Demographic and Clinical Features Associated with in-Hospital Mortality in Egyptian COVID-19 Patients: A Retrospective Cohort Study

Aim: We evaluated in this study the demographic and clinical characteristics of COVID-19 disease in Egyptian population with special consideration for its mortality predictors. Methods: 8162 participants (mean age 48.7±17.3 years,54.5% males) with RT-PCR positive COVID-19 were included. The electronic medical records were reviewed for demographic, clinical, laboratory, and radiologic features. The primary outcome was the in-hospital mortality rate. Results: The in-hospital mortality was 11.2%. There was a statistically significant strong association of in-hospital mortality with age >60 years old (OR:4.7; 95% CI 4.1-5.4;p<0.001), diabetes mellitus (OR:4.6; 95% CI 3.99-5.32;p<0.001), hypertension (OR:3.9; 95% CI 3.4-4.5;p<0.001), coronary artery disease (OR:2.7; 95% CI 2.2-3.2;p<0.001), chronic obstructive pulmonary disease (OR:2.1; 95% CI 1.7-2.5;p<0.001), chronic kidney disease (OR:4.8; 95% CI 3.9-5.9;p<0.001), malignancy (OR:3.7; 95% CI 2.3-5.75;p<0.001), neutrophil-lymphocyte ratio >3.1 (OR:6.4; 95% CI 4.4-9.5;P< 0.001), and ground glass opacities (GGOs) in CT chest (OR:3.5; 95% CI 2.84-4.4;P<0.001), respectively. There was a statistically significant moderate association of in-hospital mortality with male gender (OR:1.6; 95% CI 1.38-1.83;p<0.001) and smoking (OR:1.6; 95% CI 1.3-1.9;p<0.001). GGOs was reported as the most common CT finding (occurred in 73.1% of the study participants). Conclusion: This multicenter, retrospective study ascertained the higher in-hospital mortality rate in Egyptian COVID-19 patients with different comorbidities.

A minimally interactive and reproducible method for abdominal aortic aneurysm quantification in 3D ultrasound and computed tomography with implicit template deformations

The maximum diameter of abdominal aortic aneurysm (AAA) is a key quantification parameter for disease assessment. Although it is routinely measured on 2D-ultrasound images, using a volumetric approach is expected to improve measurement reproducibility. In this work, 3D-ultrasound or computed tomography imaging of patients with AAA was combined with a minimally interactive 3D segmentation based on implicit template deformation. Segmentation usability and reproducibility were evaluated on 81 patients, showing a mean measurement time of [2;8]min per case, and Dice coefficients of 0.87±0.12 for 3D-US and 0.81±0.08 for CT. Quantification parameters included a diameter measurement from 3D-US and CT volumes with respective confidence intervals of 0.51 [-2.5;3.52]mm and 1.00 [-1.68;3.67]mm. Additional volume measurements showed confidence intervals of 0.91 [-4.17;5.99]ml for 3D-US and 4.10 [-4.11;12.30]ml for CT.

National surveillance of health care-associated infections in Egypt: Developing a sustainable program in a resource-limited country

BACKGROUND

Health care-associated infections (HAIs) are a major global public health concern. The lack of surveillance systems in developing countries leads to an underestimation of the global burden of HAI. We describe the process of developing a national HAI surveillance program and the magnitude of HAI rates in Egypt.

METHODS

The detailed process of implementation of a national HAI surveillance program is described. A 3-phase surveillance approach was implemented in intensive care units (ICUs). This article focuses on results from the phase 2 surveillance. Standard surveillance definitions were used, clinical samples were processed by the hospital laboratories, and results were confirmed by a reference laboratory.

RESULTS

Ninety-one ICUs in 28 hospitals contributed to 474,544 patient days and 2,688 HAIs. Of these, 30% were bloodstream infections, 29% were surgical site infections, 26% were pneumonia, and 15% were urinary tract infections. Ventilator-associated pneumonia had the highest incidence of device-associated infections (4.3/1,000 ventilator days). The most common pathogens reported were Klebsiella spp (28.7%) and Acinetobacter spp (13.7%). Of the Acinetobacter spp, 92.8% (157/169) were multidrug resistant, whereas 42.5% (151/355) of the Klebsiella spp and 54% (47/87) of Escherichia coli were extended-spectrum β-lactamase producers.

CONCLUSIONS

Implementation of a sustainable surveillance system in a resource-limited country was possible following a stepwise approach with continuous evaluation. Enhancing infection prevention and control programs should be an infection control priority in Egypt.

Antimicrobial stewardship to optimize the use of antimicrobials for surgical prophylaxis in Egypt: A multicenter pilot intervention study

OBJECTIVE

To measure the impact of an antimicrobial stewardship (AMS) program on the use of antibiotics for surgical prophylaxis at acute care hospitals in Egypt.

METHODS

This was a before-and-after intervention study conducted in 5 tertiary, acute-care surgical hospitals. The baseline, intervention, and follow-up periods were 3, 6, and 3 months, respectively. The impact of the intervention was measured by preintervention and postintervention surveys for surgical patients with clean and clean-contaminated wounds. Information was collected on demographic characteristics and antibiotic use. The intervention focused mainly on educating surgical staff on the optimal timing and duration of antibiotics used for surgical prophylaxis. Only 3 hospitals identified a surgeon to audit antibiotic surgical prescriptions. The primary outcome measures were the percentages of surgical patients receiving optimal timing and duration of surgical prophylaxis.

RESULTS

Data were collected for 745 patients before the intervention and for 558 patients after the intervention. The optimal timing of the first dose improved significantly in 3 hospitals, increasing from 6.7% to 38.7% (P < .01), from 2.6% to 15.2% (P < .01), and from 0% to 11% (P < .01). All hospitals showed a significant rise in the optimal duration of surgical prophylaxis, with an overall increase of 3%-28% (P < .01). Days of therapy per 1000 patient-days were decreased significantly in hospitals A, B, C, and D, with no change in hospital E.

CONCLUSIONS

An AMS program focusing on education supported by auditing and feedback can have a significant impact on optimizing antibiotic use in surgical prophylaxis practices.

Olanzapine versus placebo for out-patients with anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) is a serious psychiatric illness associated with significant morbidity and mortality. There is little empirical support for specific treatments and new approaches are sorely needed. This two-site study aimed to determine whether olanzapine is superior to placebo in increasing body mass index (BMI) and improving psychological symptoms in out-patients with AN.

METHOD

A total of 23 individuals with AN were randomly assigned in double-blind fashion to receive olanzapine or placebo for 8 weeks together with medication management sessions that emphasized compliance. Weight, other physical assessments and measures of psychopathology were collected.

RESULTS

End-of-treatment BMI, with initial BMI as a covariate, was significantly greater in the group receiving olanzapine [F(1, 20)=6.64, p=0.018]. Psychological symptoms improved in both groups, but there were no statistically significant group differences. Of the 23 participants, 17 (74%) completed the 8-week trial. Participants tolerated the medication well with sedation being the only frequent side effect and no adverse metabolic effects were noted.

CONCLUSIONS

This small study suggests that olanzapine is generally well tolerated by, and may provide more benefit than placebo for out-patients with AN. Further study is indicated to determine whether olanzapine may affect psychological symptoms in addition to BMI.

The slippery slope: prediction of successful weight maintenance in anorexia nervosa

BACKGROUND

Previous research has found that many patients with anorexia nervosa (AN) are unable to maintain normal weight after weight restoration. The objective of this study was to identify variables that predicted successful weight maintenance among weight-restored AN patients.

METHOD

Ninety-three patients with AN treated at two sites (Toronto and New York) through in-patient or partial hospitalization achieved a minimally normal weight and were then randomly assigned to receive fluoxetine or placebo along with cognitive behavioral therapy (CBT) for 1 year. Clinical, demographic and psychometric variables were assessed after weight restoration prior to randomization and putative predictors of successful weight maintenance at 6 and 12 months were examined.

RESULTS

The most powerful predictors of weight maintenance at 6 and 12 months following weight restoration were pre-randomization body mass index (BMI) and the rate of weight loss in the first 28 days following randomization. Higher BMI and lower rate of weight loss were associated with greater likelihood of maintaining a normal BMI at 6 and 12 months. An additional predictor of weight maintenance was site; patients in Toronto fared better than those in New York.

CONCLUSIONS

This study found that the best predictors of weight maintenance in weight-restored AN patients over 6 and 12 months were the level of weight restoration at the conclusion of acute treatment and the avoidance of weight loss immediately following intensive treatment. These results suggest that outcome might be improved by achieving a higher BMI during structured treatment programs and on preventing weight loss immediately following discharge from such programs.

Population attributable risk for adverse pregnancy outcomes related to smoking in adolescents and adults

BACKGROUND

Little is known about how population-attributable risks (PAR) for adverse birth outcomes due to smoking differ in adolescent and adult pregnancies.

METHODS

An analysis of community and hospital-based cross-sectional studies in Liverpool was undertaken to estimate the PAR values of low birthweight (LBW), preterm birth, and small for gestational age (SGA) births resulting from pregnancy smoking covering the period between 1983 and 2003. Maternal smoking status and pregnancy outcomes were available for a sample of 12631 women.

RESULTS

The prevalence of maternal pregnancy smoking was 40% in the community sample and 33% in adults and 40% among adolescent pregnancies in the hospital sample. The PAR values (95% CI) associated with LBW, preterm birth and SGA outcomes due to maternal pregnancy smoking in the community sample were 27% (25-30), 13% (11-15) and 25% (23-27), respectively. The PAR values in adults in the hospital sample were 29% (27-31) for LBW, 16% (14-19) for preterm birth and 28% (26-31) for SGA. The corresponding PAR values in adolescents were 39% (34-43), 12% (7-18) and 31% (23-40). The LBW risk attributed to pregnancy smoking in adolescents was significantly higher than for adults (P=0.05).

CONCLUSION

About one-third of LBW, one-quarter of SGA and one-sixth of preterm births could be attributed to maternal smoking during pregnancy. The magnitude of the problem was greater among adolescent pregnancies, among whom a sub-group of mothers with very high risk for adverse birth outcomes due to pregnancy smoking was identified.

An open trial of an intensive summer day treatment program for severely overweight adolescents

This open trial examined the feasibility and usefulness of treating adolescents with a body mass index (BMI) > or =95th percentile in a 6-week day treatment program within a psychiatric outpatient setting. Sixteen adolescents, ages 12-15, attended a 6-week multidisciplinary summer day treatment program. Outcome measures include pre- and post-program assessments of BMI, body fat, laboratory measures, nutritional status, physical activity, mood and eating disorder symptoms, motivation, self-esteem and quality of life. BMI, waist/hip circumferences, blood pressure, heart rate, and body fat did not change significantly from baseline to week 6. Fasting glucose decreased significantly from baseline to week 6, but there were no significant changes in other laboratory measures. The teen-rated feelings subscale of the Peds Quality of Life Scale improved. Self-esteem, as measured by the Rosenberg Self- Esteem Scale, indicated a strong trend towards improvement, and motivation measures also showed a trend for improvement. These findings suggest that a brief, intensive intervention for overweight adolescents may yield meaningful changes in quality of life, self-esteem, and motivation, even in the absence of significant weight loss.

Medication response in the treatment of patients with anorexia nervosa

Anorexia nervosa (AN) is a serious mental disorder, characterized by severely low weight and cognitive distortions about body shape and weight. AN is generally associated with a constellation of psychological symptoms, including depression, anxiety, obsessionality, and ritualistic behaviors. The presence of these associated symptoms, together with the great challenge of treating patients with AN, has led clinicians to try many psychopharmacologic agents in the treatment of these patients, usually to no avail. Investigators have studied a range of agents, but have found little, if any, utility in treating underweight patients with medication. In this article, the authors review the literature regarding medication treatment for patients with AN, propose a theoretical basis for the poor response of these patients to the agents that have been tried, and conclude with recommendations for treatment strategies and additional research that should be pursued to further our understanding of this difficult illness.

The effect of ciprofloxacin on tendon, paratenon, and capsular fibroblast metabolism

The pathologic mechanisms underlying fluoroquinolone-induced tendinopathy are poorly understood. The observed incidence of tendinitis and tendon rupture in patients treated with ciprofloxacin hydrochloride suggests that the fluoroquinolone antibiotics alter tendon fibroblast metabolism. The purpose of this study was to examine the effect of ciprofloxacin on fibroblast metabolism in vitro. Canine Achilles tendon, paratenon, and shoulder capsule specimens were maintained in culture with ciprofloxacin (5, 10, or 50 microg/ml). Fibroblast proliferation, collagen synthesis, proteoglycan synthesis, and matrix-degrading activity were analyzed. Incubation of Achilles tendon, Achilles paratenon, and shoulder capsule fibroblasts with ciprofloxacin resulted in a statistically significant 66% to 68% decrease in cell proliferation compared with control cells at day 3 in culture. Ciprofloxacin caused a statistically significant 36% to 48% decrease in collagen synthesis compared with controls in all fibroblast cultures. Ciprofloxacin caused a statistically significant 14% to 60% decrease in proteoglycan synthesis in all fibroblast cell lines. Compared with unstimulated control fibroblasts, culture media from Achilles tendon, paratenon, and shoulder capsule cells that were exposed to ciprofloxacin demonstrated statistically significant increases in matrix-degrading proteolytic activity after 72 hours in culture. This study demonstrates that ciprofloxacin stimulates matrix-degrading protease activity from fibroblasts and that it exerts an inhibitory effect on fibroblast metabolism. The increase in protease activity and the inhibition of both cell proliferation and the synthesis of matrix ground substance may contribute to the clinically described tendinopathies associated with ciprofloxacin therapy.

Effect of serum and platelet-derived growth factor on chondrocytes grown in collagen gels

In this in vitro study, cell proliferation, viability, and morphology; proteoglycan (PG) synthesis; and gel contraction were assessed over a 15-day period (on days 3, 6, 9, 12, and 15) for mature bovine chondrocytes cultured in collagen gels. The environment within the gel was varied by changing the concentration of fetal bovine serum (1% and 10%) and platelet-derived growth factor-BB (PDGF; 0, 10, 50, 100 ng/ml) within the gel and incubation media. Our results showed that the amount of serum or PDGF added to the gels had no effect on cell viability, with >95% of cells remaining alive throughout the experiment. There was a significant increase in cell number over time in all groups, with a higher rate of cell proliferation in gels containing 10% serum and higher concentrations of PDGF. In addition, the amount of serum significantly affected gel contraction with or without PDGF. Gels containing 10% serum contracted on day 10-12, while none of the gels containing 1% serum contracted over the course of the experiment. The PG content within each gel increased with incubation time only for the gels containing 1% serum, and 10 or 100 ng/ml of PDGF. However, on a per cell basis, there was no change in the PG content with time when only serum was used and a significant decrease in the rate of PG production with the addition of PDGF (9.1-27.8 pgPG/cell/day). Cell morphology was also affected by PDGF, with the cells becoming more spindle shaped. Cell alignment within the gels appeared to be most affected by gel contraction. Collagen gels can act as cell carriers for the purpose of tissue engineering. These gels provide a three-dimensional environment in which chondrocytes can proliferate and produce matrix. We have shown how this environment can be controlled to affect gel contraction, rates of cell growth and PG production, and cellular morphology while maintaining cell viability. This information will be useful in determining the conditions in which chondrocytes can be grown within collagen gels and combined with cytokines to create an ideal tissue construct.

Low levels of transthyretin in the CSF of depressed patients

OBJECTIVE

Transthyretin plays an important role in the transport and distribution of thyroid hormone in the central nervous system (CNS). This study replicated and extended to patients with nonrefractory depressive illness a pilot study indicating that patients with refractory major depression have significantly lower levels of CSF transthyretin than do healthy comparison subjects.

METHOD

Lumbar punctures were performed in drug-free subjects with DSM-III-R major depression (N = 18), DSM-III-R bipolar disorder, depressed phase (N = 1), and healthy comparison subjects (N = 24). CSF concentrations of transthyretin, determined by a quantitative dot-immunobinding assay, of the depressed patients and comparison subjects were compared by analysis of covariance (ANCOVA). The relationship between CSF transthyretin levels and Hamilton Depression Rating Scale scores was determined in a subset of the depressed patients.

RESULTS

CSF concentrations of transthyretin were significantly lower in the depressed patients than in the comparison subjects by ANCOVA. Within the depressed group there was no significant overall correlation between CSF transthyretin levels and Hamilton depression scale scores, but there was a significant inverse correlation in male depressed patients (N = 8) between CSF transthyretin concentrations and Hamilton depression scores.

CONCLUSIONS

Lower CSF transthyretin concentrations in depressed patients may reflect either a stable trait in this population or a state change secondary to depression or other factors. Lower CSF transthyretin concentrations may result in altered CNS thyroid hormone homeostasis. Such alteration could account for certain mood and neurovegetative symptoms of depression and might contribute to failure of standard antidepressant treatment.

Cardiovascular effects of fluoxetine in depressed patients with heart disease

OBJECTIVE

The purpose of this study was to determine the cardiovascular effects of fluoxetine in depressed patients with cardiac disease.

METHOD

Twenty-seven depressed patients (26% of whom were female and whose average age was 73 years) who had congestive heart failure, conduction disease, and/or ventricular arrhythmia were studied in an open medication trial of fluoxetine, up to 60 mg/day, for 7 weeks. The main outcome measures were heart rate and rhythm measured by 24-hour ECG recordings, ejection fraction determined by radionuclide angiography, cardiac conduction intervals, and blood pressure. Baseline values were compared with those at weeks 2 and 7 of fluoxetine treatment. In 60 comparable patients, values of these same cardiovascular measures at baseline and after 3 weeks of treatment with a tricyclic antidepressant, nortriptyline, were also examined.

RESULTS

Fluoxetine induced a statistically significant 6% decrease in heart rate, a 2% increase in supine systolic pressure, and a 7% increase in ejection fraction. There was no effect on cardiac conduction, ventricular arrhythmia, or orthostatic blood pressure. Overall, 4% of the fluoxetine patients had an adverse cardiovascular effect. In contrast, nortriptyline treatment caused a significant increase in heart rate and orthostatic hypotension, and 20% of the nortriptyline-treated patients had an adverse cardiovascular effect.

CONCLUSIONS

In depressed patients with heart disease, fluoxetine treatment was not associated with the cardiovascular effects documented for the tricyclic antidepressants or with significant adverse cardiac events. However, limited conclusions about fluoxetine's cardiovascular effects and safety can be drawn from this study of only 27 patients monitored for 7 weeks.

Does fluoxetine augment the inpatient treatment of anorexia nervosa?

OBJECTIVE

While pharmacological interventions are of established utility in bulimia nervosa, medications have no clear role in the treatment of anorexia nervosa. Because patients with anorexia nervosa frequently exhibit mood disturbances and symptoms of obsessive-compulsive disorder, the authors tested the utility of fluoxetine in the treatment of women participating in an inpatient program for anorexia nervosa.

METHOD

The authors conducted a randomized, placebo-controlled, double-blind, 7-week study of fluoxetine at a target daily dose of 60 mg in 31 women with anorexia nervosa receiving treatment for their eating disorder on a clinical research unit. Body weight and measures of eating behavior and psychological state were obtained at baseline and at termination.

RESULTS

There were no significant differences in clinical outcome on any measure between patients receiving fluoxetine and patients receiving placebo.

CONCLUSIONS

Fluoxetine does not appear to add significant benefit to the inpatient treatment of anorexia nervosa.

Comparative efficacy of selective serotonin reuptake inhibitors and tricyclics in the treatment of melancholia

OBJECTIVE

The popularity of selective serotonin reuptake inhibitors stems from their apparent efficacy for numerous disorders and their favorable side effect profile. However, several studies have suggested that selective serotonin reuptake inhibitors may be relatively ineffective for treating melancholia. The objective of this study was to compare the responses to fluoxetine and nortriptyline of older patients with both severe depression and heart disease.

METHOD

The outcome of 22 hospitalized patients with unipolar depression and heart disease who were treated with fluoxetine was compared to the outcome of 42 comparable patients treated with nortriptyline. The average age of the fluoxetine group was 73 years, and their mean pretreatment score on the Hamilton Depression Rating Scale was 26; the average age of the nortriptyline group was 70, and their mean pretreatment Hamilton score was 28.

RESULTS

Of the 42 nortriptyline-treated patients, 28 were responders, six were nonresponders, and eight dropped out. The intent-to-treat response rate was 67% (28 of 42), and the response rate of the melancholic patients who completed the nortriptyline trial was 83% (20 of 24). Of the 22 fluoxetine-treated patients, five were responders, 13 were nonresponders, and four dropped out. The intent-to-treat response rate was 23% (five of 22), and the response rate of the melancholic patients who completed the fluoxetine trial was 10% (one of 10).

CONCLUSIONS

Fluoxetine appears to be significantly less effective than nortriptyline for treating hospitalized elderly patients with unipolar major affective disorder, especially those with the melancholic subtype and concurrent cardiovascular disease.

Laryngeal lymphoscintigraphy

A method of studying lymphatic drainage of the larynx was undertaken using radioactive colloids. Sites of injection were the true and false cords, aryepiglottic folds, anterior and posterior commissure, epiglottis and arytenoid. The patient was then scanned with the gamma camera 3 to 5 hours and again 24 hours post injection. Thirty-six patients were injected and results were recorded as to previous X-ray therapy, nodal activity post scanning, ipsilateral or contralateral and distant spread, and the type of radioactive particle--99mTc labeled sulfur colloid, 99mTc microalbumin (200-800 nm diameter), and 99mTc minimicroalbumin (less than 50 nm diameter). The three radiopharmaceuticals gave similar results. Previous X-ray therapy did not alter lymphatic drainage. Of 36 patients, 23 showed nodal activity on scintiscanning: none showed any axillary nor mediastinal activity.