A Horned Viper Bite Victim with PRES

Neurological complications of snake bites have been well documented in the literature as neuromuscular paralysis and cerebrovascular complications; posterior reversible encephalopathy syndrome was rarely described. A 23-year-old lady presented near full term of her pregnancy with a horned snake Cerastes cerastes bite; after successful delivery she started complaining of altered mental status and visual disturbance with ulceration over the site of the snake bite. On admission, the patient had Glasgow Coma Score of 12, blood pressure 130/80 mmHg, temperature 38°C, sinus tachycardia at 120 beats per minute, severe dehydration, and reduction in visual acuity to “hand motion” in both eyes with poor light projection and sluggish pupillary reactions. CT brain was not conclusive; MRI revealed features of PRES. Treatment was mostly supportive within one week; the patient regained consciousness; visual disturbance, however, persisted. This patient as well as the few previously described cases highlights PRES as a possible complication of snake bites

Prevalence of infections and antimicrobial use in the acute-care hospital setting in the Middle East: Results from the first point-prevalence survey in the region

Objectives: Community-acquired (CAIs) and healthcare-associated (HAIs) infections are associated with significant morbidity and mortality. Data related to the epidemiology of these infections in the Middle East is scarce. The aim of this study is to estimate the prevalence of infections and antimicrobial use in the acute hospital setting in this region. Methods: A multicentre Point-Prevalence Survey was conducted in seven Middle Eastern countries: Egypt, Kingdom of Saudi Arabia, United Arab Emirates, Lebanon, Oman, Kuwait and Bahrain. Data were collected by the infection control and infectious diseases teams of the respective hospitals. Study surveys were completed in one day (03 April 2018). Results: The overall point prevalence of infection was 28.3%; HAI and CAI point prevalence was 11.2% and 16.8%, respectively. The majority of patients with an infection (98.2%) were receiving antimicrobial therapy. There were high levels of resistance to antimicrobials among Acinetobacter baumannii, Enterobacter cloacae, Klebsiella pneumoniae and other Klebsiella sp. Conclusions: Our findings indicate that the point prevalence of both HAI and CAI is high in a sample of Middle Eastern countries. These findings along with the increased use of antimicrobials represent a significant public health problem in the region; particularly in light of the growing regional antimicrobial resistance. © 2020 The Author

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Neurological manifestations of COVID-19 in adults and children

Different neurological manifestations of coronavirus disease 2019 (COVID-19) in adults and children and their impact have not been well characterized. We aimed to determine the prevalence of neurological manifestations and in-hospital complications among hospitalized COVID-19 patients and ascertain differences between adults and children. We conducted a prospective multicentre observational study using the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) cohort across 1507 sites worldwide from 30 January 2020 to 25 May 2021. Analyses of neurological manifestations and neurological complications considered unadjusted prevalence estimates for predefined patient subgroups, and adjusted estimates as a function of patient age and time of hospitalization using generalized linear models. Overall, 161 239 patients (158 267 adults; 2972 children) hospitalized with COVID-19 and assessed for neurological manifestations and complications were included. In adults and children, the most frequent neurological manifestations at admission were fatigue (adults: 37.4%; children: 20.4%), altered consciousness (20.9%; 6.8%), myalgia (16.9%; 7.6%), dysgeusia (7.4%; 1.9%), anosmia (6.0%; 2.2%) and seizure (1.1%; 5.2%). In adults, the most frequent in-hospital neurological complications were stroke (1.5%), seizure (1%) and CNS infection (0.2%). Each occurred more frequently in intensive care unit (ICU) than in non-ICU patients. In children, seizure was the only neurological complication to occur more frequently in ICU versus non-ICU (7.1% versus 2.3%, P < 0.001). Stroke prevalence increased with increasing age, while CNS infection and seizure steadily decreased with age. There was a dramatic decrease in stroke over time during the pandemic. Hypertension, chronic neurological disease and the use of extracorporeal membrane oxygenation were associated with increased risk of stroke. Altered consciousness was associated with CNS infection, seizure and stroke. All in-hospital neurological complications were associated with increased odds of death. The likelihood of death rose with increasing age, especially after 25 years of age. In conclusion, adults and children have different neurological manifestations and in-hospital complications associated with COVID-19. Stroke risk increased with increasing age, while CNS infection and seizure risk decreased with age

A Horned Viper Bite Victim with PRES

Neurological complications of snake bites have been well documented in the literature as neuromuscular paralysis and cerebrovascular complications; posterior reversible encephalopathy syndrome was rarely described. A 23-year-old lady presented near full term of her pregnancy with a horned snake Cerastes cerastes bite; after successful delivery she started complaining of altered mental status and visual disturbance with ulceration over the site of the snake bite. On admission, the patient had Glasgow Coma Score of 12, blood pressure 130/80 mmHg, temperature 38°C, sinus tachycardia at 120 beats per minute, severe dehydration, and reduction in visual acuity to “hand motion” in both eyes with poor light projection and sluggish pupillary reactions. CT brain was not conclusive; MRI revealed features of PRES. Treatment was mostly supportive within one week; the patient regained consciousness; visual disturbance, however, persisted. This patient as well as the few previously described cases highlights PRES as a possible complication of snake bites

Dextrose 5% versus normal saline as maintenance fluid therapy in patients with septic shock (DEMANDS): a randomized controlled trial

Objective To determine the effects of Dextrose 5% for maintenance and creep fluids on cumulative fluid balance (CFB) for septic shock concerning adult people.Design An open-label randomized clinical trial with a single center and parallel groups.Setting ICUs of a tertiary care academic medical center.Patients Adult individuals who have developed septic shock as described by the Sepsis 3 criteria.Interventions Dextrose 5% (n = 50) versus Saline 0.9% (n = 50) for maintenance and creep fluid for 72 hours.Main variables of interest The primary outcome measured was the CFB at 72 hours. Secondary outcomes assessed included mortality within 28 days, the number of days patients were free from (coma and delirium, ICU, mechanical ventilation, vasopressors), the occurrence of acute kidney injury, and disturbances in electrolyte levels.Results The CFB was significantly lower in Dextrose group vs Saline group (4.46 versus 6.75 L, median difference; −2.06 L; 95% CI, −2.63 to −1.35; p = P < 0.001). No significant difference mortality within 28 days (32% in the Dextrose vs 42% in the saline group; hazard ratio, 0.7; 95% CI, 0.36 to 1.34, p = 0.28). The proportions of patients with hyponatremia were higher in the Dextrose than the Saline group (31% versus 0%, p < 0.001).Conclusions Particularly in cases of septic shock, maintenance and creep fluids with Dextrose 5% as compared to Saline 0.9% resulted in a significantly lower CFB at 72 hours

Comparison between carotid corrected flow time changes in septic shock patients induced by fluid challenge tests

Objective We aimed to compare between Carotid Corrected Flow Time (CCFT) Changes in septic shock patients induced by fluid challenge tests. Design: A prospective, open-label, randomized, controlled, parallel-arm, and monocentric.Settings and patients This study was carried out on 200 septic shock cases.Intervention and main variable of interest Patients were randomized 1:1 as an intervention group receiving 500 ml of intravenous glucose 5% over 5 min and a standard group receiving 500 ml of intravenous saline solution over 5 min then carotid artery corrected flow time shift was compared between the baseline and after the fluid expanded to its final state.Results After treatment, average heart rate was 97 ± 11 and 102 ± 11 beat/min in the standard care and intervention groups of both cohorts decreased significantly in comparison (p < .001). Similarly, the average MAP was 63 ± 5 and 66 ± 3 in the standard care and intervention groups, respectively, with no significant difference (p = 0.132). No significant difference existed between the two groups after treatment (p = 0.154), average Ccft differed significantly between both groups with a larger increase among the intervention group (p = 0.005). But Ccft change revealed no discernible variation between the two groups.Conclusions In septic shock patients, there were no differences in changes occurred in carotid artery corrected flow time induced by normal saline and glucose 5% intravenous infusions and percentage of fluid responder to non-responder in each group; so glucose 5% is not inferior to normal saline as it made closely similar stroke volume variations identified by carotid corrected flow time measurement

Early assessment of aspiration risk in acute stroke by fiberoptic endoscopy in critically ill patients

Background: Fiberoptic endoscopic evaluation of swallowing (FEES) has been recommended to assess aspiration in stroke. This study aimed to determine the diagnostic and prognostic roles of FEES in the early assessment of aspiration, intensive care unit (ICU) stay and mortality in acute stroke patients.Methods: Fifty-two patients with acute stroke admitted to the Alexandria Main University Hospital were included. Complete examinations and assessment of aspiration using the 8-point penetration-aspiration scale (PAS) with FEES protocol were performed.Results: The patients were classified into three groups: normal with no or low risk of aspiration (n=15, 27.3%; PAS level 1), low to moderate risk (n=8, 14.5%; PAS level 2–4), and high risk (n=32, 58.2%; PAS ≥5). There was high incidence of aspiration pneumonia, prolonged ICU stay, and mortality in both moderate- and high-risk groups (P=0.001, P&lt;0.001, and P&lt;0.001, respectively). The PAS score predicted aspiration pneumonia (hospital-acquired pneumonia) with sensitivity and specificity of 80.0% and 76.0%, respectively (negative predictive value [NPV], 76.0; positive predictive value [PPV], 80.0; 95% confidence interval [CI], 0.706–0.940) and mortality with sensitivity and specificity of 88.46% and 68.97% (NPV, 87.0; PPV, 71.9; 95% CI, 0.749–0.951). The PAS score could predict the length of ICU stay with sensitivity and specificity of 70.21% and 87.50, respectively (NPV, 33.3; PPV, 97.1; 95% CI, 0.605–0.906).Conclusions: The standard FEES protocol using PAS score is a useful tool to assess aspiration in acute stroke patients and could be used to predict length of ICU stay and mortality.</jats:p

Waxy-Maize HES 130/0.4; evidence based clinical decisions

AbstractThe profile of an ideal volume substitution solution can be defined by volume effect and safety. The volume effect should be stable and reliable, offer a constant plateau effect and be easily controllable. Many in depth characteristics has been offered by recognized societies [1] and includes: no tissue storage, no plasma accumulation, no influence on haemostasis, no influence on the immune system, no infectivity, no antigenicity, no allergenic potential, no proinflammatory properties, no toxicity, teratogenity or mutagenity, no influence on diagnostic tests, good compatibility with other medication, good tolerance, and complete elimination. Research has shown that it is possible to meet these objectives in the development of hydroxyethyl starches (HES) by optimizing the combination of concentration, the molecular weight, the degree and pattern of substitution. A new starch (HES 130/0.4) has therefore been developed. This new generation of HES offers the same volume effect and duration as the previous standard HES 200/0.5, yet with more favorable pharmacological characteristics and an improved safety profile. The following article is a collection of experts’ opinion from different recognized universities, hospitals and healthcare organizations about the evidence based clinical decisions when using Waxy-Maize HES 130/0.4 (Voluven®) in various clinical situations