerase chain reaction test, confirmed SARS-CoV-2 infection. The patient was treated with potassium chloride infusion, spironolactone, and remdesivir, and was eventually discharged from the hospital.in conclusion, SARS-CoV-2 infection can potentially exacerbate HPP and should be considered a risk factor for its occurrence.

Pulmonary embolism can cause cardiac arrest. Fibrinolytic therapy and surgical embolectomy can be used to manage it. This case report presents the clinical course of a patient who experienced intraoperative cardiac arrest resulting from massive pulmonary embolism. The patient encountered three instances of cardiac arrest requiring 35 minutes of cardiopulmonary resuscitation. Subsequent treatment involved the administration of reteplase, a thrombolytic agent. Following resuscitation, the patient developed multiple organ dysfunction in the intensive care unit, necessitating the use of diverse medications. Successful resolution of organ dysfunction led to the patient's transfer to the neurosurgery department. This case highlights the complexities involved in managing pulmonary embolism-induced cardiac arrest and subsequent multiorgan dysfunction, emphasizing the significance of a multidisciplinary approach in the comprehensive care and treatment of these patients.

The coronavirus disease of 2019 (COVID-19) may be considered sepsis on the basis that all the pathological events and the subsequent organ-to-organ interaction in sepsis also occur in COVID-19. In this article, the authors first discussed the rationale for the use of vitamin C (Vit-C) in sepsis and septic patients. They also reviewed the role of a high dose of Vit-C in COVID-19, which included clinical trials designed for the management of this viral disease.

The researchers explored databases of PubMed, Scopus, ISI Web of Science, and Google Scholar. Data were extracted to assess the effects of Vit-C in septic patients and also the efficacy of supplementation with a high dose of Vit-C regarding the clinical outcomes of patients with COVID-19.

Recent research findings indicate that severe inflammatory responses (cytokine storms) and oxidative stress are important causes for the high mortality in COVID-19 patients. It seems, however, that administering high doses of Vit-C can offer a therapeutic benefit. High doses of intravenous Vit-C, with its antioxidant properties and pleiotropic functions, could attenuate the tissue damage caused by excessive levels of free radicals following the cytokine storm and septic shock in severe cases of the disease.

Recent literature suggests that high doses of Vit-C have a potential role in reducing mortality and intubation rates in critically ill COVID-19 patients. However, determining the optimal duration and dose of Vit-C in these patients requires further studies.

Different virulence factors are involved in the pathogenesis of urinary tract infection (UTI) caused by Uropathogenic Escherichia coli (UPEC); hence, this study aimed to study the prevalence of biofilm formation, virulence factors, and phylogenetic groups and their correlation with biofilm formation among UPEC isolates through a systematic review and meta?analysis.

A literature search was conducted from 1, 2000, to the end of 2021 in different databases for studies that reported biofilm together with virulence genes or phylogenetic groups in UPEC isolates from patients with UTI according to PRISMA protocol. Data were analyzed by Comprehensive meta?analysis software.

The pooled prevalence of biofilm formers was 74.7%. The combined prevalence of phylogenetic Groups A, B1, B2, and D (s) were reported at 19.6%, 11%, 50.7%, and 20.5%, respectively. The most common virulence genes reported worldwide were fimA, ecpA, and fimH, with a combined prevalence of 90.3%, 86.6%, and 64.9%, respectively. The pooled prevalence of biofilm formation in UPEC isolates with phylogenetic Groups A, B1, B2, D, C, and Fwere 12.4%, 8.7%, 33.7%, 12.4%, 2.6%, and 2.65%, respectively. Several studies showed a correlation between biofilm production and virulence genes, or phylogenetic groups.

Regarding data obtained, the high level of combined biofilm formation (74.7%) and the presence of a positive correlation between biofilm production and virulence genes, or phylogenetic groups as reported by the most studies included in the present review, indicates an important role of biofilm in the persistence of UPEC in the UTI.

Cytokine storm in severe Covid-19 disease is one of the leading causes of death in these patients. Hemoperfusion is a method used to purify the blood from toxins and inflammatory factors. The aim of this study was to evaluate the effect of hemoperfusion on mortality and morbidity in patients with severe Covid - 19 disease.

This was a retrospective study which performed by reviewing the files of 30 patients with severe Covid-19 disease referred to Sina Hospital affiliated to Tehran University of Medical Sciences in 2020. Thirty patients with severe covid-19 disease and positive PCR participated in the study. All patients received routine treatment protocol for covid-19. Hemoperfusion was used for 15 patients in addition to receiving routine care. The remaining 15 patients were included in the control group. Patients in the hemoperfusion group underwent four sessions of hemoperfusion using continuous renal replacement therapy with continuous venovenous hemofiltration.

the ICU length of stay in the control and hemoperfusion groups was 3.40 ± 11.40 and 9.65 ± 16.33 days, respectively (P= 0.075). 8 patients died and 7 patients were discharged in the control group, but 11 patients died and 4 patients were discharged in the hemoperfusion group (P= 0.256). The respiratory rate of patients in the control and hemoperfusion groups decreased from 7.43 ± 29.40 to 4.03 ± 24.60 and from 6.11 ± 31.60 to 5.04 ± 24.46, respectively (P < 0.001). The percentage of arterial blood oxygen saturation in the control and hemoperfusion groups increased from 90.86 ± 5.61 to 93.06 30 4.30 and from 92.33 26 3.26 to 92.06 31 5.31, respectively (P= 0.456).

Hemoperfusion could not prevent the mortality of patients and finally out of 15 patients, 11 patients died and 4 patients were discharged. Also, no significant difference was observed between the two groups in terms of arterial blood oxygen saturation.

Sepsis is one of the leading causes of mortality in intensive care unit. Despite advances in its management, its mortality rate remains high. Recently, high dose of vitamin C in sepsis treatment has attracted the attention of researchers. In the current study, the impacts of 25 mg/kg of vitamin C every 6 hours as a bolus for 3 days were assessed in septic patients in intensive care unit (ICU).

This was a prospective cohort study that was performed on adult patients with diagnosis of sepsis. Patients were assigned to control group (administration of placebo) or intervention group, i.e., those receiving a 25 mg/kg dose of vitamin C every 6 hours as a bolus for 3 days. Clinical data were recorded before and after the experiment. Also, plasma levels of antithrombin III, syndecan-1, fibrin degradation product (FDP), D-dimer, and C-reactive protein (CRP) were measured at 0, 24, 48, and 72 hours.

In septic patients receiving vitamin C, a significant upregulation of antithrombin III and significant decreases in the levels of syndecan-1 (at 48 hours; P-value=0.046 and at 72 hours; P-value=0.007), D-dimer and CRP were observed compared to the control. Reductions in sequential organ failure assessment (SOFA) score, in-hospital mortality, and ICU length of stay were seen in septic patients receiving vitamin C.

Prescribing high dose of intravenous vitamin C can reduce the mortality of sepsis patients and reduce the length of stay in the ICU.

Cognitive impairment has been identified in all stages and affects all subtypes of multiple sclerosis (MS) (40 - 65% of people with clinically definite MS). A defined therapeutic strategy has not yet been determined.

This study aimed to assess the efficacy of levetiracetam (LEV) to improve cognitive impairments in patients with relapsing-remitting MS (RRMS).

A Pilot randomized; double-blinded, placebo-controlled clinical trial was conducted. The patients with a definite diagnosis of RRMS treated with first-line drugs. They were assigned into two groups; LEV and the placebo for four months. The primary outcome was the changes in cognitive domains based on the minimal assessment of cognitive function in multiple sclerosis (MACFIMS) compared to baseline. The MACFIMS was accomplished by seven tests: California verbal learning test-II (CVLT-II), paced auditory serial addition test (PASAT), symbol digit modalities testing (SDMT), brief visuospatial memory testrevised (BVMT-R), delis-Kaplan executive function system (D-KEFS), controlled oral word association test (COWAT), and judgment of line orientation (JLO).

A total of 32 patients entered the study and 28 patients completed the trial. The change in JLO score in the LEV group was significantly greater than in the placebo group (P-value = 0.03). After intervention in the LEV group, the SDMT and JLO scores were significantly higher than the baseline scores.

This is the study to evaluate the effects of LEV on cognitive disorders in patients with MS. Levetiracetam was significantly effective in improving the JLO and SDMT scores in patients with RRMS compared to the placebo group.

The Covid-19 pandemichas caused widespread worldwidehuman catastrophe over the past two years. Thus, the global management of Corona disease is of great importance due to its high prevalence and mortality rate as well as the numerous challenges caused by this illness. For this reason, it is of high importance to study the various aspects of this epidemic in order to provide practical solutions and suggestions for better management of similar biological events.

This article has been performedby reviewing international sources and guidelines and summarizing the materials presented in expert meetings.

The study addresses challenges related to reopening of school and universities, empowering people, Covid-19 monitoring process and benefit from support groups, social components of global health, intelligent quarantines and rapid screening and management defects of healthcare system during COVID-19 (Corona Disease) Pandemic Strategies related to challenges in each area are also provided.

The time interval between the possible future waves of Covid-19 provides a good opportunity for health systems at the national (our dear country, Iran) and global levels to make necessary preparations, strengthening, and reforming structure. According to the findings of this study, it is recommended that while continuously evaluating the risk of biological events, the surveillance system and early warning network must be intensified and a comprehensive plan must be compiled in order to respond to biological events. Also, by training healthcare staffs and practicing the above-mentioned program, the essential steps must be taken continuously.

Iran was one of the first countries to become an epicenter of the coronavirus disease 2019 (COVID-19) epidemic. However, there is a dearth of data on the outcomes of COVID-19 and predictors of death in intensive care units (ICUs) in Iran. We collected extensive data from patients admitted to the ICUs of the one of the tertiary referral hospitals in Tehran, Iran, to investigate the predictors of ICU mortality.

The study population included 290 COVID-19 patients who were consecutively admitted to the ICUs of the Sina hospital from May 5, 2021, to December 6, 2021, a period that included the peak of the epidemic of the delta (δ) variant. Demographic data, history of prior chronic diseases, laboratory data (including markers of inflammation), radiologic data, and medication data were collected.

Of the 290 patients admitted to the ICUs, 187 (64.5%) died and 103 (35.5%) survived. One hundred forty-one (141, 48.6%) were men, and the median age (10th percentile, 90th percentile) was 60 (41, 80). Using logistic regression models, older age, history of hypertension, high levels of inflammatory markers, low oxygen saturation, substantial lung involvement in computed tomography (CT) scans, and gravity of the disease as indicated by the WHO 8-point ordinal scale were primary predictors of mortality at ICU. The use of remdesivir and imatinib was associated with a statistically non-significant reduction in mortality. The use of tocilizumab had almost no effect on mortality.

The findings are consistent with and add to the currently existing international literature. The findings may be used to predict risk of mortality from COVID-19 and provide some guidance on potential treatments.

Proper utilization of high-quality clinical practice guidelines (CPGs) eliminates the dependence of patients’ outcomes on the ability and knowledge of “individual” health care providers and reduces unwarranted variation in care. The aim of this study was to adapt/adopt two CPGs for pharmacologic management of acute spinal cord injury (SCI) using guideline adaptation methods.

This study was conducted based on the ADAPTE process. Following establishment of an organizing committee and choosing the health topics, we appraised the quality of the CPGs using the Appraisal of Clinical Guidelines for Research & Evaluation II (AGREE II). Then, the authors extracted and categorized suggestions according to Population, Intervention, Professions, Outcomes and Health care setting (PIPOH). The decision-making process was based on systemic evaluation of each suggestion, utilizing a combination of AGREE II scores, the quality of supporting evidence for or against each suggestion and the triad of feasibility, acceptance and adoptability for the Iranian health-care context.

Two guidelines were included in the adaptation process. Based on high-quality of these guidelines and the feasibility and adoptability evaluation of the organizing committee, we decided to adopt the suggestion of both guidelines. Overall, seven suggestions were extracted from the source guidelines.

This work provides a framework to apply guidelines for acute SCI to the developing regions of the world. Attempts should be made to implement these suggestions in order to improve the health outcomes of Iranian SCI patients.

Non-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE) are of the acute complications of patients admitted to the intensive care unit (ICU), which lead to increased mortality and morbidity. In these cases, immediate treatment with antiepileptic drugs (AEDs) is important to prevent further damage to the brain. AEDs are the first line of treatment, however, most of these medications have many side effects. In the recent years, significant advances have been made in this area and lacosamide is one of the therapeutic options. The intravenous formulation of this drug is most popular due to the lack of drug-drug interaction and properly designed studies which have been conducted in this field. In this review, the latest findings on the effect of lacosamide on acute non-convulsive and generalized-convulsive seizures (G-CS) are evaluated in critically ill patients admitted to the ICU.

Obesity is a multifactorial disorder, and gut microbiota has a fundamental role in its pathophysiology. Bacteroides spp. has significant roles in gut microbiota- host interactions that determine health and disease development. Since the gut microbiota pattern changes based on different criteria in each population, we studied the abundance of two important Bacteroides strains, Bacteroides fragilis, and Bacteroides thetaiotaomicron, in Iranian obese and normal-weight subjects for the first time.

In this study, 100 participants were recruited and classified based on their body mass index (BMI). The subjects were divided into normal (average BMI, 22.37 kg/m2 ) and obese (average BMI, 29.10 kg/m2 ) groups. Bacterial DNA was extracted from the samples, and quantitative polymerase chain reaction (qPCR) was conducted based on 16s rDNA universal primers. Finally, the correlation between bacterial abundance and obesity was investigated.

The results of qPCR showed that the relative abundance means of B. fragilis in normal weight and obese subjects was 8.68 × 1012 and 9.27 × 1012 cfu/mL, respectively. Also, the relative abundance mean of B. thetaiotaomicron in normal weight and obese subjects was 2.32 × 1012 and 5.39 × 1012 cfu/mL, respectively. Although obese subjects had more B. fragilis and B. thetaiotaomicron abundance compared to subjects with normal weight, no significant difference was identified between relative abundance of B. fragilis (P = 0.79) and B. thetaiotaomicron (P = 0.18) in the two groups.

Although obese subjects had more B. fragilis and B. thetaiotaomicron abundance compared to normal-weight subjects, no significant difference was identified between the two groups. Since Bacteroides spp. have significant role in gut microbiota-host interaction, determination of their abundance in obesity development and targeting restoration of gut microbiota pattern could be valuable in controlling obesity. In this regard, dietary intervention could be based on determination of gut microbiota pattern in certain populations.

The present study was conducted to compare mechanically ventilated patients with and without COVID-19 in terms of hemodynamic instability using cardiovascular indicators. 

This prospective cohort study assigned intubated and mechanically ventilated patients to two groups, i.e. with COVID-19 and without COVID-19. The hemodynamic parameters measured and compared between the two groups on the first day of ICU admission and the following four consecutive days using an ultrasonic cardiac output monitor (USCOM) included cardiac output (CO), systemic vascular resistance (SVR), stroke volume (SV), flow time corrected (FTc), minute distance (MD) and potential kinetic energy (PKE). 

Forty-three patients (males: 62.7%) were assigned to the COVID-19 group and 40 (males: 64.1%) to the one without COVID-19. Insignificant differences were observed between the two groups at baseline in terms of the mean homodynamic variables measured using the USCOM (P>0.05). The mean CO increased (P=0.020), the mean SVR insignificantly changed (P=0.267), the mean MD increased (P=0.005) and PKE decreased (P=0.066) in the COVID-19 group during the five days of evaluation. In the same period, the mean CO insignificantly changed (P=0.937), the mean SVR increased (P=0.028) and changes in MD (P=0.808) and PKE (P=0.539) were insignificant in the group without COVID-19. The two groups were not significantly different in terms of the other homodynamic parameters during the follow-up (P>0.05). 

The five-day changes in the USCOM-measured homodynamic parameters were lower in the group without COVID-19 compared to in that with COVID-19. In the group without COVID-19, no statistically-significant differences were observed between the mean follow-up values of the variables, excluding SVR, and their baseline values.

Several studies have examined the possible role of beta-blockers, including esmolol, in controlling intracranial pressure (ICP). This study aimed to evaluate the effect of esmolol on ICP in patients with severe traumatic brain injury.

In this case-control study, all TBI patients with ICP > 20 cmH2O, who were admitted to ICU during the study period, were included. Some patients received standard treatment plus esmolol (500 μg/kg and then 50 mg/kg/min for 24 hours), and some others just received standard treatment with no esmolol. The patients were monitored, and the ICP measurement was performed via inserted intra-ventricular catheter. The ICP and vital signs were measured and recorded before, 8, 16, and 24 hours after starting the treatment in the two groups, and the findings were then compared.

Twenty-two patients (13 males and 9 females) were included in this study, of whom 12 patients received esmolol, and 10 patients were in the control group. The mean age of those who received esmolol was smaller than those who did not receive it (46.6 ± 18.5 vs. 62.3 ± 19.1 years; P = 0.08). Moreover, the mean length of the ICU stay was smaller in the esmolol receivers than the control group (5.6 ± 1.1 vs. 17.3 ± 7.7 days; P = 0.04 (there was no significant difference between the two groups in terms of mortality rates (P = 0.30). The variations of the vital signs over time was not significantly different between the two groups (P > 0.05); however, the mean of ICP was lower in those who received esmolol compared to the control group at all checkpoints (P < 0.05).

Those patients with TBI who received esmolol as part of their ICP control management in ICU had lower ICP than those who received no esmolol.

Phenobarbital is still one of the drugs of choice in managing patients with brain injury in the intensive care unit (ICU). However, the impact of acute physiological changes on phenobarbital pharmacokinetic parameters is not well studied. This study aimed to evaluate the pharmacokinetic parameters of parenteral phenobarbital in critically ill patients with brain injury. Patients with severe traumatic or non-traumatic brain injury at high risk of seizure were included and followed for seven days. All patients initially received phenobarbital as a loading dose of 15 mg/kg over 30-minutes infusion, followed by 2 mg/kg/day divided into three doses. Blood samples were obtained on the first and fourth day of study at 1, 2, 5, 8, and 10 hours after the end of the infusion. Serum concentrations of phenobarbital were measured by high-pressure liquid chromatography (HPLC) with an ultraviolet (UV) detector. Pharmacokinetic parameters, including the volume of distribution (Vd), half-life (t1/2), and the drug clearance (CL), were provided by MonolixSuite 2019R1 software using stochastic approximation expectation-maximization (SAEM) algorithm and compared with previously reported parameters in healthy volunteers. Data from seventeen patients were analyzed. The mean value±standard deviation of pharmacokinetic parameters was calculated as follows: Vd: 0.81±0.15 L/kg; t1/2: 6.16±2.66 days; CL: 4.23±1.51 ml/kg/h. CL and Vd were significantly lower and higher than the normal population with the value of 5.6 ml/kg/h (P=0.002) and 0.7 L/kg (P=0.01), respectively. Pharmacokinetic behavior of phenobarbital may change significantly in critically ill brain-injured patients. This study affirms the value of early phenobarbital therapeutic drug monitoring (TDM) to achieve therapeutic goals.

At the end of 2019, Sars-CoV-2 was identified and has since spread in the world. Coronavirus is commonly caused by the upper respiratory tract and severe acute respiratory syndrome in humans. Due to the novel nature of the virus and high mortality among high-risk people, today health care providers used several medications with different mechanisms to overcome this virus. The course of COVID-19 represents three stages that have different symptoms and used different drugs depends on each stage. Ultimately the minority of patients progress to stage III with high mortality. The aim of this study is a comprehensive review of COVID-19 adjuvant therapies. We explained the current study on the use of Glucocorticoids, Interferon, Vitamin C, Tocilizumab, Anakinra, Pentoxifylline, IVIG, Allopurinol, Ivermectin, and Selenium in sepsis, pneumonia, and ARDS and we suggested a new protocol for prescribing each medication currently used in COVID-19 Outbreak. At the end of 2019, Sars-CoV-2 was identified and has since spread in the world. Coronavirus is commonly caused by the upper respiratory tract and severe acute respiratory syndrome in humans. Due to the novel nature of the virus and high mortality among high-risk people, today health care providers used several medications with different mechanisms to overcome this virus. The course of COVID-19 represents three stages that have different symptoms and used different drugs depends on each stage. Ultimately the minority of patients progress to stage III with high mortality. The aim of this study is a comprehensive review of COVID-19 adjuvant therapies. We explained the current study on the use of Glucocorticoids, Interferon, Vitamin C, Tocilizumab, Anakinra, Pentoxifylline, IVIG, Allopurinol, Ivermectin, and Selenium in sepsis, pneumonia, and ARDS and we suggested a new protocol for prescribing each medication currently used in COVID-19 Outbreak.