Hypotension Prediction Score for Endotracheal Intubation in Critically Ill Patients: A Post Hoc Analysis of the HEMAIR Study

BACKGROUND

Hypotension with endotracheal intubation (ETI) is common and associated with adverse outcomes. We sought to evaluate whether a previously described hypotension prediction score (HYPS) for ETI is associated with worse patient outcomes and/or clinical conditions.

METHODS

This study is a post hoc analysis of a prospective observational multicenter study involving adult (age ≥18 years) intensive care unit (ICU) patients undergoing ETI in which the HYPS was derived and validated on the entire cohort and a stable subset (ie, patients in stable condition). We evaluated the association between increasing HYPSs in both subsets and several patient-centered outcomes and clinical conditions.

RESULTS

Complete data for HYPS calculations were available for 783 of 934 patients (84%). Logistic regression analysis showed increasing odds ratios (ORs) for the highest risk category for new-onset acute kidney injury (OR, 7.37; 95% CI, 2.58-21.08); new dialysis need (OR, 8.13; 95% CI, 1.74-37.91); ICU mortality (OR, 16.39; 95% CI, 5.99-44.87); and hospital mortality (OR, 18.65; 95% CI, 6.81-51.11). Although not increasing progressively, the OR for the highest risk group was significantly associated with new-onset hypovolemic shock (OR, 6.06; 95% CI, 1.47-25.00). With increasing HYPSs, median values (interquartile ranges) decreased progressively (lowest risk vs. highest risk) for ventilator-free days (23 [18-26] vs. 1 [0-21], P < .001) and ICU-free days (20 [11-24] vs. 0 [0-13], P < .001). Of the 729 patients in the stable subset, 598 (82%) had complete data for HYPS calculations. Logistic regression analysis showed significantly increasing ORs for the highest risk category for new-onset hypovolemic shock (OR, 7.41; 95% CI, 2.06-26.62); ICU mortality (OR, 5.08; 95% CI, 1.87-13.85); and hospital mortality (OR, 7.08; 95% CI, 2.63-19.07).

CONCLUSIONS

As the risk for peri-intubation hypotension increases, according to a validated hypotension prediction tool, so does the risk for adverse clinical events and certain clinical conditions.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02508948).

Safety and efficacy of colchicine in COVID-19 patients: A systematic review and meta-analysis of randomized control trials

BACKGROUND

Colchicine has been used an effective anti-inflammatory drug to treat gout diseases. Owing to its pharmacodynamic of inhibiting interleukins, it has been repurposed to target the cytokine storm post-SARS-CoV-2 invasion. The goal of this meta-analysis was to evaluate the safety profile of colchicine in COVID-19 patients using the gold-standard randomised-control trials.

METHODS

Electronic databases (Pubmed, Google Scholar, and Cochrane) were systematically searched until June 2021 and RCTs were extracted. Outcomes of interest included all-cause mortality, COVID-19 severity, mechanical ventilation, C-reactive protein and D-dimer levels. Using a random-effects model, dichotomous outcomes were pooled using odds ratios (OR) through the generic inverse variance formula while weighted mean differences were calculated using the Wan's method. P-values < 0.05 were considered statistically significant for all outcomes.

RESULTS

A total population of 16,048 from five RCTs were included in the analysis. Of this, 7957 were randomized to colchicine, and 8091 received standard care, with an average age of 60.67 years. Colchicine was observed to significantly reduce COVID-19 severity (OR: 0.41, 95% CI [0.22, 0.76]; p = 0.005), and CRP levels (WMD: -19.99, 95% CI [-32.09, -7.89]; p = 0.001). However, there was no significant difference in D-dimer levels (WMD: 0.31, 95% CI [-0.61, 1.23]; p = 0.51), mechanical ventilation (OR: 0.42, 95% CI [0.17, 1.03]; p = 0.06; I2 = 74%) and all-cause mortality (OR: 0.98, 95% CI [0.83, 1.16]; p = 0.84) among patients receiving colchicine or standard care.

CONCLUSION

Colchicine treatment decreased CRP levels and COVID-19 severity, with dimer levels, all-cause mortality and mechanical ventilation remaining seemingly unaffected. Thus, clinical trials need to be carried out that allow effective evaluation of colchicine in COVID-19 patients.

Demographic, Clinical, and Co-Morbidity Characteristics of COVID-19 Patients: A Retrospective Cohort from a Tertiary Hospital in Kenya

Introduction

The first documented case of COVID-19 in Kenya was recorded March of 2020. Co-morbidities including hypertension and diabetes have been associated with increased morbidity, hospitalization, and mortality among COVID-19 patients. This retrospective study describes the clinical characteristics, disease severity, and outcomes among the patient population at a tertiary hospital in Kenya.

Methods

This was a retrospective descriptive study of COVID-19 patients who were admitted between March 2020 and December 2020 at the Aga Khan University Hospital in Nairobi, Kenya. Data collected include patient demographic and baseline characteristics. Differences between patients who were known to have diabetes and hypertension during admission were compared for statistical significance. Difference between those who survived and those who died were also compared for statistical significance.

Results

A total of 913 records of patients were studied with a mean age of 51.2 years (SD = 16.7), 66.5% were male and 80.8% were of African origin. History of diabetes, hypertension, and HIV status were at 27.3%, 33.1%, and 2.3%, respectively. At presentation, 33.1% (302/913) of patients had known hypertension by history, and following admission, this proportion increased to 37.7% (344/913). At presentation, 27.3% (249/913) of patients had known diabetes. During hospital stay, 20.8% (190) more patients were found to have diabetes, raising the overall percent to 48.1% (439/913). When comparing diabetes and hypertension at baseline versus at the end of admission, diabetes increased by 20.8% (p < 0.001) and hypertension by 4.6% (p = 0.049). HIV co-infection was 2.3%, and no patient had tuberculosis.

Conclusion

This study showed a high incidence of co-morbidities in patients infected with COVID-19. Diabetes was most common, followed by hypertension. All patients admitted with COVID-19 infection should routinely be tested for diabetes with HbA1c and have regular blood pressure monitoring in order to diagnose occult diabetes and hypertension. Adverse outcomes were found in patients with these co-morbidities and should be monitored and treated appropriately.

Call for a Global Vaccine Plan to Combat Current and Future Pandemics: One for ALL and ALL for One

The emergence of SARS-CoV-2 in late December 2019 has taken the world by storm. In March 2020, the World Health Organization (WHO) named this virus COVID-19. To date, it has infected approximately 186 million people worldwide and is attributed as the cause of death of more than 5 million people (and this number is only increasing.) The global effort to develop vaccines and therapeutics occurred at the fastest pace yet, with several vaccines' approval under emergency authorization use. There are also several post-marketing side effects, including myocarditis, cerebral venous embolism, and Guillain Barre Syndrome. Global vaccine disparity complicates the control of pandemic challenges. Several highly infectious variants have emerged, and more variants are feared to emerge if global vaccination plans are not developed soon.

Advancements in Oncology with Artificial Intelligence—A Review Article

Simple Summary

With the advancement of artificial intelligence, including machine learning, the field of oncology has seen promising results in cancer detection and classification, epigenetics, drug discovery, and prognostication. In this review, we describe what artificial intelligence is and its function, as well as comprehensively summarize its evolution and role in breast, colorectal, and central nervous system cancers. Understanding the origin and current accomplishments might be essential to improve the quality, accuracy, generalizability, cost-effectiveness, and reliability of artificial intelligence models that can be used in worldwide clinical practice. Students and researchers in the medical field will benefit from a deeper understanding of how to use integrative AI in oncology for innovation and research.

Abstract

Well-trained machine learning (ML) and artificial intelligence (AI) systems can provide clinicians with therapeutic assistance, potentially increasing efficiency and improving efficacy. ML has demonstrated high accuracy in oncology-related diagnostic imaging, including screening mammography interpretation, colon polyp detection, glioma classification, and grading. By utilizing ML techniques, the manual steps of detecting and segmenting lesions are greatly reduced. ML-based tumor imaging analysis is independent of the experience level of evaluating physicians, and the results are expected to be more standardized and accurate. One of the biggest challenges is its generalizability worldwide. The current detection and screening methods for colon polyps and breast cancer have a vast amount of data, so they are ideal areas for studying the global standardization of artificial intelligence. Central nervous system cancers are rare and have poor prognoses based on current management standards. ML offers the prospect of unraveling undiscovered features from routinely acquired neuroimaging for improving treatment planning, prognostication, monitoring, and response assessment of CNS tumors such as gliomas. By studying AI in such rare cancer types, standard management methods may be improved by augmenting personalized/precision medicine. This review aims to provide clinicians and medical researchers with a basic understanding of how ML works and its role in oncology, especially in breast cancer, colorectal cancer, and primary and metastatic brain cancer. Understanding AI basics, current achievements, and future challenges are crucial in advancing the use of AI in oncology.

Secondary Infections in Patients with COVID-19 Pneumonia Treated with Tocilizumab Compared to Those Not Treated with Tocilizumab: A Retrospective Study at a Tertiary Hospital in Kenya

Introduction

From the first case of SARS-Co-2 in Wuhan, China, to the virus being declared as a pandemic in March 2020, the world has witnessed morbidity and mortality on a global scale. Scientists have worked at a record pace to deliver a vaccine for the prevention of this deadly disease. Tocilizumab, an interleukin-6 (IL-6) blocker, received an emergency use authorization (EUA) by the Federal Drug Agency (FDA) in June 2021.

Methods

This retrospective observational cohort study was conducted at the Aga Khan University Hospital, Nairobi, from March 8, 2020, to December 31, 2020. All patients with PCR confirmed COVID-19 pneumonia were included. Data were obtained from the medical records, and the admission registry was used to identify the patients, and both their electronic and paper-based files were retrieved from the medical records. Patient demographic data, medical history, baseline comorbidities, clinical characteristics, and outcome data were collected to study the infectious complications of Tocilizumab in patients affected by COVID-19 pneumonia.

Results

A total of 913 patients who were diagnosed with COVID-19 were included. The overall superinfection infection rate among the COVID-19 patients was 6%. Superinfection in patients who received the Tocilizumab was 17.2% and in the non-Tocilizumab group was 4.8%. The superinfection rate among severe and critically ill patients was even higher at 41.8% and 69.9% (Tocilizumab group) and 2.1% and 11.8% (non-Tocilizumab group), respectively (p < 0.001). There was no difference in mortality observed between the groups (p = 0.846). Infection among HIV co-infection was very low at 2.3%.

Conclusion

Contrary to some studies, a higher rate of infection was observed among the Tocilizumab group, and no difference in mortality was observed between Tocilizumab and the non-Tocilizumab group. Infection among patients with HIV remains low in this susceptible population.

Infection risk with the use of interleukin inhibitors in hospitalized patients with COVID-19: A narrative review

INTRODUCTION

To date, only corticosteroids and interleukin-6 (IL-6) inhibitors have been shown to reduce mortality of hospitalized patients with COVID-19. In this literature review, we aimed to summarize infection risk of IL inhibitors, with or without the use of corticosteroids, used to treat hospitalized patients with COVID-19.

METHODS

A literature search was conducted using the following evidence-based medicine reviews: Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Embase; Ovid Medline; and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions 1946 to April 28, 2021. All relevant articles were identified using the search terms COVID-19 or SARS-coronavirus-2, infections, interleukins, inpatients, adults, and i ncidence.

RESULTS

We identified 36 studies of which 2 were meta-analyses, 5 were randomized controlled trials, 9 were prospective studies, and 20 were retrospective studies. When anakinra was compared with control, 2 studies reported an increased risk of infection, and 3 studies reported a similar or decreased incidence of infection. Canakinumab had a lower associated incidence of infection compared with placebo in one study. When sarilumab was compared with placebo, one study reported an increased risk of infection. Nine studies comparing tocilizumab with placebo reported decreased or no difference in infection risk (odds ratio [OR] for the studies ranged from 0.39-1.21). Fourteen studies comparing tocilizumab with placebo reported an increased risk of infection, ranging from 9.1% to 63.0% (OR for the studies ranged from 1.85-5.04). Infection most commonly presented as bacteremia. Of the 6 studies comparing tocilizumab and corticosteroid use with placebo, 4 reported a nonsignificant increase toward corticosteroids being associated with bacterial infections (OR ranged from 2.76-3.8), and 2 studies reported no increased association with a higher infection risk.

CONCLUSIONS

Our literature review showed mixed results with variable significance for the association of IL-6 inhibitors with risk of infections in patients with COVID-19.

Hepatopulmonary syndrome: An update

Hepatopulmonary syndrome (HPS) is characterized by defects in oxygenation caused by intra-pulmonary vasodilation occurring because of chronic liver disease, portal hypertension, or congenital portosystemic shunts. Clinical implications of portal hypertension are very well-known, however, awareness of its effect on multiple organs such as the lungs are less known. The presence of HPS in chronic liver disease is associated with increased mortality. Medical therapies available for HPS have not been proven effective and definitive treatment for HPS is mainly liver transplantation (LT). LT improves mortality for patients with HPS drastically. This article provides a review on the definition, clinical presentation, diagnosis, and management of HPS.

Abnormal liver enzymes: A review for clinicians

Liver biochemical tests are some of the most commonly ordered routine tests in the inpatient and outpatient setting, especially with the automatization of testing in this technological era. These tests include aminotransferases, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, albumin, prothrombin time and international normalized ratio (INR). Abnormal liver biochemical tests can be categorized based on the pattern and the magnitude of aminotransferases elevation. Generally, abnormalities in aminotransferases can be classified into a hepatocellular pattern or cholestatic pattern and can be further sub-classified based on the magnitude of aminotransferase elevation to mild [< 5 × upper limit of normal (ULN)], moderate (> 5-< 15 × ULN) and severe (> 15 × ULN). Hepatocellular pattern causes include but are not limited to; non-alcoholic fatty liver disease/non-alcoholic steatohepatitis, alcohol use, chronic viral hepatitis, liver cirrhosis (variable), autoimmune hepatitis, hemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, celiac disease, medication-induced and ischemic hepatitis. Cholestatic pattern causes include but is not limited to; biliary pathology (obstruction, autoimmune), other conditions with hyperbilirubinemia (conjugated and unconjugated). It is crucial to interpret these commonly ordered tests accurately as appropriate further workup, treatment and referral can greatly benefit the patient due to prompt treatment which can improve the natural history of several of the diseases mentioned and possibly reduce the risk of progression to the liver cirrhosis.

Fungal infections following liver transplantation

With increasing morbidity and mortality from chronic liver disease and acute liver failure, the need for liver transplantation is on the rise. Most of these patients are extremely vulnerable to infections as they are immune-compromised and have other chronic co-morbid conditions. Despite the recent advances in practice and improvement in diagnostic surveillance and treatment modalities, a major portion of these patients continue to be affected by post-transplant infections. Of these, fungal infections are particularly notorious given their vague and insidious onset and are very challenging to diagnose. This mini-review aims to discuss the incidence of fungal infections following liver transplantation, the different fungi involved, the risk factors, which predispose these patients to such infections, associated diagnostic challenges, and the role of prophylaxis. The population at risk is increasingly old and frail, suffering from various other co-morbid conditions, and needs special attention. To improve care and to decrease the burden of such infections, we need to identify the at-risk population with more robust clinical and diagnostic parameters. A more robust global consensus and stringent guidelines are needed to fight against resistant microbes and maintain the longevity of current antimicrobial therapies.

Performance in mortality prediction of SAPS 3 And MPM-III scores among adult patients admitted to the ICU of a private tertiary referral hospital in Tanzania: a retrospective cohort study

Background

Illness predictive scoring systems are significant and meaningful adjuncts of patient management in the Intensive Care Unit (ICU). They assist in predicting patient outcomes, improve clinical decision making and provide insight into the effectiveness of care and management of patients while optimizing the use of hospital resources. We evaluated mortality predictive performance of Simplified Acute Physiology Score (SAPS 3) and Mortality Probability Models (MPM₀-III) and compared their performance in predicting outcome as well as identifying disease pattern and factors associated with increased mortality.

Methods

This was a retrospective cohort study of adult patients admitted to the ICU of the Aga Khan Hospital, Dar- es- Salaam, Tanzania between August 2018 and April 2020. Demographics, clinical characteristics, outcomes, source of admission, primary admission category, length of stay and the support provided with the worst physiological data within the first hour of ICU admission were extracted. SAPS 3 and MPM₀-III scores were calculated using an online web-based calculator. The performance of each model was assessed by discrimination and calibration. Discrimination between survivors and non-survivors was assessed by the area under the receiver operator characteristic curve (ROC) and calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test.

Results

A total of 331 patients were enrolled in the study with a median age of 58 years (IQR 43-71), most of whom were male (n = 208, 62.8%), of African origin (n = 178, 53.8%) and admitted from the emergency department (n = 306, 92.4%). In- hospital mortality of critically ill patients was 16.1%. Discrimination was very good for all models, the area under the receiver-operating characteristic (ROC) curve for SAPS 3 and MPM₀-III was 0.89 (95% CI [0.844-0.935]) and 0.90 (95% CI [0.864-0.944]) respectively. Calibration as calculated by Hosmer-Lemeshow goodness-of-fit test showed good calibration for SAPS 3 and MPM₀-III with Chi- square values of 4.61 and 5.08 respectively and P-Value > 0.05.

Conclusion

Both SAPS 3 and MPM₀-III performed well in predicting mortality and outcome in our cohort of patients admitted to the intensive care unit of a private tertiary hospital. The in-hospital mortality of critically ill patients was lower compared to studies done in other intensive care units in tertiary referral hospitals within Tanzania.

Evaluation of Vitamin-D Status and Its Association with Clinical Outcomes Among COVID-19 Patients in Pakistan

The risk of acute respiratory tract infections is particularly pronounced in patients deficient in 25-hydroxyvitamin D (25(OH)D). With respect to COVID-19, there are conflicting evidence on the association of 25(OH)D levels with disease severity. We undertook this study to evaluate the 25(OH)D status in COVID-19 patients admitted in Karachi, Pakistan, and associated vitamin D deficiency with primary outcomes of mortality, length of stay, intubation, and frequency of COVID-19 symptoms. A total of 91 patients were evaluated for 25(OH)D status during their COVID-19 disease course. 25-hydroxyvitamin D levels were classified as deficient (< 10 ng/mL), insufficient (10–30 ng/mL), or sufficient (> 30 ng/mL). The study population comprised 68.1% males (N = 62). The mean age was 52.6 ± 15.7 years. Vitamin D deficiency was significantly associated with intensive care unit (ICU) admission (RR: 3.20; P = 0.048), invasive ventilation (RR: 2.78; P = 0.043), persistent pulmonary infiltrates (RR: 7.58; P < 0.001), and death (RR: 2.98; P < 0.001) on univariate Cox regression. On multivariate Cox regression, only death (RR: 2.13; P = 0.046) and persistent pulmonary infiltrates (RR: 6.78; P = 0.009) remained significant after adjustment for confounding factors. On Kaplan Meier curves, vitamin D deficient patients had persistent pulmonary infiltrates and a greater probability of requiring mechanical ventilation than patients with 25(OH)D ≥ 10 ng/mL. Mechanical ventilation had to be initiated early in the deficient group during the 30-day hospital stay (Chi-square: 4.565, P = 0.033). Patients with 25(OH)D ≥ 10 ng/mL also demonstrated a higher probability of survival than those with 25(OH)D concentrations < 10 ng/mL. 25-hydroxyvitamin D deficient population had longer hospital stays and worse outcomes.

Comparison of first and second waves of COVID-19 through severity markers in ICU patients of a developing country

Background: Many countries are experiencing outbreaks of the second wave of COVID-19 infection. With these outbreaks, the severity of the disease is still ambiguously projected. Certain inflammatory markers are known to be associated with the severity of the disease and regular monitoring of these biomarkers in intensive care unit admissions is paramount to improve clinical outcomes.Objectives: This study was aimed to compare the severity markers of the patients infected during the first wave versus the second wave in an intensive care unit.Methods: We conducted a retrospective study obtaining patient's data from hospital records, admitted during the first wave in March-May 2020, and compared the data with those COVID-19 patients admitted during the second wave from October-November 2020. A descriptive comparison was done among the patients admitted to intensive care unit (ICU) during both waves of the pandemic.Results: 92 patients from first wave and 68 patients from second wave were included in the analysis, all admitted to ICU with equal gender distribution. Increased age and length of ICU stay was observed during the first wave. BMI, in-hospital mortality and invasive ventilation were statistically indifferent between both the waves. There was significantly higher APACHE-II during first wave (p = 0.007), but SOFA at day 1 (p = 0.213) and day 7 of ICU stay remain indifferent (p = 0.119). Inflammatory markers were less severe during second wave while only neutrophils and lymphocytes were found to peak higher.Conclusion: Most of the severity markers were less intense during the early analysis of second wave.

Genomics in medicine: A new era in medicine

The sequencing of complete human genome revolutionized the genomic medicine. However, the complex interplay of gene-environment-lifestyle and influence of non-coding genomic regions on human health remain largely unexplored. Genomic medicine has great potential for diagnoses or disease prediction, disease prevention and, targeted treatment. However, many of the promising tools of genomic medicine are still in their infancy and their application may be limited because of the limited knowledge we have that precludes its use in many clinical settings. In this review article, we have reviewed the evolution of genomic methodologies/tools, their limitations, and scope, for current and future clinical application.

Factors Associated with Mortality Among Hospitalized Adults with COVID-19 Pneumonia at a Private Tertiary Hospital in Tanzania: A Retrospective Cohort Study

Background

The emergence of the novel coronavirus disease 2019 (COVID-19) has caused millions of deaths worldwide. There has been paucity of data for hospitalized African patients suffering from COVID-19. This study aimed to identify factors associated with in-hospital mortality in patients suffering from COVID-19 in Tanzania.

Methods

This was a single center, retrospective, observational cohort study in adult patients hospitalized with confirmed COVID-19 infection. Demographics, clinical pattern, laboratory and radiological investigations associated with increased odds of mortality were analyzed.

Results

Of the 157 patients, 107 (68.1%) patients survived and 50 (31.8%) died. Mortality was highest in patients suffering with severe (26%) and critical (68%) forms of the disease. The median age of the cohort was 52 years (IQR 42-61), majority of patients were male (86%) and of African origin (46%), who presented with fever (69%), cough (62%) and difficulty in breathing (43%). Factors that were associated with mortality among our cohort were advanced age (OR 1.07, 95% CI 1.03-1.11), being overweight and obese (OR 9.44, 95% CI 2.71-41.0), suffering with severe form of the disease (OR 4.77, 95% CI 1.18-25.0) and being admitted to the HDU and ICU (OR 6.68, 95% CI 2.06-24.6).

Conclusion

The overall in-hospital mortality was 31.8%. Older age, obesity, the severe form of the disease and admission to the ICU and HDU were major risk factors associated with in-hospital mortality.

Role of proning and positive end-expiratory pressure in COVID-19

The novel coronavirus, which was declared a pandemic by the World Health Organization in early 2020 has brought with itself major morbidity and mortality. It has increased hospital occupancy, heralded economic turmoil, and the rapid transmission and community spread have added to the burden of the virus. Most of the patients are admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure often secondary to acute respiratory distress syndrome (ARDS). Based on the limited data available, there have been different opinions about the respiratory mechanics of the ARDS caused by coronavirus disease 2019 (COVID-19). Our article provides an insight into COVID-19 pathophysiology and how it differs from typical ARDS. Based on these differences, our article explains the different approach to ventilation in COVID-19 ARDS compared to typical ARDS. We critically analyze the role of positive end-expiratory pressure (PEEP) and proning in the ICU patients. Through the limited data and clinical experience are available, we believe that early proning in COVID-19 patients improves oxygenation and optimal PEEP should be titrated based on individual lung compliance.

Smart Watch Detection of Supraventricular Tachycardia (SVT): First Case from Tanzania

Smartwatches like the Apple Watch have been on the rise worldwide and their use is gaining popularity in developing countries. Their ability to detect dysrhythmias is well documented. Present practice discourages the use of these devices as a diagnostic tool. Nevertheless, atypical findings from these devices should be clinically investigated. This case demonstrates an eventual diagnosis of supraventricular tachycardia (SVT) based on an Apple watch alert which was subsequently confirmed by electrophysiological evaluation.

Current state of medical tourism involving liver transplantation-the risk of infections and potential complications

Liver transplant has been shown to significantly improve mortality and quality of life in various liver diseases such as acute liver failure, end-stage liver disease, and liver cancer. While the organ transplant demand is continuing to rise, the organ donation supply remains unmatched. The organ shortage, high cost, and long waiting lists have stimulated a desire for routes that may be unethical. This process which is named transplant tourism is the term used to describe traveling to another country to purchase an organ for transplant. Liver transplant tourism has been associated with post-transplant complications and higher mortality compared to a domestic liver transplant. Improper pre-and post-transplant infectious screening, inadequate opportunistic infection prophylaxis, and loss to follow-up were noted in patients who travel abroad for a liver transplant. It is crucial to understand the risk of transplant tourism to prevent morbidity and mortality.

Diagnosis of Obstructive Sleep Apnea from ECG Signals Using Machine Learning and Deep Learning Classifiers

Obstructive sleep apnea (OSA) is a well-known sleep ailment. OSA mostly occurs due to the shortage of oxygen for the human body, which causes several symptoms (i.e., low concentration, daytime sleepiness, and irritability). Discovering the existence of OSA at an early stage can save lives and reduce the cost of treatment. The computer-aided diagnosis (CAD) system can quickly detect OSA by examining the electrocardiogram (ECG) signals. Over-serving ECG using a visual procedure is challenging for physicians, time-consuming, expensive, and subjective. In general, automated detection of the ECG signal’s arrhythmia is a complex task due to the complexity of the data quantity and clinical content. Moreover, ECG signals are usually affected by noise (i.e., patient movement and disturbances generated by electric devices or infrastructure), which reduces the quality of the collected data. Machine learning (ML) and Deep Learning (DL) gain a higher interest in health care systems due to its ability of achieving an excellent performance compared to traditional classifiers. We propose a CAD system to diagnose apnea events based on ECG in an automated way in this work. The proposed system follows the following steps: (1) remove noise from the ECG signal using a Notch filter. (2) extract nine features from the ECG signal (3) use thirteen ML and four types of DL models for the diagnosis of sleep apnea. The experimental results show that our proposed approach offers a good performance of DL classifiers to detect OSA. The proposed model achieves an accuracy of 86.25% in the validation stage.

Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis

Introduction

Our goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA).

Methods

We searched medical databases systematically for randomized controlled trials (RCT) and observational studies published between January 1, 2000–October 1, 2020 that compared mechanical chest compression (using any device) with manual chest compression following OHCA. We only included studies in the English language that reported ROSC outcomes in adult patients in non-trauma settings to conduct random-effects metanalysis and trial sequence analysis (TSA). Multivariate meta-regression was performed using preselected covariates to account for heterogeneity. We assessed for risk of biases in randomization, allocation sequence concealment, blinding, incomplete outcome data, and selective outcome reporting.

Results

A total of 15 studies (n = 18474), including six RCTs, two cluster RCTs, five retrospective case-control, and two phased prospective cohort studies, were pooled for analysis. The pooled estimates’ summary effect did not indicate a significant difference (Mantel-Haenszel odds ratio = 1.16, 95% confidence interval, 0.97 to 1.39, P = 0.11, I2 = 0.83) between mechanical and manual compressions during CPR for ROSC. The TSA showed firm evidence supporting the lack of improvement in ROSC using mechanical compression devices. The Z-curves successfully crossed the TSA futility boundary for ROSC, indicating sufficient evidence to draw firm conclusions regarding these outcomes. Multivariate meta-regression demonstrated that 100% of the between-study variation could be explained by differences in average age, the proportion of females, cardiac arrests with shockable rhythms, witnessed cardiac arrest, bystander CPR, and the average time for emergency medical services (EMS) arrival in the study samples, with the latter three attaining statistical significance.

Conclusion

Mechanical compression devices for resuscitation in cardiac arrests are not associated with improved rates of ROSC. Their use may be more beneficial in non-ideal situations such as lack of bystander CPR, unwitnessed arrest, and delayed EMS response times. Studies done to date have enough power to render further studies on this comparison futile.

What we learned in the past year in managing our COVID-19 patients in intensive care units?

Coronavirus disease 2019 is a pandemic, was first recognized at Wuhan province, China in December 2019. The disease spread quickly across the globe, spreading stealthily from human to human through both symptomatic and asymptomatic individuals. A multisystem disease which appears to primarily spread via bio aerosols, it has exhibited a wide clinical spectrum involving multiple organ systems with the respiratory system pathology being the prime cause of morbidity and mortality. Initially unleashing a huge destructive trail at Wuhan China, Lombardy Italy and New York City, it has now spread to all parts of the globe and has actively thrived and mutated into new forms. Health care systems and Governments responded initially with panic, with containment measures giving way to mitigation strategies. The global medical and scientific community has come together and responded to this huge challenge. Professional medical societies quickly laid out "expert" guidelines which were conservative in their approach. Many drugs were re formulated and tested quickly with the help of national and international collaborative groups, helping carve out effective treatment strategies and help build a good scientific foundation for evidence-based medicine. Out of the darkness of chaos, we now have an orderly approach to manage this disease both from a public health preventive and therapeutic standpoint. With preventive measures such as masking and social distancing to the development of highly effective and potent vaccines, the public health success of such measures has been tempered by behavioral responses and resource mobilization. From a therapy standpoint, we now have drugs that were promising but now proven ineffective, and those that are effective when given early during viral pathogenesis or later when immune dysregulation has established, and the goal is to help reign in the destructive cascade. It has been a fascinating journey for mankind and our work here recapitulates the evolution of various aspects of critical care and other inpatient practices which continue to evolve.

Cardiac manifestations of the coronavirus disease-19: a review of pathogenesis, clinical manifestations, diagnosis, and treatment

The coronavirus disease-19 (COVID-19), first appearing in Wuhan, China, and later declared as a pandemic, has caused serious morbidity and mortality worldwide. Severe cases usually present with acute respiratory distress syndrome (ARDS), pneumonia, acute kidney injury (AKI), liver damage, or septic shock. However, with recent advances in severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) research, the virus´s effect on cardiac tissues has become evident. Reportedly, an increased number of COVID-19 patients manifested serious cardiac complications such as heart failure, increased troponin, and N-terminal pro-B-type natriuretic peptide levels (NT-proBNP), cardiomyopathies, and myocarditis. These cardiac complications initially present as chest tightness, chest pain, and heart palpitations. Diagnostic investigations such as telemetry, electrocardiogram (ECG), cardiac biomarkers (troponin, NT-proBNP), and inflammatory markers (D-dimer, fibrinogen, PT, PTT), must be performed according to the patient´s condition. The best available options for treatment are the provision of supportive care, anti-viral therapy, hemodynamic monitoring, IL-6 blockers, statins, thrombolytic, and anti-hypertensive drugs. Cardiovascular disease (CVD) healthcare workers should be well-informed about the evolving research regarding COVID-19 and approach as a multi-disciplinary team to devise effective strategies for challenging situations to reduce cardiac complications.

Stethoscope - An essential diagnostic tool or a relic of the past?

Rene Laennec came up with the idea of a stethoscope in 1816 to avoid the embarrassment of performing immediate auscultation on women. Soon many doctors around the world started using this tool because of its increased accuracy and ease of use. Stethoscopes hold great significance in the medical community. However, is the importance placed on stethoscopes justified today? We now have devices like portable ultrasound machines that make it much easier to visualize the body. These devices offset their higher initial cost by reducing downstream costs due to their greater accuracy and their capability of detecting diseases at an earlier stage. Also, because of the COVID-19 pandemic, new ways are being investigated to reduce the transmission of diseases. Stethoscopes being a possible vector for infectious agents coupled with the advent of newer devices that can visualize the body with greater accuracy put into question the continued use of stethoscopes today. With that said, the use of stethoscopes to diagnose diseases is still crucial in places where buying these new devices is not yet possible. The stethoscope is a great symbol of medicine, but its use needs to be in line with what is best for the patient.

An Unusual and Rare Presentation of Pulmonary Aspergillosis: Endobronchial Aspergilloma

Aspergillosis is a wide spectrum of the disease process that is caused by the fungus Aspergillus. Endobronchial aspergilloma is a very rare type of aspergillosis which is not yet included in the classification of aspergillosis. Due to its rare nature and a limited number of cases, there are no current treatment guidelines. Here we present the case of a 57-year-old female with an endobronchial aspergilloma. The patient was started on intravenous voriconazole and subsequently discharged on oral voriconazole.

Drug-induced liver injury and prospect of cytokine based therapy; A focus on IL-2 based therapies

Drug-induced liver injury (DILI) is one of the most frequent sources of liver failure and the leading cause of liver transplant. Common non-prescription medications such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and other prescription drugs when taken at more than the recommended doses may lead to DILI. The severity of DILI is affected by factors such as age, ethnicity, race, gender, nutritional status, on-going liver diseases, renal function, pregnancy, alcohol consumption, and drug-drug interactions. Characteristics of DILI-associated inflammation include apoptosis and necrosis of hepatocytes and hepatic infiltration of pro-inflammatory immune cells. If untreated or if the inflammation continues, DILI and associated hepatic inflammation may lead to development of hepatocarcinoma. The therapeutic approach for DILI-associated hepatic inflammation depends on whether the inflammation is acute or chronic. Discontinuing the causative medication, vaccination, and special dietary supplementation are some of the conventional approaches to treat DILI. In this review, we discuss a concise overview of DILI-associated liver complications, and current therapeutic options with special emphasis on biologics including the scope of cytokine therapy in hepatic repair and resolution of inflammation caused by over- the-counter (OTC) or prescription drugs.

Mediastinal lymphadenopathy in COVID-19: A review of literature

A novel coronavirus disease 2019 (COVID-19) is a progressive viral disease that affected people around the world with widespread morbidity and mortality. Patients with COVID-19 infection typically had pulmonary manifestation but can also present with gastrointestinal, cardiac, or neurological system dysfunction. Chest imaging in patients with COVID-19 commonly show bilateral lung involvement with bilateral ground-glass opacity and consolidation. Mediastinal lymphadenopathy can be found due to infectious or non-infectious etiologies. It is commonly found to be associated with malignant diseases, sarcoidosis, and heart failure. Mediastinal lymph node enlargement is not a typical computer tomography of the chest finding of patients with COVID-19 infection. We summarized the literature which suggested or investigated the mediastinal lymph node enlargement in patients with COVID-19 infection. Further studies are needed to better characterize the importance of mediastinal lymphadenopathy in patients with COVID-19 infection.

Tsunami of economic turmoil to hit the healthcare in 2021-2022: COVID-19 pandemic is just an earthquake

The COVID-19 pandemic caused the United States to hit record numbers of COVID-19 cases: peak unemployment of 14.7%, an increase in $4 trillion in national debt, and an estimated 3.4% GDP decline. The current socio-economic environment the pandemic created is just an earthquake that can create a tsunami that is bound to hit the healthcare system and can be felt around the globe. This tsunami is composed of a post-pandemic increase in healthcare facilities admission of indigent patients, decrease in medical reimbursement, and high operating costs to maintain healthcare workers, which can cause a synergistic effect that can lead to healthcare facilities experiencing significant negative total revenue. Time is of the essence, and it is imperative to make a collective effort from all healthcare professionals and legislatures to shift the nation's attention to the issue at hand that can threaten the closure of many healthcare facilities post-pandemic.

Current Utility of Sequential Organ Failure Assessment Score: A Literature Review and Future Directions

The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.

Diagnostic procedures and clinico-radiological findings of acute fibrinous and organizing pneumonia: a systematic review and pooled analysis

OBJECTIVES

To evaluate the clinico-radiological findings of acute fibrinous and organizing pneumonia (AFOP) in the literature according to whether a surgical or non-surgical biopsy was performed, as well as to identify prognostic predictors.

METHODS

We searched the Embase and OVID-MEDLINE databases to identify studies that presented CT findings of AFOP and had extractable individual patient data. We compared the clinical and CT findings of the patients depending on whether a surgical or non-surgical biopsy was performed and identified survival predictors using a multivariate logistic regression analysis.

RESULTS

Eighty-one patients (surgical biopsy, n = 52; non-surgical biopsy, n = 29) from 63 studies were included. The surgical biopsy group frequently experienced an acute fulminant presentation (p = .011) and dyspnea (p = .001) and less frequently had a fever (p = .006) than the non-surgical biopsy group. The surgical biopsy group had a worse prognosis than the non-surgical biopsy group in terms of mechanical ventilation and mortality (both, p = .023). For survival analysis, the patients with the predominant CT finding of patchy or mass-like air-space consolidation survived more frequently (p < .001) than those with other CT findings. For prognostic predictors, subacute indolent presentation (p = .001) and patchy or mass-like air-space consolidation on CT images (p = .002) were independently associated with good survival.

CONCLUSIONS

Approximately one-third of alleged AFOP cases in the literature were diagnosed via non-surgical biopsy, but those cases had different symptomatic presentations and prognosis from surgically proven AFOP. Subacute indolent presentation and patchy or mass-like air-space consolidation at the presentation on CT images indicated a good prognosis in patients with AFOP.

KEY POINTS

• Acute fibrinous and organizing pneumonia (AFOP) cases diagnosed via non-surgical biopsy had different symptomatic presentations and prognosis from surgically proven AFOP. • Subacute indolent presentation and patchy or mass-like air-space consolidation on CT images indicated a good prognosis in patients with acute fibrinous and organizing pneumonia.

Pulmonary Hypertension in Pregnancy: A Review

Pulmonary hypertension (PH) is a disease, which targets the pulmonary vasculature affecting the heart and the lungs, and is characterized by a vast array of signs and symptoms. These manifestations of PH in pregnancy are highly variable and non-specific hence, it is prudent to have a very keen and high index of suspicion while evaluating these patients. This rare disease can be extremely debilitating and can be associated with a poor overall prognosis. Pregnancy in women with PH puts them at an elevated risk because the physiological changes associated with pregnancy are not well endured leading to even higher morbidity and mortality in these patients. Although there are various modalities for evaluation and workup of PH, right heart catheterization (RHC) remains the gold standard. A mean pulmonary artery pressure (PAP) of more than 20 mm of Hg is considered diagnostic. It is indeed heartening to see that in the past decade many novel therapeutic modalities have emerged and along with a better understanding of the disease process have proved to be promising in terms of reducing the adverse outcomes and preventing death in this population of patients.

Comorbid insomnia and sleep apnea: characterization of the syndrome and understanding its associations with comorbid sleep conditions

PURPOSE

Obstructive sleep apnea (OSA) is traditionally associated with excessive daytime sleepiness. Insomnia is characterized by hyperarousal, and is seen as a predominant feature in a subgroup of patients with OSA. The aim of this study was to describe the prevalence of comorbid insomnia and sleep apnea (COMISA) in a sleep apnea population and to characterize its features.

METHODS

This was a chart review of patients who underwent overnight polysomnography (PSG). All patients completed questionnaires with the Epworth Sleepiness Scale (ESS), and symptoms of insomnia and other sleep-related comorbidities. Patients with OSA on the PSG were included.

RESULTS

A total of 296 patients with OSA were included, of which 80% reported at least 1 major symptom of insomnia: 57% reported sleep onset insomnia, 68% sleep maintenance insomnia, and 48% had early morning awakenings. COMISA (OSA plus 2 or more major symptoms of insomnia) was seen in 63%. These patients were more likely to report an abnormal ESS score, gastroesophageal reflux (GER), and restless legs (RL) than those without; no difference was seen in self-reported sleep bruxism. Among the patients with COMISA, 85% reported at least 1 representative symptom of psychophysiological insomnia (PPI); each of the 5 PPI symptoms was present in at least 40% of patients with COMISA.

CONCLUSIONS

Insomnia is extremely prevalent in our population of patients with OSA, accompanied by daytime sleepiness and symptoms of PPI, GER, and RL. Further study is needed to determine the interactions between symptoms and OSA treatments in these patients.

COVID-19 pandemic: from origins to outcomes. A comprehensive review of viral pathogenesis, clinical manifestations, diagnostic evaluation, and management

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), the causative pathogen for the COVID-19, first emerged in Wuhan, China, in December 2019 and by March 2020, it was declared a pandemic. COVID-19 pandemic has overburdened healthcare systems in most countries and has led to massive economic losses. SARS-CoV-2 transmission typically occurs by respiratory droplets. The average incubation period is 6.4 days and presenting symptoms typically include fever, cough, dyspnea, myalgia or fatigue. While the majority of patients tend to have a mild illness, a minority of patients develop severe hypoxia requiring hospitalization and mechanical ventilation. Management is mostly supportive. However, several direct anti-viral agents, and immunomodulatory therapy with steroids and various cytokine blockers seem promising in early results. However, an effective vaccine has been established, which will help curb the pandemic.

Medical chart validation of inpatient diagnosis codes for transfusion-related acute lung injury 2013-2015

INTRODUCTION

Transfusion-related acute lung injury (TRALI), an adverse event occurring during or within 6 hours of transfusion, is a leading cause of transfusion-associated fatalities reported to the US Food and Drug Administration. There is limited information on the validity of diagnosis codes for TRALI recorded in inpatient electronic medical records (EMRs).

STUDY DESIGNS AND METHODS

We conducted a validation study to establish the positive predictive value (PPV) of TRALI International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes recorded within a large hospital system between 2013 and 2015. A physician with critical care expertise confirmed the TRALI diagnosis. As TRALI is likely underdiagnosed, we used the specific code (518.7), and codes for respiratory failure (518.82) in combination with transfusion reaction (999.80, 999.89, E934.7).

RESULTS

Among almost four million inpatient stays, we identified 208 potential TRALI cases with ICD-9-CM codes and reviewed 195 medical records; 68 (35%) met clinical definitions for TRALI (26 [38%] definitive, 15 [22%] possible, 27 [40%] delayed). Overall, the PPV for all inpatient TRALI diagnoses was 35% (95% confidence interval (CI), 28-42). The PPV for the TRALI-specific code was 44% (95% CI, 35-54).

CONCLUSION

We observed low PPVs (<50%) for TRALI ICD-9-CM diagnosis codes as validated by medical charts, which may relate to inconsistent code use, incomplete medical records, or other factors. Future studies using TRALI diagnosis codes in EMR databases may consider confirming diagnoses with medical records, assessing TRALI ICD, Tenth Revision, Clinical Modification codes, or exploring alternative ways for of accurately identifying TRALI in EMR databases.

KEY POINTS

In 169 hospitals, we identified 208 potential TRALI cases, reviewed 195 charts, and confirmed 68 (35%) cases met TRALI clinical definitions. As many potential TRALI cases identified with diagnosis codes did not meet clinical definitions, medical record confirmation may be prudent.

Painful Sleep: Insomnia in Patients with Chronic Pain Syndrome and its Consequences

Insomnia is a chronic condition that occurs a minimum of three times per week over a period of three or more subsequent months. There are multiple causes of insomnia, and even though it is considered a symptom, it can be associated with chronic illnesses. Chronic pain syndrome, which is defined as pain that persists for a period longer than 3 months, is one of several etiologies of insomnia. The prevalence of insomnia among chronic pain patients is greater in comparison with the general population (percentage or ratio). Chronic pain is common in patients with rheumatoid arthritis, spinal pain (such as chronic back pain) and fibromyalgia. The prevalence of in-somnia is also higher in cancer patients when compared to the general population. When the clinical history indicates a straightforward diagnosis of chronic pain syndrome, patients will complain of insomnia as part of their symptomatology. It is imperative to manage their underlying illness to alleviate their sleep disorder. Various medications may be used to relieve and even improve pain symptoms. Other than pharmacological interventions, non-pharmacological alternatives such as yoga, meditation, acupuncture, and psychotherapy can help improve the quality of life of these patients. The purpose of this article is to review the diagnosis and management of insomnia in chronic pain syndrome and its impact on the quality of life.

Novel and Controversial Therapies in COVID-19

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the coronavirus disease (COVID-19) pandemic, which has led scientists all over the world to push for the identification of novel therapies for COVID-19. The lack of a vaccine and specific treatment has led to a surge of novel therapies and their publicity in recent times. Under these unprecedented circumstances, a myriad of drugs used for other diseases is being evaluated and repositioned to treat COVID-19 (example- Remdesivir, Baricitinib). While multiple trials for potential drugs and vaccines are ongoing, and there are many unproven remedies with little or no supporting evidence. Presently, discussions are revolving around the use of multivitamins (Vitamin, C, D, A), minerals (selenium, zinc), probiotics, flavonoids, polyphenols, and herbal remedies (curcumin, artemisinin, herbal drinks). Our review delves further into the details of some of these controversial therapies for COVID-19.

Ethnic Variance in Prevalence of COPD among Smokers in a Real World Setting

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is characterized by persistent and progressive airflow limitation generally caused by prolonged cigarette smoking. Ethnic differences have been reported regarding COPD risk from smoking. The purpose of this study was to compare COPD prevalence in Hispanic and Caucasian smokers in a real-world setting. We studied consecutive patients referred to the community-based pulmonary practice. Hispanic and Caucasian smokers were included in the study.

METHODS

The clinical diagnosis of COPD was recorded from the chart. COPD was defined by PFT using GOLD criteria. Exclusion criteria were other ethnicities, non-smokers, and patients with a history of asthma /other pulmonary conditions. We reviewed a total of 1,313 consecutive PFTs of which 797 patients met our inclusion criteria.

RESULTS AND DISCUSSION

The prevalence of COPD among Hispanics was found to be lower by both clinical diagnosis as well as by spirometry compared to Caucasians (41.6% vs 54.2%). In Hispanics, clinical diagnosis was 91% higher by PFT, whereas for Caucasians, it was 6% lower. The odds of developing COPD (diagnosed based on FEV1/FVC ratio <70%) in the Caucasians are 4.1 times higher than Hispanics (Odds Ratio: 4.1; 95%CI: 2.8-5.9). Hispanic smokers have a lower prevalence of COPD both by the clinical diagnosis as well as by PFT. There is a significant disconnection between clinical and PFT diagnosis of COPD in Hispanic patients.

CONCLUSION

The genetic basis of lower COPD risk and prevalence in Hispanics needs to be better understood. Spirometry threshold criteria for confirming a diagnosis of COPD may need to be modified based on ethnicity in clinical practice.

Revisiting One of the Dreaded Outcomes of the Current Pandemic: Pulmonary Embolism in COVID-19

Pulmonary embolism (PE) is a commonly encountered clinical entity in patients with coronavirus disease 2019 (COVID-19). Up to 1/3 of patients have been found to have PE in the setting of COVID-19. Given the novelty of the virus causing this pandemic, it has not been easy to address diagnostic and management issues in PE. Ongoing research and publications of the scientific literature have helped in dealing with COVID-19 lately and this applies to PE as well. In this article, we attempt to succinctly yet comprehensively discuss PE in patients with COVID-19 with a review of the prevailing literature.

Ogilvie syndrome: peculiar manifestation of acquired immunodeficiency syndrome in non-institutionalized middle age female in Tanzania

Since it was first documented in 1948 by Sir William Heneage Ogilvie, numerous cases of Ogilvie syndrome have been described in literature due to various medical and surgical causes. Nonetheless, only a handful of cases only have been documented due to underlying Acquired Immunodeficiency Syndrome (AIDS). A 41-year-old female was admitted with an acute abdomen secondary to partial mechanical intestinal obstruction or paralytic ileus based on signs and symptoms and Abdominal X-Ray (AXR). She was known to be HIV/AIDS WHO clinical stage II on treatment. On diagnostic imaging studies she had distended large bowels without features of mechanical intestinal obstruction and the diagnosis of Ogilvie syndrome was suspected after other differentials were excluded. Early recognition and appropriate management are essential, because if left untreated the bowel distension may progress to caecal perforation and fatal peritonitis. Medical imaging with Computer Tomography (CT) scan and colonoscopy has helped in achieving an accurate diagnosis and avoiding unnecessary laparotomies. Although an uncommon disorder, for earlier and accurate diagnosis a high index of suspicion is required by clinicians and radiologists who are treating patients with underlying HIV/AIDS. Ogilvie’s syndrome is a rare condition and if missed can be fatal. In patients with HIV/AIDS, the symptoms may be directly due to HIV infection, secondary to opportunistic infections or possible neurotoxic effects of HIV treatment or lack of vitamin and minerals. It is important to exclude Ogilvie syndrome in patients from surgical causes of the acute abdomen to avoid unnecessary surgical procedures.

Breaking Bad News, a Pertinent Yet Still an Overlooked Skill: An International Survey Study

Delivering bad news to patients is a challenging yet impactful everyday task in clinical practice. Ideally, healthcare practitioners should receive formal training in implementing these protocols, practice in simulation environments, and real-time supervision with feedback. We aimed to investigate whether healthcare providers involved in delivering bad news have indeed received formal training to do so. We conducted a cross-sectional survey study that targeted all healthcare providers in the intensive care units of 174 institutions in 40 different countries. Participants included physicians, nurses, medical students, nursing students, pharmacists, respiratory technicians, and others. The survey tool was created, validated, and translated to the primary languages of these countries to overcome language barriers. A total of 10,106 surveys were collected. Only one third of participants indicated that they had received a formal training. Providers who had received formal training were more likely to deliver bad news than those who had not. Younger and less experienced providers tend to deliver bad news more than older, more experienced providers. The percentage of medical students who claimed they deliver bad news was comparable to that of physicians. Medical schools and post-graduate training programs are strongly encouraged to tackle this gap in medical education.

The PROCESS 2020 Guideline: Updating Consensus Preferred Reporting Of CasESeries in Surgery (PROCESS) Guidelines

INTRODUCTION

The PROCESS Guidelines were first published in 2016 and were last updated in 2018. They provide a structure for reporting surgical case series in order to increase reporting robustness and transparency, and are used and endorsed by authors, journal editors and reviewers alike. In order to drive forwards reporting quality, they must be kept up to date. As such, we have updated these guidelines via a DELPHI consensus exercise.

METHODS

The updated guidelines were produced via a DELPHI consensus exercise. Members from the previous DELPHI group were again invited, alongside editorial board members and peer reviewers of the International Journal of Surgery and the International Journal of Surgery Case Reports. An online survey was completed by this expert group to indicate their agreement with proposed changes to the checklist items.

RESULTS

A total of 53 surgical experts agreed to participate and 49 (92%) completed the survey. The responses and suggested modifications were incorporated into the previous 2018 guidelines. There was a high degree of agreement amongst the PROCESS Group, with all but one of the PROCESS items receiving over 70% of scores ranging 7-9.

CONCLUSION

A DELPHI consensus exercise was completed and an updated and improved PROCESS Checklist is now presented.

Psychological effects of the COVID 19 pandemic on healthcare workers globally: A systematic review

In this systematic review, we compared the incidences of psychological issues during the COVID-19 pandemic, such as anxiety, depression, occupational stress, PTSD and insomnia, in healthcare workers (HCW) and non-healthcare workers (NHCW). PubMed, Ovid, Google Scholar and PsycInfo were systematically searched for related published articles. In all electronic databases, the following search strategy was implemented, and these key words were used: "COVID 19″ OR "SARS-CoV-2″ AND "psychological" OR "stress" OR "depression" AND "healthcare$". We identified 6 studies, out of the final 15 selected, which reported numerical estimates for incidences of psychological effects. Meta-analysis was conducted, comparing both combined and individual effect sizes of all psychological manifestations. Qualitative evidence was reported from the remaining 9 cross- sectional studies. The summary effects of the combined quantitative meta-analysis conducted on 6 studies did indicate near significant differences between HCW and NHCW. Summary effects of individual manifestations indicated significantly higher incidence of insomnia among HCW, when compared to NHCW. Qualitative evidence from remaining cross-sectional studies provided additional information into the nature of the psychological issues. We conclude that even though reasons for psychological distress among HCW and NHCW may be different, both suffered in equal measures excepting for insomnia.

Invasive liver abscess syndrome caused by Klebsiella pneumoniae: first Tanzanian experience

Over the past 20 years there has been growing awareness of community-acquired primary liver abscess caused by strains of Klebsiella pneumoniae (K. pneumoniae) especially in patients of Asian descent, a minority of which are characterized by metastatic spread. A common and frequent destructive complication is endophthalmitis as well as the involvement of the central nervous system (CNS), causing suppurative meningitis or brain abscess. Here we report a case of invasive liver abscess caused by K. pneumoniae in an Asian patient who presented to our hospital in Tanzania with bilateral lower limb swelling for 6 weeks with acute onset of difficulty in breathing.

Postoperative myocardial injury in a patient with left ureteric stone and asymptomatic COVID-19 disease

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first identified on 8^thDecember 2019 in Wuhan, Hubei, China, and has since spread globally to become an emergency of international concern. Patients infected with SARS-CoV-2 may be asymptomatic or present with symptoms ranging from mild clinical manifestations: such as fever, cough, and sore throat to moderate and severe form of the disease such as pneumonia and acute respiratory distress syndrome (ARDS). In some patients, SARS-CoV-2 can affect the heart and cause myocardial injury which is evidenced either by electrocardiographic (ECG) changes or by a rise in serum troponin level. Patients with myocardial involvement are generally at risk of developing severe illness and tend to have a poor outcome. We hereby present a case of a hypertensive male patient with undiagnosed, asymptomatic COVID-19, who underwent an emergency urologic procedure for ureteric calculi. He eventually sustained a postoperative myocardial injury resulting in his demise. This case highlights the importance of detailed preoperative assessment and anticipation of complications during this global pandemic.

When a Dead Patient Is Not Really Dead: Lazarus Phenomenon

Lazarus phenomenon refers to autoresuscitation of a patient declared dead after cessation of cardiopulmonary resuscitation (CPR). The Lazarus phenomenon is rarely encountered and pathophysiology is not very well understood, but physicians need to be aware of this phenomenon. It is prudent that a physician leading a CPR effort waits for some time and monitors the patient further using blood pressure and electrocardiogram before confirming that a patient is actually dead.

Case Report: Sudden Splenic Rupture in a Plasmodium falciparum-Infected Patient

Spontaneous splenic rupture is a rare and life-threatening complication of severe malaria. It demands particular attention since delayed or missed diagnosis can be potentially fatal. The exact incidence is unknown largely due to underreporting. Acute malarial infection accounts for most of the spontaneous splenic rupture. Plasmodium vivax has been associated with the majority of them; however, on rare occasion, other Plasmodium infections have also resulted in splenic rupture. We report the case of a 74-year-old male who was diagnosed with severe malaria caused by Plasmodium falciparum (P. falciparum) infection and developed an acute abdomen while on treatment due to spontaneous splenic rupture which necessitated emergency splenectomy.

Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study

Objective

Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation.

Methods

A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation.

Results

Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients’ pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients’ risk of hypotension.

Conclusions

A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients.

Study registration

Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.