Role of continuous pulse oximetry and capnography monitoring in the prevention of postoperative respiratory failure, postoperative opioid-induced respiratory depression and adverse outcomes on hospital wards: A systematic review and meta-analysis

OBJECTIVE

The current standards of postoperative respiratory monitoring on medical-surgical floors involve spot-pulse oximetry checks every 4-8 h, which can miss the opportunity to detect prolonged hypoxia and acute hypercapnia. Continuous respiratory monitoring can recognize acute respiratory depression episodes; however, the existing evidence is limited. We sought to review the current evidence on the effectiveness of continuous pulse oximetry (CPOX) with and without capnography versus routine monitoring and their effectiveness for detecting postoperative respiratory failure, opioid-induced respiratory depression, and preventing downstream adverse events.

METHODS

We performed a systematic literature search on Ovid Medline, Embase, and Cochrane Library databases for articles published between 1990 and April 2023. The study protocol was registered in Prospero (ID: 439467), and PRISMA guidelines were followed. The NIH quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using the software R version 4.1.1 and the package meta. The stability of the results was assessed using sensitivity analysis.

DESIGN

Systematic Review and Meta-Analysis.

SETTING

Postoperative recovery area.

PATIENTS

56,538 patients, ASA class II to IV, non-invasive respiratory monitoring, and post-operative respiratory depression.

INTERVENTIONS

Continuous pulse oximetry with or without capnography versus routine monitoring.

MEASUREMENTS

Respiratory rate, oxygen saturation, adverse events, and rescue events.

RESULTS

23 studies (17 examined CPOX without capnography and 5 examined CPOX with capnography) were included in this systematic review. CPOX was better at recognizing desaturation (SpO2 < 90%) OR: 11.94 (95% CI: 6.85, 20.82; p < 0.01) compared to standard monitoring. No significant differences were reported for ICU transfer, reintubation, and non-invasive ventilation between the two groups.

CONCLUSIONS

Oxygen desaturation was the only outcome better detected with CPOX in postoperative patients in hospital wards. These comparisons were limited by the small number of studies that could be pooled for each outcome and the heterogeneity between the studies.

Experimental validation and clinical feasibility of 3D reconstruction of coronary artery bifurcation stents using intravascular ultrasound

The structural morphology of coronary stents and the local hemodynamic environment following stent deployment in coronary arteries are crucial determinants of procedural success and subsequent clinical outcomes. High-resolution intracoronary imaging has the potential to facilitate geometrically accurate three-dimensional (3D) reconstruction of coronary stents. This work presents an innovative algorithm for the 3D reconstruction of coronary artery stents, leveraging intravascular ultrasound (IVUS) and angiography. The accuracy and reproducibility of our method were tested in stented patient-specific silicone models, with micro-computed tomography serving as a reference standard. We also evaluated the clinical feasibility and ability to perform computational fluid dynamics (CFD) studies in a clinically stented coronary bifurcation. Our experimental and clinical studies demonstrated that our proposed algorithm could reproduce the complex 3D stent configuration with a high degree of precision and reproducibility. Moreover, the algorithm was proved clinically feasible in cases with stents deployed in a diseased coronary artery bifurcation, enabling CFD studies to assess the hemodynamic environment. In combination with patient-specific CFD studies, our method can be applied to stenting optimization, training in stenting techniques, and advancements in stent research and development.

Role of second look endoscopy in endoscopic submucosal dissection and peptic ulcer bleeding: Meta-analysis of randomized controlled trials

BACKGROUND

Second-look endoscopy (SLE) to prevent recurrent bleeding in patients with peptic ulcer disease (PUD) and those undergoing endoscopic submucosal dissection (ESD) is routinely being performed. Conflicting evidence exists regarding efficacy, risk, benefit, and cost-effectiveness.

AIM

To identify the role and effectiveness of SLE in ESD and PUD, associated rebleeding and PUD-related outcomes like mortality, hospital length of stay, need for endoscopic or surgical intervention and blood transfusions.

METHODS

A systematic review of literature databases PubMed, Cochrane, and Embase was conducted from inception to January 5, 2023. Randomized controlled trials that compared patients with SLE to those who did not have SLE or evaluated the role of prophylactic hemostasis during SLE compared to other conservative interventions were included. The study was conducted per PRISMA guidelines, and the protocol was registered in PROSPERO (ID CRD42023427555:). RevMan was used to perform meta-analysis, and Mantel-Haenszel Odds ratio (OR) were generated using random effect models.

RESULTS

A total of twelve studies with 2687 patients were included in our systematic review and meta-analysis, of which 1074 patients underwent SLE after ESD and 1613 patients underwent SLE after PUD-related bleeding. In ESD, the rates of rebleeding were 7% in the SLE group compared to 4.4% in the non-SLE group with OR 1.65, 95% confidence intervals (CI) of 0.96 to 2.85; P = 0.07, whereas it was 11% in the SLE group compared to 13% in the non-SLE group with OR 0.8 95%CI: 0.50 to 1.29; P = 0.36. The mean difference in the blood transfusion rates in the SLE and no SLE group in PUD was OR 0.01, 95%CI: -0.22 to 0.25; P = 0.91. In SLE vs non-SLE groups with PUD, the OR for Endoscopic intervention was 0.29, 95%CI: 0.08 to 1.00; P = 0.05 while it was OR 2.03, 95%CI: 0.95 to 4.33; P = 0.07, for surgical intervention. The mean difference in the hospital length of stay was -3.57 d between the SLE and no SLE groups in PUD with 95%CI: -7.84 to 0.69; P = 0.10, denoting an average of approximately 3 fewer days of hospital stay among patients with PUD who underwent SLE. For mortality between SLE and non-SLE groups in PUD, the OR was 0.88, 95%CI: 0.45 to 1.72; P = 0.70.

CONCLUSION

SLE does not confer any benefit in preventing ESD and PUD-associated rebleeding. SLE also does not provide any significant improvement in mortality, need for interventions, or blood transfusions in PUD patients. SLE decreases the hospital length of stay on average by 3.5 d in PUD patients.

Effect of breathing exercises on blood pressure and heart rate: A systematic review and meta-analysis

Background

Breathing exercises have been reported to have positive physiological effects on the body. The incidence of hypertension has become a major risk factor for cardiac complications leading to higher morbidity and mortality. Our aim was to conduct a systematic review and meta-analysis to study the effect of breathing exercises on blood pressure (BP) and heart rate (HR).

Methods

A systematic review and meta-analysis analyzing randomized clinical trials (RCTs) about the effect of breathing exercises on blood pressure was conducted (PROSPERO Registration ID: CRD42022316413). PubMed, ScienceDirect, WebofScience, and Cochrane Library databases were screened for RCTs from January 2017 to September 2022. The main search terms included "breathing exercise", "Pranayam", "Bhramari", "alternate nostril breathing", "deep breathing", "slow breathing", "hypertension", and "high blood pressure". The primary outcome was the value of the systolic blood pressure and diastolic blood pressure after the intervention. The effect on heart rate was also analyzed as a secondary outcome.

Results

A total of 15 studies were included in the meta-analysis. Breathing exercises have a modest but significant effect on decreasing systolic blood pressure (-7.06 [-10.20, -3.92], P = <0.01) and diastolic blood pressure (-3.43 [-4.89, -1.97], P = <0.01) mm Hg. Additionally, breathing exercises were also observed to cause a significant decrease in the heart rate (-2.41 [-4.53, -0.30], P = 0.03) beats/minute.

Conclusion

In a comprehensive systematic review and meta-analysis of breathing exercises and its effect on BP and HR, there is a moderate but significant positive effect. The studies are not deprived of bias.

Guiding principles for the conduct of the Violence Study of Healthcare Workers and System (ViSHWaS): Insights from a global survey

Background

Although many studies worldwide have reported on violence against health care workers, there is a lack of homogeneous data for understanding the current state of the issue. Conducting a global survey required a robust team organisation structure, unique dissemination strategies, and continual networking to maintain and propagate the pool of survey collaborators and responders. Here we aimed to describe the strategies that helped us carry out a global survey-based study, the lessons learned, and provide a practical roadmap for future large-scale cross-sectional studies.

Methods

We conducted this cross-sectional survey-based study from 6 June to 9 August 2022, basing it on the 'Hub and Spoke' model, with a single core team and subgroups in different regions managed by country leads. The key steps included team organisation, strategy formulation for survey dissemination and data collection, social media launch, and conducting a post-survey analysis amongst the collaborators. The core team convened weekly via video conference to discuss the modus operandi. The language barrier was managed through audio translation or by shifting to 'an interviewer-administered' questionnaire.

Results

The core team included 11 members from seven countries, followed by 28 country leads from 110 countries. We also gathered 80 regional collaborators who provided feedback and spread the message. The Violence Study of Healthcare Workers and Systems (ViSHWaS) returned 5500 responses globally. Guiding principles garnered through this collaborative project include focusing on effective team organisation, ensuring external validation of survey tool, personalised communication, global networking, timely communication for maintaining momentum, and addressing regional limitations. The post-survey analysis showed that WhatsApp messaging was the most common modality used for survey dissemination, followed by in-person meetings and text messaging. We noted that the successful techniques were direct communication with respondents, regular progress updates, responsiveness to regional and country lead needs, and timely troubleshooting. The most common barriers for the respondents were limitations in language proficiency, technical fallouts, lack of compliance with, and difficulty understanding the questionnaire.

Conclusions

In this global survey-based study of more than 5500 responses from over 110 countries, we noted valuable lessons in team management, survey dissemination, and addressing barriers to collaborative research.

Rapid automated lumen segmentation of coronary optical coherence tomography images followed by 3D reconstruction of coronary arteries

Purpose

Optical coherence tomography has emerged as an important intracoronary imaging technique for coronary artery disease diagnosis as it produces high-resolution cross-sectional images of luminal and plaque morphology. Precise and fast lumen segmentation is essential for efficient OCT morphometric analysis. However, due to the presence of various image artifacts, including side branches, luminal blood artifacts, and complicated lesions, this remains a challenging task.

Approach

Our research study proposes a rapid automatic segmentation method that utilizes nonuniform rational B-spline to connect limited pixel points and identify the edges of the OCT lumen. The proposed method suppresses image noise and accurately extracts the lumen border with a high correlation to ground truth images based on the area, minimal diameter, and maximal diameter.

Results

We evaluated the method using 3300 OCT frames from 10 patients and found that it achieved favorable results. The average time taken for automatic segmentation by the proposed method is 0.17 s per frame. Additionally, the proposed method includes seamless vessel reconstruction following the lumen segmentation.

Conclusions

The developed automated system provides an accurate, efficient, robust, and user-friendly platform for coronary lumen segmentation and reconstruction, which can pave the way for improved assessment of the coronary artery lumen morphology.

Alpha-2 Agonists in Children and Adolescents With Post-traumatic Stress Disorder: A Systematic Review

Exposure to traumatic stress is common among children. Post-traumatic stress disorder (PTSD) is a debilitating chronic mental disorder that can develop following exposure to a traumatic event. Psychopharmacological research in pediatric PTSD is limited. There is some evidence supporting the use of alpha-2 (α2) agonists for symptoms associated with PTSD. This systematic review identified published studies evaluating the effectiveness of α2 agonists in treating PTSD symptoms in children and adolescents. We conducted an extensive literature search on PubMed, MEDLINE, EMBASE, Cochrane Collaboration, and PsycINFO databases for published articles that evaluated the use of α2 agonists (clonidine and guanfacine) for treating symptoms of PTSD in children and adolescents. The study protocol was registered in Prospero (ID: CRD42021273692) and followed the PRISMA guidelines. A total of 10 published articles about clonidine or guanfacine use in PTSD in children and adolescents were identified. Studies found clonidine effective in reducing PTSD symptoms; however, the effects were variable. Clonidine and guanfacine showed effectiveness in treating nightmares, hyperarousal, aggression, and sleep disturbances and reducing re-experiencing, avoidant, and hyperarousal symptom clusters. No randomized, double-blind, placebo-controlled trials were found during the literature search. α2 agonists' effectiveness in treating symptoms associated with PTSD in children and adolescents is preliminary. Future placebo-controlled trials are needed to assess the efficacy and safety of α2 agonists.

New-onset atrial fibrillation among COVID-19 patients: A narrative review

Over the last three years, research has focused on examining cardiac issues arising from coronavirus disease 2019 (COVID-19) infection, including the emergence of new-onset atrial fibrillation (NOAF). Still, no clinical study was conducted on the persistence of this arrhythmia after COVID-19 recovery. Our objective was to compose a narrative review that investigates COVID-19-associated NOAF, emphasizing the evolving pathophysiological mechanisms akin to those suggested for sustaining AF. Given the distinct strategies involved in the persistence of atrial AF and the crucial burden of persistent AF, we aim to underscore the importance of extended follow-up for COVID-19-associated NOAF. A comprehensive search was conducted for articles published between December 2019 and February 11, 2023, focusing on similarities in the pathophysiology of NOAF after COVID-19 and those persisting AF. Also, the latest data on incidence, morbidity-mortality, and management of NOAF in COVID-19 were investigated. Considerable overlaps between the mechanisms of emerging NOAF after COVID-19 infection and persistent AF were observed, mostly involving reactive oxygen pathways. With potential atrial remodeling associated with NOAF in COVID-19 patients, this group of patients might benefit from long-term follow-up and different management. Future cohort studies could help determine long-term outcomes of NOAF after COVID-19.

Artificial Intelligence, Computational Simulations, and Extended Reality in Cardiovascular Interventions

Artificial intelligence, computational simulations, and extended reality, among other 21st century computational technologies, are changing the health care system. To collectively highlight the most recent advances and benefits of artificial intelligence, computational simulations, and extended reality in cardiovascular therapies, we coined the abbreviation AISER. The review particularly focuses on the following applications of AISER: 1) preprocedural planning and clinical decision making; 2) virtual clinical trials, and cardiovascular device research, development, and regulatory approval; and 3) education and training of interventional health care professionals and medical technology innovators. We also discuss the obstacles and constraints associated with the application of AISER technologies, as well as the proposed solutions. Interventional health care professionals, computer scientists, biomedical engineers, experts in bioinformatics and visualization, the device industry, ethics committees, and regulatory agencies are expected to streamline the use of AISER technologies in cardiovascular interventions and medicine in general.

Bartter Syndrome: A Systematic Review of Case Reports and Case Series

Background and Objectives: Bartter syndrome (BS) is a rare group of autosomal-recessive disorders that usually presents with hypokalemic metabolic alkalosis, occasionally with hyponatremia and hypochloremia. The clinical presentation of BS is heterogeneous, with a wide variety of genetic variants. The aim of this systematic review was to examine the available literature and provide an overview of the case reports and case series on BS. Materials and Methods: Case reports/series published from April 2012 to April 2022 were searched through Pubmed, JSTOR, Cochrane, ScienceDirect, and DOAJ. Subsequently, the information was extracted in order to characterize the clinical presentation, laboratory results, treatment options, and follow-up of the patients with BS. Results: Overall, 118 patients, 48 case reports, and 9 case series (n = 70) were identified. Out of these, the majority of patients were male (n = 68). A total of 21 patients were born from consanguineous marriages. Most cases were reported from Asia (73.72%) and Europe (15.25%). In total, 100 BS patients displayed the genetic variants, with most of these being reported as Type III (n = 59), followed by Type II (n = 19), Type I (n = 14), Type IV (n = 7), and only 1 as Type V. The most common symptoms included polyuria, polydipsia, vomiting, and dehydration. Some of the commonly used treatments were indomethacin, potassium chloride supplements, and spironolactone. The length of the follow-up time varied from 1 month to 14 years. Conclusions: Our systematic review was able to summarize the clinical characteristics, presentation, and treatment plans of BS patients. The findings from this review can be effectively applied in the diagnosis and patient management of individuals with BS, rendering it a valuable resource for nephrologists in their routine clinical practice.

ViSHWaS: Violence Study of Healthcare Workers and Systems-a global survey

OBJECTIVE

To provide insights into the nature, risk factors, impact and existing measures for reporting and preventing violence in the healthcare system. The under-reporting of violence against healthcare workers (HCWs) globally highlights the need for increased public awareness and education.

METHODS

The Violence Study of Healthcare Workers and Systems study used a survey questionnaire created using Research Electronic Data Capture (REDCap) forms and distributed from 6 June to 9 August 2022. Logistic regression analysis evaluated violence predictors, including gender, age, years of experience, institution type, respondent profession and night shift frequency. A χ2 test was performed to determine the association between gender and different violence forms.

RESULTS

A total of 5405 responses from 79 countries were analysed. India, the USA and Venezuela were the top three contributors. Female respondents comprised 53%. The majority (45%) fell within the 26-35 age group. Medical students (21%), consultants (20%), residents/fellows (15%) and nurses (10%) constituted highest responders. Nearly 55% HCWs reported firsthand violence experience, and 16% reported violence against their colleagues. Perpetrators were identified as patients or family members in over 50% of cases, while supervisor-incited violence accounted for 16%. Around 80% stated that violence incidence either remained constant or increased during the COVID-19 pandemic. Among HCWs who experienced violence, 55% felt less motivated or more dissatisfied with their jobs afterward, and 25% expressed willingness to quit. Univariate analysis revealed that HCWs aged 26-65 years, nurses, physicians, ancillary staff, those working in public settings, with >1 year of experience, and frequent night shift workers were at significantly higher risk of experiencing violence. These results remained significant in multivariate analysis, except for the 55-65 age group, which lost statistical significance.

CONCLUSION

This global cross-sectional study highlights that a majority of HCWs have experienced violence, and the incidence either increased or remained the same during the COVID-19 pandemic. This has resulted in decreased job satisfaction.

3D reconstruction of coronary artery bifurcations from intravascular ultrasound and angiography

Coronary bifurcation lesions represent a challenging anatomical subset, and the understanding of their 3D anatomy and plaque composition appears to play a key role in devising the optimal stenting strategy. This study proposes a new approach for the 3D reconstruction of coronary bifurcations and plaque materials by combining intravascular ultrasound (IVUS) and angiography. Three patient-specific silicone bifurcation models were 3D reconstructed and compared to micro-computed tomography (µCT) as the gold standard to test the accuracy and reproducibility of the proposed methodology. The clinical feasibility of the method was investigated in three diseased patient-specific bifurcations of varying anatomical complexity. The IVUS-based 3D reconstructed bifurcation models showed high agreement with the µCT reference models, with r2 values ranging from 0.88 to 0.99. The methodology successfully 3D reconstructed all the patient bifurcations, including plaque materials, in less than 60 min. Our proposed method is a simple, time-efficient, and user-friendly tool for accurate 3D reconstruction of coronary artery bifurcations. It can provide valuable information about bifurcation anatomy and plaque burden in the clinical setting, assisting in bifurcation stent planning and education.

Association of Non-Alcoholic Fatty Liver Disease and Metabolic-Associated Fatty Liver Disease with COVID-19-Related Intensive Care Unit Outcomes: A Systematic Review and Meta-Analysis

Background and Objective: The association of non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) with intensive care unit (ICU) admissions and the need for mechanical ventilation and disease severity in COVID-19 patients. Material and Methods: A systematic literature review was conducted on the databases: Cochrane, Embase, PubMed, ScienceDirect, and the Web of Science from January 2019 to June 2022. Studies evaluating MAFLD using laboratory methods, non-invasive imaging, or liver biopsy were included. The study protocol was registered in PROSPERO (ID CRD42022313259), and PRISMA guidelines were followed. The NIH quality assessment tool was used for quality assessment. RevMan version 5.3 software was used for pooled analysis. A sensitivity analysis was performed to assess the result's stability. Results: A total of 37,974 patients from 17 studies were assessed for the association between MAFLD and ICU admission. A total of 3396 COVID-19 patients required ICU admission: 1236 (20.41%) in the MAFLD group and 2160 (6.77%) in the non-MAFLD group. The odds ratio was 1.86 for ICU admission, p = 0.007, and a (95% CI) of [1.18-2.91]. A total of 37,166 patients from 13 studies were included in the need for invasive mechanical ventilation analysis. A total of 1676 patients required mechanical ventilation: 805 in the MAFLD group (14.20% of all MAFLD patients) and 871 patients in the non-MAFLD group (2.76% of all non-MAFLD patients). The odds ratio was 2.05, p = 0.02, and a (95% CI) of [1.12-3.74]. A total of 5286 patients from 14 studies were included in the COVID-19 disease severity analysis. Severe COVID-19 was seen in 1623 patients, with 33.17% (901/2716) of MAFLD patients and 28.09% (722/2570) of non-MAFLD patients having severe disease. The odds ratio was 1.59 for disease severity, p = 0.010, and a (95% CI) of [1.12-2.26]. Conclusions: Our meta-analysis suggests that there are significantly increased odds of ICU admissions, a need for invasive mechanical ventilation, and disease severity in MAFLD patients who acquire COVID-19.

Writing strategies for improving the access of medical literature

When conducting a literature review, medical authors typically search for relevant keywords in bibliographic databases or on search engines like Google. After selecting the most pertinent article based on the title’s relevance and the abstract’s content, they download or purchase the article and cite it in their manuscript. Three major elements influence whether an article will be cited in future manuscripts: the keywords, the title, and the abstract. This indicates that these elements are the “key dissemination tools” for research papers. If these three elements are not determined judiciously by authors, it may adversely affect the manuscript’s retrievability, readability, and citation index, which can negatively impact both the author and the journal. In this article, we share our informed perspective on writing strategies to enhance the searchability and citation of medical articles. These strategies are adopted from the principles of search engine optimization, but they do not aim to cheat or manipulate the search engine. Instead, they adopt a reader-centric content writing methodology that targets well-researched keywords to the readers who are searching for them. Reputable journals, such as Nature and the British Medical Journal, emphasize “online searchability” in their author guidelines. We hope that this article will encourage medical authors to approach manuscript drafting from the perspective of “looking inside-out.” In other words, they should not only draft manuscripts around what they want to convey to fellow researchers but also integrate what the readers want to discover. It is a call-to-action to better understand and engage search engine algorithms, so they yield information in a desired and self-learning manner because the “Cloud” is the new stakeholder.

Association of non-alcoholic fatty liver and metabolic-associated fatty liver with COVID-19 outcomes: A systematic review and meta-analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) are on the rise like any other liver disease, and tend to affect 25% of the United States population. The impact of NAFLD and MAFLD on patients with coronavirus disease 2019 (COVID-19) remains unclear.

AIM

To identify the association of NAFLD and MAFLD with mortality, hospitalization, hospital length of stay, and supplemental oxygen utilization in COVID-19 patients.

METHODS

A systematic review of literature on Cochrane, Embase, PubMed, ScienceDirect, and Web of Science databases was conducted from January 2019 to July 2022. Studies that evaluated NAFLD/MAFLD using laboratory methods, noninvasive imaging, or liver biopsy were included. The study protocol was registered in PROSPERO (ID CRD42022313259) and PRISMA guidelines were followed. The National Institutes of Health quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using software Rev Man version 5.3. The stability of the results was assessed using sensitivity analysis.

RESULTS

Thirty-two studies with 43388 patients were included in the meta-analysis of whom 8538 (20%) patients were observed to have NAFLD. There were 42254 patients from 28 studies included in the mortality analysis. A total of 2008 patients died from COVID-19; 837 (10.52%) in the NAFLD group and 1171 (3.41%) in the non-NAFLD group. The odds ratio (OR) was 1.38 for mortality with a 95% confidence interval (95%CI) = 0.97-1.95 and P = 0.07. A total of 5043 patients from eight studies were included in the hospital length of stay analysis. There were 1318 patients in the NAFLD group and 3725 patients in the non-NAFLD group. A qualitative synthesis showed that the mean difference in hospital length of stay was about 2 d between the NAFLD and non-NAFLD groups with a 95%CI = 0.71-3.27 and P = 0.002. For hospitalization rates, the OR was 3.25 with a 95%CI of 1.73-6.10 and P = 0.0002. For supplemental oxygen utilization, the OR was 2.04 with a 95%CI of 1.17-3.53 and P = 0.01.

CONCLUSION

Our meta-analysis suggests that there are increased odds of hospitalization, longer hospital length of stay, and increased use of supplemental oxygen in NAFLD/MAFLD patients.

Evaluating the Use of CT-Derived Lung Volumes in Donor-Recipient Lung Size Matching for Lung Transplantation in Patients With Interstitial Lung Disease and/or Idiopathic Pulmonary Fibrosis

PURPOSE

This study aims to assess the efficacy of current measurement strategies for lung sizing and the feasibility of future use of computed tomography (CT)-derived lung volumes to predict a donor-recipient lung size match during bilateral lung transplants.

METHODS

We reviewed the data of 62 patients who underwent bilateral lung transplantation for interstitial lung disease and/or idiopathic pulmonary fibrosis from 2018 to 2019. Data for recipients was retrieved from the department's transplant database and medical records, and the donor's data was retrieved from the DonorNet. The data included demographic data, lung heights, measured total lung capacity (TLC) from plethysmography for recipients and estimated TLC for donors, clinical data, and CT-derived lung volumes in both pre- and post-transplant recipients. The post-transplant CT-derived lung volume in recipients was used as a surrogate for donor lung CT volumes due to inadequate or poor donor CT data. Computed tomography-derived lung volumes were calculated using thresholding, region growing, and cutting techniques on Computer-Aided Design and Mimics (Materialise NV, Leuven, Belgium) programs. Preoperative CT-derived lung volumes in recipients were compared with the plethysmography TLC, Frustum Model, and donor-predicted TLC. The ratio of the recipient's pre-and postoperative CT-derived volumes, the ratio of preoperative CT-derived lung volume, and donor-estimated TLC were studied to detect a correlation with 1-year outcomes.

RESULTS

The recipient preoperative CT-derived volume correlated with the recipient preoperative plethysmography TLC (Pearson correlation coefficient [PCC] of 0.688) and with the recipient Frustum model volume (PCC of 0.593). The recipient postoperative CT-derived volume correlated with the recipient's postoperative plethysmography TLC (PCC of 0.651). There was no statistically significant correlation between recipients' CT-derived pre- or postoperative volume with donor-estimated TLC. The ratio of preoperative CT-derived volume to donor-estimated TLC correlated inversely with the length of ventilation (P value = .0031). The ratio of postoperative CT-derived volume to preoperative CT-derived volume correlated inversely with delayed sternal closure (P = .0039). No statistically significant correlations were found in evaluating outcomes related to lung oversizing in the recipient (defined as a postoperative to preoperative CT-derived lung volume ratio of >1.2).

CONCLUSIONS

Generating CT-derived lung volumes is a valid and convenient method for evaluating lung volumes for transplantation in patients with ILD and/or IPF. Donor-estimated TLC should be interpreted carefully. Further studies should derive donor lung volumes from CT scans for a more accurate evaluation of lung size matching.

Guiding Principles for the Conduct of Violence Study of Healthcare Workers and System (ViSHWaS): Insights from a Global Survey

Background Globally many studies have reported on violence faced by healthcare workers. However, there is still a lack of homogeneous data to give us a concrete understanding of the present scenario on a global scale. Conducting a global survey required a robust team organization structure, unique dissemination strategies accounting for the regional limitations, and continual networking to maintain and propagate the pool of survey collaborators and responders. This study aims to describe the strategies that helped carry out a global survey- based study, the lessons learned, and recommendations for future studies.   Methods This cross-sectional survey-based study was based on methodology of the “Hub and Spoke” model with the core team and sub-groups about different regions and managing country leads. The study was conducted across eight weeks from 6th June 2022 to 8th August 2022. The key steps included team organization, strategy formulation for survey dissemination and data collection, launching the project on social media, and conducting a post-survey amongst the collaborators. The Core Team convened weekly via video conference platforms to discuss the modus operandi, including the responsibilities of team members in communicating with HCWs from each country; strategies for data extraction and analysis. A standard message was created for the survey in English, which was spread via text, audio and video messages; the message was tailored according to the target region and population. The language barrier was managed by creating an audio translation or shifting to “an interviewer-administered” questionnaire. Call for leads and collaborators was organized through social media platforms and incentivized by proposing collaborative authorship.   Results A core team of 11 members from 7 countries was assembled, which expanded to 40 country leads from around 110 countries. We also amassed more than 75 regional collaborators who worked to provide feedback and spread the message. The “Violence Study of Healthcare Workers and Systems” (VISHWAS) amassed 5500 responses across the world. A weekly alternating trend in the number of survey responses was observed for eight weeks. Guiding principles garnered through this collaborative project include focusing on 1. Effective team organization, 2. Ensuring external validation of survey tool, 3. Personalized communication, 4. Global networking, 5. Timely communication for maintaining momentum, and 6. Addressing regional limitations. The post-survey analysis showed that WhatsApp messaging was the most common modality used for survey dissemination, followed by in-person meetings and text messaging. The successful techniques were noted to be 1. Direct communication with respondents, 2. Regular progress updates, 3. Responsiveness for regional and country lead’s needs  4. Timely troubleshooting. The most common barriers for the respondents were limitations in language proficiency, technical fallouts, lack of compliance with, and difficulty understanding the questionnaire.   Conclusion In this global survey-based study of more than 5500 responses from over 110 countries, valuable lessons in team management, survey dissemination, and addressing barriers to collaborative research. We thereby recommend incorporating the guiding principles from this study to design future surveys on a global scale.

CARE Score on Chest Radiograph at Diagnosis Predicts Early and Late Outcomes Among Lung Transplant Patients with COVID-19

Purpose

To assess the ability of an objective radiographic scoring system to predict outcomes among lung transplant (LT) patients with Coronavirus disease 2019 (COVID-19).

Methods

We included all LT patients diagnosed with COVID-19 during a one-year period (March 2020 to Feb 2021; n=54; median age: 60, 20-73 years; M:F 37:17) in our program. Patient characteristics and laboratory values during the acute illness were reviewed. Chest radiographs at time of COVID-19 diagnosis were scored by extent of ground-glass opacity and consolidation using the CARE score (0-18 for each lung). The CARE score was calculated using only the allograft in single LT and the average of both lungs in bilateral LT. Primary outcome was six-month survival after COVID-19. Hospital complications and one-month survival were secondary outcomes.

Results

A minority of patients had a clear allograft (CARE=0, n=12, 22.2%) at presentation. The median score was 2 (interquartile range 0.5-4.625), indicating mild abnormalities. Demographics, underlying diagnosis, comorbidities, symptoms, and spirometry changes were not associated with the baseline CARE score. Baseline CARE score >5 was strongly associated with development of respiratory failure (91.7% vs 35.7%; OR, 95% CI: 19.8, 2.3-168.7; p=0.001), ICU admission (p<0.001), need for ventilator support (p<0.001), and one-month mortality (41.7% vs 2.4%; OR, 95% CI: 29.4, 2.96-333.3; p=0.001). Overall six-month survival was 81.5%. The CARE score was significantly higher among non-survivors (7.7±4.1 vs 2.2±2.7; p=0.002). Patients with a CARE score>5 at diagnosis were significantly less likely to survive at six-month follow-up (41.7%.vs 92.3%; p<0.001). The CARE score had an excellent area under the curve (86.8%, 74.4%-99.2%; p<0.001) on the Receiver operating characteristic curve for predicting six-month survival after COVID-19.

Conclusion

The CARE score at time of COVID-19 diagnosis provides useful prognostic information among patients with LT.

Characteristics and Outcomes Among Patients With Early Venous Thromboembolic Events After Lung Transplant

BACKGROUND

Despite several previous studies reporting a high frequency of venous thromboembolism (VTE) after lung transplant (LT), few actionable risk factors have been identified. There are limited data regarding the practice patterns of anticoagulation use among patients with LT.

METHODS

All adult patients with single or bilateral LT between 2012 and 2016 were included (n = 324; mean age, 56.3 ± 13.3 years; male, 61.1%). Demographic, clinical, and laboratory variables before and after LT were recorded. Follow-up data included survival up to 3 years post-transplant. Development of VTE during the first 30 days after LT was the primary outcome variable.

RESULTS

The overall incidence of VTE during the first 30 days after LT was 29.9% (n = 97), among which the majority were upper extremity thromboses. Female sex, personal history of VTE, hospitalization at the time of transplant, and use of 3 or more central venous catheters during index hospitalization were independently associated with VTE. The use of anticoagulants was independently associated with a reduced risk of VTE. Despite increased morbidity, the development of VTE was not associated with worse post-transplant survival.

CONCLUSIONS

A significant proportion of patients develop early VTE after LT. Limiting the number of central catheters to < 3 during the post-transplant period, along with the early institution of thromboprophylaxis, may lower the risk of VTE.

Predictors of requirement of mechanical ventilation in patients with chronic obstructive pulmonary disease with acute respiratory failure

Background and Objective:

Acute exacerbation of chronic obstructive pulmonary disease (COPD) leads to increased morbidity, mortality and requirement of invasive mechanical ventilation (MV). The aim of this study was to identify predictors of need of MV in these patients.

Materials and Methods:

Clinical symptomatology, demographic profile, biochemical parameters including renal functions, liver functions and acid base parameters, and acute physiology and chronic health evaluation II (APACHE II) score at the time of admission were recorded in 100 patients of COPD exacerbation. Various parameters were compared between patients in whom MV was required with those managed with medical therapy.

Results:

MV was required in 73% of the patients. Parameters found to be independent predictors of need of MV were: Admission APACHE-II score ≥ 11.5 {adjusted odds ratio (OR) [95% confidence interval (CI)]: 1.42 [1.08-1.86]; P = 0.012}, first day pH ≤ 7.28 (adjusted OR [95% CI]: 1.09 [1.02-1.15]; P = 0.008), first day PaCO₂ ≥ 68.6 mmHg (adjusted OR [95% CI]: 1.09 [1.02-1.15]; P = 0.004) and worse premorbid functional status (adjusted OR [95% CI]: 17.01 [1.95-148.68]; P = 0.01).

Conclusions:

Underlying disease severity as assessed by premorbid functional status and APACHE-II score, and the acuity of respiratory system decompensation as assessed by the admitting arterial pH and PaCO₂, are independent predictors of need of MV in patients with exacerbation of COPD.

Validation of the modified Berlin questionnaire to identify patients at risk for the obstructive sleep apnoea syndrome

BACKGROUND & OBJECTIVES

Awareness regarding obstructive sleep apnoea (OSA) among general public as well as practicing physicians is low in India. The present study was undertaken to test the utility of modified Berlin questionnaire for risk categorization of OSA in Indian setting.

METHODS

The modified Berlin questionnaire was administered in 180 middle aged adults (of 320 screened), of whom, 104 underwent overnight polysomnograhy, in a cross-sectional study at a tertiary care, referral center in north India. Questionnaire addressed the presence of frequency of snoring, wake time sleepiness, fatigue, obesity and hypertension. Subjects with persistent and frequent symptoms in any two of these three domains were considered in high risk category for obstructive sleep apnoea. Overnight polysomnograhy was performed to measure apnoea and hypopnoea index (AHI).

RESULTS

Questions about the symptoms demonstrated internal consistency (Cronbach alpha correlations 0.92-0.96). Of the 180 respondents to the screening questions, 80 were in the high risk and the rest were in low risk group. For 104 subjects who underwent polysomnograhy, risk grouping was useful in prediction of AHI. High risk category predicted an AHI >5 with a sensitivity of 86 per cent, specificity of 95 per cent, positive and negative predictive values of 96 and 82 per cent respectively. These results were comparable to Berlin questionnaire study done in the western population for validation.

INTERPRETATION & CONCLUSION

On the basis of the findings of present study it is concluded that administration of modified Berlin questionnaire prior to a polysomnography study can identify high risk subjects and can thus avoid unnecessary polysomnography studies especially in resource-limited settings. To identify subjects at risk for OSA syndrome in general population, this questionnaire can be applied. However, the findings of the present study need to be confirmed further in a large number of subjects in a community-based setting.

Predictors of development and outcome in patients with acute respiratory distress syndrome due to tuberculosis

OBJECTIVE

To study the predictors of development and determinants of outcome in patients with acute respiratory distress syndrome (ARDS) due to tuberculosis (TB).

METHODS

Retrospective case-control study of demographic, clinical and laboratory data of hospitalised adult patients with active TB.

RESULTS

Of 2733 TB patients treated during 1980-2003, 29 (1.06%; 1.21 patients/year; mean age 31.6 +/- 10.9 years; 16 males) developed ARDS (cases). Seven had pulmonary TB and 22 had miliary TB (MTB); 298 (mean age 32.0 +/- 14.2 years; 110 males) who did not develop ARDS constituted controls. Presence of MTB (OR 4.6, 95%CI 1.2-17.8; P = 0.02), duration of illness beyond 30 days at presentation (OR 177.9, 95%CI 39-811.7; P < 0.001), absolute lymphocyte count < 1625/ mm3 (OR 4.5, 95%CI 1.1-19.3; P = 0.04) and serum ALT > 100 IU (OR 15.7, 95%CI 3.0-81.1, P < 0.001) were independent predictors of ARDS development. Twelve cases died (41.4%). Patients with APACHE II score >18; those with APACHE II score <18 in the presence of hyponatraemia and PaO2/FIO2 ratio <108.5 were likely to die.

CONCLUSIONS

In patients with TB, prolonged illness, MTB, absolute lymphocytopaenia and elevated ALT are independently associated with ARDS development. APACHE II score, serum sodium and PaO2/FIO2 ratio are determinants of outcome.

A stepped approach for prediction of obstructive sleep apnea in overtly asymptomatic obese subjects: a hospital based study

BACKGROUND AND PURPOSE

Prevalence of obstructive sleep apnea (OSA) is high in obese subjects, many of whom may not be overtly symptomatic. Polysomnography (PSG) is a costly and time-consuming investigation. Since it is not feasible to subject all obese individuals to PSG, it is useful to define predictors of OSA among these subjects.

PATIENTS AND METHODS

One hundred and eighteen obese subjects [body mass index (BMI)> or =25 kg/m(2)] presenting to the hospital with non-sleep related complaints were included, of which 53 subjects with PSG evidence of OSA [apnea-hypopnea index (AHI)> or =15/h] were defined as cases and 65 subjects without any evidence of OSA (AHI<15/h) were defined as controls. Anthropometry, biochemical investigations, blood gas analysis, pulmonary function tests, and PSG were performed for all subjects.

RESULTS

Waist hip ratio (WHR) (as percentage of a standard) [odds ratio (95% CI): 1.07 (1.00-1.14); P = 0.049] male gender [odds ratio (95% CI): 3.97 (0.99-15.81); P = 0.046] and neck circumference (NC) [odds ratio (95% CI): 1.23 (1.03-1.47); P = 0.023] were found to be independent predictors of OSA. Overnight oxygen desaturation data were evaluated in patients selected as having OSA on the basis of these clinical markers, and the best cut-off for level of desaturation (10%) was defined. The stepped approach had a specificity, sensitivity, positive and negative predictive value of 89.2, 88.5, 86.8 and 90.6%, respectively, for the diagnosis of OSA.

CONCLUSIONS

Male gender, WHR and NC are independent predictors of OSA in overtly asymptomatic obese subjects. A stepped approach to diagnose OSA should be used, as it is accurate and cost-effective.

Wegener's granulomatosis: an isolated lung mass responding to antituberculosis therapy and atypical course

We describe an unusual case of Wegener's granulomatosis (WG), in a middle aged, non-smoking female who presented with a lung mass with constitutional symptoms. FNABC from mass revealed a single ill-defined granuloma without necrosis. There was a definite clinical and radiological response to anti-tuberculosis treatment. She was later found to have another mass lesion in nasopharynx. ANCA was negative initially but became positive once disease flare up occurred. Multisystem involvement with clinical features of vasculitis were seen during the flare up and resulted in a fatal outcome. Unusual features and literature on this entity is discussed.