Faculty Bibliography

Homocysteine is an amino acid derived from methionine which is metabolized via vitamin B₆ (pyridoxine)- and vitamin B₁₂ (cobalamin)-dependent pathways. Supplementation of B vitamins has been shown to effectively reduce plasma homocysteine levels. Previous research has also demonstrated an association between lower plasma homocysteine levels and decreased risk of myocardial infarction, stroke, and venous thromboembolism. However, whether supplementation of B vitamins is associated with risk reduction in thromboembolic events and confers clinical benefits remains inconclusive. This review examines clinical trials published over the past 29 years to assess the effects of B vitamin supplementation on thrombotic risk reduction and homocysteine metabolism. The findings from these studies are inconsistent, and the impact of B vitamins on thrombosis prevention remains uncertain. Given the conflicting evidence, further clinical and translational research is necessary to clarify the role of B vitamin supplementation in thrombosis risk reduction.

The prevalence of vitamin D deficiency among intensive care unit (ICU) patients is potentially associated with an increased risk of mechanical ventilation, sepsis, prolonged hospital stays, and mortality. Although ICU patient care has significantly improved in recent years, the role of vitamin D supplementation remains under investigation. A literature review was conducted using PubMed, Web of Science, Embase, and Cochrane databases, focusing on randomized controlled trials published in the past five years on vitamin D supplementation in adult ICU patients. Patients' baseline vitamin D levels, administration routes, doses, biomarker changes, mechanical ventilation duration, length of hospital stay, and mortality were analyzed. Although vitamin D supplementation appears safe and may reduce ICU stay duration and mechanical ventilation time and improve SOFA scores, its impact on overall mortality remains uncertain. Routine supplementation for all ICU patients is not currently recommended; clinical decisions should consider individual baseline vitamin D levels, patient characteristics, severity of illness, doses, and administration methods.

BACKGROUND/UNASSIGNED:High-dose (HD) tigecycline is often required for severe multidrug-resistant gram-negative infections in liver failure patients, despite package recommendations to halve the dose for those with severe liver impairment. This study evaluated the efficacy and safety of different tigecycline doses in this population. RESEARCH DESIGN AND METHODS/UNASSIGNED:A retrospective cohort of 192 patients with Child-Pugh grade C liver failure was divided into label-dose (LD), standard-dose (SD), and HD groups. Primary and secondary outcomes included microbial eradication, mortality, and adverse effects. RESULTS/UNASSIGNED: = 0.062). Optimal microbial eradication and minimized adverse effects occurred with the SD group at 7 days of treatment. CONCLUSIONS/UNASSIGNED:Standard-dose tigecycline offers a balanced approach to microbial eradication and safety, making it preferable in liver failure patients.

Covid 19 patients often present with elevated D-dimer levels. The purpose of this study is to evaluate the role of D-Dimer levels in Covid 19 patients to predict mortality and venous thromboembolism (VTE) events. This is a retrospective chart review study from 1 April 2020 to 30 June 2020, during the peak Covid pandemic. A total of 350 patients were enrolled in this study; 69 (19.7%) patients died; 12 (3.4%) had a deep venous thrombosis; and 8 (2.3%) had a pulmonary embolism outcome. Peak D-dimer levels were collected with median levels of 765 ng/ml (266, 3135). Patients with VTE outcomes had significantly higher levels of peak D-dimers than patients in the non-VTE group (4876 vs 680, p < 0.0001). Patients who died had higher peak D-dimer levels than those who survived (4690 vs 501, p < 0.0001). The optimal cutoff point in peak D-dimer in predicting VTE events was 1437, yielding a sensitivity of 84.2% and a specificity of 65.0%. The optimal cutoff point in peak D-dimer in predicting mortality was 2004, yielding a sensitivity of 71.0% and a specificity of 77.9%. This study suggests that D-dimer levels can be elevated in Covid 19 hospitalized patients and can serve as indicators for mortality and VTE events.

In critically ill patients, fluid resuscitation with balanced crystalloids close to plasma osmolarity have a lower risk of electrolyte imbalances and demonstrated better clinical outcomes compared to normal saline (NS). While lactated ringer's (LR) has shown benefit over NS, plasma-lyte (PL) with a higher osmolarity and different electrolyte formulation is hypothesized to be superior. We performed a retrospective observational cohort study over 37 months at a tertiary hospital. Inclusion criteria were hospitalization in the surgical intensive care unit (SICU), trauma indication, ≥18 years old, and received either PL or LR. All PL administrations and every fifth patient with LR as resuscitation were included in order to match the sample size in each group. Primary outcomes were SICU length of stay (LOS), hospital LOS, and mortality. Secondary outcomes were biomarker changes from baseline. There were 113 patients in both PL and LR groups. The PL arm had higher APACHE II scores (16 vs 13, P = .033) and were more likely ventilated (39.3% vs 20.4%, P = .002) compared to LR. Median hospital LOS (12.0 vs 8.0, P < .001) and SICU LOS (6.0 vs 3.0, P < .001) are significantly longer in PL group compared to the LR group. However, there was no difference in in-hospital mortality (5.3% vs 3.5% P = .519) and SICU mortality (9.7% vs 5.3%, P > .208) between PL and LR. Overall, PL use was associated with prolonged hospital and SICU LOS. PL use did not demonstrate mortality benefit. However, patients were more critically ill in PL group based on higher APACHE II scores and higher rates of mechanical ventilation, which could be contributing to these unfavorable outcomes.

Aseptic abscess (AA) syndrome is a rare inflammatory disorder often associated with inflammatory bowel disease (IBD). Cases of IBD-associated AA have been reported in Japan, India, and Canada, but rarely in China. Herein, we present the case of a Chinese patient with IBD-associated AAs and review the literature on AA with underlying IBD. We report the case of a 48-year-old male patient with multiple AAs on his left hand and lungs who was successfully treated with prednisone. He had undergone cutaneous abscess incision and drainage twice in the previous 2 years. The patient presented to our hospital with ulcerative colitis and pain in the dorsum of the left hand. Pus from his hand and blood cultures revealed sterile cutaneous abscesses. Chest computed tomography examination during hospitalization revealed a lung abscess. The AA was unresponsive to cefotiam or cefoperazone-sulbactam. The patient's left hand and lung conditions did not improve until prednisone was administered. The patient was followed up as an outpatient for 3 months and recovered without any clinical symptoms. We retrieved 17 cases of IBD-associated AA from the literature. None of the patients showed evidence of infection and failed antibiotic treatment, and all improved with corticosteroid use. AA may be an extra-intestinal manifestation of IBD. Effective medications include corticosteroids and immunosuppressive agents. This case may increase the awareness of AA and aid in early identification.

BACKGROUND:Tigecycline has been widely used for multi-drug resistant bacterial infections in China. Although many studies have reported the risk factors for tigecycline-induced hypofibrinogenemia, it remains unknown whether valproic acid or voriconazole in combination with tigecycline is related to fibrinogen decline, as both drugs could lead to coagulation disorders. The aim of the study was to develop a nomogram for the prediction of tigecycline-induced hypofibrinogenemia. METHODS:This is a multi-center retrospective case-control study. The primary outcomes for the nomograms were tigecycline-induced hypofibrinogenemia. The nomograms were developed from logistic regression models with least absolute shrinkage and selection operator (LASSO) regression for variable selection. Model performance was assessed via calibration plots, and models were internally validated using bootstrapping on a validation cohort. RESULTS:In total, 2362 patients were screened, of which 611 were eligible and were divided into training (n=488) and validation (n=123) cohorts. Predictors included in the nomograms for total population were total dose, age, fibrinogen, prothrombin time (PT), comorbidity and concomitant use of voriconazole. Total dose, fibrinogen, PT, activated partial thromboplastin time (APTT), white blood cell and concomitant use of voriconazole were selected to predict hypofibrinogenemia for patients with malignant hematologic diseases. Both models were adequately calibrated and their predictions correlated with the observed outcome. The cut-off of treatment durations in total population and subgroup were 10 and 6 days, respectively. CONCLUSIONS:Tigecycline in combination with voriconazole could increase the risk of hypofibrinogenemia and tigecycline-induced hypofibrinogenemia is more likely to occur in patients with malignant hematologic diseases.

Post-neurosurgical infections caused by multidrug-resistant Enterobacterales are difficult to treat due to limited therapeutic options. Ceftazidime-avibactam (CAZ-AVI), a combination of cephalosporin and a novel β-lactamase inhibitor, has exhibited potential activity against multi/extensive drug-resistant (MDR/XDR) gram-negative bacilli. Several reports have described the successful treatment of central infections caused by MDR/XDR Pseudomonas aeruginosa or Enterobacterales. However, data on the efficacy and effective drug distribution of CAZ-AVI in the central nervous system (CNS), particularly in children, are lacking. We report a case of a 4-year-old girl with post-neurosurgical meningitis and abscess caused by extended-spectrum β-lactamase-producing Escherichia coli successfully treated with CAZ-AVI. CAZ-AVI therapeutic drug monitoring was performed to evaluate its efficacy and effective drug distribution in the CNS. We measured CAZ (15.6, 7.1, and 3.5 μg/mL) and AVI (4.0, 2.1, and 1.2 μg/mL) in cerebrospinal fluid (CSF) samples obtained 3, 5, and 7 h after the administration of the 15th CAZ-AVI dose (2.5 g, q8h, iv), respectively. We also measured CAZ (57.0 and 25.8 μg/mL) and AVI (11.3 and 4.5 μg/mL) in serum samples obtained 3 and 5 h after the administration, respectively. CAZ-AVI achieved an adequate CSF concentration throughout the drug interval. Our case provides evidence for using CAZ-AVI to treat CNS infections.

Dialysis patients are often iron deficient due to a multiple factors. Ferric pyrophosphate citrate is a complex iron salt that can be given via dialysate allowing maintenance of hemoglobin (Hgb) concentration and iron balance while reducing the need for IV iron. The purpose of this study is to perform a cost evaluation of FPC and the effect it has on lowering the dose/use of ESAs and IV iron therapy. This study reviewed the same 100 hemodialysis patient's charts before and after the use of FPC. The data points that were collected and analyzed are as follows: hemoglobin, ferritin levels, average weekly ESA dosing, and IV iron replacement therapy dose. Out of 100 patients, there was no statistical difference in the average hemoglobin, ferritin, and iron saturation levels observed in the patients before and after FPC use. The average weekly dose of darbepoetin alfa per patient was 52.74 μg before the FPC group compared to 39.27 μg in the post FPC group (P < .0001). The total dose of ferric gluconate per patient was 3290.01 mg in the before FPC group and 585.60 mg in the post FPC group (P < .0001). The average total iron sucrose dose per patient in the before FPC group was 3097.92 mg versus 1216.67 mg in the post FPC group (P < .1563). When comparing FPC's cost and implementation into both of our outpatient dialysis centers, this yielded a net savings of $296 751.49.