0.9% saline versus Plasma-Lyte as initial fluid in children with diabetic ketoacidosis (SPinK trial): a double-blind randomized controlled trial

A tri-light warning system for hospitalized COVID-19 patients: Credibility-based risk stratification for future pandemic preparedness

Purpose

The novel coronavirus pneumonia (COVID-19) has continually spread and mutated, requiring a patient risk stratification system to optimize medical resources and improve pandemic response. We aimed to develop a conformal prediction-based tri-light warning system for stratifying COVID-19 patients, applicable to both original and emerging variants.

Methods

We retrospectively collected data from 3646 patients across multiple centers in China. The dataset was divided into a training set (n = 1451), a validation set (n = 662), an external test set from Huoshenshan Field Hospital (n = 1263), and a specific test set for Delta and Omicron variants (n = 544). The tri-light warning system extracts radiomic features from CT (computed tomography) and integrates clinical records to classify patients into high-risk (red), uncertain-risk (yellow), and low-risk (green) categories. Models were built to predict ICU (intensive care unit) admissions (adverse cases in training/validation/Huoshenshan/variant test sets: n = 39/21/262/11) and were evaluated using AUROC ((area under the receiver operating characteristic curve)) and AUPRC ((area under the precision-recall curve)) metrics.

Results

The dataset included 1830 men (50.2 %) and 1816 women (50.8 %), with a median age of 53.7 years (IQR [interquartile range]: 42-65 years). The system demonstrated strong performance under data distribution shifts, with AUROC of 0.89 and AUPRC of 0.42 for original strains, and AUROC of 0.77-0.85 and AUPRC of 0.51-0.60 for variants.

Conclusion

The tri-light warning system can enhance pandemic responses by effectively stratifying COVID-19 patients under varying conditions and data shifts.

Out-of-hospital cardiac arrest in Bahrain: National retrospective cohort study

Aim

There is limited research on Out-of-hospital cardiac arrest (OHCA) in the Gulf Cooperation Council (GCC) and especially in Bahrain. This is the first study to describe the incidence, characteristics, and outcomes of OHCA in Bahrain.

Methods

This was a retrospective national observational study on OHCA patients in Bahrain using the Utstein framework for resuscitation. Data was collected between 1st July 2022 to 30th June 2023 from the electronic medical records of the only three governmental hospitals emergency departments (EDs) and National Ambulance (NA).

Results

The annual incidence of OHCA attended by (Emergency Medical Services) EMS was nearly 21 per 100,000 population. The majority were males (n = 228, 68.8 %) with median age of 65 years (IQR=49-78). Most OHCA cases were witnessed (n = 265, 81 %), with (n = 247, 76 %) happened at home/residence. Rates for bystander CPR was low (n = 122, 36.8 %) and bystander automated external defibrillator (AED) was not performed in any of the cases. The OHCA cases transported by the NA was (n = 314, 94.8 %), with median response time of 9 min (IQR=7-12). However, only (n = 20, 6.0 %) were witnessed by EMS, and (n = 7, 2.1 %) received EMS defibrillation for shockable rhythms. First monitored rhythms included shockable rhythm in (n = 28, 8.5 %) versus non-shockable rhythm in (n = 303, 91.5 %). In the EDs, return of spontaneous circulation was achieved in (n = 60, 18.1 %) cases. But survival rate to hospital discharge at 30-day was (n = 4, 1.2 %) and survival rate to hospital discharge with good neurological outcomes was (n = 0, 0 %). Conclusion: In Bahrain the estimated annual incidence of OHCA is 21 individuals per 100,000 population, with a very low survival rate. Solutions should focus on community-level CPR and AED training, evaluating OHCA care provided by EMS, and establishing OHCA registry.

Health-related quality of life in children with presumptive TB

BACKGROUND

Respiratory illnesses, including pulmonary TB (PTB), cause significant morbidity. We aimed to understand the health-related quality of life (HRQoL) of children with presumptive PTB.

METHODS

Children aged 0-13 years presenting with presumptive PTB were enrolled. This study includes children who started TB treatment and children in whom TB was excluded (symptomatic controls). Quantitative data were collected using the Toddler and Infant quality of life Instrument (TANDI) (<3 years) and European Quality of Life-5 Dimensions-Youth (EQ-5D-Y) (>3 years) measures. Qualitative data were collected through in-depth interviews using thematic analysis.

RESULTS

Quantitative data from caregivers of 201 children (TANDI: n = 170; EQ-5D-Y: n = 31) showed 77 (38.3%) were diagnosed with TB, while 124 (61.7%) were symptomatic controls. Qualitative data from 15 caregivers of 21 children included 10 (67%) children with TB and 5 (33%) symptomatic controls. The median TANDI Visual Analogue Score (VAS) for overall health was 90% (IQR 80-100); the EQ-5D-Y VAS median was 95% (IQR 80-100). Caregivers described decreased energy, difficulty eating, and increased sleep using qualitative interviews, which were not reflected in the quantitative data. No differences were found between children with TB and symptomatic controls.

CONCLUSIONS

HRQoL was high in children with TB, but discrepancies between quantitative and qualitative measures highlight the limitations of the current HRQoL measures.

Point of care lactate for differentiating septic shock from hypovolemic shock in non-ICU settings: a prospective observational study

Background

Septic shock and hypovolemic shock are life-threatening illnesses that necessitate immediate recognition and intervention, as they can result in deadly consequences. While the underlying processes may vary, both entities can exhibit hypotension and organ dysfunction. No studies have been conducted on bedside testing to differentiate between these illnesses. Lactate measurement has been established as a viable option for early detection of septic shock. However, its role in diagnosing hypovolemic shock has yet to be evaluated. The aim of the study was to investigate alterations in lactate levels among diarrheal patients with septic shock and hypovolemic shock following the administration of first fluid resuscitation.

Methods

We conducted a prospective observational study in critically ill diarrheal adults aged ≥18 years in the emergency ward in Dhaka Hospital of icddr,b from 21st October 2021 to 31st May 2023 (total 19 months). The enrollment process was operational between 8:30 AM and 5:00 PM. Diarrheal adults with a diagnosis of sepsis with shock featured with poor peripheral perfusion (characterized by cold periphery and weak or absent pulse and capillary refill time >3 s) or hypotension (characterized by mean arterial pressure <65 mm-Hg) were enrolled as cases and consecutive diarrheal patients without any obvious features of sepsis with hypovolemic shock (due to severe dehydration) comprised the comparison group. POC lactate test was done at hours 0, 1st and 6th by StatStrip Lactate meters (Nova Biomedical, US) to all enrolled patients. For comparison of POC lactate levels, we used paired t-test for comparing the lactate samples drawn at hour 0, hour 1 and 6 with the septic shock and hypovolemic shock group. Odds ratio (OR) and their 95% confidence intervals (CIs) were used to demonstrate the strength of association. The study was registered at Clinicaltrials.gov (NCT05108467) and received institutional ethical approval (PR-21097).

Findings

Of 435 patients, 135 had septic shock and 141 had hypovolemic shock, rest 41 patient responded with fluid bolus. 25% (34/135) of the people in the septic shock group died whereas there is no mortality in the hypovolemic shock group. The number of patients visiting from outside Dhaka city had more septic shock than from inside were higher in comparison with (55% vs. 28%; p < 0.001). Statistically significant difference was observed between septic shock and hypovolemic shock group for a median POC lactate in 0, 1st and 6th hours with an OR of 1.07 (95% CI: 0.99, 1.17; p = 0.039); 1.48, (95% CI: 1.28, 1.70; p < 0.001) and 2.36 (95% CI: 1.85, 3.00; p < 0.001), respectively. The gradient of 1st to 2nd sample between septic shock and hypovolemic shock was found to be significantly different (OR: 0.74, 95% CI: 0.64, 0.85; p < 0.001).

Interpretation

POC lactate test can detect septic shock by differentiating hypovolemic shock in diarrheal patients. By providing quick, reliable and accurate result this test can help clinicians quickly diagnose and treat time-sensitive condition, like septic shock.

Funding

The study was funded by Global Affairs of Canada (GR-01726). The donors had no role in the design, implementation, analysis, data interpretation or writing manuscript, or decision to publish. The corresponding author had access to all data and takes responsibility for the final approval and submission of the manuscript.

N-alkylation of amines for the synthesis of potential antiviral agents: A structural modification approach

The threat of emerging viral outbreaks has increased the need for fast and effective development of therapeutics against emerging pathogens. One approach is to modify the structure of existing therapeutic agents to achieve the desired antiviral properties. Here, we attempted to synthesize a new antiviral compound by modifying the structure of chloroquine using the N-alkylation of the primary amine (N1,N1-diethylpentane-1,4-diamine) that is used in chloroquine synthesis. Chloroquine is commonly used to treat malaria. Like chloroquine, chloroquine is used for treating conditions such as rheumatoid arthritis, lupus, and malaria. For instance, in malaria treatment, it targets and inhibits the growth of the malaria parasite, aiding in its elimination from the body. The synthesized compounds MP1, C1, and TT1 were further tested in vitro against the B.1 lineage of SARS-CoV-2. One of the compounds, MP1, demonstrated minor effectiveness, with an IC50 of XX at only a high concentration (at a concentration of 60 μM) and decreased both the number of SARS-CoV-2 copies and the amount of infectious virus. Although the synthesized compounds failed to markedly inhibit SARS-CoV-2, this could be a pontial mechanism for manipulating the drug structure against other pathogens. MP1, TT1, C1, and chloroquine diphosphate were used as ligands for molecular docking to determine the principal interactions between these compounds and the active site of the protein downloaded from the Protein Data Bank (PDB ID: 6lzg). Finally, ADMET assays were performed on the synthesized compounds to determine their pharmacokinetics and bioavailability.

Is there a relationship between hyperchloremia status and the risk of developing acute kidney injury in pediatric patients with diabetic ketoacidosis?

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM). Prerenal acute kidney injury (AKI) is associated with profound hypovolemia and reduced renal perfusion. Results regarding hyperchloremia-associated AKI in patients with DKA are conflicting; we therefore investigated the potential relationship between hyperchloremia status and the risk of developing AKI. This single-center cohort study included 113 newly diagnosed T1DM patients with DKA admitted to the pediatric intensive care unit. Laboratory parameters, including Na, K, urea, creatinine, and chloride levels, were retrospectively reviewed at the time of presentation and at 12, 24 and 36 h. AKI was defined using the eGFR according to the pediatric RIFLE classification criteria. Twenty-two (19.5%) of the 113 patients were in the AKI group. Two-way repeated-measures ANOVA showed significant (P values ≤ 0.01) time interaction effects within the groups based on the eGFR and the serum chloride, hyperchloremia, and phosphate levels. Serum chloride levels did not differ between the groups during the first 12 h (p > 0.05) but were significantly greater in the AKI group than in the non-AKI group at 24 h and 36 h (p < 0.01). The final DKA resolution time was significantly greater in the AKI group than in the non-AKI group [22.2 (9.5) vs. 17.0 (12.0) h, respectively; p = 0.03]. However, the groups had similar lengths of hospital stay [13.0 (8.0) days vs. 12.0 (4.0) days, respectively; p = 0.17].Conclusions: Hyperchloremia may be iatrogenic rather than causative during treatment. This may worsen renal failure and prolong the recovery and treatment time for DKA patients. What is Known? • Acute kidney injury resulting from severe volume depletion is a common occurrence in diabetic ketoacidosis and typically requires significant volume replacement therapy. • In recent years, hyperchloremia has been associated with increased risks of AKI, morbidity, and mortality in some conditions, such as diabetic ketoacidosis. What is New? • The incidence of hyperchloremia increases over time during the treatment of diabetic ketoacidosis. • Hyperchloremia may be an iatrogenic element rather than a cause of acute kidney injury during the treatment of diabetic ketoacidosis.

Normal Saline Versus Ringer's Lactate for Intravenous Fluid Therapy in Children with Diabetic Ketoacidosis: A Randomized Controlled Trial

OBJECTIVES

To compare normal saline (NS) and ringer's lactate (RL) as intravenous fluid therapy in children with diabetic ketoacidosis (DKA).

METHODS

This was a triple blinded randomized controlled trial conducted in the Pediatric Intensive Care Unit (PICU) of a tertiary care hospital in New Delhi from November 2018 to March 2020. The study compared intravenous fluid therapy with ringer's lactate and normal saline in children aged 6 mo to 18 y with DKA as defined by The International Society for Pediatric and Adolescent Diabetes (ISPAD). The primary objective was comparing the time taken to achieve resolution of acidosis (pH ≥ 7.3) in both groups. Secondary objectives included comparing the proportion of patients that develop acute kidney injury; comparing the time taken for normalization of anion gap and blood glucose; time taken to change the type of fluid; total amount of fluid and insulin administered; and total length of PICU and hospital stay.

RESULTS

Fifty patients were enrolled, with 25 in each arm and all but one achieved the primary outcome. The median age of the patients was 9 (5, 12) y. The time taken for resolution of acidosis in patients treated with NS was 12 (4, 18) h and with RL was 8 (4, 10) h (p = 0.16). The NS group had a significantly higher incidence of hyperchloremia (p < 0.05) and longer PICU stay (p < 0.05). The metabolic profile and incidence of complications were comparable in both groups.

CONCLUSIONS

Ringer's lactate can safely be considered for the management of pediatric DKA and may be preferred in patients that are at a risk of complications due to hyperchloremia.

Clinico-radiological and pulmonary function assessment of post-COVID-19 patients with respiratory symptoms

Background

Respiratory symptoms may persist for several weeks following the initial coronavirus disease 2019 (COVID-19) infection. The aims and objectives were to assess the clinical symptoms, pulmonary functions, and radiological changes and to assess the cardio-vascular complications in post-COVID-19 patients.

Methods

This observational study was conducted in the Department of Pulmonary Medicine in collaboration with the Department of Cardiology, SCBMCH, Cuttack, from March 2021 to August 2022 on 75 post-COVID-19 patients with respiratory symptoms from 4 weeks to 2 years after treatment for COVID-19 infection. Post-COVID patients having previous respiratory diseases were excluded from the study.

Results

Among 75 patients, the most common age group was 18-30 years with a male-to-female ratio of 2.5:1. Based on O2 requirement, patients were divided into the mild symptomatic group and moderate to severe pneumonia group. The most common respiratory symptom was dyspnea, followed by cough with expectoration. Bilateral crepitations were found in 17% of cases. C-reactive protein (CRP) and D-dimer were increased in 38.6% and 32% of patients, respectively. 42.6% had abnormal chest X-ray, and the most common abnormal finding was reticular thickening. In spirometry, the restrictive pattern and mixed pattern were the predominant types documented in 49.3% and 13.3% of cases, respectively, which were significant in the moderate-severe group. Diffusion capacity of the lungs for carbon monoxide (DLCO) was performed in only 19 patients (mild group 13 and moderate-severe group 6). Twelve (63.2%) patients had abnormal DLCO. P- values were significant for RV (0.0482) and RV/TLC (0.0394). High-resolution computed tomography (HRCT) of the thorax was abnormal in 55.7% with the most common abnormalities as inter- and intra-lobular septal thickening. The left ventricular ejection fraction was preserved in all patients, with right atrium and right ventricle enlargement in 2.6% and pulmonary hypertension in 4.0% of participants.

Conclusion

All post-COVID-19 patients having respiratory symptoms after recovery from acute COVID-19 may be referred by family care physicians to a dedicated post-COVID center for further evaluation, management, and early rehabilitation to decrease the morbidity in recovered patients. Persistent increased blood parameters like TLC, N/L ratio, RBS, CRP, and D-dimer seen in recovered post-COVID-19 patients. The long-term impact of CT findings on respiratory symptoms, pulmonary functions, and quality of life is unknown. Cardiovascular abnormalities in post-COVID-19 patients are infrequent.

Mortality and morbidity associated with new onset acute kidney injury in critically ill COVID-19 infection patients

BACKGROUND

The recent global pandemic due to severe acute respiratory syndrome coronavirus-2 resulted in a high rate of multi-organ failure and mortality in a large patient population across the world. As such, a possible correlation between acute kidney injury (AKI) and increased mortality rate in these patients has been suggested in literature.

METHODS

This is a two-year retrospective study of critically ill adult patients infected with COVID-19 that were admitted to the intensive care unit (ICU) on ventilatory support. Two groups of patients were identified in this study, those who were directly admitted to the ICU or those who were initially admitted to the Medical Floor and were later transferred to the ICU due to either worsening respiratory status or change in their hemodynamic conditions. Within each group, three subgroups were created based on the status of AKI, namely, those who did not develop AKI, those who developed AKI, and those who with previous history of dialysis dependent AKI.

RESULTS

The AKI subgroup had the highest mortality rate in the ICU and Floor patients. Of note, those patients who were directly admitted to the Floor and were later transferred to the ICU for worsening conditions also experienced a higher mortality rate if they had developed AKI during their course of hospital stay.

CONCLUSIONS

This study identified a statistically significant higher mortality in patients who developed AKI than those who did not develop AKI among critically ill patients.

TRIAL REGISTRATION

Clinicaltrials.gov registration number NCT05964088. Date of registration: July 24 2023.

At-admission prediction of mortality and pulmonary embolism in an international cohort of hospitalised patients with COVID-19 using statistical and machine learning methods

By September 2022, more than 600 million cases of SARS-CoV-2 infection have been reported globally, resulting in over 6.5 million deaths. COVID-19 mortality risk estimators are often, however, developed with small unrepresentative samples and with methodological limitations. It is highly important to develop predictive tools for pulmonary embolism (PE) in COVID-19 patients as one of the most severe preventable complications of COVID-19. Early recognition can help provide life-saving targeted anti-coagulation therapy right at admission. Using a dataset of more than 800,000 COVID-19 patients from an international cohort, we propose a cost-sensitive gradient-boosted machine learning model that predicts occurrence of PE and death at admission. Logistic regression, Cox proportional hazards models, and Shapley values were used to identify key predictors for PE and death. Our prediction model had a test AUROC of 75.9% and 74.2%, and sensitivities of 67.5% and 72.7% for PE and all-cause mortality respectively on a highly diverse and held-out test set. The PE prediction model was also evaluated on patients in UK and Spain separately with test results of 74.5% AUROC, 63.5% sensitivity and 78.9% AUROC, 95.7% sensitivity. Age, sex, region of admission, comorbidities (chronic cardiac and pulmonary disease, dementia, diabetes, hypertension, cancer, obesity, smoking), and symptoms (any, confusion, chest pain, fatigue, headache, fever, muscle or joint pain, shortness of breath) were the most important clinical predictors at admission. Age, overall presence of symptoms, shortness of breath, and hypertension were found to be key predictors for PE using our extreme gradient boosted model. This analysis based on the, until now, largest global dataset for this set of problems can inform hospital prioritisation policy and guide long term clinical research and decision-making for COVID-19 patients globally. Our machine learning model developed from an international cohort can serve to better regulate hospital risk prioritisation of at-risk patients.

The Effects of Subcutaneous Rapid-Acting Insulin Aspart in the Treatment of Mild and Moderate Diabetic Ketoacidosis in Children: A Prospective Study

Background and objectives The traditional treatment approach to diabetic ketoacidosis (DKA) involves the replacement of fluid and electrolyte deficits and a continuous intravenous infusion of regular insulin. Several clinical trials supported the administration of subcutaneous rapid-acting insulin analogs in the management of uncomplicated DKA. This study aimed to determine the effects/safety of subcutaneous rapid-acting insulin aspart injections in treating uncomplicated mild and moderate DKA in children. Methods In this prospective study in 2022, 25 children with mild/or moderate DKA were enrolled. The main outcome measure was median time (hours) for the resolution of ketoacidosis. Data recorded were as follows: clinical characteristics, severity of ketoacidosis and dehydration, blood glucose, sodium, potassium, creatinine, urine ketones, hospitalization's duration, and complications. Based on the degree of dehydration, fluid deficit was replaced by sodium chloride 0.45%. Insulin aspart 0.15 units/kg subcutaneous injections were given every 2 hours in the hospital outside ICU. Blood glucose was measured hourly and blood gases every 2 hours. Ketoacidosis was considered resolved when the patient did not have nausea/vomiting, was conscious, and could eat, and blood glucose was <250 mg/dL, pH was >7.30, and/or HCO3 was >15 mmol/L. Results Of 25 DKA patients (mean age 11.06±3.89, range 4-17 years, 60% girls), 16 cases (64%) had established type 1 diabetes. Overall, 13 (52%) cases had mild ketoacidosis (average pH=7.25), and 12 (48%) cases had moderate ketoacidosis (average pH=7.15). The mean time to resolution of ketoacidosis was 11.24 hours. All but one patient met DKA recovery criteria without complications. Mild cases compared to moderate cases of DKA had a shorter duration to resolution of DKA (p = 0.04). Mean duration of hospitalization was 2.3 days. No electrolyte disturbances, hypoglycemia events, readmission or mortality, or other adverse effects were observed. Conclusion In children with mild and moderate DKA, subcutaneous rapid-acting insulin aspart administration was an effective, safe, and convenient treatment.

Clinical features and multiomics profiles indicate coagulation and platelet dysfunction in COVID-19 viral sepsis

Increased cases of sepsis during COVID-19 in the absence of known bacterial pathogens highlighted role of viruses as causative agents of sepsis. In this study, we investigated clinical, laboratory, proteomic, and metabolomic characteristics of viral sepsis patients (n = 45) and compared them to non-sepsis patients with COVID-19 (n = 186) to identify molecular mechanisms underlying the pathology of viral sepsis in COVID-19. We identified unique metabolomic and proteomic signatures that suggest a substantial perturbation in the coagulation, complement, and platelet activation pathways in viral sepsis. Our proteomic data indicated elevated coagulation pathway protein (fibrinogen), whereas a decrease in many of the complement proteins was observed. These alterations were associated with the functional consequences such as susceptibility to secondary bacterial infections and potentially contributing to both local and systemic disease phenotypes. Our data provide novel aspect of COVID-19 pathology that is centered around presence of sepsis phenotype in COVID-19.

Fluids in the treatment of diabetic ketoacidosis in children: A systematic review

AIM

To determine the comparative effectiveness of fluid schemes for children with diabetic ketoacidosis (DKA).

METHODS

We conducted a systematic review with an attempt to conduct network meta-analysis (NMA). We searched MEDLINE, EMBASE, CENTRAL, Epistemonikos, Virtual Health Library, and gray literature from inception to July 31, 2022. We included randomized controlled trials (RCTs) in children with DKA evaluating any intravenous fluid schemes. We planned to conduct NMA to compare all fluid schemes if heterogeneity was deemed acceptable.

RESULTS

Twelve RCTs were included. Studies were heterogeneous in the population (patients and DKA episodes), interventions with different fluids (saline, Ringer's lactate (RL), and polyelectrolyte solution-PlasmaLyte®), tonicity, volume, and administration systems. We identified 47 outcomes that measured clinical manifestations and metabolic control, including single and composite outcomes and substantial heterogeneity preventing statistical combination. No evidence was found of differences in neurological deterioration (main outcome), but differences were found among interventions in some comparisons to normalize acid-base status (∼2 h less with low vs. high volume); time to receive subcutaneous insulin (∼1 h less with low vs. high fluid rate); length of stay (∼6 h less with RL vs. saline); and resolution of the DKA (∼3 h less with two-bag vs. one-bag scheme). However, available evidence is scarce and poor.

CONCLUSIONS

There is not enough evidence to determine the best fluid therapy in terms of fluid type, tonicity, volume, or administration time for DKA treatment. There is an urgent need for more RCTs, and the development of a core outcome set on DKA in children.

Exploring the tradeoff between data privacy and utility with a clinical data analysis use case

BACKGROUND

Securing adequate data privacy is critical for the productive utilization of data. De-identification, involving masking or replacing specific values in a dataset, could damage the dataset's utility. However, finding a reasonable balance between data privacy and utility is not straightforward. Nonetheless, few studies investigated how data de-identification efforts affect data analysis results. This study aimed to demonstrate the effect of different de-identification methods on a dataset's utility with a clinical analytic use case and assess the feasibility of finding a workable tradeoff between data privacy and utility.

METHODS

Predictive modeling of emergency department length of stay was used as a data analysis use case. A logistic regression model was developed with 1155 patient cases extracted from a clinical data warehouse of an academic medical center located in Seoul, South Korea. Nineteen de-identified datasets were generated based on various de-identification configurations using ARX, an open-source software for anonymizing sensitive personal data. The variable distributions and prediction results were compared between the de-identified datasets and the original dataset. We examined the association between data privacy and utility to determine whether it is feasible to identify a viable tradeoff between the two.

RESULTS

All 19 de-identification scenarios significantly decreased re-identification risk. Nevertheless, the de-identification processes resulted in record suppression and complete masking of variables used as predictors, thereby compromising dataset utility. A significant correlation was observed only between the re-identification reduction rates and the ARX utility scores.

CONCLUSIONS

As the importance of health data analysis increases, so does the need for effective privacy protection methods. While existing guidelines provide a basis for de-identifying datasets, achieving a balance between high privacy and utility is a complex task that requires understanding the data's intended use and involving input from data users. This approach could help find a suitable compromise between data privacy and utility.

Comparison of balanced crystalloids versus normal saline in patients with diabetic ketoacidosis: a meta-analysis of randomized controlled trials

Purpose

The optimal resuscitative fluid for patients with diabetic ketoacidosis (DKA) remains controversial. Therefore, our objective was to assess the effect of balanced crystalloids in contrast to normal saline on clinical outcomes among patients with DKA.

Methods

We searched electronic databases for randomized controlled trials comparing balanced crystalloids versus normal saline in patients with DKA, the search period was from inception through October 20th, 2023. The outcomes were the time to resolution of DKA, major adverse kidney events, post-resuscitation chloride, and incidence of hypokalemia.

Results

Our meta-analysis encompassed 11 trials, incorporating a total of 753 patients with DKA. There was no significant difference between balanced crystalloids and normal saline group for the time to resolution of DKA (MD -1.49, 95%CI -4.29 to 1.31, P=0.30, I2 = 65%), major adverse kidney events (RR 0.88, 95%CI 0.58 to 1.34, P=0.56, I2 = 0%), and incidence of hypokalemia (RR 0.80, 95%CI 0.43 to 1.46, P=0.46, I2 = 56%). However, there was a significant reduction in the post-resuscitation chloride (MD -3.16, 95%CI -5.82 to -0.49, P=0.02, I2 = 73%) among patients received balanced crystalloids.

Conclusion

Among patients with DKA, the use of balanced crystalloids as compared to normal saline has no effect on the time to resolution of DKA, major adverse kidney events, and incidence of hypokalemia. However, the use of balanced crystalloids could reduce the post-resuscitation chloride.

Systematic review registration

https://osf.io, identifier c8f3d.

A systematic review of thromboembolic complications and outcomes in hospitalised COVID-19 patients

Thromboembolic (TE) complications [myocardial infarction (MI), stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE)] are common causes of mortality in hospitalised COVID-19 patients. Therefore, this review was undertaken to explore the incidence of TE complications and mortality associated with TE complications in hospitalised COVID-19 patients from different studies. A literature search was performed using ScienceDirect and PubMed databases using the MeSH term search strategy of "COVID-19", "thromboembolic complication", "venous thromboembolism", "arterial thromboembolism", "deep vein thrombosis", "pulmonary embolism", "myocardial infarction", "stroke", and "mortality". There were 33 studies included in this review. Studies have revealed that COVID-19 patients tend to develop venous thromboembolism (PE:1.0-40.0% and DVT:0.4-84%) compared to arterial thromboembolism (stroke:0.5-15.2% and MI:0.8-8.7%). Lastly, the all-cause mortality of COVID-19 patients ranged from 4.8 to 63%, whereas the incidence of mortality associated with TE complications was between 5% and 48%. A wide range of incidences of TE complications and mortality associated with TE complications can be seen among hospitalized COVID-19 patients. Therefore, every patient should be assessed for the risk of thromboembolic complications and provided with an appropriate thromboprophylaxis management plan tailored to their individual needs.

Implication of serum and salivary albumin tests in the recent oral health related epidemiological studies: A narrative review

Albumin is the most abundant protein in human serum and a specific amount of albumin also can be found in the saliva. It has several physiological functions such as blood colloidal osmotic pressure, antioxidant activity, binding and transporting of endogenous and exogenous substrates. We conducted an electronic search across several databases such as PubMed, Scopus, Cochrane, Embase and Science Direct using the relevant MeSH terms and keywords like "albumin", "serum albumin", "salivary albumin", "oral health" "dental caries" and "epidemiology". Only the epidemiological studies published between 2010 and 2023 were included. After the application of the inclusion criteria, a total of 51 studied were included in this narrative review. Serum and salivary albumin tests have been used in various aspects of oral health as a diagnostic and prognostic factor. Some of the results point out to a pattern of association while some of them are inconclusive and even contradictory. This narrative review discusses the role, significance and impact of albumin in epidemiological oral health related studies including the categories of periodontal health and disease, dental caries, oral function and hypofunction, nutrition and malnutrition, tooth loss and its treatment, diabetes and cancer. In addition, it offers a short manual for the researchers on when, where and how to use albumin tests in planning their study designs whether investigating an association or measure them as a covariate.

Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis

BACKGROUND

Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used.

METHODS

We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer's solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip.

RESULTS

Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001).

CONCLUSIONS

In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.

Point-of-care ultrasound in early diagnosis and monitoring of deep abscess in newborns: a case report of two cases

Objective

This study sought to analyze the value of point of care ultrasound (POCUS) in early diagnosis and monitoring of deep abscess in newborns.

Methods

Retrospective analysis of the clinical data of two newborns admitted to the Neonatal Intensive Care Unit (NICU) of our hospital and diagnosed with deep abscess of the newborn. Combined with literature analysis, the value of POCUS in early diagnosis and monitoring of deep abscess of the newborn was evaluated.

Results

The two newborns reported in this article were all admitted to NICU due to" "fever". POCUS was used to assist in early diagnosis of "liver abscess" and "lung abscess". Subsequently, POCUS was used to monitor lesion changes and adjust treatment plans. All patients were cured and discharged with a good prognosis.

Conclusions

Deep abscesses in newborns are very rare and often life-threatening, but apart from fever, they often have no specific clinical manifestations and are easily misdiagnosed or missed. POCUS, as a bedside auxiliary examination tool, has high accuracy, radiation free, non-invasive, and convenient, and has high diagnostic and monitoring value in early diagnosis and monitoring of deep abscess in newborns.

Haemodynamic changes during prone versus supine position in patients with COVID-19 acute respiratory distress syndrome

BACKGROUND

Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood.

OBJECTIVES

The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position.

METHODS

We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively.

RESULTS

We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001).

CONCLUSION

Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.

Changes of college students' psychological stress during the COVID-19 pandemic in China: A two-wave repeated survey

COVID-19 has posed unprecedented challenges to the mental health of college students worldwide. We examined the trends in students' stress levels during and after China's first wave of COVID-19 outbreaks by analyzing their demographics, behavior, mental health status, career confidence, and Chinese Perceived Stress Scale (CPSS) scores. Our findings indicate an increase in students' stress levels since the COVID-19 onset, with more students experiencing higher stress levels after the first outbreak than during it (OR = 2.03, 95% CI 1.79, 2.30). Several factors were identified as being associated with higher CPSS scores, including higher class levels, residence in rural or town areas, low family income, and lack of familiarity with COVID-19, among others. Our study highlighted the urgency of developing and implementing effective strategies to cope with students' stress during and after a global pandemic.

Quinazolines and thiazolidine-2,4-dions as SARS-CoV-2 inhibitors: repurposing, in silico molecular docking and dynamics simulation

This paper presents an extensive analysis of COVID-19 with a specific focus on VEGFR-2 inhibitors as potential treatments. The investigation includes an overview of computational methodologies employed in drug repurposing and highlights in silico research aimed at developing treatments for SARS-CoV-2. The study explores the possible effects of twenty-eight established VEGFR-2 inhibitors, which include amide and urea linkers, against SARS-CoV-2. Among these, nine inhibitors exhibit highly promising in silico outcomes (designated as 3-6, 11, 24, 26, 27, and sorafenib) and are subjected to extensive molecular dynamics (MD) simulations to evaluate the binding modes and affinities of these inhibitors to the SARS-CoV-2 Mpro across a 100 ns timeframe. Additionally, MD simulations are conducted to ascertain the binding free energy of the most compelling ligand-pocket complexes identified through docking studies. The findings provide valuable understanding regarding the dynamic and thermodynamic properties of the interactions between ligands and pockets, reinforcing the outcomes of the docking studies and presenting promising prospects for the creation of therapeutic treatments targeting COVID-19.

Using EEG total energy as a noninvasively tracking of intracranial (and cerebral perfussion) pressure in an animal model: A pilot study

PURPOSE

This study aims to describe the total EEG energy during episodes of intracranial hypertension (IH) and evaluate its potential as a classification feature for IH.

NEW METHODS

We computed the sample correlation coefficient between intracranial pressure (ICP) and the total EEG energy. Additionally, a generalized additive model was employed to assess the relationship between arterial blood pressure (ABP), total EEG energy, and the odds of IH.

RESULTS

The median sample cross-correlation between total EEG energy and ICP was 0.7, and for cerebral perfusion pressure (CPP) was 0.55. Moreover, the proposed model exhibited an accuracy of 0.70, sensitivity of 0.53, specificity of 0.79, precision of 0.54, F1-score of 0.54, and an AUC of 0.7.

COMPARISON WITH EXISTING METHODS

The only existing comparable methods, up to our knowledge, use 13 variables as predictor of IH, our model uses only 3, our model, as it is an extension of the generalized model is interpretable and it achieves the same performance.

CONCLUSION

These findings hold promise for the advancement of multimodal monitoring systems in neurocritical care and the development of a non-invasive ICP monitoring tool, particularly in resource-constrained environments.

Clinical features and outcomes of COVID-19 patients with concomitant herpesvirus co-infection or reactivation: A systematic review

Background

Since the first case of COVID-19 was diagnosed in Wuhan, China in late 2019, concomitant infections with Herpesviridae were documented that were presented from simple skin manifestations to severe life-threatening conditions that may lead to mortality. In this systematic review, we have included studies conducted in different parts of the world to find out the association of clinical features and outcomes of COVID-19 infection and concomitant Herpesviridae infection.

Methods

A comprehensive search was conducted in electronic databases including Medline through PubMed, Cochrane database, Scopus and Web of science (core collection). Two review authors independently screened the articles and extracted data. The Risk of bias assessment was done by using RoBANS tool.

Results

A total of 919 studies were retrieved and 19 studies were included having data of 539 patients who were infected with both COVID-19 and Herpesviridae. Herpes Simplex-1, Varicella Zoster, Cytomegalovirus, Epstein-Barr virus and Human Herpes Virus-6 were the detected viruses in the included studies. Cytomegalovirus (CMV) reactivation was the most detected concomitant infection. In case of reactivation with more than one Herpes virus mortality among patients were detected along with single viral infection in some studies. Significant association was noted in dosage and usage of steroid and Herpesviridae reactivation in COVID-19 patients. Blood markers such as D-dimer, CRP along with length of stay in the ICU and usage of invasive mechanical ventilation were found to be the significantly associated markers.

Conclusion

Findings from this study will aid clinicians to assess and treat COVID-19 cases with co-infections.

The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis

BACKGROUND

Acute kidney injury (AKI) is a recognized comorbidity in pediatric diabetic ketoacidosis (DKA), although the exact etiology is unclear. The unique physiology of DKA makes dehydration assessments challenging, and these patients potentially receive excessive amounts of intravenous fluids (IVF). We hypothesized that dehydration is over-estimated in pediatric DKA, leading to over-administration of IVF and hyperchloremia that worsens AKI.

METHODS

Retrospective cohort of all DKA inpatients at a tertiary pediatric hospital from 2014 to 2019. A total of 145 children were included; reasons for exclusion were pre-existing kidney disease or incomplete medical records. AKI was determined by change in creatinine during admission, and comparison to a calculated baseline value. Linear regression multivariable analysis was used to identify factors associated with AKI. True dehydration was calculated from patients' change in weight, as previously validated. Fluid over-resuscitation was defined as total fluids given above the true dehydration.

RESULTS

A total of 19% of patients met KDIGO serum creatinine criteria for AKI on admission. Only 2% had AKI on hospital discharge. True dehydration and high serum urea levels were associated with high serum creatinine levels on admission (p = 0.042; p < 0.001, respectively). Fluid over-resuscitation and hyperchloremia were associated with delayed kidney recovery (p < 0.001). Severity of initial AKI was associated with cerebral edema (p = 0.018).

CONCLUSIONS

Dehydration was associated with initial AKI in children with DKA. Persistent AKI and delay to recovery was associated with hyperchloremia and over-resuscitation with IVF, potentially modifiable clinical variables for earlier AKI recovery and reduction in long-term morbidity. This highlights the need to re-address fluid protocols in pediatric DKA.

Improving ECMO therapy: Monitoring oxygenator functionality and identifying key indicators, factors, and considerations for changeout

INTRODUCTION

The optimal timing for extracorporeal membrane oxygenation (ECMO) circuit change-out is crucial for the successful management of patients with severe cardiopulmonary failure. This comprehensive review examines the various factors that influence the timing of oxygenator replacement in the ECMO circuit. By considering these factors, clinicians can make informed decisions to ensure timely and effective change-out, enhancing patient outcomes and optimizing the delivery of ECMO therapy.

METHODOLOGY

A thorough search of relevant studies on ECMO circuits and oxygenator change-out was conducted using multiple scholarly databases and relevant keywords. Studies published between 2017 and 2023 were included, resulting in 40 studies that met the inclusion criteria.

DISCUSSION

Thrombosis within the membrane oxygenator and its impact on dysfunction were identified as significant contributors, highlighting the importance of monitoring coagulation parameters and gas exchange. Several factors, including fibrinogen levels, pre and post-membrane blood gases, plasma-free hemoglobin, D-dimers, platelet function, flows and pressures, and anticoagulation strategy, were found to be important considerations when determining the need for an oxygenator or circuit change-out. The involvement of a multidisciplinary team and thorough preparation were also highlighted as crucial aspects of this process.

CONCLUSION

In conclusion, managing circuit change-outs in ECMO therapy requires considering factors such as fibrinogen levels, blood gases, plasma-free hemoglobin, D-dimers, platelet function, flows, pressures, and anticoagulation strategy. Monitoring these parameters allows for early detection of issues, timely interventions, and optimized ECMO therapy. Standardized protocols, personalized anticoagulation approaches, and non-invasive monitoring techniques can improve the safety and effectiveness of circuit change-outs. Further research and collaboration are needed to advance ECMO management and enhance patient outcomes.

Fluid therapy in diabetic ketoacidosis

PURPOSE OF REVIEW

To evaluate recent evidence (2021-2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed.

RECENT FINDINGS

Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of "two-bag" compared to conventional "one-bag" fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials.

SUMMARY

Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.

Decoding acute myocarditis in patients with COVID-19: Early detection through machine learning and hematological indices

During the persistent COVID-19 pandemic, the swift progression of acute myocarditis has emerged as a profound concern due to its augmented mortality, underscoring the urgency of prompt diagnosis. This study analyzed blood samples from 5,230 COVID-19 individuals, identifying key blood and myocardial markers that illuminate the relationship between COVID-19 severity and myocarditis. A predictive model, applying Bayesian and random forest methodologies, was constructed for myocarditis' early identification, unveiling a balanced gender distribution in myocarditis cases contrary to a male predominance in COVID-19 occurrences. Particularly, older men exhibited heightened vulnerability to severe COVID-19 strains. The analysis revealed myocarditis was notably prevalent in younger demographics, and two subvariants COVID-19 progression paths were identified, characterized by symptom intensity and specific blood indicators. The enhanced myocardial marker model displayed remarkable diagnostic accuracy, advocating its valuable application in future myocarditis detection and treatment strategies amidst the COVID-19 crisis.

Pulmonary function in children post -SARS-CoV-2 infection: a systematic review and meta-analysis

OBJECTIVE

There are some concerns regarding long-term complications of COVID-19 in children. A systematic review and meta-analysis was performed evaluating the respiratory symptoms and pulmonary function, post-SARS-CoV-2 infection.

METHODS

A systematic search was performed in databases up to 30 March 2023. Studies evaluating respiratory symptoms and pulmonary function after COVID-19 infection in children were selected. The major outcomes were the frequency of respiratory symptoms and the mean of spirometry parameters. A pooled mean with 95% confidence intervals (CIs) was calculated.

RESULTS

A total of 8 articles with 386 patients were included in meta-analysis. Dyspnea, cough, exercise intolerance, and fatigue were the most common symptoms. The meta-mean of forced expiratory volume (FEV1) and forced vital capacity (FVC) was 101.72%, 95% CI= (98.72, 104.73) and 101.31%, 95% CI= (95.44, 107.18) respectively. The meta-mean of FEV1/FVC and Forced expiratory flow at 25 and 75% was 96.16%, 95% CI= (90.47, 101.85) and 105.05%, 95% CI= (101.74, 108.36) respectively. The meta-mean of diffusing capacity for carbon monoxide was 105.30%, 95%CI= (88.12, 122.49). There was no significant difference in spirometry parameters before and after bronchodilator inhalation.

CONCLUSIONS

Despite some clinical respiratory symptoms, meta-results showed no abnormality in pulmonary function in follow-up of children with SARS-CoV-2 infection. Disease severity and asthma background had not confounded this outcome.

COVID-19 induced ischemic stroke and mechanisms of viral entry in brain and clot formation: a systematic review and current update

Background: Coronavirus disease 2019, caused by SARS-CoV-2 (SCV-2) was stated as a pandemic on March 11 2020 by World Health Organization (WHO), and since then, it has become a major health issue worldwide. It mainly attacks the respiratory system with various accompanying complications, including cardiac injury, renal failure, encephalitis and Stroke.Materials and Methods: The current systematic review has been compiled to summarize the available literature on SCV-2 induced ischemic Stroke and its subtypes. Further, the mechanisms by which the virus crosses the blood-brain barrier (BBB) to enter the brain have also been explored. The role of CRP and D-dimer as potent prognostic markers was also explored. The literature search was carried out comprehensively on Google scholar, PubMed, SCOP US, Embase and Cochrane databases by following guidelines.Results: All the studies were reviewed thoroughly by authors and disagreements were resolved by consensus and help of the senior authors. The most common subtype of the IS was found to be large artery atherosclerosis in SCV-2 induced IS. Hypertension emerged as the most significant risk factor. The mechanism resulting in elevated levels of CRP and D-dimer have also been discussed. However, there is a scarcity of definitive evidence on how SCV-2 enters the human brain. The available literature based on various studies demonstrated that SCV-2 enters through the nasopharyngeal tract via olfactory cells to olfactory neurons, astrocytes and via choroid plexus through endothelial cells. Further, disruption of gut-brain axis has been also discussed.Conclusion: Data available in the literature is not adequate to come to a conclusion. Therefore, there is a need to carry out further studies to delineate the possible association between SCV-2 induced IS.

Nursing Care Challenges for Patients Suffering from COVID-19 from Nurses' Perspective in Iran: A Descriptive Qualitative Study

Background

Encountering the coronavirus disease 2019 (COVID-19) pandemic, nurses face many challenges due to various strategies and resources that can compromise the quality of care. This study aimed to identify nursing care challenges for patients with COVID-19 from nurses' viewpoint in Iran.

Materials and Methods

This descriptive qualitative study was conducted in one of the main admission centers in Isfahan to treat patients with COVID-19. Data were collected through semi-structured in-depth interviews with 19 nurses from April 2020 to June 2020. The recorded interviews were transcribed and then analyzed through inductive content analysis.

Results

The challenges of nursing care for patients infected with COVID-19 from the nurses' viewpoint were categorized into 11 subcategories and four main categories: work overload in disaster (lack of nurses with adequate clinical qualification and restrictions on the compliance of the infection control protocols), immersion in an ocean of psychological and social tensions (personal and family tensions, work environment tensions, perception of organizational injustice, and social stigma), quality of care in fragile condition (self-preservation rather than patient care and contradictory patient care standards), and disaster preparedness, response, and management (passive resource management, information system challenges, and lack of guideline-supported protocols).

Conclusions

The findings of this study suggest that policymakers should actively participate in supporting nurses in the form of reducing physical and mental stress in pandemics such as COVID-19. Having the right perception of the challenges nurses face in such crises can contribute to providing patient safety, improving the quality of care, maintaining organizational resources, and properly managing the disaster.

Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial

OBJECTIVE

To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock.

DESIGN

Parallel-group, blinded multicenter trial.

SETTING

PICUs of four tertiary care centers in India from 2017 to 2020.

PATIENTS

Children up to 15 years of age with septic shock.

METHODS

Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality.

INTERVENTIONS

MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days.

MEASUREMENTS AND MAIN RESULTS

The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups.

CONCLUSIONS

Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.

Frequency of extra pulmonary complications in critically ill COVID-19 patients and their association with inflammatory markers and hypoxia: Retrospective analysis at a tertiary care hospital in Karachi, Pakistan

Background and Objective

This study aimed to determine the incidence of extra pulmonary complications among critically ill COVID-19 patients requiring invasive mechanical ventilation and association of these complications with various inflammatory markers and degree of hypoxia.

Methods

A retrospective cohort study was conducted among 173 adults in Karachi having COVID-19 and were admitted to ICU in a tertiary care private hospital between August 2020 to July 2021.

Results

The median age of patients included in the analysis was 61 years (IQR; 16). Acute kidney injury, septic shock, cardiac injury, and electrolytes imbalance were the most frequent extra pulmonary complications with proportion of 65.3% (n=113), 63.6% (n=110), 61.8% (n=107) and 33.5% (n=58). Statistically significant differences in the median serum levels of ferritin were observed among male versus female, critically ill covid patients with and without ICU mortality as well as patients with and without hospital mortality (p-value <0.05). Significantly higher serum levels of d-dimer were noted among patients who developed acute liver injury or NSTEMI, or had ICU stay of > 3 days or received mechanical ventilation for >2 days.

Conclusion

Acute kidney injury, septic shock, cardiac injury, and electrolytes imbalance were the most common extra pulmonary complications among mechanically ventilated COVID-19 patients with ARDS. Higher serum d-dimer levels were associated with acute liver injury, NSTEMI, ICU stay longer >3 days and invasive mechanical ventilation >2 days. Higher serum ferritin levels are associated with male sex and serve as an important predictor of ICU as well as hospital mortality.

Artificial intelligence-based preventive, personalized and precision medicine for cardiovascular disease/stroke risk assessment in rheumatoid arthritis patients: a narrative review

The challenges associated with diagnosing and treating cardiovascular disease (CVD)/Stroke in Rheumatoid arthritis (RA) arise from the delayed onset of symptoms. Existing clinical risk scores are inadequate in predicting cardiac events, and conventional risk factors alone do not accurately classify many individuals at risk. Several CVD biomarkers consider the multiple pathways involved in the development of atherosclerosis, which is the primary cause of CVD/Stroke in RA. To enhance the accuracy of CVD/Stroke risk assessment in the RA framework, a proposed approach involves combining genomic-based biomarkers (GBBM) derived from plasma and/or serum samples with innovative non-invasive radiomic-based biomarkers (RBBM), such as measurements of synovial fluid, plaque area, and plaque burden. This review presents two hypotheses: (i) RBBM and GBBM biomarkers exhibit a significant correlation and can precisely detect the severity of CVD/Stroke in RA patients. (ii) Artificial Intelligence (AI)-based preventive, precision, and personalized (aiP3) CVD/Stroke risk AtheroEdge™ model (AtheroPoint™, CA, USA) that utilizes deep learning (DL) to accurately classify the risk of CVD/stroke in RA framework. The authors conducted a comprehensive search using the PRISMA technique, identifying 153 studies that assessed the features/biomarkers of RBBM and GBBM for CVD/Stroke. The study demonstrates how DL models can be integrated into the AtheroEdge™-aiP3 framework to determine the risk of CVD/Stroke in RA patients. The findings of this review suggest that the combination of RBBM with GBBM introduces a new dimension to the assessment of CVD/Stroke risk in the RA framework. Synovial fluid levels that are higher than normal lead to an increase in the plaque burden. Additionally, the review provides recommendations for novel, unbiased, and pruned DL algorithms that can predict CVD/Stroke risk within a RA framework that is preventive, precise, and personalized.

Balanced crystalloid solutions versus normal saline in intensive care units: a systematic review and meta-analysis

BACKGROUND

Intravenous fluid therapy is important for pediatric and adult patients in intensive care units (ICUs). However, medical professionals continue to struggle to determine the most appropriate fluids to obtain the best possible outcomes for each patient.

OBJECTIVE

We conducted a meta-analysis involving cohort studies and randomized controlled trials (RCTs) to compare the influence of balanced crystalloid solutions and normal saline among patients in ICUs.

PATIENTS AND METHODS

Studies that compared balanced crystalloid solutions and saline in ICU patients from databases including PubMed, Embase, Web of Science, and Cochrane Library were systematically searched up to July 25, 2022. The primary outcomes were mortality and renal-related outcomes, which included major adverse kidney events within 30 days (MAKE30), acute kidney injury (AKI), new receipt of renal replacement therapy (RRT), maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline. Service utilization including length of hospital stay, ICU stay, ICU-free days and ventilator-free days were also reported.

RESULTS

A total of 13 studies (10 RCTs and 3 cohort studies) involving 38,798 patients in ICUs met the selection criteria. Our analysis revealed that each subgroup had no significant difference in mortality outcomes among ICU patients between balanced crystalloid solutions and normal saline. A significant difference was detected between the adult groups (odds ratio [OR], 0.92; 95% confidence interval [CI], [0.86, 1.00]; p = 0.04) indicating that the AKI in the balanced crystalloid solutions group was lower than that in the normal saline group. Other renal-related outcomes, such as MAKE30, RRT, maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline showed no significant difference between the two groups. Regarding secondary outcomes, the balanced crystalloid solution group had a longer ICU stay time (WMD, 0.02; 95% CI, [0.01, 0.03]; p = 0.0004 and I2 = 0%; p = 0.96) than the normal saline group among adult patients. Furthermore, children treated with balanced crystalloid solution had a shorter hospital stay time (WMD, - 1.10; 95% CI, [- 2.10, - 0.10]; p = 0.03 and I2 = 17%; p = 0.30) than those treated with saline.

CONCLUSIONS

Compared with saline, balanced crystalloid solutions could not reduce the risk of mortality and renal-related outcomes, including MAKE30, RRT, maximum creatinine increasing, maximum creatinine level, and final creatinine level ≥ 200% of baseline, but the solutions may reduce total AKI incidence among adult patients in ICUs. For service utilization outcomes, balanced crystalloid solutions were associated with a longer length of ICU stay in the adult group and shorter length of hospital stay in the pediatric group.

Towards precise PICO extraction from abstracts of randomized controlled trials using a section-specific learning approach

MOTIVATION

Automated extraction of participants, intervention, comparison/control, and outcome (PICO) from the randomized controlled trial (RCT) abstracts is important for evidence synthesis. Previous studies have demonstrated the feasibility of applying natural language processing (NLP) for PICO extraction. However, the performance is not optimal due to the complexity of PICO information in RCT abstracts and the challenges involved in their annotation.

RESULTS

We propose a two-step NLP pipeline to extract PICO elements from RCT abstracts: (i) sentence classification using a prompt-based learning model and (ii) PICO extraction using a named entity recognition (NER) model. First, the sentences in abstracts were categorized into four sections namely background, methods, results, and conclusions. Next, the NER model was applied to extract the PICO elements from the sentences within the title and methods sections that include >96% of PICO information. We evaluated our proposed NLP pipeline on three datasets, the EBM-NLPmoddataset, a randomly selected and reannotated dataset of 500 RCT abstracts from the EBM-NLP corpus, a dataset of 150 COVID-19 RCT abstracts, and a dataset of 150 Alzheimer's disease (AD) RCT abstracts. The end-to-end evaluation reveals that our proposed approach achieved an overall micro F1 score of 0.833 on the EBM-NLPmod dataset, 0.928 on the COVID-19 dataset, and 0.899 on the AD dataset when measured at the token-level and an overall micro F1 score of 0.712 on EBM-NLPmod dataset, 0.850 on the COVID-19 dataset, and 0.805 on the AD dataset when measured at the entity-level.

AVAILABILITY

Our codes and datasets are publicly available at https://github.com/BIDS-Xu-Lab/section_specific_annotation_of_PICO.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

The Impact of Mechanical Energy Assessment on Mechanical Ventilation: A Comprehensive Review and Practical Application

Mechanical ventilation (MV) provides basic organ support for patients who have acute hypoxemic respiratory failure, with acute respiratory distress syndrome as the most severe form. The use of excessive ventilation forces can exacerbate the lung condition and lead to ventilator-induced lung injury (VILI); mechanical energy (ME) or power can characterize such forces applied during MV. The ME metric combines all MV parameters affecting the respiratory system (ie, lungs, chest, and airways) into a single value. Besides evaluating the overall ME, this parameter can be also related to patient-specific characteristics, such as lung compliance or patient weight, which can further improve the value of ME for characterizing the aggressiveness of lung ventilation. High ME is associated with poor outcomes and could be used as a prognostic parameter and indicator of the risk of VILI. ME is rarely determined in everyday practice because the calculations are complicated and based on multiple equations. Although low ME does not conclusively prevent the possibility of VILI (eg, due to the lung inhomogeneity and preexisting damage), individualization of MV settings considering ME appears to improve outcomes. This article aims to review the roles of bedside assessment of mechanical power, its relevance in mechanical ventilation, and its associations with treatment outcomes. In addition, we discuss methods for ME determination, aiming to propose the most suitable method for bedside application of the ME concept in everyday practice.

Pediatric Diabetes and Diabetic Ketoacidosis After COVID-19: Challenges Faced and Lessons Learnt

The coronavirus disease (COVID-19) pandemic affected the management and follow-up of several chronic ailments, including pediatric type 1 diabetes mellitus (T1DM). Restricted access to healthcare and fear of contracting the virus during medical facility visits resulted in poor compliance, irregular follow-up visits, treatment, and delayed diagnosis of complications in pediatric diabetes such as diabetic ketoacidosis (DKA). As such, the incidence of complicated DKA in resource-limited settings is high due to delayed presentation, poor compliance with therapy, and associated comorbidities such as malnutrition and sepsis. The pandemic had only added to the woes. The increased surge in DKA, in the face of limited resources, prompted clinicians to find alternative solutions to manage these children effectively. In this narrative review, we discuss the key challenges faced globally while caring for children with T1DM and DKA during the COVID-19 pandemic, and the lessons learned thereof.

A systematic review and meta-analysis on the prevalence and impact of coronary artery disease in hospitalized COVID-19 patients

Background

COVID-19 accounts for more than half a billion deaths globally. The clinical manifestations may vary in due course. Despite several studies aimed at determining the extent to which the disease's severity and mortality remain high when combined with other comorbidities, more research is required. Therefore, this review aimed to measure the pooled prevalence of coronary artery disease (CAD) among COVID-19 patients, specifically those with a history of CAD. Additionally, we aim to assess the association between mortality due to CAD and the severity of COVID-19 among hospitalized patients.

Method

A comprehensive search in PubMed, Web of Science, the Cochrane Library, and the WHO COVID-19 database was conducted. English studies with original data on CAD, mortality, and ARDS among COVID-19 patients were included. PRISMA guidelines were followed.

Results

Among the 2007 identified articles, 76 studies met the inclusion criteria. The pooled prevalence of CAD among COVID-19 patients was 14.4%(95% CI: 12.7-16.2). The highest prevalence was observed in European studies at 18.2%(95% CI: 13.3-24.2), while the lowest was in Asian studies at 10.4% (95% CI: 6.4-16.3). Participants with concurrent CAD at the time of hospital admission had twice the odds of mortality due to COVID-19 (2.64 [95% CI: 2.30-3.04]) with moderate heterogeneity (I2 = 45%, p < 0.01). Hospitalized COVID-19 patients with CAD had a 50% higher risk of ARDS (95% CI: 0.62-3.66), but this difference was not statistically significant.

Conclusion

Although our analysis revealed evidence for a relationship between concurrent CAD at the time of hospital admission and mortality from COVID-19, however, global variation in health infrastructure, limitations of data reporting, and the effects of emerging variants must be considered in future investigations.

Ferritin/lymphocyte percentage ratio to predict the severity and mortality of COVID-19

Objective

In this study, we aimed to investigate the relationship between ferritin/lymphocyte percentage ratio (FLPR) with clinical and radiological disease severity and mortality in COVID-19 patients.

Methods

This retrospective study was conducted with patients who had polymerase chain reaction positive results for COVID-19. We calculated FLPRs from laboratory tests taken during emergency clinic admission. The relationship between chest computed tomography (CT) scores, disease severity, and 30-day mortality with FLPR was evaluated.

Results

Our study included 309 patients. 30-day mortality occurred in 12.3% (n=38) of the patients. A statistically significant association was found between FLPR and clinical disease severity (p <0.001). In the post hoc analysis, the difference was caused by the critical and severe groups and FLPR was significantly higher in these groups. A significant correlation was found between CT scores and FLPR (r=0.496, p<0.001). Logistic regression analysis revealed that hypertension, smoking, C-reactive protein (CRP), and FLPR levels were independent risk factors for mortality in COVID-19 patients. In the receiver operating characteristics curve analysis, determined the predictive value and the optimal cut-off value of FLPR. The areas under the curve of WBC, lymphocyte, neutrophil, ferritin, CRP, FLPR were found 0.707, 0.233, 0.735, 0.878, 0.831, 0.924 (p<0.001), respectively. This analysis showed that the FLPR can predict 30-day mortality better than the other biomarkers in the comparison. When the optimal cut-off value of FLPR is 42.4, the sensitivity is 84.2% and specificity is 86.7%.

Conclusion

FLPR can be used as an independent biomarker of disease severity and mortality in COVID-19.

The Minnesota first-responder AED project: Aiming to increase survival in out-of-hospital cardiac arrest

There are 350,000 out-of-hospital cardiac arrest (OHCA) cases annually in the United States of America. Using automated external defibrillators (AEDs) has increased survival in cardiac arrests (CA) with an initial shockable rhythm. Thus, guidelines recommend complete geographical coverage with AEDs. To fill in the gaps in Minnesota, the Center for Resuscitation Medicine at the University of Minnesota raised an $18.8 million grant from the Helmsley Charitable Trust to supply law enforcement first responders with AEDs and, thus, increase survival rates after OHCA by reducing the time to first shock. This report elaborates on the decision-making, fundraising, and logistic strategy required to reach statewide AED coverage.

Methods

The baseline need for AEDs was analyzed using a questionnaire sent out to state law enforcement agencies, state patrols, city and county agencies, and tribal agencies in 2021. Furthermore, OHCA cases of 2021 were reviewed. The combination of this information led to an action plan to equip and train all agencies throughout the state's eight regions with AEDs.

Results

The electronic survey was initially sent out to 358 agencies. The initial response rate was 77% (n = 276). This resulted in a total need of 8300 AEDs to be deployed over three years (2022-2025). As of 2023, over 4769 AEDs have been distributed, covering 237 sites.

Conclusion

By equipping first responders with AED systems, the Center for Resuscitation Medicine aims to shorten the gap in statewide AED coverage, thus increasing the chances of survival after OHCA.

Acute Epiglottitis Secondary to the Severe Acute Respiratory Syndrome Coronavirus 2: A Case Report

INTRODUCTION

Acute epiglottis is a rapidly progressive, potentially life-threatening infection causing inflammation of the epiglottis and adjacent supraglottic structures.- Since the introduction of the Haemophilus influenzae vaccine, the incidence of pediatric cases has decreased dramatically while adult instances have increased. Likewise, the etiology has changed considerably with the increasing prevalence of other causative bacterial and viral pathogens.

CASE REPORT

We present a novel case of acute epiglottis secondary to infection with the severe acute respiratory syndrome coronavirus 2. This case report highlights the changing landscape of epiglottitis and the importance of airway assessment.

CONCLUSION

Present-day epiglottitis differs greatly from our traditional understanding. Numerous etiologies beyond Haemophilus influenzae now afflict adults predominately. As a clinically significant, novel complication of coronavirus disease 2019, acute epiglottitis is a life-threatening airway emergency. Emergency physicians must maintain a high index of suspicion, especially given the evolving clinical landscape. Early airway assessment with nasopharyngolaryngoscopic is critical.

Dietary Supplement Use among Iranian Households during COVID-19 Epidemic Lockdown: Less Access in Those Who May Need More National Food and Nutrition Surveillance

Background

The coronavirus disease 2019 (COVID-19) pandemic elicited the general population to use various dietary supplements (DSs) and nutraceuticals as a protective means against the disease. The present study aimed to evaluate changes and certain determinants of DS intake during the COVID-19 lockdown among Iranian households.

Methods

This nationwide cross-sectional study was conducted from April 4 to April 25, 2020, during which Iran was in lockdown. To collect data, a web-based electronic self-administered questionnaire was created. The data were compared among provinces based on their food security situations.

Results

A total of 21,290 households were included in the analyses. Approximately 27% of the households were using DSs after the epidemic. The most common DSs used were vitamin D (42%) and vitamin C (20%), followed by multi-vitamin (16%), zinc (9%), omega-3 (6%), vitamin A (4%), and probiotics (3%). Logistic regression analysis revealed that DS intake was directly associated with the household income but inversely with household size and the food security status of the provinces. DS intake was positively associated with the presence of high-risk persons in the households, the education of the households' head, and the presence of a person with a history of COVID-19 within the household.

Conclusions

During epidemic lockdown, DS use was remarkably increased among the Iranian households. Apart from the debatable usefulness of DSs against COVID-19, the inverse association of DS use with a household's income and provincial food security well indicates inequity in accessibility to DS. Actions to improve the nutritional status of the under-privileged populations including targeted supplementation are strongly recommended.

A brief history of crystalloids: the origin of the controversy

Fluid resuscitation with crystalloids has been used in humans for more than 100 years. In patients with trauma, sepsis or shock of any etiology, they can help modify the clinical course of the illness. However, these solutions are medications which are not side-effect free. Recently, they have been questioned in terms of quantity (fluid overload) and their composition. The most frequently used crystalloids, both in high and low-income countries, are 0.9% normal saline (NS) and Ringer's lactate. The first descriptions of the use of sodium and water solutions in humans date from the cholera epidemic which spread throughout Europe in 1831. The composition of the fluids used by medical pioneers at that time differs greatly from the 0.9% NS used routinely today. The term "physiological solution" referred to fluids which did not cause red blood cell hemolysis in amphibians in in vitro studies years later. 0.9% NS has an acid pH, a more than 40% higher chloride concentration than plasma and a strong ion difference of zero, leading many researchers to consider it an unbalanced solution. In many observational studies and clinical trials, this 0.9% NS composition has been associated with multiple microcirculation and immune response complications, acute kidney injury, and worse clinical outcomes. Ringer's lactate has less sodium than plasma, as well as other electrolytes which can cause problems in patients with traumatic brain injury. This review provides a brief summary of the most important historical aspects of the origin of the most frequently used intravenous crystalloids today.

On the relationship between neurocognitive measures and olfactory dysfunction in COVID-19 patients with and without anosmia

One of the predominant symptoms of the COVID-19 virus is the complete (anosmia) or partial (hyposmia) loss of smell. Anosmia may be a critical neurocognitive symptom because there is an empirically demonstrated association of anosmia with neurodegenerative diseases like Parkinson's disease, Alzheimer's disease, etc. The present study assessed the neurocognitive disorder patterns in recovered COVID-19 patients who either self-reported anosmia or its absence. Of the 60 adult participants (n = 32 males, n = 28 females; M_age = 20.78 years, range = 18-31 years), 15 reported COVID-19 induced anosmia, 15 reported COVID-19 without anosmia, and 30 reported not having contracted COVID-19. The participants were first administered a 10-item smell test, and analysis of variance revealed significantly better scores for the control group than the other two groups. Further, there was no significant difference in smell scores between the patients who self-reported anosmia or denied it. This statistical pattern was consistent across all neuropsychological tests: short- and long-term verbal memory, digit span, Trail Making, and a self-report 46-item neurocognitive scale. Regardless of the self-report of anosmia or denial, all thirty COVID-19 patients scored significantly poorer than the control group on all of the tests and neurocognitive scale. In summary, the self-report of anosmia appears to be unreliable, and the COVID-19 patients who were found to be anosmic on the initial objective smell test demonstrated poorer neuropsychological performance than controls.

Comparing the clinical effects of balanced electrolyte solutions versus normal saline in managing diabetic ketoacidosis: A systematic review and meta-analyses

The first-line treatment of diabetes ketoacidosis (DKA) involves fluid resuscitation with normal saline infusion to correct hypovolemia. Hyperchloremic metabolic acidosis from aggressive normal saline administration was associated with worse clinical outcomes in managing DKA. Other choices for normal saline include balanced electrolyte solutions (BESs). This study aimed to compare the clinical effects between BESs and normal saline in managing DKA. This study was a systematic review of probing articles published from inception to October 2021 in Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Google Scholar, and Scopus. Eight randomized controlled trials with a total of 595 individuals were included. The data were analyzed at 95% confidence level using random-effects models. For the primary outcomes, there was no difference in the duration of DKA resolution. (Mean difference [MD] -4.73, 95% confidence interval [CI] -2.72-4.92; I² = 92%; P = 0.180). However, there was a significantly lower postresuscitation chloride concentration in the BES (MD 2.96 95% CI - 4.86 to - 1.06; I² = 59%; P = 0.002). For the secondary outcomes, there was a significant reduction in duration for normalization of bicarbonate in the BES group (MD 3.11 95% CI - 3.98-2.23; I² = 5%; P = 0.0004). There were no significant differences between groups in duration for recovery of pH, intensive unit admission, and adverse events (mortality and acute renal failure). Resuscitation with BES was associated with decreased chloride and increased bicarbonate values in DKA patients. It suggests that BES prevents DKA patients from hyperchloremic metabolic acidosis.

Comparison of two antifibrotic treatments for lung fibrosis in post-COVID-19 syndrome: A randomized, prospective study

Background

Although pulmonary fibrosis secondary to COVID-19 infection is uncommon, it can lead to problems if not treated effectively in the early period. This study aimed to compare the effects of treatment with nintedanib and pirfenidone in patients with COVID-19-related fibrosis.

Methods

Thirty patients who presented to the post-COVID outpatient clinic between May 2021 and April 2022 with a history of COVID-19 pneumonia and exhibited persistent cough, dyspnea, exertional dyspnea, and low oxygen saturation at least 12 weeks after diagnosis were included. The patients were randomized to receive off-label treatment with nintedanib or pirfenidone and were followed up for 12 weeks.

Results

After 12 weeks of treatment, all pulmonary function test (PFT) parameters, 6MWT distance, and oxygen saturation were increased compared to baseline in both the pirfenidone group and nintedanib groups, while heart rate and radiological score levels were decreased (p < 0.05 for all). The changes in 6MWT distance and oxygen saturation were significantly greater in the nintedanib group than in the pirfenidone group (p = 0.02 and 0.005, respectively). Adverse drug effects were more frequent with nintedanib than pirfenidone, with the most common being diarrhea, nausea, and vomiting.

Conclusion

In patients with interstitial fibrosis after COVID-19 pneumonia, both nintedanib and pirfenidone were observed to be effective in improving radiological score and PFT parameters. Nintedanib was more effective than pirfenidone in increasing exercise capacity and saturation values but caused more adverse drug effects.