Early predictors of intensive care unit admission among COVID-19 patients in Qatar

Background

COVID-19 is associated with significant morbidity and mortality. This study aimed to explore the early predictors of intensive care unit (ICU) admission among patients with COVID-19.

Methods

This was a case-control study of adult patients with confirmed COVID-19. Cases were defined as patients admitted to ICU during the period February 29-May 29, 2020. For each case enrolled, one control was matched by age and gender.

Results

A total of 1,560 patients with confirmed COVID-19 were included. Each group included 780 patients with a predominant male gender (89.7%) and a median age of 49 years (interquartile range = 18). Predictors independently associated with ICU admission were cardiovascular disease (adjusted odds ratio (aOR) = 1.64, 95% confidence interval (CI): 1.16-2.32, p = 0.005), diabetes (aOR = 1.52, 95% CI: 1.08-2.13, p = 0.016), obesity (aOR = 1.46, 95% CI: 1.03-2.08, p = 0.034), lymphopenia (aOR = 2.69, 95% CI: 1.80-4.02, p < 0.001), high AST (aOR = 2.59, 95% CI: 1.53-4.36, p < 0.001), high ferritin (aOR = 1.96, 95% CI: 1.40-2.74, p < 0.001), high CRP (aOR = 4.09, 95% CI: 2.81-5.96, p < 0.001), and dyspnea (aOR = 2.50, 95% CI: 1.77-3.54, p < 0.001).

Conclusion

Having cardiovascular disease, diabetes, obesity, lymphopenia, dyspnea, and increased AST, ferritin, and CRP were independent predictors for ICU admission in patients with COVID-19.

Distal Radius Reconstruction Using Proximal Non-vascularized Fibula Graft in a Patient During the Syrian Conflict: A Case Study of Treatment Outcomes

In conflict zones like Syria, accessing specialized medical care presents significant challenges. Here, we present the case of a 22-year-old female with a giant cell tumor in her distal forearm, exacerbated by limited access to healthcare due to the Syrian conflict. Despite these obstacles, we successfully performed en bloc resection and reconstructed the defect with a proximal non-vascularized fibular graft, restoring arm function. This case underscores the critical importance of adapting to adverse circumstances to deliver essential medical interventions in conflict-affected regions.

Acetabular Aneurysmal Bone Cyst During the Syrian Conflict: A Case Report of Surgical Treatment and Outcomes

Aneurysmal bone cysts (ABCs) are uncommon benign bone lesions that consist of blood-filled vascular spaces surrounded by fibrous tissue septa. Their diagnosis and surgical management are challenging in a war-torn region. In this case report, we present a rare case of a giant aneurysmal bone cyst located around the acetabulum in a 10-year-old female child who presented with an antalgic limp and left hip pain. The lesion was successfully treated with curettage and mixed autologous and synthetic bone grafts, and the follow-up for two years revealed a complete resolution of symptoms and radiological evidence of bone regeneration. This case highlights the successful surgical treatment of a challenging case of ABC in a difficult setting during the Syrian conflict.

Extracorporeal blood purification with Oxiris® filter in critically ill patients with COVID-19 requiring continuous renal replacement therapy

INTRODUCTION

Severe COVID-19 is associated with a dysregulated immune response that usually leads to cytokine release syndrome. This study aimed to compare the use of extracorporeal blood purification therapy (Oxiris®) versus standard continuous renal replacement therapy (CRRT) in critically-ill patients with severe COVID-19.

METHODS

This was a national, multicenter, retrospective study of patients with COVID-19 admitted to the intensive care unit (ICU) between March and October 2020 who required CRRT. Patients were categorized into two groups: Oxiris® CRRT and standard CRRT. The primary outcome was the number of patients alive and ventilator-free at 30-days post-CRRT treatment. Key secondary endpoints included change in inflammatory markers, Sequential Organ Failure Assessment (SOFA) scores, and PaO2/FiO2 ratio at 24- and 72-h post Oxiris® initiation.

RESULTS

Thirty-five patients received Oxiris® CRRT and 23 patients received standard CRRT. The primary outcome was 31.4% in the Oxiris® group versus 4.3% in the standard CRRT group (adjusted odds ratio 5.97, 95% confidence interval [CI], 0.64-55.6; p = 0.117). In the Oxiris® group, interleukin-6 (IL-6) concentrations significantly decreased at 24 and 72-h (p = 0.033) and PaO2/FiO2 ratio significantly increased at 24 and 72 h after Oxiris® initiation (p = 0.001). There was no significant change in SOFA scores at 24- and 72-h after Oxiris® initiation.

CONCLUSION

The number of patients alive and ventilator-free at 30-days was higher in the Oxiris® group than that in the standard CRRT group; however, the difference did not reach statistical significance after adjusting for the baseline severity of illness. There was a significant reduction in IL-6 and significant improvement in PaO2/FiO2 ratio after Oxiris® CRRT initiation.

Polysaccharides and Phenolic Compounds Recovered from Red Bell Pepper, Tomato and Basil By-Products Using a Green Extraction by Extractor Timatic®

Fruits and vegetables processing produces significant amounts of by-products rich in valuable bioactive compounds such as polyphenols and dietary fiber. Food by-product re-use promotes the eco-sustainability of several crops. This study aimed to apply green extractions of bioactive compounds from by-products of basil, tomato, and red bell pepper production. Tests were performed by applying extraction procedures both at laboratory scale and using the Timatic® extractor. Water and ethanol 10% and 20% were used for extraction of red bell pepper and tomato, testing different temperatures (30, 50, and 90 °C; water at 90 °C and ethanol 20% were applied for basil. The obtained phenolic extracts were analyzed by HPLC-DAD-MS. Polysaccharides of tomato and red bell pepper were extracted at laboratory scale and chemically characterized using 1H-NMR to define the methylation and acylation degree, and DLS to estimate the hydrodynamic volume. Laboratory extraction tests allowed efficient scaling-up of the process on the Timatic® extractor. Phenolic content in the dried extracts (DE) ranged 8.0-11.2 mg/g for tomato and red bell pepper and reached 240 mg/g for basil extracts. Polysaccharide yields (w/w on DM) reached 6.0 and 10.4% for dried tomato and red bell pepper, respectively. Dry extracts obtained using the Timatic® extractor and water can be useful sources of bioactive phenols. The study provided new data on tomato and red bell pepper polysaccharides that may be useful for future applications.

Plasma-Lyte-148 Versus Normal Saline 0.9% in Diabetic Ketoacidosis Management: A Review

Diabetic ketoacidosis (DKA) is a critical complication of diabetes mellitus characterized by hyperglycemia, ketonemia, circulatory collapse, hypokalemia, and metabolic acidosis. The therapeutic management of DKA includes vigilant fluid resuscitation to address dehydration and electrolyte imbalances and restore hemodynamic stability. The choice of fluid, either isotonic saline or a balanced electrolyte solution like Plasma-Lyte 148 (PL), is pivotal in the clinical outcomes of DKA patients. Recent studies have compared the effectiveness of these fluid solutions in DKA management, focusing on different clinical outcomes such as the resolution of metabolic acidosis, electrolyte imbalances, the incidence of acute kidney injury, and length of hospital stay. This review examines the literature comparing isotonic saline and balanced electrolyte solutions for fluid resuscitation in DKA, analyzing the associated clinical outcomes. Through synthesizing research findings, this review aims to elucidate the efficacy and potential advantages of utilizing PL as an alternative to traditional isotonic saline for fluid resuscitation in treating DKA. This would further facilitate evidence-based decision-making among healthcare professionals and contribute to optimizing DKA management strategies. Understanding the intricacies and implications of fluid resuscitation is crucial, given its profound impact on patient outcomes in DKA management.

Rhabdomyolysis in Critically Ill Patients With COVID-19: A Retrospective Study

INTRODUCTION

The total number of ICU admissions for COVID-19 patients has increased steadily. Based on the research team's clinical observations, many patients developed rhabdomyolysis, but few cases were reported in the literature. This study explores the incidence of rhabdomyolysis and its outcomes, like mortality, the need for intubation, acute kidney injury, and the need for renal replacement therapy (RRT).

METHODS

We retrospectively reviewed the characteristics and outcomes of patients admitted to the ICU at a COVID-19-designated hospital in Qatar between March and July 2020. Logistic regression analysis was used to determine factors associated with mortality.

RESULTS

1079 patients with COVID-19 were admitted to the ICU, and 146 developed rhabdomyolysis. Overall, 30.1% died (n = 44), and 40.4% developed Acute Kidney Injury (AKI) (n = 59), with only 19 cases (13%) recovering from the AKI. AKI was significantly associated with increased mortality rates among rhabdomyolysis patients. Moreover, significant differences were found between groups regarding the subject's age, calcium level, phosphorus level, and urine output. However, the AKI was the best predictor of mortality for those who got the COVID-19 infection and rhabdomyolysis.

CONCLUSION

Rhabdomyolysis increases the risk of death in COVID-19 patients admitted to the ICU. The strongest predictor of a fatal outcome was acute kidney injury. The findings of this study emphasize the importance of early identification and prompt treatment of rhabdomyolysis in patients with severe COVID-19.

Ellagitannins and triterpenoids extracts of Anogeissus leiocarpus stem bark extracts: Protective effects against osteoarthritis

Osteoarthritis (OA) is a complex joint disease characterized by persistent pain. Unfortunately, current pharmacological therapies are unsatisfactory and characterized by side effects, reason why new strategies are needed. We tested the efficacy of different classes of compounds, ellagitannins and olean-type triterpenoids, contained in Anogeissus leiocarpus extract (Combretaceae family) in comparison to ellagitannins of Castanea sativa extract in a rat model of osteoarthritis induced by the intra-articular injection of sodium monoiodoacetate (MIA). The decoction of stem bark of A. leiocarpus AL-DEC-TOT (300 mg/kg; 4.8% triterpenoids; 11.0% tannins), the butanol extract AL-BuOH-EXT (120 mg/kg; triterpenoids 20.9%; tannins 6.4%) and its correlated aqueous residue AL-Res-H₂ O (300 mg/kg; triterpenoids 0.7%; tannins 8.7%) and the decoction of C. sativa, CS-DEC-TOT, (240 mg/kg; triterpenoids 0.65%; tannins 10.8%) were orally administered for two weeks starting from the day of the damage. Behavioural tests highlighted that all stem bark extracts of A. leiocarpus counteracted hypersensitivity development, reduced spontaneous pain, and improved motor skills. Histologically, AL-DEC-TOT, AL-BuOH-EXT and AL-Res-H₂ O were effective in preventing joint alterations. In conclusion, all the extracts were effective demonstrating that both olean-type triterpenoid and ellagitannin fractions have anti-hypersensitivity and restorative properties running the stem bark extracts of A. leiocarpus as a candidate in the treatment of OA.

Rhabdomyolysis-Induced Acute Kidney Injury (AKI) in a Young Bodybuilder: A Case Report

Acute kidney injury (AKI) is a serious medical condition that can have many causes, including rhabdomyolysis. Rhabdomyolysis is the breakdown of muscle tissue that can lead to the release of muscle fiber contents into the bloodstream. This can cause serious damage to the kidneys, leading to AKI. In this case, a young bodybuilder was diagnosed with rhabdomyolysis induced by AKI after consuming Ibuprofen for a casual fever. The etiology of AKI in rhabdomyolysis is complex, with multiple factors contributing to the development of the condition. These include muscle trauma, dehydration, infection, and drug toxicity. In this case, Ibuprofen may have contributed to the development of AKI, as it can cause kidney damage when taken in large doses. Additionally, the bodybuilder's physical activity may have contributed to the development of rhabdomyolysis, as intense exercise can cause muscle damage. Treatment for AKI in rhabdomyolysis patients typically involves aggressive fluid resuscitation, electrolyte replacement, and dialysis if necessary. Additionally, the underlying cause of the rhabdomyolysis must be identified and treated. In this case, the patient should be monitored closely for any signs of kidney damage, and the Ibuprofen should be discontinued. In conclusion, this is a case of a relatively common presentation with uncommon circumstances. It is crucial to have a heightened understanding of the likelihood of AKI in patients with rhabdomyolysis and the impact of drug toxicity in exacerbating the condition. Early diagnosis and treatment are essential for the successful management of AKI.

Lung Cancer Mimicking Aspergilloma: A Case Report

An aspergilloma is a conglomeration of Aspergillus hyphae, fibrin, mucus, and cellular debris, typically found within a pulmonary cavity or ectatic bronchus. Computerized tomography (CT) scans often depict a cavity containing a solid mass and a notable crescent sign. Though these signs are indicative of aspergilloma, the European Respiratory Society emphasizes the need for a more detailed diagnostic criteria. A patient with a history of hemoptysis was initially diagnosed with an aspergilloma based on CT chest findings, showing a cavitary lesion in the left upper lobe with an intracavitary lobular opacity. Post resection, histological examination contradicted the initial diagnosis, revealing lung cancer instead. This case underscores the importance of tissue diagnosis from the outset or employing a multifaceted diagnostic criteria encompassing radiological findings, serology and microbiology tests. In the absence of an initial tissue diagnosis, rigorous follow-up, including early interval scanning, is crucial.

The effect of non-oncology drugs on clinical and genomic risk in early luminal breast cancer

BACKGROUND

An effect of non-oncology medications on cancer outcome has been proposed. In this study, we aimed to systematically examine the impact of commonly prescribed non-oncology drugs on clinical risk and on the genomic risk [based on the Oncotype DX recurrence score (RS)] in early breast cancer (BC).

EXPERIMENTAL DESIGN

We collected data on clinical risk (stage and grade), genomic risk (Oncotype DX RS), and on non-oncology medications administered to 1423 patients with estrogen receptor-positive human epidermal growth factor receptor 2-negative BC during the month of their surgery. The influence of various medications on clinical and genomic risks was evaluated by statistical analysis.

RESULTS

Out of the multiple drugs we examined, levothyroxine was significantly associated with a high Oncotype DX RS (mean 24.78; P < 0.0001) and metformin with a low Oncotype DX RS (mean 14.87; P < 0.01) compared with patients not receiving other non-oncology drugs (mean 18.7). By contrast, there were no differences in the clinical risk between patients receiving metformin, levothyroxine, or no other non-oncology drugs. Notably, there was no association between the consumption of levothyroxine and metformin and proliferation marker (Ki67) levels, but both drugs were significantly associated with progesterone-related features, suggesting that they influence genomic risk through estrogen-dependent signaling.

CONCLUSIONS

The results of this study indicate a significant impact of metformin and levothyroxine on clinical decisions in luminal BC, with potential impact on the clinical course of these patients.

Phenolic compounds and polysaccharides in the date fruit (Phoenix dactylifera L.): Comparative study on five widely consumed Arabian varieties

The study analysed polysaccharides and phenolic compounds in widely consumed but little studied date fruits varieties such as Sukkari, Ajwa, Segae, Barrny and Khalas harvested at Tamr stage. The total phenols were in similar amount in the five varieties and ranged from 20 to 50 mg/100 g DW. The decoction and successive centrifugation made it possible to collect two main polysaccharide fractions for all the selected fruits. For each variety the first fraction was more abundant, with a lower swelling capacity and a higher amount of galacturonic acid (28.3% to 40.1%). The second fraction was only soluble in alkaline solution, with an average galacturonic acid content of only 17%. The different structure of the two polysaccharide fractions was also confirmed by the composition in neutral sugars and the degrees of methylation and acetylation. The proposed extraction procedure could be applied for larger scale extraction of the date fruit polysaccharides.

Critical care tele-pharmacy services during COVID-19 pandemic: A qualitative exploration of healthcare practitioners' perceptions

What is Known and Objective

The scope of clinical pharmacy services has changed during COVID‐19 pandemic with the view to mitigating both exposure and spread of the virus. The performance of novel pandemic‐driven services such as tele‐pharmacy has remained unexplored, until now. The aim of this study is to investigate the perceptions of healthcare providers of the impact of tele‐pharmacy services provided in critical care units during COVID‐19.

Methods

A qualitative study of semi‐structured interviews conducted with healthcare practitioners who worked in COVID‐19 intensive care units and remotely interacted with clinical pharmacists at the Weill Cornell‐affiliated Hamad Medical Corporation, Doha, Qatar. Random sampling technique was employed to recruit participants, with the resultant interview guide piloted before commencement of data collection process.

Results and Discussion

From a total 129 and 200 physicians and nurses, respectively, 20 interviews were conducted with physicians (n = 15), and nurses (n = 5). From these interactions, a number of major themes emerged including: satisfactory understanding across clinical environment and personnel (physician and nurses) about remote clinical pharmacists' roles; additional robust feedback on the perception of the remote clinical pharmacy service; an understanding by ‘frontline’ health personnel on the discernible differences between remote and in‐person coverage of clinical pharmacists; a reflection by both physicians and nurses on the novel challenges involved in the implementation of such pandemic‐driven service; and solutions to overcome these challenges.

What is New and Conclusion

In this novel qualitative study of pandemic‐driven tele‐pharmacy service, we found a positive perception amongst healthcare practitioners towards this service; with residual challenges that will need further evaluation by large sampled sized surveys or mixed methods research.

Spontaneous tension pneumothorax as a complication of Coronavirus disease 2019: Case report and literature review

Primary spontaneous tension pneumothorax (STP) is a rare and life‐threatening condition. We report a case of COVID‐19‐pneumonia patient who developed STP as a complication. He had a prolonged hospital stay and was ultimately discharged asymptomatic. A systematic literature search was performed to review studies (N=12) reporting STP in the setting of COVID‐19.

Characteristics and Early Predictors of Intensive Care Unit Admission among COVID-19 Patients in Qatar

Purpose

This study aimed to explore the early predictors of intensive care unit (ICU) admission and in-hospital mortality among patients diagnosed with Coronavirus disease (COVID-19).

Methods & Materials

This was a case-control study of adult patients with confirmed COVID-19. Cases were defined as patients admitted to ICU during the period February 29 - May 29, 2020. For each case enrolled, one control was matched by age and gender. Univariate and multivariate logistic regression models were used to identify the predictors for ICU admission and in-hospital mortality among the COVID‐19 patients.

Results

A total of 1560 patients with confirmed COVID-19 were included. Each group included 780 patients with a predominant male gender (89.7%) and a median age of 49 years (interquartile range, IQR=18). Predictors independently associated with ICU admission included having cardiovascular disease (CVD) (adjusted odds ratio (aOR)=1.64, 95% confidence interval (CI): 1.16 - 2.32, p= 0.005), diabetes (aOR=1.52, 95% CI: 1.08 - 2.13, p= 0.016), body mass index ≥30 kg/m2 (aOR=1.46, 95% CI: 1.03-2.08, p= 0.034), lymphocytes ≤0.8 × 103/μL (aOR=2.69, 95% CI: 1.80-4.02, p<0.001), aspartate aminotransferase (AST) >120 U/L (aOR= 2.59, 95% CI: 1.53-4.36, p<0.001), ferritin >600 μg/L (aOR=1.96, 95% CI: 1.40-2.74, p<0.001), C-reactive protein (CRP) >100 mg/L (aOR=4.09, 95% CI: 2.81-5.96, p<0.001), and dyspnea (aOR=2.50, 95% CI: 1.77-3.54, p <0.001). Similarly, significant predictors of mortality included CVD (aOR=2.16, 95% CI: 1.32- 3.53, p=0.002), diabetes (aOR=1.77, 95% CI: 1.07-2.90, p=0.025), cancer (aOR=4.65, 95% CI: 1.50-14.42, p= 0.008), lymphocytes ≤0.8 x,103/μL (aOR=2.34, 95% CI: 1.45-3.78, p= 0.001), and AST >120 U/L (aOR= 1.89, 95% CI: 1.04-3.43, p=0.036).

Conclusion

Having CVD, diabetes, lymphopenia, and increased AST were independent predictors for both ICU admission and in-hospital mortality in patients with COVID-19. In addition, obesity, high ferritin, and CRP levels were also associated with increased risk of ICU admission, while cancer was strongly associated with in-hospital mortality. Early identification and monitoring of patients at risk is essential in planning the level of care needed to prevent delay in medical intervention.

1H NMR and HPLC-DAD-MS for the characterization of ellagitannins and triterpenoids of less investigated Anogeissus leiocarpus DC (Combretaceae) stem bark

Anogeissus leiocarpus DC is an evergreen tree, widely distributed in Asia and Africa. The stem bark is used in traditional medicine, and as chewing sticks and infusion. Nowadays, it is becoming increasingly important to define the phytochemical profile of less studied edible plants. Aim of this research was a first complete characterization of ellagitannins and triterpenoids profiles by HPLC-DAD-MS and ¹H NMR and analyses. A total of 59 compounds were identified including 43 ellagitannins and 16 triterpenoids, mainly oleane derivatives and glycosylated forms. Among ellagitannins, roburin, vescalin and castalin were found for the first time. Tannins accounted for 38.9% whereas triterpenoids were 4.8%, both estimated on dry decoction. The decoction was preliminary tested against osteoarthritis in rats. The characterization of the main phytochemicals of Anogeissus leiocarpus DC stem bark decoction is a necessary step to evaluate nutraceutical properties, paving the way for possible food applications of this plant.

395. Early Predictors of Intensive Care Unit Admission among COVID-19 Patients in Qatar

Background

Coronavirus disease (COVID-19) is associated with significant morbidity and mortality. This study aimed to explore the early predictors of intensive care unit (ICU) admission and in-hospital mortality among patients diagnosed with COVID-19.

Methods

This was a case-control study of adult patients with confirmed COVID-19. Cases were defined as patients admitted to ICU during the period February 29 - May 29, 2020. For each case enrolled, one control was matched by age and gender.

Results

A total of 1560 patients with confirmed COVID-19 were included. Each group included 780 patients with a predominant male gender (89.7%) and a median age of 49 years (interquartile range = 18). Predictors independently associated with ICU admission were cardiovascular disease (CVD) (adjusted odds ratio (aOR)=1.64, 95% confidence interval (CI): 1.16 - 2.32, p=0.005), diabetes (aOR=1.52, 95% CI: 1.08 - 2.13, p= 0.016), obesity (aOR=1.46, 95% CI: 1.03-2.08, p= 0.034), lymphopenia (aOR=2.69, 95% CI: 1.80-4.02, p< 0.001), high aspartate aminotransferase (AST) (aOR= 2.59, 95% CI: 1.53-4.36, p< 0.001), high ferritin (aOR=1.96, 95% CI: 1.40-2.74, p< 0.001), high C-reactive protein (CRP) (aOR=4.09, 95% CI: 2.81-5.96, p< 0.001), and dyspnea (aOR=2.50, 95% CI: 1.77-3.54, p< 0.001). Similarly, significant predictors of mortality included CVD (aOR=2.16, 95% CI: 1.32- 3.53, p=0.002), diabetes (aOR=1.77, 95% CI: 1.07-2.90, p=0.025), cancer (aOR=4.65, 95% CI: 1.50-14.42, p= 0.008), lymphopenia (aOR=2.34, 95% CI: 1.45-3.78, p= 0.001), and high AST (aOR= 1.89, 95% CI: 1.04-3.43, p=0.036).

Risk Factors for ICU admission among patients with COVID-19 (N=1560)

Conclusion

Having CVD, diabetes, lymphopenia, and increased AST were independent predictors for both ICU admission and in-hospital mortality in patients with COVID-19. In addition, obesity, high ferritin, and CRP levels were associated with increased risk of ICU admission, while cancer was strongly associated with in-hospital mortality. Early identification and monitoring of patients at risk is essential in planning the level of care needed to prevent delay in medical intervention.

Disclosures

Adel Abou-Ali, PharmD, PhD, Astellas Pharma Global Development, Inc. (Employee)

The role of simulation in training breast surgeons: a systematic review

BACKGROUND

As surgical education has evolved, most curricula have favoured a competency-based approach over traditional apprenticeship models. Surgical simulation can be a useful aide in the training of both oncological and reconstructive breast surgery trainees. This review investigates the extent to which simulation of breast surgery procedures has been validated as a training tool.

METHODS

A comprehensive literature search for studies evaluating the objective validity of breast surgery simulators was performed, using MEDLINE, EMBASE and the Cochrane Library databases. Studies assessing construct, concurrent or predictive validity were included, as well as those demonstrating skill acquisition.

FINDINGS

The initial literature search returned 1,625 hits, with only five articles meeting the inclusion criteria. Simulators were designed to train procedures such as breast augmentation, lesion biopsy and excision. Of these, breast biopsy was the most simulated procedure (three studies). Two studies evaluated animal models, two evaluated synthetic models and one study assessed both a synthetic and animal model. Construct validity was confirmed in two studies, concurrent validity in one study and a learning curve demonstrated in another study. No association between experience and performance was seen in the remaining study. The quality of the evidence presented in each article was low due to numerous limitations. Despite the abundance of breast surgery simulators created for trainees, few have been objectively validated and they only cover a narrow range of breast procedures. Although early results are promising, further studies are required before routine use of simulators is considered in breast surgery curricula.

COVID-19: Prolonged viral shedding in an HIV patient with literature review of risk factors for prolonged viral shedding and its implications for isolation strategies

Our work highlights patients at risk of prolonged viral shedding in COVID-19 and its implications for isolation strategies and explores possible solution by PCR-CT value testing (cycle threshold value). We also review the impact of HIV on COVID-19.

Pneumothorax In Covid-19 Pneumonia: A case series

BACKGROUND

Coronavirus disease 2019 (Covid-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It mainly affects the lungs and common symptoms are fever, cough and shortness of breath. Pneumothorax has been noted to complicate Covid-19 cases requiring hospital admission, however the exact incidence and risk factors are still unknown.

DISCUSSION

We present a series of 3 cases of primary spontaneous pneumothorax with Covid-19 pneumonia. All cases in our series did not require positive pressure ventilation and none had any pre-existing lung disease. All were never smokers and had favourable outcomes despite having severe Covid-19 with a pneumothorax during the course of the disease. In our literature review we discuss several plausible mechanisms and risk factors resulting in a pneumothorax with Covid-19.

CONCLUSION

Our cases are a reminder that an acute deterioration with hypoxia in a Covid-19 patient could indicate a pneumothorax. Pneumothorax is one of the reported complications in Covid-19 and clinician vigilance is required during assessment of patients, as both share the common symptom of breathlessness and therefore can mimic each other.

Pomegranate Mesocarp against Colitis-Induced Visceral Pain in Rats: Effects of a Decoction and Its Fractions

The management of chronic visceral pain related to Inflammatory Bowel Diseases or Irritable Bowel Syndrome is still a clinical problem and new therapeutic strategies continue to be investigated. In the present study, the efficacy of a pomegranate decoction and of its polysaccharide and ellagitannin components in preventing the development of colitis-induced abdominal pain in rats was evaluated. After colitis induction by 2,4-dinitrobenzenesulfonic acid (DNBS), the pomegranate decoction (300 mg kg-1), polysaccharides (300 mg kg-1), and ellagitannins (45 mg kg-1) were orally administered for 14 days. Repeated treatment with decoction reduced visceral hypersensitivity in the colitic animals both at 7 and 14 days. Similar efficacy was shown by polysaccharides, but with lower potency. Ellagitannins administered at dose equivalent to decoction content showed higher efficacy in reducing the development of visceral pain. Macroscopic and microscopic evaluations performed on the colon 14 days after the damage showed that all three preparations reduced the overall amount of mast cells, the number of degranulated mast cells, and the density of collagen fibers in the mucosal stroma. Although ellagitannins seem to be responsible for most of the beneficial effects of pomegranate on DNBS-induced colitis, the polysaccharides support and enhance its effect. Therefore, pomegranate mesocarp preparations could represent a complementary approach to conventional therapies for promoting abdominal pain relief.

Immediate unilateral breast reconstruction and contralateral breast augmentation with bilateral free deep inferior epigastric perforator flaps

A 42-year-old woman was referred for consideration of left-sided mastectomy and immediate reconstruction. She previously had a bilateral breast augmentation using silicone implants. She desired to maintain her breast size and natural appearance. Owing to the availability of sufficient abdominal tissue, the option of an immediate unilateral breast reconstruction and contralateral augmentation with a differentially split deep inferior epigastric perforator flaps was offered to the patient. The patient had a successful reconstructive and contralateral symmetrising procedure with an uneventful postoperative recovery. She was satisfied with her breast size, which was achieved without the use of implants. In selected patients the free deep inferior epigastric perforator flap provides an appropriate option for unilateral breast reconstruction and contralateral breast augmentation. It has numerous advantages including making use of available excess abdominal tissue and avoiding implant related complications.

Characterization of Arils Juice and Peel Decoction of Fifteen Varieties of Punica granatum L.: A Focus on Anthocyanins, Ellagitannins and Polysaccharides

Pomegranate is receiving renewed commercial and scientific interest, therefore a deeper knowledge of the chemical composition of the fruits of less studied varieties is required. In this work, juices from arils and decoctions from mesocarp plus exocarp were prepared from fifteen varieties. Samples were submitted to High Performance Liquid Chromatography-Diode Array Detector-Mass Spectrometry, spectrophotometric and colorimetric CIEL*a*b* analyses. Antioxidant, antiradical and metal chelating properties, inhibitory activity against tyrosinase and α-amylase enzymes were also evaluated. All varieties presented the same main phenols; anthocyanins and ellagitannins were widely variable among varieties, with the richest anthocyanin content in the juices from the Wonderful and Soft Seed Maule varieties (approx. 660 mg/L) and the highest ellagitannin content in the peel of the Black variety (approx. 133 mg/g dry matter). A good correlation was shown between the colour hue and the delphinidin/cyanidin ratio in juices (R2 = 0.885). Total polysaccharide yield ranged from 3% to 12% of the peels' dry weight, with the highest content in the Black variety. Decoctions (24.44-118.50 mg KAE/g) showed better in vitro antioxidant properties and higher inhibitory capacity against tyrosinase than juices (not active-16.56 mg KAE/g); the inhibitory capacity against α-amylase was similar and quite potent for juices and decoctions. Knowledge about the chemical composition of different pomegranate varieties will allow for a more aware use of the different parts of the fruit.

Use of Pamidronate to Treat Hypercalcemia in an Oncology Dialysis Patient: A Case Report

Patient: Female, 60

Final Diagnosis: Hypercalcemia secondary to malignancy

Symptoms: Hypercalcemia

Medication: —

Clinical Procedure: —

Specialty: Nephrology

Pomegranate By-Products in Colorectal Cancer Chemoprevention: Effects in Apc-Mutated Pirc Rats and Mechanistic Studies In Vitro and Ex Vivo

SCOPE

To investigate the effect of pomegranate mesocarp, a polyphenol-rich by-product of juice production, in colorectal cancer (CRC) chemoprevention.

METHODS AND RESULTS

A mesocarp decoction (PMD) is administered for 6 weeks in the diet to Pirc rats, mutated in Apc, a key-gene in CRC. Mucin-depleted foci (MDFs), as CRC biomarkers, are reduced in PMD-fed rats compared to controls (MDF/colon: 34 ± 4 versus 47 ± 3, p = 0.02). There is an increase in apoptosis in MDFs from PMD-treated rats compared to controls (2.5 ± 0.2 versus 1.6 ± 0.2, p < 0.01). To elucidate the involved mechanisms, two colon-relevant metabolites of the polyphenolic and fiber PMD components, urolithin-A (u-A) and sodium butyrate (SB), are tested alone or in combination in vitro (colon cancer cells), and ex vivo in adenoma (AD) and normal mucosa (NM) from Pirc rats. u-A 25 μm plus SB 2.5 mm (USB) causes a significant reduction in COX-2 protein expression compared to untreated controls (about -70% in cancer cell cultures, AD, and NM), and a strong increase in C-CASP-3 expression in cells (about ten times), in AD and NM (+74 and +69%).

CONCLUSION

These data indicate a chemopreventive activity of PMD due, at least in part, to pro-apoptotic and anti-inflammatory action of its metabolites that could be exploited in high-risk patients.

Infection of PTFE mesh 15 years following pedicled TRAM flap breast reconstruction: mechanism and aetiology

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedure is still widely used for breast reconstruction. The repair of the flap harvest site in the transverse rectus abdominis muscle and sheath is often assisted by the use of prosthetic meshes. This decreases the risk of abdominal wall weakness and herniation but, being a foreign body, it also carries the risk of infection. In this report, we describe the case of a 63-year-old patient who, whilst receiving chemotherapy for metastatic breast cancer, presented with an infected polytetrafluoroethylene mesh 15 years after pedicled TRAM flap immediate breast reconstruction. This necessitated mesh removal to treat the infection. Following a thorough review of the English literature, this is the longest recorded presentation of an abdominal prosthetic mesh infection. The mechanism and aetiology of such a late complication are discussed.

The management of pretibial lacerations

Introduction Pretibial lacerations are common injuries, often presenting in the elderly and infirm. Unclear management pathways often result in inappropriate care. We identify patient demographics, morbidity risk factors, injury severity and management options. Materials and methods This retrospective study involved analysing databases and hardcopy notes for patients admitted with pretibial lacerations to Addenbrooke's Hospital, January to December 2012. Microsoft Excel and Fishers exact test were used to analyse the data with a P-value of less than 0.05 representative of statistical significance. Information on patient demographics, site of lesion, preoperative symptoms, management, operative details and clinical outcomes were collected. Results A total of 36 patients were identified; the mean age was 79 years (± 16 years, 1 standard deviation) with a three to two female to male preponderance; 57% of injuries were caused by mechanical fall, 33% traumatic blunt impact and 7% road traffic accidents. American Society of Anesthesiologists physical status classification was 43% level III, 40% II, 9% I and 9% IV. Dunkin classification of severity was 33% grade III, 30% grade I, 24% grade IV and 12% grade II. Median inpatient duration was 11 days for surgically managed compared with 15 days for conservatively managed patients. Discussion Pretibial lacerations tend to affect the elderly. Management is compounded by polypharmacy and comorbidities. If inadequately managed, such injuries can adopt characteristics of chronic wounds, with lengthy inpatient stays. Surgical intervention may be appropriate where injuries are severe and the patient stable enough for theatre. Conclusions We believe that surgical management with autologous tissue repair, with minimal delay between presentation and theatre, is warranted for extensive injuries wherever possible, with conservative management used for predominantly less extensive pretibial lacerations.

Acute effect of Capparis spinosa root extracts on rat articular pain

ETHNOPHARMACOLOGICAL RELEVANCE

Capparis spinosa L. originates from dry regions of Asia and Mediterranean basin. In traditional medicine of these areas, infusions from caper root are considered to be beneficial for the treatment of rheumatism, gout and against abdominal pains.

AIM OF THE STUDY

To evaluate the pain relieving properties of a Syrian cultivar of Capparis spinosa roots in rat models of osteoarthritis and rheumatoid arthritis.

MATERIALS AND METHODS

Decoction (DEC) and hydroalcoholic extract (EtH₂O) were obtained from powdered roots; the latter was further separated in CH₂Cl₂ and aqueous (H₂O-Res) fractions. The extracts were characterized in terms of spermidine alkaloids by HPLC/DAD/MS and stachydrine by NMR. Different amount of free and glycosilated forms of capparispine and analogues (from 0.5% w/w for DEC up to 7.6% w/w for CH₂Cl₂ fraction) were detected. Rat models of rheumatoid arthritis and osteoarthritis were induced by the intra-articular administration of Complete Freund's Adjuvant (CFA) or monosodium iodoacetate (MIA), respectively.

RESULTS

Fourteenth days after CFA or MIA injection, the different preparations of Capparis spinosa (3, 30, 100 and 300mgkg^-1) were acutely administered p.o.. Powdered roots (300mgkg^-1), DEC (100mgkg^-1), and EtH₂O (300mgkg^-1) significantly reduced hypersensitivity to mechanical noxious stimuli as well as spontaneous pain evaluated as hind limb bearing alterations in both models. The CH₂Cl₂ and the H₂O-Res (30mgkg^-1) were the most potent in reverting pain threshold alterations despite the different content of free alkaloids.

CONCLUSIONS

Capparis spinosa extracts relieved pain related to rheumatoid arthritis and osteoarthritis after single administration. A synergistic effect due to a specific "phytochemical mixture" is suggested.

Implementation of “CODE SEPSIS” for septic patients at Al Wakra Hospital: A practice improvement initiative

Introduction: Sepsis is a major cause of hospitalization with a high mortality rate. Early recognition and management of sepsis have shown to improve mortality outcomes. A proactive alert system for improving the response of the interdisciplinary team may decrease the time to intervention and improve patient outcomes.

Objective: The study evaluated the impact of an early alert system, “CODE SEPSIS”, on adherence to the sepsis management bundle and time to intervention among patients at risk for sepsis.

Method: Patients presenting to the Emergency Department (ED) and meeting two or more criteria on the sepsis screening tool were intended to trigger an overhead alert known as CODE SEPSIS, which was activated based on the physician's decision. Data were retrospectively collected over a 3-month period for all hospitalized adult patients with confirmed sepsis (age above 18 years). We evaluated the time from ED presentation to diagnostic and treatment interventions. A data collection tool was designed to record information.

Results: A total of 36 sepsis patients were identified, among which 18 were classified as CODE SEPSIS and 18 were classified as non-CODE SEPSIS. We found that the CODE SEPSIS group showed greater improvement than the non-CODE SEPSIS group from ED presentation to intravenous catheter insertion (37.3 to 31.5 minutes, 15.6%), fluid administration (41 to 39 minutes, 4.9%), microbiological workup (91 to 33 minutes, 63.7%), lactate level (69 to 66 minutes, 4.3%), prescribing antimicrobial therapy (92 to 44 minutes, 52%), and administration of antimicrobial therapy (88 to 46 minutes, 47.7%). Patients in the non-CODE SEPSIS group showed a 1-day decrease in length of hospital stay.

Conclusion: The CODE SEPSIS alert system developed at Al Wakra Hospital promoted early and standardized management among patients at risk for sepsis, which may lead to improved patient outcomes.

An insight on the alkaloid content of Capparis spinosa L. root by HPLC-DAD-MS, MS/MS and (1)H qNMR

The Capparis spinosa L. has a wide distribution in the Old World from South Europe, North and East Africa, Madagascar, Southwest and Central Asia to Australia and Oceania. The consolidated traditional use of C. spinosa root as remedy against different pains in human is well known since the antiquity. Various secondary metabolites have been found in caper plant, nevertheless, few studies have been focused to the analysis of root constituents. To date, several free and glycosilated spermidine alkaloids and a more polar alkaloid, the stachydrine, have been isolated from the root of C. spinosa. Aim of this work was to improve the knowledge on the alkaloid content of the root of a Syrian sample of C. spinosa by HPLC-DAD-MS(n) and to propose methods to quantify these molecules in different raw extracts. A decoction, an hydroalcoholic extraction and a fractionation process to selectively recover the spermidine alkaloids were applied. To our knowledge, this is the first HPLC-DAD-MS(n) profile that pointed out the co-presence of stachydrine, several isobaric forms of capparispine and/or capparisine in free and glycosylated forms and some isobars of isocodonocarpine or codonocarpine as monoglycosides in extracts of C. spinosa root. The determination by HPLC/DAD for the spermidine alkaloids expressed as p-OH-coumaric acid gave values up to 3.5mg/g dried root and the stachydrine evaluated by (1)H NMR was close to 12.5mg/g dried root. Overall, the total alkaloids were almost doubled in hydroalcoholic extract with respect to the decoction, and the stachydrine in the cortex was almost double than in the whole root.

Mastectomy and reconstruction in stage IV breast cancer: a survey of UK breast and plastic surgeons

The number of women with stage IV disease who have breast reconstruction is small. The primary aim of this study was to examine opinions as to the appropriateness of breast reconstruction in this group. The Association of Breast Surgeons (ABS) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) were invited to take part in an online survey. Of the respondents, 78.7% would operate on the primary tumour. Plastic surgeons showed a propensity for immediate reconstruction compared to their breast surgery colleagues, and 26.3% of breast surgeons would not offer reconstruction at all. Immediate latissimus dorsi (LD) flap and implant were the favoured method in early stage disease with delayed LD and implant the most popular option for stage IV disease. As survival figures continue to improve, the number of patients requesting reconstruction is likely to increase. Further debate will be necessary in anticipation of future service development.

Complicated negative pressure pulmonary oedema in a child with cerebral palsy

A 3-year-old child with cerebral palsy developed postextubation upper airway obstruction secondary to laryngospasm and/or masseteric spasm,which may have been triggered by the muscular spasticity and the slow recovery from inhalational anaesthesia associated with cerebral palsy. This upper airway obstruction was followed by negative pressure pulmonary oedema. The patient improved on mechanical ventilation; however, his condition was complicated with the occurrence of bilateral pneumothoraces. After release of the pneumothoraces and reexpansion of the lungs, the child developed reexpansion pulmonary oedema, culminating in acute lung injury.

Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU

STUDY OBJECTIVE

To evaluate the effectiveness of warning labels permanently attached to mechanical ventilators in improving the practice of hand washing and use of gloves by respiratory care practitioners (RCPs) in the ICU.

DESIGN

The study consisted of two 4-week periods. Daily observations of hand washing and use of gloves by RCPs were made over four 1-h observation periods. Prior to the first 4-week period, the importance of hand washing and use of gloves was presented to all staff. At the end of the first period, "Wash Hands Use Gloves" labels were permanently placed on all ventilators in the ICU. The RCPs were not aware they were being observed for hand washing and use of gloves in either period.

MEASUREMENTS AND RESULTS

The total number of encounters between the RCPs and patients as well as the rates of hand washing and use of gloves were obtained during the study. The rates of hand washing and use of gloves were significantly higher during the second period when labels were attached to the ventilators, as compared to the rates during the first period: hand washing, 92% vs 46% (p < 0.05); use of gloves, 92% vs 43% (p < 0.05), respectively. During the first period, the rates of pre-encounter hand washing (78%, 48%, 27%, and 29% in weeks 1 through 4, respectively) and the use of gloves (56%, 37%, 32%, and 45% in weeks 1 through 4, respectively) were primarily declining. This was not observed during the second period of the study (94%, 88%, 95%, and 92% in weeks 1 through 4, respectively) for the rates of pre-encounter hand washing and the use of gloves.

CONCLUSIONS

Simple measures such as the placement of warning labels on mechanical ventilators can significantly improve hand washing and use of gloves by RCPs in the ICU.

Excitatory interactions between phrenic motoneurons: intracellular study in the cat

1. Intracellular recordings were made from 220 Phrenic Motoneurons (PM) in anaesthetized, spontaneously breathing cats, deafferented from C3 to C7, in order to look for somatic events related to the Recurrent Responses (RR) evoked in PM axons by repetitive stimulation of the phrenic nerve. RR appear sporadically at a constant latency, originate from a spinal nicotinic mechanism and can be evoked in a PM without the presence of an antidromic volley in its axon (Khatib et al. 1986). 2. Using stimuli effective for eliciting RR in axons, we failed to observe intracellularly somatic events corresponding to RR after the occurrence of an antidromic action potential. RR were observed extracellularly in two cases, but in both cases the recording originated from axons. 3. We attempted to elicit somatic RR without a preceding antidromic action potential, using either parathreshold stimulation of the impaled PM, or suprathreshold stimulation of a phrenic strand which excluded the axon of the impaled PM. In both cases, RR-like events, with very stable latencies, appeared sporadically in 4/142 and 2/15 PMs respectively. 4. Parathreshold stimuli or stimulation of a strand were coupled with averaging of the synaptic noise in order to look for small events temporally related to the stimuli. Short latency small depolarizations, looking-like recurrent EPSPs, were revealed in 22/142 and 5/15 PMs respectively. 5. These results confirm the existence of interrelations between PMs, providing for re-excitation and coupling within the phrenic pool, in addition to centrally imposed synchronization.

Central drive on Renshaw cells coupled with phrenic motoneurons

In anesthetized spontaneously breathing cats (C4-C5 deafferentation), recurrent inhibition of phrenic motoneurons was analyzed by studying either recurrent IPSPs in phrenic motoneurons, or Renshaw cell discharges evoked by C5 phrenic nerve stimulation. Of 90 intracellularly recorded phrenic motoneurons, 7 motoneurons showed evoked recurrent IPSPs with stimulation of C5 phrenic axons subthreshold for eliciting antidromic activation of the motoneuron from which intracellular recording was done. These IPSPs could be reversed by imposed hyperpolarization of the motoneuron, and were of greater amplitude during inspiration than during expiration. Within the phrenic nucleus, interneurons were classified as Renshaw cells if they responded to C5 phrenic axon stimulation with a typical high frequency burst of potentials. Reactivity of these Renshaw cells was related to the respiratory cycle, number of spikes in the burst being greater during inspiration than during expiration. Injection of a nicotinic cholinergic blocker (mecamylamine) decreased responses of Renshaw cells but the respiratory modulation was still present. Some Renshaw cells (18/33) were spontaneously active during inspiration. Their activity was generally maximal during the last third of inspiration. Since: spontaneous activity of Renshaw cells is related to the respiratory drive; persists after C7 spinal transection and after mecamylamine poisoning of the axonal recurrent pathway; and might appear before sustained phrenic activity, the assumption of a central respiratory drive impinging on the Renshaw cells has to be retained.