Preventing unrecognized deterioration & improving outcomes of critically ill patients using the National Early Warning Score 2 in a high dependency unit in Bangladesh: A quality improvement project

This Quality Improvement Project (QIP) aimed to assess the acceptability and utility of the National Early Warning Score 2 (NEWS2) in a Bangladeshi level-2 care setting. All nurses and physicians were trained on NEWS2 scores and a proper response before starting the QIP. Utilization of NEWS2 and patient outcome were documented and analyzed. Acceptability was acknowledged by increase in utilization, and utility by reduction in unrecognized deterioration of patients. The modified NEWS2 was well adopted and utilized by the nursing staff. There was a statistically significant reduction in unrecognized deterioration leading to cardiac arrest and the need for transfer to the Intensive Care Unit after implementation of NEWS2. With adequate training, motivation and appropriate modification, NEWS2 can become a well-accepted, widely adopted and realistic bedside monitoring tool in resource-limited settings like Bangladesh.

Dynamic antibody response in SARS-CoV-2 infected patients and COVID-19 vaccine recipients alongside vaccine effectiveness in comorbid and multimorbid groups

Objectives

Underlying medical conditions are critical risk factors for COVID-19 susceptibility and its rapid clinical manifestation. Therefore, the preexisting burden of non-communicable diseases (NCDs) makes the preparedness for COVID-19 more challenging for low- and middle-income countries (LMICs). These countries have relied on vaccination campaigns as an effective measure to tackle COVID-19. In this study, we investigated the impact of comorbidities on humoral antibody responses against the specific receptor-binding domain (RBD) of SARS-CoV2.

Methods

A total of 1005 patients were selected for the SARS-CoV-2 specific immunoglobulin G (IgG1, IgG2, IgG3, and IgG4 subclasses) and total antibody (TAb) tests (IgG and IgM), of which 912 serum samples were ultimately selected based on the specimen cutoff analyte value. Patients with multimorbidity (N = 60) were recruited for follow-up studies from the initial cohort, and their immune response (IgG and TAb) was measured at multiple time points after the second dose of vaccination. Siemens Dimension Vista SARS-CoV-2 IgG (CV2G) and SARS-CoV-2 TAb assay (CV2T) were used to carry out the serology test.

Results

Out of a total of 912 participants, vaccinated individuals (N = 711) had detectable antibody responses up to 7-8 months. The synergistic effect of natural infection and vaccine response was also studied. Participants with breakthrough infections (N = 49) mounted a greater antibody response compared to individuals with normal vaccination response (N = 397) and those who were naturally infected before receiving the second dose of vaccine (N = 132). Investigation of the impact of comorbidities revealed that diabetes mellitus (DM) (N = 117) and kidney disease (N = 50) had a significant negative impact on the decline of the humoral antibody response against SARS-CoV-2. IgG and TAb declined more rapidly in diabetic and kidney disease patients compared to the other four comorbid groups. Follow-up studies demonstrated that antibody response rapidly declined within 4 months after receiving the second dose.

Conclusion

The generalized immunization schedule for COVID-19 needs to be adjusted for high-risk comorbid groups, and a booster dose must be administered early within 4 months after receiving the second dose.

Spontaneous bilateral perirenal and splenic haematoma in childhood onset polyarteritis nodosa

Spontaneous bilateral perirenal haematoma, as well as splenic haematoma, are rare occasions in polyarteritis nodosa (PAN). We report a case of a young man, who suffered from various typical and atypical manifestations of PAN since childhood. The diagnosis was delayed due to symptoms mimicking with other clinical conditions. Finally, the diagnosis was confirmed when presented with perirenal and splenic haematoma and was managed successfully.

Spontaneous calf haematoma in severe dengue

We report a case of spontaneous calf muscle haematoma, formed during the recovery phase of dengue haemorrhagic fever, which, to the best of our knowledge, has never been encountered before. A 45-year-old man presented with features of severe dengue and got admitted to our intensive care unit. He was treated with intravenous fluid therapy and supportive measures, and gradually improved, initially. However, during the recovery phase, he suddenly developed painful left calf, which was found tender, hot and swollen on physical examination. Colour Doppler ultrasound revealed left calf haematoma. As the patient rapidly developed local compartmental syndrome, surgical evacuation of the haematoma followed by urgent fasciotomy was performed. He recovered without further complication and was discharged home. At follow-up after 2 months, he remained well.

Expanded dengue syndrome: three concomitant uncommon presentations in the same patient

We report a case of expanded dengue syndrome, where three uncommon presentations occurred concomitantly. A patient with dengue haemorrhagic fever presented initially with acute acalculous cholecystitis along with acute pancreatitis, but later on, during resolution of pancreatitis and cholecystitis, developed pancytopenia, most likely due to haemophagocytic syndrome. Such presentations, besides being rare themselves, have not been reported to occur concomitantly, in the same patient, during the same disease process.

Acute arsenic poisoning diagnosed late

Acute arsenicosis, although having a ‘historical’ background, is not common in our times. This report describes a case of acute arsenic poisoning, missed initially due to its gastroenteritis-like presentation, but suspected and confirmed much later, when the patient sought medical help for delayed complications after about 2 months.

Subsequent pancreatitis and haemothorax in a patient of expanded dengue syndrome

We report a case of expanded dengue syndrome, where two different presentations occurred subsequently. A patient of dengue haemorrhagic fever initially was admitted with acute pancreatitis, complicated with left pancreatic effusion, but later on, during resolution of pancreatitis and effusion, developed spontaneous right haemothorax. Such presentations, besides being rare themselves, have not been reported to occur subsequently, in the same patient, during the same disease process.

Predilection of zonal involvement and pattern of opacities in chest x-ray in post primary pulmonary tuberculosis

A cross sectional analysis of chest radiograph was performed in 100 patients with tuberculosis to observe the recent trends of radiographic presentation. The study was done from April to December, 2009, in Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh. The chest x-ray findings were analyzed and zonal involvement and pattern of opacities were categorized and compared. Majority of patients (45%) showed involvement of the upper zone. Dominating lesion was consolidation (25%). Most of the patients were between 15-40 years. Forty-four percent patients were sputum positive for Acid Fast Bacilli and cavitation was the dominant lesion among them. Chest x-ray of patients with post primary tuberculosis shows involvement predominantly in the upper zone of lung. The most common opacity was consolidation. This correlates with different studies done over different population.