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Objective: The objective of this study was to describe the lung sonographic findings of COVID-19 patients prospectively and investigate its association with disease severity.Methods: This study was conducted in an emergency department and included consecutively enrolled laboratory confirmed COVID-19 patients. Lung sonography findings were described in all the included patients and analysed with respect to the clinical severity of the patients.Results: 106 patients were included in the study. Common sonographic findings in COVID-19 patients were pleural line irregularity or shredding (70% of patients), followed by B - profile (59%), pleural line thickening (33%), occasional B - lines (26%), sub-pleural consolidations (35%), deep consolidations (6%), spared areas (13%), confluent B - lines or waterfall sign (14%) and pleural effusion (9%). These findings tended to be present more bilaterally and in lower lung zones. Sonographic characteristics like bilateral lung involvement, B - profile, spared areas and confluent B - lines or waterfall sign were significantly associated (p < 0.01) with clinical severity (more frequent with increasing disease severity).Conclusion: The lung sonographic findings of COVID-19 were found more bilaterally and in lower lung zones, and specific findings like B - profile, pleural thickening, spared areas and confluent B - lines or waterfall sign were associated with severe COVID-19. [ABSTRACT FROM AUTHOR]

With the pandemic of obesity and the growing experience in metabolic and bariatric surgery (MBS), the number of patients with obesity and liver cirrhosis undergoing MBS is increasing. To analyze the morbidity and mortality following MBS in patients with obesity and liver cirrhosis. Systematic review and meta-analysis. The published literature was systematically reviewed, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, for studies reporting outcomes of MBS among patients with liver cirrhosis. The predetermined endpoints were the overall complication after MBS, intraoperative complications, liver-related complications after MBS, all-cause 90-day mortality after MBS, and liver-related mortality post-MBS. The pooled weighted proportions for each of the endpoints was calculated using random effect meta-analysis. A total of 18 studies, including 471 patients with obesity and liver cirrhosis undergoing MBS, qualified for the final quantitative analysis. The mean age and mean body mass index (BMI) of the pooled patient cohort were 50.2 years and 47.2 kg/m2. The pooled weighted proportions of the overall post-MBS complications, intraoperative complications, liver-related complications, overall 90-day mortality, and liver failure related mortality post MBS were 22.14% (CI 95% : 15.43%–29.55%),.08% (CI 95% : 0%–1.02%), 4.62% (CI 95% : 1.27%–9.30%), 0% (CI 95% : 0%–.44%),.08% (CI 95% : 0%–1.03%), respectively. Significantly lower postoperative complications were noted with sleeve gastrectomy (10.08% [95%CI: 5.14%–16%]) compared with Roux-en-Y gastric bypass (31.53% [95%CI: 18.62%–45.68%]; (P =.02). We found an overall low postoperative surgical and liver-related mortality post MBS among patients with obesity and liver cirrhosis. The overall postoperative complications and liver-related complications were higher among patients with liver cirrhosis than in noncirrhotic patients. Sleeve gastrectomy showed lower postoperative complications compared with Roux-en-Y gastric bypass. • Metabolic and bariatric surgery (MBS) in obese patients with liver cirrhosis is associated with an overall low post-operative surgical and liver-related mortality. • The overall post-operative complications and liver-related complications post-MBS were higher in cirrhotics compared to non-cirrhotics. • Sleeve gastrectomy showed lower post-operative complications compared to Roux-en-Y gastric bypass. [ABSTRACT FROM AUTHOR]

Background and Objectives: To assess the impact of personal protective equipment (PPE) on different aspects of chest compression (CC) during cardiopulmonary resuscitation, we conducted this study.Methods: This systematic review was performed according to the PRISMA. We searched PubMed, EMBASE and Web of Science from inception to June-6, 2020, limiting to the studies that reported the comparison of the effectiveness of CC in terms of CC rate, CC depth, the proportion of adequate CC rate, the proportion of adequate CC depth or proportion of adequate recoil; in study arms with or without PPE. Risk of bias was assessed by the ROB-2 and ROBINS-I tool. Quantitative data synthesis was done using the generic inverse variance method and the fixed-effects model.Results: Five simulation-based studies were finally included. A Significant decrease in CC rate (SMD: -0.28, 95%CI: -0.47 to -0.10) and CC depth (SMD: -0.26, 95%CI: -0.44 to -0.07) were observed in the PPE arm as compared to the no-PPE arm. The difference in CC rate was more prominently seen in adult CPR than in paediatric CPR. Without PPE, the proportion of adequate CC rate delivered was 0.74, which reduced significantly to 0.60 after use of PPE (p - 0.035). Similarly, the proportion of adequate CC depth was significantly lesser (p - 0.001) in PPE arm (0.55), as compared to that of the no-PPE arm (0.78).Conclusion: The use of PPE compromises the quality of CC during CPR significantly, and newer ways to deliver chest compression has to be investigated. This study was prospectively registered in PROSPERO (CRD42020192031). [ABSTRACT FROM AUTHOR]

Background and Objectives: It is essential to know the proportion of health care workers (HCW) who are COVID 19 positive, as well as the severity and mortality among them.Methods: This systematic review was performed according to the Preferred Reporting Items for Systematic review and meta-analysis. Databases including PubMed, EMBASE and Web of Science were searched from December-31, 2019 to April-23, 2020. The search was limited to the studies that reported the data on the number of COVID-19 positive healthcare workers, among the COVID-19 positive patients. Case reports, duplicate publications, reviews, and family-based studies were excluded. The methodological quality of studies was assessed by the Appraisal tool for Cross-Sectional Studies (AXIS) tool.Results: In this systematic review and meta-analysis, we pooled eleven studies to investigate the above factors. The overall proportion of HCW who were SARS-CoV-2 positive among all COVID-19 patients was 10.1% (95%CI: 5.3-14.9). This proportion varied according to the country of study i.e. China (7 studies) - 4.2%, 95%CI:2.4-6.0; United States (3 studies) - 17.8%, 95%CI:7.5-28.0; and Italy (1 study) - 9.0%, 95%CI:8.6-9.4. The incidence of severe or critical disease in HCW (9.9%, 95%CI:0.8-18.9) was significantly lower (p < 0.001) than the incidence of severe or critical disease in all COVID-19 positive patients (29.4%, 95%CI:18.6-40.2). Similarly, the mortality among HCW (0.3%, 95%CI:0.2-0.4) was also significantly lower (p < 0.001) as compared to that of all patients (2.3%, 95%CI:2.2-2.4).Conclusion: Health care workers who are COVID-19 positive constituted a significant proportion of all COVID-19 patients; but the severity and mortality were lower among them. [ABSTRACT FROM AUTHOR]

Background: The integration of point-of-care ultrasound in endotracheal tube placement confirmation has been focus of many recent studies.Objectives: We sought to determine the diagnostic accuracy of ultrasonography in confirmation of endotracheal intubation compared with standard confirmatory methods.Methods: We completed an extensive search of PubMed, EMBASE, Cochrane Central, Web of Science, and bibliographies of the selected articles from inception to October 2019. The search was limited to prospective studies conducted in human adults that compared the accuracy of ultrasonography in confirming the endotracheal tube position with a reference standard. The methodologic quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate random-effects model summarized diagnostic accuracy statistics. Subgroup analyses by ultrasonographic signs, study location, the operator's specialty, types of transducer, the technique of ultrasound confirmation, and clinical setting (cardiac arrest vs. non-cardiac arrest) were performed.Results: Thirty studies involving 2534 patients were selected for this meta-analysis. The estimated pooled sensitivity and specificity for ultrasonography were 0.982 (95% confidence interval [CI] 0.971-0.988) and 0.957 (95% CI 0.901-0.982), respectively. Subgroup analyses did not reveal significant difference by ultrasonographic sign used, location, the sonographer's specialty, transducer type, or ultrasound technique used. Ultrasound was also found to be a useful adjunct in confirming endotracheal tube position in the subgroup of patients with cardiac arrest, with sensitivity of 0.99 (95% CI 0.98-1.00) and specificity of 0.84 (95% CI 0.67-1.00), respectively.Conclusions: Ultrasonography is a valuable and reliable adjunct for endotracheal tube confirmation, including during cardiac arrest resuscitation. [ABSTRACT FROM AUTHOR]

Sympathetic Crashing Acute Pulmonary Edema (SCAPE) lies on the end of the acute heart failure syndrome spectrum with pulmonary edema in all lung zones. NTG at lower doses (10–20 μg/min) cause preload reduction, and at higher doses (> 100 μg/min) causes after-load reduction by arterial dilatation. The main aim is to decrease the afterload at the earliest to cut the vicious cycle caused by sudden sympathetic upsurge. To our knowledge, this is the highest nitroglycerin dose usage in the literature. A 60-year-old male with no known prior co-morbidities presented to our Emergency with complaints of acute onset severe shortness of breath, which was also associated with extreme diaphoresis, agitation, anxiety, and palpitations. On Examination, the patient was hypoxic and hypertensive with severe tachypnea and tachycardia. On Auscultation, diffuse bilateral crackles in all areas were heard. Point of care ultrasound showed bilateral B-profile in all lung zones, inferior vena cava was >50% collapsible. We managed the patient with non-invasive ventilation and ultrahigh dose nitroglycerin/ highest ever- 9 mg intravenous bolus with 76 mg infusion. The patient had improved within hours and did not require oxygen. The patient was discharged from the emergency after a few hours of observation. SCAPE occurs due to a vicious spiral involving increasing sympathetic outflow, excessive afterload, and worsening heart failure. The central, defining pathophysiological feature of SCAPE is pathologically elevated afterload due to systemic vasoconstriction and hypertension. SCAPE patients may be euvolemic, hypovolemic or hypervolemic. The problem is shift of fluid into the lungs rather than hypervolemia. The emphasis on treating pulmonary edema has shifted from diuretics to vasodilators, especially high-dose nitrates, combined with non-invasive positive pressure ventilation. This is the first report describing the safe and effective administration of ultra-high dose bolus/ highest dose ever and prolonged high-dose infusion for SCAPE, along with Non-invasive ventilation, which has prevented mechanical ventilation and mortality. High doses of intravenous NTG are extremely effective and safe for SCAPE patients. [ABSTRACT FROM AUTHOR]

Background: Sympathetic crashing acute pulmonary edema (SCAPE) is a severe form of hypertensive acute heart failure with a dramatic presentation. Rapid identification and management in the emergency department (ED) is key to saving these patients and preventing morbidity associated with endotracheal intubation and intensive care treatment. Use of high-dose nitroglycerin (NTG) and noninvasive ventilation (NIV) has been advocated in management of such patients.Objective: To study the feasibility and safety of high-dose NTG combined with NIV in SCAPE.Methods: This was a prospective observational pilot study done in the ED of a tertiary care hospital. All patients were treated with high-dose NTG and NIV. The primary objective was to study the feasibility and safety of the SCAPE management protocol in terms of the outcome of the patient. Resolution of symptoms in 6 h and need for intubation were recorded as endpoints. Any complications associated with high-dose NTG were also recorded.Results: A total of 25 patients were recruited. The mean bolus dose of NTG given was 872 μg, and mean cumulative dose, 35 mg. There was no incidence of hypotension after the bolus dose of nitroglycerin. Eleven patients had resolution of symptoms at 3 h of therapy. Twenty-four patients were discharged from the ED itself after a brief period of observation, and one patient was intubated and shifted to the intensive care unit.Conclusion: Use of our specific SCAPE treatment algorithm, which included high-dose NTG and NIV, was safe and provided rapid resolution of symptoms. [ABSTRACT FROM AUTHOR]

Background: Various risk-stratification scores have been developed to identify low-risk febrile neutropenia (FN). The Multinational Association of Supportive Care in Cancer (MASCC) score is a commonly used validated scoring system, although its performance varies due to its subjectivity. Biomarkers like procalcitonin (PCT) are being used in patients with FN to detect bacteremia and additional complications.Objective: Our objective was to compare the performance of MASCC score with PCT in predicting adverse outcomes in patients with FN.Methods: This was a prospective observational study that included chemotherapy-induced FN in hematologic or solid malignancy. The MASCC score, PCT levels, and blood cultures were taken at the first point of contact, and patient treatment was managed according to routine institutional protocol. The primary outcome was mortality at 30 days.Results: A total of 100 patients were recruited, of which 92 had hematologic malignancy and 8 had solid malignancy. Forty-six patients were classified as low risk by MASCC score (≥21). The PCT threshold, 1.42 ng/mL, was taken as a cutoff value, with area under the receiver operating characteristic curve (AUROC) of 0.664 (95% confidence interval [CI] -0.55 to 0.77) for predicting mortality. AUROC for MASCC was 0.586 (95% CI 0.462 to 0.711).Conclusions: PCT is a useful marker with better prognostic efficacy than MASCC score in patients with FN and can be used as an adjunct to the score in risk-stratifying patients with FN. [ABSTRACT FROM AUTHOR]