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| 1 | Delphi methodology in healthcare research:How to decide its appropriateness显示文摘The Delphi technique is a systematic process of forecasting using the collective opinion of panel members.The structured method of developing consensus among panel members using Delphi methodology has gained acceptance in diverse fields of medicine.The Delphi methods assumed a pivotal role in the last few decades to develop best practice guidance using collective intelligence where research is limited,ethically/logistically difficult or evidence is conflicting.However,the attempts to assess the quality standard of Delphi studies have reported significant variance,and details of the process followed are usually unclear.We recommend systematic quality tools for evaluation of Delphi methodology;identification of problem area of research,selection of panel,anonymity of panelists,controlled feedback,iterative Delphi rounds,consensus criteria,analysis of consensus,closing criteria,and stability of the results.Based on these nine qualitative evaluation points,we assessed the quality of Delphi studies in the medical field related to coronavirus disease 2019.There was inconsistency in reporting vital elements of Delphi methods such as identification of panel members,defining consensus,closing criteria for rounds,and presenting the results.We propose our evaluation points for researchers,medical journal editorial boards,and reviewers to evaluate the quality of the Delphi methods in healthcare research. | Prashant Nasa Ravi Jain Deven Juneja | 2021 | World Journal of Methodology2021，11，4： | 21 |
| 2 | Severe sepsis and septic shock in the elderly:An overview显示文摘The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units(ICUs). The elderly are predisposed to sepsis due to co-existing comorbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations and above all due to the effects of aging itself. A lower threshold and a higher index of suspicion is required to diagnose sepsis in this patient population because the initial clinical picture may be ambiguous, and aging increases the risk of a sudden deterioration in sepsis to severe sepsis and septic shock. Management is largely based on standard international guidelines with a few modifications. Age itself is an independent risk factor for death in patients with severe sepsis, however, many patients respond well to timely and appropriate interventions. The treatment should not be limited or deferred in elderly patients with severe sepsis only on the grounds of physician prejudice, but patient and family preferences should also be taken into account as the outcomes are not dismal. Future investigations in the management of sepsis should not only target good functional recovery but also ensure social independence and quality of life after ICU discharge. | Prashant Nasa Deven Juneja Omender Singh | 2012 | World Journal of Critical Care Medicine2012，1，1： | 9 |
| 3 | Approach to thromboelastography-based transfusion in cirrhosis:An alternative perspective on coagulation disorders显示文摘Viscoelastic tests,specifically thromboelastography and rotational thromboelastometry,are increasingly being used in the management of postoperative bleeding in surgical intensive care units(ICUs).However,life-threatening bleeds may complicate the clinical course of many patients admitted to medical ICUs,especially those with underlying liver dysfunction.Patients with cirrhosis have multiple coagulation abnormalities that can lead to bleeding or thrombotic complications.Compared to conventional coagulation tests,a comprehensive depiction of the coagulation process and point-of-care availability are advantages favoring these devices,which may aid physicians in making a rapid diagnosis and instituting early interventions.These tests may help predict bleeding and rationalize the use of blood products in these patients. | Sahil Kataria Deven Juneja Omender Singh | 2023 | World Journal of Gastroenterology2023，29，9： | 3 |
| 4 | Upper extremity deep vein thrombosis:An intensivist’s perspective显示文摘Upper extremity deep vein thrombosis(UEDVT)is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients.Increasing cancer incidence,prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT.It is also associated with high rates of complications like pulmonary embolism,post-thrombotic syndrome and recurrent thrombosis.Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT;hence,a high suspicion index is required for diagnosis.Doppler ultrasound is commonly employed for diagnosis,but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients.Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies.Anticoagulant therapy alone is sufficient in most patients,and thrombolysis and surgical decompression is seldom indicated.The outcome depends on the cause and underlying comorbidities. | Omender Singh Deven Juneja | 2023 | World Journal of Critical Care Medicine2023，12，3： | 1 |
| 5 | Capillary leak syndrome:A rare cause of acute respiratory distress syndrome显示文摘Capillary leak syndrome(CLS)is a rare clinical syndrome associated with significant morbidity and mortality.Intensive care and supportive therapy constitute the mainstay of the treatment,along with judicious use of crystalloids and colloids such as dextran and starch during the leak phase.The advantages of proning,steroids,and intravenous immunoglobins are worth contemplating in patients with such a presentation.Extracorporeal membrane oxygenation appears to be an excellent strategy to surmount the impediments of the leak and post leak phase of CLS,especially in patients with severe or refractory hypoxemia. | Deven Juneja Sahil Kataria | 2022 | World Journal of Clinical Cases2022，10，13： | 1 |
| 6 | Current role of high dose vitamin C in sepsis management:A concise review显示文摘Sepsis and septic shock are common diagnoses for patients requiring intensive care unit admission and associated with high morbidity and mortality.In addition to aggressive fluid resuscitation and antibiotic therapy,several other drugs have been tried as adjuvant therapies to reduce the inflammatory response and improve outcomes.Vitamin C has been shown to have several biological actions,including anti-inflammatory and immunomodulatory effects,which may prove beneficial in sepsis management.Initial trials showed improved patient outcomes when high dose vitamin C was used in combination with thiamine and hydrocortisone.These results,along with relative safety of high-dose(supra-physiological)vitamin C,encouraged physicians across the globe to add vitamin C as an adjuvant therapy in the management of sepsis.However,subsequent largescale randomised control trials could not replicate these results,leaving the world divided regarding the role of vitamin C in sepsis management.Here,we discuss the rationale,safety profile,and the current clinical evidence for the use of highdose vitamin C in the management of sepsis and septic shock. | Deven Juneja Prashant Nasa Ravi Jain | 2022 | World Journal of Critical Care Medicine2022，11，6： | 1 |
| 7 | Scoring systems in critically ill: Which one to use in cancer patients?显示文摘BACKGROUND Scoring systems have not been evaluated in oncology patients.We aimed to assess the performance of Acute Physiology and Chronic Health Evaluation(APACHE)II,APACHE III,APACHE IV,Simplified Acute Physiology Score(SAPS)II,SAPS III,Mortality Probability Model(MPM)II0 and Sequential Organ Failure Assessment(SOFA)score in critically ill oncology patients.AIM To compare the efficacy of seven commonly employed scoring systems to predict outcomes of critically ill cancer patients.METHODS We conducted a retrospective analysis of 400 consecutive cancer patients admitted in the medical intensive care unit over a two-year period.Primary outcome was hospital mortality and the secondary outcome measure was comparison of various scoring systems in predicting hospital mortality.RESULTS In our study,the overall intensive care unit and hospital mortality was 43.5%and 57.8%,respectively.All of the seven tested scores underestimated mortality.The mortality as predicted by MPM II0 predicted death rate(PDR)was nearest to the actual mortality followed by that predicted by APACHE II,with a standardized mortality rate(SMR)of 1.305 and 1.547,respectively.The best calibration was shown by the APACHE III score(χ^(2)=4.704,P=0.788).On the other hand,SOFA score(χ^(2)=15.966,P=0.025)had the worst calibration,although the difference was not statistically significant.All of the seven scores had acceptable discrimination with good efficacy however,SAPS III PDR and MPM II0 PDR(AUROC=0.762),had a better performance as compared to others.The correlation between the different scoring systems was significant(P<0.001).CONCLUSION All the severity scores were tested under-predicted mortality in the present study.As the difference in efficacy and performance was not statistically significant,the choice of scoring system used may depend on the ease of use and local preferences. | Anisha Beniwal Deven Juneja Omender Singh Amit Goel Akhilesh Singh Hemant Kumar Beniwal | 2022 | World Journal of Critical Care Medicine2022，11，6： | 1 |
| 8 | Physician staffing pattern in intensive care units:Have we cracked the code?显示文摘Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units(ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a 'turf' war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffingmay be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients. | Deven Juneja Prashant Nasa Omender Singh | 2012 | World Journal of Critical Care Medicine2012，1，1： | 1 |
| 9 | Scoring systems in acute pancreatitis: Which one to use in intensive care units?显示文摘 | Deven Juneja Palepu B. Gopal Murthy Ravula | 2010 | Journal of Critical Care2010，，2： | 1 |
| 10 | Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients:A comparative observational study显示文摘BACKGROUND As per the latest Surviving Sepsis Campaign guidelines,fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization.Nevertheless,raised lactate levels should be interpreted in the clinical context,as there may be other causes of elevated lactate levels.Thus,it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation,and exploring alternative resuscitation targets should be an essential research priority in sepsis.AIM To compare the 28-d mortality in two clinical patterns of septic shock:hyperlactatemic patients with hypoperfusion context and hyperlactatemic patients without hypoperfusion context.METHODS This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients with hyperlactatemia in a hypoperfusion context(Group 1,n=95)and patients with hyperlactatemia in a non-hypoperfusion context(Group 2,n=40).Hypoperfusion context was defined by a central venous saturation less than 70%,central venousarterial PCO_(2)gradient[P(cv-a)CO_(2)]≥6 mmHg,and capillary refilling time(CRT)≥4 s.The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h,3 h,and 6 h.All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals.Nominal categorical data were compared using theχ^(2)or Fisher’s exact test.Nonnormally distributed continuous variables were compared using the Mann-Whitney U test.Receiver operating characteristic curve analysis with the Youden index determined the cutoff values of lactate,CRT,and metabolic perfusion parameters to predict the 28-d all-cause mortality.A P value of<0.05 was considered significant.RESULTS Patient demographics,comorbidities,baseline laboratory,vital parameters,source of infection,baseline lactate levels,and lactate clearance at 3 h and 6 h,Sequential Organ Failure scores,need for invasive mechanical ventilation,days on mechanical ventilation,and renal replacement therapy-free days within 28 d,duration of intensive care unit stay,and hospital stay were comparable between the two groups.The stratification of patients into hypoperfusion and nonhypoperfusion context did not result in a significantly different 28-d mortality(24%vs 15%,respectively;P=0.234).However,the patients within the hypoperfusion context with high P(cva)CO_(2)and CRT(P=0.022)at baseline had significantly higher mortality than Group 2.The norepinephrine dose was higher in Group 1 but did not achieve statistical significance with a P>0.05 at all measured intervals.Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion(18.88±9.04 vs 21.08±8.76;P=0.011).The mean lactate levels and lactate clearance at 3 h and 6 h,CRT,P(cv-a)CO_(2)at 0 h,3 h,and 6 h were found to be associated with 28-d mortality in patients with septic shock,with lactate levels at 6 h having the best predictive value(area under the curve lactate at 6 h:0.845).CONCLUSION Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibited similar 28-d all-cause hospital mortality,although patients with hypoperfusion displayed a more severe circulatory dysfunction.Lactate levels at 6 h had a better predictive value in predicting 28-d mortality than other parameters.Persistently high P(cv-a)CO_(2)(>6 mmHg)or increased CRT(>4 s)at 3 h and 6 h during early resuscitation can be a valuable additional aid for prognostication of septic shock patients. | Sahil Kataria Omender Singh Deven Juneja Amit Goel Madhura Bhide Devraj Yadav | 2023 | World Journal of Clinical Cases2023，11，16： | 0 |
| 11 | Transient elastography(FibroScan)in critical care:Applications and limitations显示文摘FibroScan®is a non-invasive device that assesses the‘hardness’(or stiffness)of the liver via the technique of transient elastography.Because fibrous tissue is harder than normal liver,the degree of hepatic fibrosis can be inferred from the liver hardness.This technique is increasingly being employed to diagnose liver fibrosis,even in critically ill patients.It is now being used not only for diagnosis and staging of liver cirrhosis,but also for outcome prognostication.However,the presence of several confounding factors,especially in critically ill patients,may make interpretation of these results unreliable.Through this review we aim to describe the indications and pitfalls of employing FibroScan in patients admitted to intensive care units. | Sahil Kataria Deven Juneja Omender Singh | 2023 | World Journal of Meta-Analysis2023，11，7： | 0 |
| 12 | Artificial intelligence in critically ill diabetic patients:current status and future prospects显示文摘Recent years have witnessed increasing numbers of artificial intelligence(AI)based applications and devices being tested and approved for medical care.Diabetes is arguably the most common chronic disorder worldwide and AI is now being used for making an early diagnosis,to predict and diagnose early complications,increase adherence to therapy,and even motivate patients to manage diabetes and maintain glycemic control.However,these AI applications have largely been tested in non-critically ill patients and aid in managing chronic problems.Intensive care units(ICUs)have a dynamic environment generating huge data,which AI can extract and organize simultaneously,thus analysing many variables for diagnostic and/or therapeutic purposes in order to predict outcomes of interest.Even non-diabetic ICU patients are at risk of developing hypo or hyperglycemia,complicating their ICU course and affecting outcomes.In addition,to maintain glycemic control frequent blood sampling and insulin dose adjustments are required,increasing nursing workload and chances of error.AI has the potential to improve glycemic control while reducing the nursing workload and errors.Continuous glucose monitoring(CGM)devices,which are Food and Drug Administration(FDA)approved for use in non-critically ill patients,are now being recommended for use in specific ICU populations with increased accuracy.AI based devices including artificial pancreas and CGM regulated insulin infusion system have shown promise as comprehensive glycemic control solutions in critically ill patients.Even though many of these AI applications have shown potential,these devices need to be tested in larger number of ICU patients,have wider availability,show favorable cost-benefit ratio and be amenable for easy integration into the existing healthcare systems,before they become acceptable to ICU physicians for routine use. | Deven Juneja Anish Gupta Omender Singh | 2022 | Artificial Intelligence in Gastroenterology2022，3，2： | 0 |
| 13 | Ideal scoring system for acute pancreatitis:Quest for the Holy Grail显示文摘Clinical scoring systems are required to predict complications,severity,need for intensive care unit admission,and mortality in patients with acute pancreatitis.Over the years,many scores have been developed,tested,and compared for their efficacy and accuracy.An ideal score should be rapid,reliable,and validated in different patient populations and geographical areas and should not lose relevance over time.A combination of scores or serial monitoring of a single score may increase their efficacy. | Deven Juneja | 2022 | World Journal of Critical Care Medicine2022，11，3： | 0 |
| 14 | Fungal arthritis:A challenging clinical entity显示文摘There has been an increasing incidence of fungal infections in recent years.Rarely joints are also affected by fungal infections.Mainly,these infections develop in prosthetic joints,but sometimes native joints are also involved.Candida infections are mostly reported,but patients may also develop infections secondary to non-Candida fungi,especially Aspergillus.Diagnosis and management of these infections is challenging and may involve multiple surgical interventions and prolonged antifungal therapy.Despite this,these infections are associated with high morbidity and mortality.This review described the clinical features,risk factors,and therapeutic interventions required to manage fungal arthritis. | Anjali Mishra Deven Juneja | 2023 | World Journal of Orthopedics2023，14，2： | 0 |
| 15 | Role of cerebrospinal fluid lactate in diagnosing meningitis in critically ill patients显示文摘BACKGROUND Meningitis is a life-threatening clinical condition associated with high mortality and morbidity.Early diagnosis and specific treatment may improve outcomes.Lack of specific clinical signs or tests make the diagnosis challenging.AIM To assess the efficacy of cerebrospinal fluid(CSF)lactate in diagnosing meningitis in critically ill patients.METHODS A prospective,observational cohort study was carried out in a neuro-medical intensive care unit(ICU)over a 22 mo period.Adult patients,with suspected meningitis admitted in ICU,were serially recruited.Patients who refused consent,those with peripheral sensorineural deficit,or with any contraindication to lumber puncture were excluded.CSF cytology,bio-chemistry,lactates,culture and polymerase chain reaction based meningo-encephalitis panel were evaluated.Patients were divided in two groups based on clinical diagnosis of meningitis.The efficacy of CSF lactate in diagnosing meningitis was evaluated and compared with other tests.RESULTS Seventy-one patients were included and 23 were diagnosed with meningitis.The mean values of CSF total leucocyte count(TLC),proteins and lactates were significantly higher in meningitis group.There was a significant correlation of CSF lactate levels with CSF cultures and meningo-encephalitis panel.CSF lactate(>2.72 mmol/L)showed good accuracy in diagnosing meningitis with an area under the curve of 0.81(95% confidence interval:0.69-0.93),sensitivity of 82.6%,and specificity 72.9%.These values were comparable to those of CSF TLC and protein.Twelve patients with bacterial meningitis had significantly higher CSF lactate(8.9±4.7 mmol/L)than those with non-bacterial meningitis(4.2±3.8 mmol/L),P=0.006.CONCLUSION CSF lactate may be used to aid in our diagnosis of meningitis in ICU patients.CSF lactate(>2.72 mmol/L)showed good accuracy,sensitivity,and specificity in diagnosing meningitis and may also help to differentiate between bacterial and non-bacterial meningitis. | Devraj Yadav Omender Singh Deven Juneja Amit Goel Sahil Kataria Anisha Beniwal | 2023 | World Journal of Critical Care Medicine2023，12，1： | 0 |
| 16 | Bedside ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure in nontraumatic neurocritically ill patients显示文摘BACKGROUND Delay in treatment of raised intracranial pressure(ICP)leads to poor clinical outcomes.Optic nerve sheath diameter(ONSD)by ultrasonography(US-ONSD)has shown good accuracy in traumatic brain injury and neurosurgical patients to diagnose raised ICP.However,there is a dearth of data in neuro-medical intensive care unit(ICU)where the spectrum of disease is different.AIM To validate the diagnostic accuracy of ONSD in non-traumatic neuro-critically ill patients.METHODS We prospectively enrolled 114 patients who had clinically suspected raised ICP due to non-traumatic causes admitted in neuro-medical ICU.US-ONSD was performed according to ALARA principles.A cut-off more than 5.7 mm was taken as significantly raised.Raised ONSD was corelated with raised ICP on radiological imaging.Clinical history,general and systemic examination findings,SOFA and APACHE 2 score and patient outcomes were recorded.RESULTS There was significant association between raised ONSD and raised ICP on imaging(P<0.001).The sensitivity,specificity,positive and negative predictive value at this cut-off was 77.55%,89.06%,84.44% and 83.82% respectively.The positive and negative likelihood ratio was 7.09 and 0.25.The area under the receiver operating characteristic curves was 0.844.Using Youden’s index the best cut off value for ONSD was 5.75 mm.Raised ONSD was associated with lower age(P=0.007),poorer Glasgow Coma Scale(P=0.009)and greater need for surgical intervention(P=0.006)whereas no statistically significant association was found between raised ONSD and SOFA score,APACHE II score or ICU mortality.Our limitations were that it was a single centre study and we did not perform serial measurements or ONSD pre-and post-treatment or procedures for raised ICP.CONCLUSION ONSD can be used as a screening a test to detect raised ICP in a medical ICU and as a trigger to initiate further management of raised ICP.ONSD can be beneficial in ruling out a diagnosis in a low-prevalence population and rule in a diagnosis in a high-prevalence population. | Madhura Bhide Omender Singh Deven Juneja Amit Goel | 2023 | World Journal of Critical Care Medicine2023，12，1： | 0 |
| 17 | Cytomegalovirus infection in non-immunocompromised critically ill patients:A management perspective显示文摘Critically ill patients are a vulnerable group at high risk of developing secondary infections.High disease severity,prolonged intensive care unit(ICU)stay,sepsis,and multiple drugs with immunosuppressive activity make these patients prone to immuneparesis and increase the risk of various opportunistic infections,including cytomegalovirus(CMV).CMV seroconversion has been reported in up to 33%of ICU patients,but its impact on patient outcomes remains a matter of debate.Even though there are guidelines regarding the management of CMV infection in immunosuppressive patients with human immunodeficiency virus/acquired immuno deficiency syndrome,the need for treatment and therapeutic approaches in immunocompetent critically ill patients is still ambiguous.Even the diagnosis of CMV infection may be challenging in such patients due to non-specific symptoms and multiorgan involvement.Hence,a better understanding of the symptomatology,diagnostics,and treatment options may aid intensive care physicians in ensuring accurate diagnoses and instituting therapeutic interventions. | Madhura Bhide Omender Singh Prashant Nasa Deven Juneja | 2024 | World Journal of Virology2024，13，1： | 0 |
| 18 | Dengue induced acute liver failure:A meta summary of case reports显示文摘BACKGROUND Dengue fever is the most common cause of viral hemorrhagic fever,with more than 400 million cases being reported annually,worldwide.Even though hepatic involvement is common,acute liver failure(ALF)is a rare complication of dengue fever.AIM To analyze the demographic profile,symptomology,hospital course and outcomes of patients presenting with ALF secondary to dengue infection by reviewing the published case reports.METHODS A systematic search was performed from multiple databases including PubMed,Reference Citation Analysis,Science Direct,and Google Scholar.The search terms used were'dengue'OR'severe dengue'OR'dengue shock syndrome'OR'dengue haemorrhagic syndrome'OR'dengue fever'AND'acute liver failure'OR'hepatic failure'OR'liver injury'.The inclusion criteria were:(1)Case reports or case series with individual patient details;(2)Reported acute liver failure secondary to dengue infection;and(3)Published in English language and on adult humans.The data were extracted for patient demographics,clinical sympto-matology,clinical interventions,hospital and intensive care unit course,need for organ support and clinical outcomes.RESULTS Data from 19 case reports fulfilling the predefined inclusion criteria were included.The median age of patients was 38 years(inter quartile range:Q3-Q126.5 years)with a female preponderance(52.6%).The median days from diagnosis of dengue to development of ALF was 4.5 d.The increase in aspartate aminotransferase was higher than that in alanine aminotransferase(median 4625 U/L vs 3100 U/L).All the patients had one or more organ failure,with neurological failure present in 73.7%cases.42.1%patients required vasopressor support and hepatic enceph-alopathy was the most reported complication in 13(68.4%)cases.Most of the patients were managed conser-vatively and 2 patients were taken up for liver transplantation.Only 1 death was reported(5.3%).CONCLUSION Dengue infection may rarely lead to ALF.These patients may frequently require intensive care and organ support.Even though most of these patients may improve with supportive care,liver transplantation may be a therapeutic option in refractory cases. | Deven Juneja Ravi Jain Prashant Nasa | 2024 | World Journal of Virology2024，13，1： | 0 |
| 19 | Metformin toxicity: A meta-summary of case reports显示文摘BACKGROUND Metformin is arguably the most commonly prescribed oral hypoglycemic agent for the management of diabetes.Due to the lack of randomized control trials,most of the data pertaining to the clinical course,therapeutic interventions and outcomes of patients with metformin induced toxicity has come from case reports or series.AIM To analyse the symptomology,clinical interventions and outcomes of patients presenting with severe metformin toxicity by reviewing the published case reports and series.METHODS We performed a systematic search from PubMed,Science Direct,Reference Citation Analysis(http://gffzzb1f9d057b5954674s5nnkb5nq5okx66nb.ffgz.tsg.suse.edu.cn/)and Google Scholar databases using the terms“metformin”AND“toxicity”OR“overdose”OR“lactic acidosis”OR“hyperlactatemia”.The inclusion criteria were:(1)Case reports or case series with individual patient details;and(2)Reported toxicity or overdose of metformin in adults,published in the English language.Data regarding baseline demographics,clinical presentation,therapeutic interventions,intensive care unit course and overall outcome were collected.RESULTS Two hundred forty-two individual cases were analysed,from 158 case reports and 26 case series,with a cumulative mortality of 19.8%.214(88.4%)patients were diabetics on metformin.57(23.6%)had acute ingestion,but a great majority(76.4%)were on metformin in therapeutic doses when they developed toxicity.Metformin associated lactic acidosis(MALA)was the most commonly reported adverse effect present in 224(92.6%)patients.Most of the patients presented with gastrointestinal and neurological symptoms and a significant number of patients had severe metabolic acidosis and hyperlactatemia.The organ support used was renal replacement therapy(RRT)(68.6%),vasopressors(58.7%)and invasive mechanical ventilation(52.9%).A majority of patients(68.6%)received RRT for toxin removal,renal dysfunction and correction of MALA.Patients with lowest pH and highest serum lactate and metformin levels also had favourable outcomes with use of RRT.CONCLUSION Most of the reported cases were on therapeutic doses of metformin but developed toxicity after an acute deterioration in renal functions.These patients may develop severe lactic acidosis,leading to significant morbidity and need for organ support.Despite severe MALA and the need for multiple organ support,they may have good outcomes,especially when RRT is used.The dose of metformin,serum pH,lactate and metformin levels may indicate the severity of toxicity and the need for aggressive therapeutic measures but may not necessarily indicate poor outcomes. | Deven Juneja Prashant Nasa Ravi Jain | 2022 | World Journal of Diabetes2022，13，8： | 0 |
| 20 | Liver injury from direct oral anticoagulants显示文摘BACKGROUND Drug-induced liver injury(DILI)can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs.Direct-acting oral anticoagulants(DOACs)are non-vitamin K-based antagonists recently introduced and increasingly used for various clinical conditions.A meta-analysis of 29 randomised controlled trials and 152116 patients reported no increased risk of DILI with DOACs.However,it is challenging to predict the risk factors for DILI in individual patients with exclusion of patients with pre-existing liver disease from these studies.AIM To determine the risk factors and outcomes of patients who developed DILI secondary to DOACs by systematic review and meta-summary of recent case reports and series.METHODS A systematic search was conducted on multiple databases including PubMed,Science Direct,Reference Citation Analysis,and Google Scholar.The search terms included“Acute Liver Failure”OR“Acute-On-Chronic Liver Failure”OR“Acute Chemical and Drug Induced Liver Injury”OR“Chronic Chemical and Drug Induced Liver Injury”AND“Factor Xa Inhibitors”OR“Dabigatran”OR“Rivaroxaban”OR“apixaban”OR“betrixaban”OR“edoxaban”OR“Otamixaban”.The results were filtered for literature published in English and on adult patients.Only case reports and case studies reporting cases of DILI secondary to DOACs were included.Data on demographics,comorbidities,medication history,laboratory investigations,imaging,histology,management,and outcomes were extracted.RESULTS A total of 15 studies(13 case reports and 2 case series)were included in the analysis,comprising 27 patients who developed DILI secondary to DOACs.Rivaroxaban was the most commonly implicated DOAC(n=20,74.1%).The mean time to onset of DILI was 40.6 d.The most common symptoms were jaundice(n=15,55.6%),malaise(n=9,33.3%),and vomiting(n=9,33.3%).Laboratory investigations showed elevated liver enzymes and bilirubin levels.Imaging studies and liver biopsies revealed features of acute hepatitis and cholestatic injury.Most patients had a favourable outcome,and only 1 patient(3.7%)died due to liver failure.CONCLUSION DOACs are increasingly used for various clinical conditions,and DILI secondary to DOACs is a rare but potentially serious complication.Prompt identification and cessation of the offending drug are crucial for the management of DILI.Most patients with DILI secondary to DOACs have a favourable outcome,but a small proportion may progress to liver failure and death.Further research,including post-marketing population-based studies,is needed to better understand the incidence and risk factors for DILI secondary to DOACs. | Deven Juneja Prashant Nasa Ravi Jain | 2023 | World Journal of Hepatology2023，15，6： | 0 |
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