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Acute respiratory failure (ARF) strikes an estimated two million people in the United States each year, with care exceeding US$50 billion. The hallmark of ARF is a heterogeneous injury, with normal tissue intermingled with a large volume of low compliance and collapsed tissue. Mechanical ventilation is necessary to oxygenate and ventilate patients with ARF, but if set inappropriately, it can cause an unintended ventilator-induced lung injury (VILI). The mechanism of VILI is believed to be overdistension of the remaining normal tissue known as the 'baby' lung, causing volutrauma, repetitive collapse and reopening of lung tissue with each breath, causing atelectrauma, and inflammation secondary to this mechanical damage, causing biotrauma. To avoid VILI, extracorporeal membrane oxygenation (ECMO) can temporally replace the pulmonary function of gas exchange without requiring high tidal volumes (VT) or airway pressures. In theory, the lower VT and airway pressure will minimize all three VILI mechanisms, allowing the lung to 'rest' and heal in the collapsed state. The optimal method of mechanical ventilation for the patient on ECMO is unknown. The ARDSNetwork Acute Respiratory Management Approach (ARMA) is a Rest Lung Approach (RLA) that attempts to reduce the excessive stress and strain on the remaining normal lung tissue and buys time for the lung to heal in the collapsed state. Theoretically, excessive tissue stress and strain can also be avoided if the lung is fully open, as long as the alveolar re-collapse is prevented during expiration, an approach known as the Open Lung Approach (OLA). A third lung-protective strategy is the Stabilize Lung Approach (SLA), in which the lung is initially stabilized and gradually reopened over time. This review will analyze the physiologic efficacy and pathophysiologic potential of the above lung-protective approaches. [ABSTRACT FROM AUTHOR]

Simple Summary: Glucagon-like peptide-1 receptor agonists are medications widely used for treating obesity and diabetes. While their metabolic benefits are well established, their potential impact on cancer risk remains unclear. This nationwide study of over 1.1 million patients examined how these medications affect cancer risk in people with obesity. Our research revealed that these drugs, particularly semaglutide, significantly reduced the risk of various cancers, though effects varied by specific medication type. These findings suggest that these medications may offer dual benefits in treating obesity while potentially reducing cancer risk, opening new possibilities for preventive medicine and personalized treatment approaches. Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have demonstrated significant efficacy in obesity treatment beyond their original development for type-2 diabetes management. This comprehensive study investigated the relationship between GLP-1RA use and cancer incidence in individuals with obesity across a 5-year follow-up period. Methods: We conducted a large-scale cohort study using the TriNetX US Collaborative Network database (2013–2023) examining adult patients with obesity. The study utilized propensity score matching to pair GLP-1RA-treated patients with controls (1:1) using the nearest neighbor method. Cancer incidence served as the primary outcome measure over the 5-year follow-up, with subgroup analyses considering individual GLP-1RA agents, patient sex, and BMI categories. Results: Analysis revealed significant cancer-risk reductions associated with GLP-1RA use across multiple cancer types compared to matched controls. Notable risk reductions were observed in gastrointestinal (HR 0.67, 95% CI 0.59–0.75), skin (HR 0.62, 95% CI 0.55–0.70), breast (HR 0.72, 95% CI 0.64–0.82), female genital (HR 0.61, 95% CI 0.53–0.71), prostate (HR 0.68, 95% CI 0.58–0.80), and lymphoid/hematopoietic cancers (HR 0.69, 95% CI 0.60–0.80). Semaglutide demonstrated superior protective effects, particularly in gastrointestinal cancers (HR 0.45, 95% CI 0.37–0.53). Conversely, liraglutide showed increased risks for thyroid (HR 1.70, 95% CI 1.03–2.82) and respiratory cancers (HR 1.62, 95% CI 1.13–2.32). Conclusions: This research provides compelling evidence for GLP-1RA's potential role in cancer-risk reduction, with semaglutide showing particularly promising results. The differential effects observed among GLP-1RA agents emphasize the importance of personalized medicine approaches. These findings suggest significant implications for clinical practice and future research in both obesity management and cancer prevention. [ABSTRACT FROM AUTHOR]

Background: Roux-en-Y gastric bypass (RYGB) surgery is an effective treatment for obesity. However, the incidence and long-term risk of hypoglycemia after surgery in patients without diabetes remains unclear. This study aimed to investigate the prevalence of hypoglycemia following RYGB surgery in patients with obesity and without diabetes. Methods: A retrospective cohort study was conducted using the TriNetX database. The study population included 15,085 patients with obesity (BMI ≥ 30 kg/m2) who underwent RYGB surgery and 3,200,074 non-surgical controls, all without a history of diabetes or GLP-1 receptor agonist use. Propensity score matching was performed to balance baseline characteristics. The primary outcome was the incidence of hypoglycemia, defined by ICD-10-CM codes or laboratory values (glucose ≤ 70 mg/dL). Cox regression analysis was employed to calculate hazard ratios (HR) and 95% confidence intervals (CI). Results: In the overall study population, the risk of hypoglycemia was significantly higher in the RYGB group (18.70%, n = 2,810) compared to the control group (3.80%, n = 120,923; HR 4.3, 95% CI 4.14–4.46, p < 0.001). After propensity score matching (n = 14,916 per group), RYGB patients maintained an elevated risk (18.70%, n = 2,795) compared to matched controls (5.0%, n = 749; HR 3.7, 95% CI 3.44–4.05, p < 0.001). Time-series analysis revealed consistently higher hypoglycemia risk in the RYGB group, with hazard ratios ranging from 5.37 (95% CI 4.09–7.03) at 1 week to 3.75 (95% CI 3.45–4.06) at 10 years post-surgery (all p < 0.001). Subgroup analysis of RYGB patients who developed hypoglycemia showed a 30-day hospitalization rate of 21.3% and a mortality rate of 0.71%. Conclusion: RYGB surgery is associated with a significantly increased risk of hypoglycemia in patients with obesity and without diabetes, both in the short-term and long-term follow-up. These findings underscore the importance of monitoring and managing hypoglycemia in patients undergoing RYGB surgery, even in the absence of preexisting diabetes. [ABSTRACT FROM AUTHOR]

Background/Objectives: The effect of glucagon-like peptide-1 receptor (GLP-1R) agonists on calcium homeostasis is poorly understood. This study aimed to investigate the association between GLP-1R agonist use and the risk of hypocalcemia and/or hypercalcemia, as well as other clinical outcomes. Methods: A retrospective cohort study used de-identified patient data from the TriNetX Global Collaborative Network, including 15,655 adult patients prescribed GLP-1R agonists and 15,655 propensity-matched controls. Outcomes included hypocalcemia, hypercalcemia, emergency visits, hospitalizations, cardiovascular events, and all-cause mortality. Results: GLP-1R agonist use was associated with a reduced risk of hypocalcemia (2.7% vs. 5.5%, RR 0.49, 95% CI: 0.44–0.55) but an increased risk of hypercalcemia (2.3% vs. 1.1%, RR 2.02, 95% CI: 1.69–2.42). The effect on hypocalcemia was most pronounced during the first six months of treatment. Among individual agents, tirzepatide showed the most pronounced effect, reducing hypocalcemia risk by 63% while increasing hypercalcemia risk by 85%. Semaglutide demonstrated similar effects, while dulaglutide and liraglutide showed modest effects. Furthermore, GLP-1R agonist use was associated with reduced risks of emergency visits (RR 0.57, 95% CI: 0.54–0.60), hospitalizations (RR 0.40, 95% CI: 0.36–0.44), cardiovascular events, and all-cause mortality (HR 0.27, 95% CI: 0.21–0.36). Conclusions: GLP-1R agonists exhibit a complex influence on calcium homeostasis, reducing hypocalcemia risk while increasing hypercalcemia risk. Beyond calcium regulation, these medications significantly reduce healthcare utilization, improve cardiovascular outcomes, and decrease mortality. Further research is needed to elucidate the mechanisms behind the differential effects of individual GLP-1R agonists, particularly tirzepatide, to optimize personalized treatment approaches and long-term safety. [ABSTRACT FROM AUTHOR]

Background: Early oral feeding has been previously postulated to contribute to developing postoperative complications following head and neck reconstructive surgeries using free flaps. This study assessed the association between the timing of oral feeding (early vs. late) and postoperative complications and length of hospital stay among these patients. Method: PubMed, Scopus, Cochrane, and Web of Science were searched using terms such as "oral feeding" and "head or neck cancer." We utilized RevMan software version 5.4 for the analysis. The study defined early oral feeding as feeding within 5-day post-operation, while late oral feeding was defined as feeding after the fifth postoperative day. Five papers that met the inclusion criteria were included in the analysis, with 1097 patients. Results: The results showed that early feeding was not significantly associated with postoperative fistulas (RR 0.49, 95% CI 0.23 to 1.05, p-value = 0.07), hematoma/seroma (RR 0.71, 95% CI 0.33 to 1.51, p-value = 0.38), or flap failure (RR 0.84, 95% CI = 0.38 to 1.87, p-value = 0.67). However, early oral feeding was significantly associated with shorter hospital stays than late oral feeding (MD −3.18, 95% CI −4.90 to −1.46, p-value = 0.0003). Conclusion: No significant difference exists between early and late oral feeding regarding the risk of postoperative complications in head and neck cancer (HNC) patients who underwent free flap reconstruction surgery. However, early oral feeding is significantly associated with a shorter hospital stay than late oral feeding. Thus, surgeons should consider implementing early oral feeding after free flap reconstruction in HNC patients. [ABSTRACT FROM AUTHOR]

Aim: We aimed to perform a meta-analysis to find out whether PCT and MDW could be used as accurate diagnostic markers for sepsis. Methods: We searched PUBMED, WOS, and SCOPUS databases. Inclusion criteria were any observational or clinical trials that compared monocyte Distribution Width [MDW] with Procalcitonin [PCT] as diagnostic markers in a patient with sepsis. Case reports, editorials, conference abstracts, and animal studies were excluded. RevMan software [5.4] was used to perform the meta-analysis. Results: After the complete screening, 5 observational studies were included in the meta-analysis. The total number of patients included in the meta-analysis in the sepsis group is 565 and 781 in the control group. The pooled analysis between the sepsis group and controls showed a statistically significant association between sepsis and increased levels of MDW and PCT [MD = 3.94, 95% CI = 2.53 to 5.36, p-value < 0.00001] and [MD = 9.29, 95% CI = 0.67 to 17.91, p-value = 0.03] respectively. Moreover, the subgroup analysis showed that the p-value of MDW levels [< 0.00001] is more significant than the p-value of PCT levels = 0.03, the p-value between the two subgroups [< 0.00001]. Additionally, the overall ROC Area for MDW [0.790] > the overall ROC Area for PCT [0.760]. Conclusion: Our study revealed a statistically significant association between sepsis and increased MDW and PCT levels compared with controls and the overall ROC Area for MDW is higher than the overall ROC Area for PCT, indicating that the diagnostic accuracy of MDW is higher than PCT.MDW can be used as a diagnostic marker for sepsis patients in the emergency department. More multicenter studies are needed to support our findings. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Guillain‐Barré syndrome (GBS) is a rare but possible complication that may occur after COVID‐19 vaccination. In this systematic review, we found that GBS presented in patients with an average age of 58. The average time for symptoms to appear was 14.4 days. Health care providers should be aware of this potential complication. Most instances of Guillain‐Barré syndrome (GBS) are caused by immunological stimulation and are discovered after vaccinations for tetanus toxoid, oral polio, and swine influenza. In this systematic study, we investigated at GBS cases that were reported after receiving the COVID‐19 vaccination. Based on PRISMA guidelines, we searched five databases (PubMed, Google Scholar, Ovid, Web of Science, and Scopus databases) for studies on COVID‐19 vaccination and GBS on August 7, 2021. To conduct our analysis, we divided the GBS variants into two groups, acute inflammatory demyelinating polyneuropathy and non‐acute inflammatory demyelinating polyneuropathy (AIDP and non‐AIDP), and compared the two groups with mEGOS and other clinical presentation In this systematic review, 29 cases were included in 14 studies. Ten cases belonged to the AIDP variant, 17 were non‐AIDP (one case had the MFS variant, one AMAN variant, and 15 cases had the BFP variant), and the two remaining cases were not mentioned. Following COVID‐19 vaccination, GBS cases were, on average, 58 years of age. The average time it took for GBS symptoms to appear was 14.4 days. About 56 percent of the cases (56%) were classified as Brighton Level 1 or 2, which defines the highest level of diagnostic certainty for patients with GBS. This systematic review reports 29 cases of GBS following COVID‐19 vaccination, particularly those following the AstraZeneca/Oxford vaccine. Further research is needed to assess all COVID‐19 vaccines' side effects, including GBS. [ABSTRACT FROM AUTHOR]

The efficacy of anteriolateral versus anterior–posterior electrode positions in the success of atrial fibrillation's (AF) electrical cardioversion is unclear. Our aim is to perform a meta‐analysis to compare the success rate of both electrode positions. PUBMED, WOS, OVID, and SCOPUS were searched. Inclusion criteria were clinical trials that compared anterior–lateral with anterior–posterior electrodes in external cardioversion of AF. After the full‐text screening, 11 trials were included in the analysis. The total number of patients included in the study is 1845. The pooled analysis showed a statistically significant association between anterior–lateral electrode and increased cardioversion rate of AF (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.02–1.92, p =.04). Subgroup analysis revealed a statistically significant association between the anterior–lateral electrode and increased cardioversion rate of AF in subgroups of less than five shocks, patients with 60 years old or more and patients with left atrial (LA) diameter >45 mm (OR = 1.72, 95% CI = 1.17–2.54, p =.006), (OR = 1.73, 95% CI = 1.18–2.54, p =.005), and (OR = 1.86, 95% CI = 1.04–3.34, p =.04), respectively. Anteriolateral electrode is more effective than anterior–posterior electrode in external cardioversion of AF, particularly in patients who have received less than 5 shocks, are 60 years old or older and have a LA diameter greater than 45 mm. [ABSTRACT FROM AUTHOR]

Background: Insomnia has been closely associated with cardiovascular disease (CVD) including myocardial infarction (MI). Our study aims to assess the eligibility of insomnia as a potential risk factor for MI. Methods: PubMed, Scopus, and Web of Science were searched using terms; such as "Insomnia" and "MI." Only observational controlled studies with data on the incidence of MI among insomniacs were included. Revman software version 5.4 was used for the analysis. Results: Our pooled analysis showed a significant association between insomnia and the incidence of MI compared with noninsomniacs (relative risk [RR] = 1.69, 95% confidence interval [CI] = 1.41–2.02, p <.00001). Per sleep duration, we detected the highest association between ≤5 h of sleep, and MI incidence compared to 7−8 h of sleep (RR = 1.56, 95% CI = 1.41–1.73). Disorders of initiating and maintaining sleep were associated with increased MI incidence (RR = 1.13, 95% CI = 1.04–1.23, p =.003). However, subgroup analysis of nonrestorative sleep and daytime dysfunction showed an insignificant association with MI among both groups (RR = 1.06, 95% CI = 0.91–1.23, p =.46). Analysis of age, follow‐up duration, sex, and comorbidities showed a significant association in insomniacs. Conclusion: Insomnia and ≤5 h of sleep are highly associated with increased incidence of MI; an association comparable to that of other MI risk factors and as such, it should be considered as a risk factor for MI and to be incorporated into MI prevention guidelines. [ABSTRACT FROM AUTHOR]

Aim: This meta‐analysis aims to look at the impact of early intravenous Metoprolol in ST‐segment elevation myocardial infarction (STEMI) before percutaneous coronary intervention (PCI) on infarct size, as measured by cardio magnetic resonance (CMR) and left ventricular ejection fraction. Methods: We searched the following databases: PubMed, Scopus, Cochrane library, and Web of Science. We included only randomized control trials that reported the use of early intravenous Metoprolol in STEMI before PCI on infarct size, as measured by CMR and left ventricular ejection fraction. RevMan software 5.4 was used for performing the analysis. Results: Following a literature search, 340 publications were found. Finally, 18 studies were included for the systematic review, and 8 clinical trials were included in the meta‐analysis after the full‐text screening. At 6 months, the pooled effect revealed a statistically significant association between Metoprolol and increased left ventricular ejection fraction (LVEF) (%) compared to controls (mean difference [MD] = 3.57, [95% confidence interval [CI] = 2.22–4.92], p <.00001), as well as decreased infarcted myocardium(g) compared to controls (MD = −3.84, [95% [CI] = −5.75 to −1.93], p <.0001). At 1 week, the pooled effect revealed a statistically significant association between Metoprolol and increased LVEF (%) compared to controls (MD = 2.98, [95% CI = 1.26−4.69], p =.0007), as well as decreased infarcted myocardium(%) compared to controls (MD = −3.21, [95% CI = −5.24 to −1.18], p =.002). Conclusion: A significant decrease in myocardial infarction and increase in LVEF (%) was linked to receiving Metoprolol at 1 week and 6‐month follow‐up. [ABSTRACT FROM AUTHOR]

Africa carries a high burden of infectious diseases. Every year, millions of Africans contract tuberculosis, malaria, and many other diseases. Malaria kills hundreds of thousands of children under the age of five years annually. More than 11,000 people died during the 2014–2016 Ebola outbreak in West Africa; still, occasional cases of Ebola, as well as monkeypox, periodically appear in the Democratic Republic of Congo. Since most of the African countries gained their independence during the 1960s, the continent has relied heavily on the outside world for diagnostics, medicines, vaccines, personal protective equipment, and other medical supplies. Africa consumes nearly 25% of the globally produced vaccines but imports 99% and 95% of its vaccines and medicines, respectively. The 55 African countries were not able to ensure the health of 1.3 billion Africans during the COVID‐19 pandemic but had to rely on other global initiatives and other countries for help and support. However, the pandemic and the shortage of vaccines may have been the much‐needed trigger for this situation to change. "When misfortunes increase, they erase each other." Naguib Mahfouz (1911–2006). [ABSTRACT FROM AUTHOR]

Background and Aim: Some studies reported a positive link between familial Mediterranean fever (FMF) and epicardial adipose tissue. Our meta‐analysis aimed to evaluate whether there is a significant association between FMF and increased epicardial adipose tissue thickness. Methods: We searched the following databases: PUBMED, WOS, OVID, SCOPUS, and EMBASE. Inclusion criteria were any original articles that reported epicardial adipose tissue in FMF patients with no age restriction, excluding reviews, case reports, editorials, animal studies, and non‐English studies. Thirty eligible studies were screened full text but only five studies were suitable. We used RevMan software (5.4) for the meta‐analysis. Results: The total number of patients included in the meta‐analysis in the FMF patients group is 256 (mean age = 24.3), and the total number in the control group is 188 (mean age = 24.98). The pooled analysis between FMF patients and controls was [mean difference = 0.82 (95% CI = 0.25–1.39), p‐value = 0.005]. We observed heterogeneity that was not solved by random effects (p > 0.00001). We performed leave one out test by removing the Kozan et al. study, and the heterogeneity was solved (p = 0.07), and the results were (MD = 0.98, 95% CI = 0.52–1.43, p‐value < 0.0001). Conclusion: FMF patients are at increased risk of developing epicardial adipose tissue compared to controls. More multicenter studies with higher sample sizes are needed to support our results. [ABSTRACT FROM AUTHOR]

Background and aims: The therapeutic strategy for the treatment of known sequelae of COVID‐19 has shifted from reactive to preventative. In this study, we aim to evaluate the effects of acetylsalicylic acid (ASA), and anticoagulants on COVID‐19 related morbidity and mortality. Methods: This record‐based analytical cross‐sectional study targeted 539 COVID‐19 patients in a single United States medical center between March and December 2020. Through a random stratified sample, we recruited outpatient (n = 206) and inpatient (n = 333) cases from three management protocols, including standard care (SC) (n = 399), low‐dose ASA only (ASA) (n = 112), and anticoagulation only (AC) (n = 28). Collected data included demographics, comorbidities, and clinical outcomes. The primary outcome measure was inpatient admission. Exploratory secondary outcome measures included length of stay, 30‐day readmission rates, medical intensive care unit (MICU) admission, need for mechanical ventilation, the occurrence of acute respiratory distress syndrome (ARDS), bleeding events, clotting events, and mortality. The collected data were coded and analyzed using standard tests. Results: Age, mean number of comorbidities, and all individual comorbidities except for asthma, and malignancy were significantly lower in the SC compared to ASA and AC. After adjusting for age and comorbidity via binary logistic regression models, no statistical differences were found between groups for the studied outcomes. When compared to the SC group, ASA had lower 30‐day readmission rates (odds ration [OR] 0.81 95% confidence interval [CI] 0.35–1.88, p = 0.63), MICU admission (OR 0.63 95% CI 0.34–1.17, p = 0.32), ARDS (OR 0.71 95% CI 0.33–1.52, p = 0.38), and death (OR 0.85 95% CI 0.36–1.99, p = 0.71). Conclusion: Low‐dose ASA has a nonsignificant but potentially protective role in reducing the risk of COVID‐19 related morbidity and mortality. Our data suggests a trend toward reduced 30‐day readmission rates, ARDS, MICU admissions, need for mechanical ventilation, and mortality compared to the standard management protocol. Further randomized control trials are needed to establish causal effects. [ABSTRACT FROM AUTHOR]

Background: The association between autonomic dysfunction and long‐COVID syndrome is established. However, the prevalence and patterns of symptoms of dysautonomia in long‐COVID syndrome in a large population are lacking. Objective: To evaluate the prevalence and patterns of symptoms of dysautonomia in patients with long‐COVID syndrome. Methods: We administered the Composite Autonomic Symptom Score 31 (COMPASS‐31) questionnaire to a sample of post‐COVID‐19 patients who were referred to post‐COVID clinic in Assiut University Hospitals, Egypt for symptoms concerning for long‐COVID syndrome. Participants were asked to complete the COMPASS‐31 questionnaire referring to the period of more than 4 weeks after acute COVID‐19. Results: We included 320 patients (35.92 ± 11.92 years, 73% females). The median COMPASS‐31 score was 26.29 (0–76.73). The most affected domains of dysautonomia were gastrointestinal, secretomotor, and orthostatic intolerance with 91.6%, 76.4%, and 73.6%, respectively. There was a positive correlation between COMPASS‐31 score and long‐COVID duration (p < 0.001) and a positive correlation between orthostatic intolerance domain score and post‐COVID duration (p < 0.001). There was a positive correlation between orthostatic intolerance domain score and age of participants (p = 0.004). Two hundred forty‐seven patients (76.7%) had a high score of COMPASS‐31 >16.4. Patients with COMPASS‐31 >16.4 had a longer duration of long‐COVID syndrome than those with score <16.4 (46.2 vs. 26.8 weeks, p < 0.001). Conclusions: Symptoms of dysautonomia are common in long‐COVID syndrome. The most common COMPASS‐31 affected domains of dysautonomia are gastrointestinal, secretomotor, and orthostatic intolerance. There is a positive correlation between orthostatic intolerance domain score and patients' age. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID‐19) is a new pandemic disease, associated with substantial morbidity and mortality. Its diagnosis requires centralized facilities and time. Aims: To describe the exposure history and clinical picture of the COVID‐19 patients, to study the SARS‐CoV‐2 Virus load and some determinants that may correlate with its prognosis, and to evaluate the role of inflammatory index NLR as an early predictor of COVID‐19 prognosis. Methodology: A prospective follow‐up study included laboratory‐confirmed 179 COVID‐19 cases out of 660 suspected COVID‐19 cases, at El‐Madinah El‐Monawarah General Hospital in April 2020. Confirmed cases were managed by the Saudi Protocol and followed up every 2 weeks by PCR, neutrophil to lymphocyte ratio (NLR) for 1 month. Data were collected through a validated questionnaire and by qualified infection control staff. Results: The majority of the COVID‐19 cases were 67 (37.4%) aged 30 to <45 years, 157 (87.7%) males, 76.0% working outside the medical field. 38.0% were asymptomatic and 26.3% had severe symptoms, while the main presenting symptoms were fever and dry cough (49.7% and 43.6%), respectively. The case fatality was 7.8%. The male, nonmedical occupation, and low level of education had a statistically significant relationship with the baseline PCR. There was an inverse significant correlation between baseline PCR readings and the recovery duration and health status outcomes. NLR was noted to be significantly higher among old age, illiterate nonmedical occupation, case with severe symptoms, MICU admission, and worst health status outcomes, but it was paradoxically higher among nonadmitted positive cases. Conclusion: Admitted COVID‐19 cases outcomes (disease severity, ICU admission, and mortality) significantly correlated to NLR and not to the baseline PCR viral load. NLR could be a beneficial prognostic and triaging parameter especially old nonmedical COVID‐19 patients. [ABSTRACT FROM AUTHOR]

Perfusion education programs use simulation to provide students with clinical skills prior to entering the operating room. To teach the psychomotor execution of skills in a simulation lab requires a list of validated skills and deconstructed substeps to fully optimize adult learning. A list of the fundamental skills of adult cardiopulmonary bypass (CPB) was recently published; however, no defined list exists regarding pediatric CPB skills. The purpose of this survey is to form a definitive list of skills fundamental to pediatric CPB. A survey of 23 proposed pediatric CPB clinical skills and 291 proposed skill sub-steps was developed. Proposed pediatric CPB skills were evaluated using an established frequency and harm index. If the skill is performed .50% of the time (frequency), and if .50% believe that if the skill is performed incorrectly patient harm is probable (risk), then the skill is accepted as fundamental. The survey content was validated by subject matter experts and then distributed to practicing perfusionists between September 2020 and December 2020. Of the 125 survey respondents, 57.9% had 10 or more years in the field. 35.2% of respondents are American Society of Extracorporeal Technology (AmSECT) Fellows of Pediatric Perfusion (FPP) and pediatric CPB represents .50% of the annual caseload for 69.7% of respondents. 22 of the 23 proposed skills were accepted as fundamental in the conduct of pediatric CPB and 258 of the 291 proposed sub-steps associated with CPB skills were accepted as integral to skill performance. By surveying practicing pediatric perfusionists, this study identifies 22 skills as fundamental to the safe execution of pediatric CPB. In addition, skill sub-elements were identified as necessary for skill execution. This knowledge will assist perfusion programs in developing a pediatric simulation curriculum that matches current clinical execution of pediatric skills. [ABSTRACT FROM AUTHOR]

The dramatic increase in the use of extracorporeal membrane oxygenation (ECMO) over the last decade with the concomitant need for ECMO competent perfusionists has raised questions of how well perfusion education programs are preparing entry-level perfusionists to participate in ECMO. While all perfusion schools teach ECMO principles, there is no standardized or systematic approach to the delivery of didactic knowledge and clinical skills in ECMO. Given this variability of ECMO education across and within perfusion schools, the CES-A exam may provide a metric for comparing curricular approaches. The purpose of this study is to examine three different curricular approaches to prepare new perfusion graduates to master the Adult ECMO Specialist Certification exam (CES-A). We examined three different curricular approaches to prepare new perfusion graduates to master the Adult ECMO Specialist Certification exam (CES-A). We hypothesized that there would be no difference in CES-A pass rate, exam score, Rasch measure, and item category scores between SUNY Cardiovascular Perfusion Program (CVP) graduates who completed SUNY's ECMO Capstone experience (Group III) and CVP graduates who did not select the ECMO Capstone experience (Group II). Further, we studied the performance of a third group of new graduates from an external program that does not offer formal ECMO courses or an ECMO Capstone experience (Group I). Every perfusion graduate in all groups passed the adult ECMO specialist exam. The graduates who as students completed an ECMO Capstone experience (Group III) scored higher on the exam and significantly higher on four exam categories: coagulation and hemostasis (p5.058), lab analysis point of care (p5.035), and monitor patient and circuit (p5.073), and the safety and failure modes (p5.017). Overall the median graduate Rasch measures ranked with Group III demonstrating the highest measure to Group I the lowest measures (not significant at p5.085). There is a positive educational effect due to CVP graduates completion of the ECMO Capstone experience compared to the program standard ECMO-related curricula in the two perfusion programs participating in this study. From this observation a structured ECMO simulation-based program appears to be equally effective as a traditional, typical lecture-only, clinical perfusion preceptorship, while demonstrating a more satisfactory experience with a higher reported case experience. In this study the standard perfusionist education curriculum prepared the new graduate to be successful on the CES-A exam. The three curricular approaches appear to prepare perfusionist graduates to be successful on the Adult ECMO Specialist exam. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary bypass is known to raise the risk of acute kidney injury (AKI). Previous studies have identified numerous risk factors of cardiopulmonary bypass including the possible impact of perioperative ultrafiltration. However, the association between ultrafiltration (UF) and AKI remains conflicting. Thus, we conducted a meta‐analysis to further examine the relationship between UF and AKI. Hypothesis: Ultrafiltration during cardiac surgery increases the risk of developping Acute kidney Injury. Methods: We searched PubMed, Web of Science, EBSCO, and SCOPUS through July 2021. The RevMan (version 5.4) software was used to calculate the pooled risk ratios (RRs) and mean differences along with their associated confidence intervals (95% CI). Results: We identified 12 studies with a total of 8005 patients. There was no statistically significant difference in the incidence of AKI between the group who underwent UF and the control group who did not (RR = 0.90, 95% CI = 0.64−1). Subgroup analysis on patients with previous renal insufficiency also yielded nonsignificant difference (RR = 0.84, 95% CI = 0.53 −1.33, p =.47). Subgroup analysis based on volume of ultrafiltrate removed (> or <2900 ml) was not significant and did not increase the AKI risk as predicted (RR = 0.82, 95% CI = 0.63 −1.07, p =.15). We also did subgroup analysis according to the type of UF and again no significant difference in AKI incidence between UF groups and controls was observed in either the conventional ultrafiltration (CUF), modified ultrafiltration (MUF), zero‐balanced ultrafiltration (ZBUF), or combined MUF and CUF subgroups. Conclusion: UF in cardiac surgery is not associated with increased AKI incidence and may be safely used even in baseline chronic injury patients. [ABSTRACT FROM AUTHOR]

Background and Objective: Low-dose acetylsalicylic acid (ASA, aspirin) is a well-known and frequently studied drug for primary and secondary prevention of disease due to its anti-inflammatory and coagulopathic effects. COVID-19 complications are attributed to the role of thrombo-inflammation. Studies regarding the use of low-dose ASA in COVID-19 are limited. For this reason, we propose that the use of low-dose ASA may have protective effects in COVID-19–related thromboembolism and lung injury. This study was conducted to assess the efficacy of low-dose ASA compared with enoxaparin, an anticoagulant, for the prevention of thrombosis and mechanical ventilation. Methods: We conducted a retrospective cohort study on COVID-19-confirmed hospitalized patients at the Mansoura University Quarantine Hospital, outpatients, and home-isolated patients from September to December 2020 in Mansoura governorate, Egypt. Binary logistic regression analysis was used to assess the effect of ASA compared with enoxaparin on thromboembolism, and mechanical ventilation needs. Results: This study included 225 COVID-19 patients. Use of ASA-only (81–162 mg orally daily) was significantly associated with reduced thromboembolism (OR 0.163, p = 0.020), but both low-dose ASA and enoxaparin, and enoxaparin-only (0.5 mg/kg subcutaneously (SC) daily as prophylactic dose or 1 mg/kg SC every 12 hours as therapeutic dose) were more protective (odds ratio [OR] 0.010, OR 0.071, respectively, p < 0.001). Neither ASA-only nor enoxaparin-only were associated with a reduction in mechanical ventilation needs. Concomitant use of low-dose ASA and enoxaparin was associated with reduced mechanical ventilation (OR 0.032, 95% CI 0.004–0.226, p = 0.001). Conclusions: Low-dose ASA-only use may reduce the incidence of COVID-19-associated thromboembolism, but the reduction may be less than that of enoxaparin-only, and both ASA and enoxaparin. Concomitant use of ASA and enoxaparin demonstrates promising results with regard to the reduction of thrombotic events, and mechanical ventilation needs. [ABSTRACT FROM AUTHOR]

Objectives To review the pathophysiology of COVID-19 disease, potential aspirin targets on this pathogenesis and the potential role of aspirin in patients with COVID-19. Design Narrative review. Setting The online databases PubMed, OVID Medline and Cochrane Library were searched using relevant headlines from 1 January 2016 to 1 January 2021. International guidelines from relevant societies, journals and forums were also assessed for relevance. Participants Not applicable. Results A review of the selected literature revealed that clinical deterioration in COVID-19 is attributed to the interplay between endothelial dysfunction, coagulopathy and dysregulated inflammation. Aspirin has anti-inflammatory effects, antiplatelet aggregation, anticoagulant properties as well as pleiotropic effects on endothelial function. During the COVID-19 pandemic, low-dose aspirin is used effectively in secondary prevention of atherosclerotic cardiovascular disease, prevention of venous thromboembolism after total hip or knee replacement, prevention of pre-eclampsia and postdischarge treatment for multisystem inflammatory syndrome in children. Prehospital low-dose aspirin therapy may reduce the risk of intensive care unit admission and mechanical ventilation in hospitalised patients with COVID-19, whereas aspirin association with mortality is still debatable. Conclusion The authors recommend a low-dose aspirin regimen for primary prevention of arterial thromboembolism in patients aged 40-70 years who are at high atherosclerotic cardiovascular disease risk, or an intermediate risk with a risk-enhancer and have a low risk of bleeding. Aspirin's protective roles in COVID-19 associated with acute lung injury, vascular thrombosis without previous cardiovascular disease and mortality need further randomised controlled trials to establish causal conclusions. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course. Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the viral pathogen responsible for coronavirus disease 2019 (COVID-19), a pandemic respiratory illness. While many patients experience mild to moderate symptoms, severely affected patients often progress to acute respiratory distress syndrome (ARDS). Specific to COVID-19, abnormal coagulability appears to be a principal instigator in the progression of disease severity and mortality. In this report we summarize a case of COVID-19 in which extreme thrombophilia led to patient demise. Case Report: A 67-year-old man in New York presented to the hospital 14 days after testing positive for SARS-CoV-2 at an outpatient site. His initial presenting symptoms included sore throat, headache, fever, and diarrhea. He was brought in by his wife after developing sudden onset confusion and dysarthria. The patient's clinical picture, which was unstable on presentation, further deteriorated to involve significant desaturations, generalized seizure activity, and cardiac arrest requiring resuscitation. Upon return to spontaneous circulation, the patient required intensive care unit admission, mechanical ventilation, and vasopressor increases. Comprehensive workup uncovered coagulopathy with multiple thrombotic events involving the brain and lungs as well as radiographic evidence of severe lung disease. In the face of an unfavorable clinical picture, the family opted for comfort care measures. Conclusions: In this case report on a 67-year-old-man with COVID-19, we present an account of extreme hypercoagulability that led to multiple thrombotic events eventually resulting in the man's demise. Abnormal coagulation 14 days from positive testing raises the question of whether outpatients with COVID-19 should be screened for hypercoagulability and treated with prophylactic anticoagulation/antiplatelet agents. [ABSTRACT FROM AUTHOR]

Mortality in acute respiratory distress syndrome (ARDS) remains unacceptably high at approximately 39%. One of the only treatments is supportive: mechanical ventilation. However, improperly set mechanical ventilation can further increase the risk of death in patients with ARDS. Recent studies suggest that ventilation-induced lung injury (VILI) is caused by exaggerated regional lung strain, particularly in areas of alveolar instability subject to tidal recruitment/derecruitment and stress-multiplication. Thus, it is reasonable to expect that if a ventilation strategy can maintain stable lung inflation and homogeneity, regional dynamic strain would be reduced and VILI attenuated. A time-controlled adaptive ventilation (TCAV) method was developed to minimize dynamic alveolar strain by adjusting the delivered breath according to the mechanical characteristics of the lung. The goal of this review is to describe how the TCAV method impacts pathophysiology and protects lungs with, or at high risk of, acute lung injury. We present work from our group and others that identifies novel mechanisms of VILI in the alveolar microenvironment and demonstrates that the TCAV method can reduce VILI in translational animal ARDS models and mortality in surgical/trauma patients. Our TCAV method utilizes the airway pressure release ventilation (APRV) mode and is based on opening and collapsing time constants, which reflect the viscoelastic properties of the terminal airspaces. Time-controlled adaptive ventilation uses inspiratory and expiratory time to (1) gradually "nudge" alveoli and alveolar ducts open with an extended inspiratory duration and (2) prevent alveolar collapse using a brief (sub-second) expiratory duration that does not allow time for alveolar collapse. The new paradigm in TCAV is configuring each breath guided by the previous one, which achieves real-time titration of ventilator settings and minimizes instability induced tissue damage. This novel methodology changes the current approach to mechanical ventilation, from arbitrary to personalized and adaptive. The outcome of this approach is an open and stable lung with reduced regional strain and greater lung protection. [ABSTRACT FROM AUTHOR]

Acute respiratory distress syndrome (ARDS) remains a serious clinical problem with the main treatment being supportive in the form of mechanical ventilation. However, mechanical ventilation can be a double-edged sword: if set improperly, it can exacerbate the tissue damage caused by ARDS; this is known as ventilator-induced lung injury (VILI). To minimize VILI, we must understand the pathophysiologic mechanisms of tissue damage at the alveolar level. In this Physiology in Medicine paper, the dynamic physiology of alveolar inflation and deflation during mechanical ventilation will be reviewed. In addition, the pathophysiologic mechanisms of VILI will be reviewed, and this knowledge will be used to suggest an optimal mechanical breath profile (MBP: all airway pressures, volumes, flows, rates, and the duration that they are applied at both inspiration and expiration) necessary to minimize VILI. Our review suggests that the current protective ventilation strategy, known as the "open lung strategy," would be the optimal lung-protective approach. However, the viscoelastic behavior of dynamic alveolar inflation and deflation has not yet been incorporated into protective mechanical ventilation strategies. Using our knowledge of dynamic alveolar mechanics (i.e., the dynamic change in alveolar and alveolar duct size and shape during tidal ventilation) to modify the MBP so as to minimize VILI will reduce the morbidity and mortality associated with ARDS. [ABSTRACT FROM AUTHOR]

It has been shown that mechanical ventilation in patients with, or at high-risk for, the development of acute respiratory distress syndrome (ARDS) can be a double-edged sword. If the mechanical breath is improperly set, it can amplify the lung injury associated with ARDS, causing a secondary ventilator-induced lung injury (VILI). Conversely, the mechanical breath can be adjusted to minimize VILI, which can reduce ARDS mortality. The current standard of care ventilation strategy to minimize VILI attempts to reduce alveolar over-distension and recruitment-derecruitment (R/D) by lowering tidal volume (Vt) to 6 cc/kg combined with adjusting positive-end expiratory pressure (PEEP) based on a sliding scale directed by changes in oxygenation. Thus, Vt is often but not always set as a 'one-size-fits-all' approach and although PEEP is often set arbitrarily at 5 cmHO, it may be personalized according to changes in a physiologic parameter, most often to oxygenation. However, there is evidence that oxygenation as a method to optimize PEEP is not congruent with the PEEP levels necessary to maintain an open and stable lung. Thus, optimal PEEP might not be personalized to the lung pathology of an individual patient using oxygenation as the physiologic feedback system. Multiple methods of personalizing PEEP have been tested and include dead space, lung compliance, lung stress and strain, ventilation patterns using computed tomography (CT) or electrical impedance tomography (EIT), inflection points on the pressure/volume curve (P/V), and the slope of the expiratory flow curve using airway pressure release ventilation (APRV). Although many studies have shown that personalizing PEEP is possible, there is no consensus as to the optimal technique. This review will assess various methods used to personalize PEEP, directed by physiologic parameters, necessary to adaptively adjust ventilator settings with progressive changes in lung pathophysiology. [ABSTRACT FROM AUTHOR]

Background: There are insufficient blood pressure control rates even in high-performing health systems, and effective management of hypertension remains a challenge in a real-life general practice. This is because of many factors including unhealthy life style, improper prescribing and poor medication adherence. Cost effective and innovative interventions to improve BP control are therefore needed. Aim: We aimed to study the impact of a 6-month Team- based Educational and Refill Monitoring (TERM) intervention in improving BP control among UAE adult citizens diagnosed with hypertension. Methods: This is a clinical trial, where, 214 hypertensive UAE citizens ≥18 years participated in a 6 months TERM intervention compared with 214 hypertensive UAE citizens receiving usual care, Primary Health Care Department, Sharjah Medical District (SMD), United Arab Emirates (UAE). Before the intervention, all physicians, pharmacists and nurses of the TERM group were enrolled in a one week medical education three sessions. These sessions provided information in two domains: practice guidelines based on guidelines of the Joint National Committee (JNC 7) (13) and principles of health education and communication. As well, a monthly health education session, telephone calls and SMS messages have been used to intensify medication adherence and hypertension self-management of TERM patients. The primary outcomes were changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), medication refill adherence (MRA) and blood pressure (BP) control. Results: Participants had a mean age of 57.4± 11 years (TERM) and 57.5± 11.1 years (control). 57.1% were males (TERM) and 57.9% were females (control). At baseline there was no significant difference between both groups in regard to occupation, education, smoking, blood lipids, body mass index (BMI), SBP, DBP and MRA. Meanwhile, at baseline, only 35% of TERM patients compared to 34.9% of usual care patients had controlled blood pressure (defined as BP< 140/90 mmHg). At 6 months, TERM participants achieved greater improvements compared to usual care group in regard to SBP (139.3 ± 14.2 mmHg vs. 152± 13.4 mm Hg, P<0.001), DBP (85.3± 9.3 vs. 92.4± 6.8 mm Hg, P<0.001), BP control (50% vs. 36%, P = 0.01) and medication refill adherence (92% vs.86%, P<0.001). Conclusion: A team-based educational intervention for both staff and patients led to significant improvement in SBP, DBP, MRA and BP control in adult hypertensive patients, primary health care setting, Sharjah Medical District, UAE. [ABSTRACT FROM AUTHOR]

The pathophysiology of acute respiratory distress syndrome (ARDS) results in heterogeneous lung collapse, edema-flooded airways and unstable alveoli. These pathologic alterations in alveolar mechanics (i.e. dynamic change in alveolar size and shape with each breath) predispose the lung to secondary ventilator-induced lung injury (VILI). It is our viewpoint that the acutely injured lung can be recruited and stabilized with a mechanical breath until it heals, much like casting a broken bone until it mends. If the lung can be "casted" with a mechanical breath, VILI could be prevented and ARDS incidence significantly reduced. [ABSTRACT FROM AUTHOR]