Discovering symptom patterns of COVID-19 patients using association rule mining

BACKGROUND: The COVID-19 pandemic is a significant public health crisis that is hitting hard on people's health, well-being, and freedom of movement, and affecting the global economy. Scientists worldwide are competing to develop therapeutics and vaccines; currently, three drugs and two vaccine candidates have been given emergency authorization use. However, there are still questions of efficacy with regard to specific subgroups of patients and the vaccine's scalability to the general public. Under such circumstances, understanding COVID-19 symptoms is vital in initial triage; it is crucial to distinguish the severity of cases for effective management and treatment. This study aimed to discover symptom patterns and overall symptom rules, including rules disaggregated by age, sex, chronic condition, and mortality status, among COVID-19 patients. METHODS: This study was a retrospective analysis of COVID-19 patient data made available online by the Wolfram Data Repository through May 27, 2020. We applied a widely used rule-based machine learning technique called association rule mining to identify frequent symptoms and define patterns in the rules discovered. RESULT: In total, 1,560 patients with COVID-19 were included in the study, with a median age of 52 years. The most frequently occurring symptom was fever (67%), followed by cough (37%), malaise/body soreness (11%), pneumonia (11%), and sore throat (8%). Myocardial infarction, heart failure, and renal disease were present in less than 1% of patients. The top ten significant symptom rules (out of 71 generated) showed cough, septic shock, and respiratory distress syndrome as frequent consequents. If a patient had a breathing problem and sputum production, then, there was higher confidence of that patient having a cough; if cardiac disease, renal disease, or pneumonia was present, then there was a higher confidence of septic shock or respiratory distress syndrome. Symptom rules differed between younger and older patients and between male and female patients. Patients who had chronic conditions or died of COVID-19 had more severe symptom rules than those patients who did not have chronic conditions or survived of COVID-19. Concerning chronic condition rules among 147 patients, if a patient had diabetes, prerenal azotemia, and coronary bypass surgery, there was a certainty of hypertension. CONCLUSION: The most frequently reported symptoms in patients with COVID-19 were fever, cough, pneumonia, and sore throat; while 1% had severe symptoms, such as septic shock, respiratory distress syndrome, and respiratory failure. Symptom rules differed by age and sex. Patients with chronic disease and patients who died of COVID-19 had severe symptom rules more specifically, cardiovascular-related symptoms accompanied by pneumonia, fever, and cough as consequents

Introduction and implementation of problem based learning in preclinical years: a survey on students’ perspective

Today’s sprouting medical technology demands that students are more innovative in their approach towards medical practice. Problem based learning (PBL) has proven to be one of the most efficacious disciplines aimed at improving problem-solving skills and self-directed learning. The objective of this study was to review students’ perspectives on the implementation and effectiveness of PBL at Avalon University School of Medicine (AUSOM). A cross-sectional questionnaires survey was conducted among basic science students with qualitative and quantitative questionnaires. The response recorded and the data analysed using Stata-15 (StataCorp LLC). Most students believed PBL was beneficial to learning. 82.18% (n=83) agreed that they benefited from PBL and 91.09 % (n=92) were in concordance PBL provided a positive learning environment to enhance their understanding. The most important objectives of PBL identified by the students were to improve the presentation skills, enhance depth of understanding and develop critical thinking. PBL is helpful in improving students understanding of the basic medical science courses, allowing for self-improvement. PBL allows students to actively engage in the collaborative active learning process. It is imperative PBL should be introduced early in pre-clinical years and implemented effectively to enhance the learning environment with the favourable outcome

Combined thoracic endovascular aortic repair and endovascular aneurysm repair and the long-term consequences of altered cardiovascular haemodynamics on morbidity and mortality: Case series and literature review

BACKGROUND: Thoracic and abdominal aortic stent grafts are firmer and more rigid than the native aorta. Aortic implanted devices have been implicated in the development of acute systolic hypertension, elevated pulse pressure, and reduced coronary perfusion. CASE SUMMARY: We report four cases of staged thoracic endovascular aortic repair (TEVAR) and then endovascular aneurysm repair (EVAR). All patients had TEVAR first for thoracic aortic aneurysm and later on developed infra-renal abdominal aortic aneurysm (AAA) that required EVAR. There were three males and one female with a median age of 74.5 years (range 67.5-78.5). None of the patients developed aortic-related major clinical adverse effects or required any aortic intervention during their follow-up. However, within 2 years, all patients developed symptomatic left ventricular hypertrophy with diastolic dysfunction. All patients had bilateral lower limb oedema, with on and off chest pain and shortness of breath (SOB), necessitating coronary angiograms, which showed no evidence of coronary artery disease. Three patients died from cardiovascular-related morbidities, and the fourth patient is still complaining of SOB despite a normal coronary angiogram. DISCUSSION: Aortic-endograft compliance mismatch is an invisible enemy, with troubling consequences for the aorta proximal and distal to the endograft. Aortic stiffness due to vascular endograft could lead to cardiovascular adverse events, even in the absence of direct aortic-related complications. After combined TEVAR and EVAR, the compliance mismatch and elasticity loss are even more pronounced than with TEVAR alone, which necessitates patient monitoring for the development of cardiovascular complications

Post cholecystectomy hemobilia: transcatheter embolization of pseudoaneurysms with homemade steel coils

Two patients presented with hemobilia, one and two months following cholecystectomy. Angiography demonstrated pseudoaneurysms arising form the gastroduodenal and right hepatic arteries. Percutaneous transcatheter embolization of the pseudoaneurysms was successfully performed in both patients using homemade steel coils

Gender Disaggregation in COVID-19 and Increased Male Susceptibility.

Novel coronavirus disease 2019 (COVID-19) is a growing public health crisis. Despite initial focus on the elderly population with comorbidities, it seems that large studies from the worst affected countries follow a sex-disaggregation pattern. Analysis of available data showed marked variations in reported cases between males and females among different countries with higher mortality in males.  At this early stage of the pandemic, medical datasets at the individual level are not available; therefore, it is challenging to conclude how different factors have impacted COVID-19 susceptibility. Thus, in the absence of patients' level data, we attempted to provide a theoretical description of how other determinants have affected COVID-19 susceptibility in males compared to females.  In this article, we have identified and discussed possible biological and behavioral factors that could be responsible for the increased male susceptibility. Biological factors include - an absence of X-chromosomes (a powerhouse for immune-related genes), a high level of testosterone that inhibits antibody production, and the presence of Angiotensin-converting enzyme 2 (ACE2) receptors that facilitate viral replication. Similarly, behavioral factors constitute - higher smoking and alcohol consumptions, low level of handwashing practices, and high-risk behavior like non-adherence to health services and reluctance to follow public health measures in males

Management of retroperitoneal fibrosis with endovascular aneurysm repair in patients refractory to medical management

BackgroundEarly diagnosis and treatment of under-recognized retroperitoneal fibrosis (RPF) are essential before reaching the poorly responsive fibrotic stage. Although most patients respond to medical therapy, relapses and unresponsiveness are common. However, open surgery in medically resistant patients is associated with major adverse clinical events.MethodsThis is a single-centre longitudinal study of optimal medical therapy (OMT) vs. endovascular aneurysm repair (EVAR) in patients presenting with RPF to our tertiary referral vascular centre. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst them, 1,006 were EVAR, TEVAR and BEVAR. Seventeen patients (1.09%) had documented peri-aortic RPF.ResultsOut of the 17 RPF patients, 11 received OMT only, while 6 underwent EVAR after the failure of OMT. 82% (n = 14) were male, and the median follow-up was 62.7 months (IQR: 28.2–106). Nine (52%) had immunoglobulin G4-related disease (4 OMT vs. 5 EVAR). EVAR patients had 100% technical success without perioperative mortality. Furthermore, all the EVAR patients were symptom-free following the intervention. Pre-operative aortic RPF index (maximum peri-aortic soft tissue diameter/maximum aortic diameter) was higher in the EVAR than in OMT. However, there was a significant decrement in the aortic RPF index following EVAR (P = 0.04).ConclusionWe believe that when optimal medical therapy fails in RPF, EVAR provides a promising outcome. Further studies are recommended to establish the role of endovascular repair

Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned

ObjectivesWe aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation.MethodsWe performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV).ResultsForty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure.ConclusionsOur re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma

Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review

BackgroundThoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.MethodsThis is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.ResultsThere were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.ConclusionAcute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS

Over the counter use of topical corticosteroid for skin conditions among patients before attending skin specialist clinic in Nepal: A qualitative study

Access to topical corticosteroids (TCs) globally includes over the counter (OTC) sale without proper guidelines, exacerbating treatment-resistant infections and complicating outcome of skin conditions. The main aim of the study was to evaluate the reasons behind OTC use of TCs among patients with skin conditions before attending a skin specialist clinic. This study was conducted from September 2021 to March 2022. The study included in-depth interviews (IDIs) and observations, among a total of thirty-one patients with specific skin conditions using TCs, at the Sarnath Skin Centre in Siddhartha Nagar (Bhairahawa), Nepal. All interviews were conducted in the Nepali language, audio-recorded, transcribed and translated into English and were coded and analyzed in NVivo. Among the 31 individuals diagnosed with Dermatophytosis, Melasma, Eczema, common treatments included use of Sonaderm (Clobetasol, Gentamycin and Miconazole), Derma-KT (Clobetasol, Gentamicin, Ketoconazole and Iodochlorhydroxyquinoline) and steroid-infused products from non-medical sources for prolonged periods of time, exposing patients to transient recovery and perpetuating a vicious cycle of OTC treatment seeking until patients failed to recover. OTC seeking was facilitated by participants’ easy access to drug dispensers, suggestions from and practice of family and friends which often led to temporary relief for a few weeks/months. In addition, access factors (e.g., distance, cost, time), convenience factors (e.g., ease of presenting at the drug store compared to skin clinic) also influenced the choice for OTC. There was a lack of knowledge related to adverse effects of topical steroids, including proper guidance on the use of topical medications and limitations of home remedies. OTC use of topical medications poses significant challenges, often leading to complicated skin cases that present late at skin-specialist clinics. A multi-pronged public and community engagement approach is critical to curb the treatment seeking dynamics among patients developing skin conditions

Non-alcoholic fatty liver disease may not be a severe disease at presentation among Asian Indians

Aim: To evaluate the clinical and biochemical profile of patients with non alcoholic fatty liver disease (NAFLD) and to assess their histological severity at presentation. Methods: Consecutive patients presenting to the liver clinic of All India Institute of Medical Sciences (AIIMS) with raised transaminases to at least 1.5 times upper limit of normal, and histologically confi rmed non-alcoholic fatty liver disease were included. Patients who had significant alcohol intake or positive markers of other liver diseases or who were taking drugs known to produce fatty liver were excluded. The clinical, biochemical and histological profi le of this group was studied. Results: Fifty-one patients with NAFLD formed the study population. Their median age and BMI were 34(17-58) years and 26.7(21.3-32.5) kg/m2 respectively and 46 (90.1%) were males. The majority of the patients had mild inflammation, either grade 1 [32 (63%)] or grade 2 [16 (31%)] and only 3 (6%) patients had severe (grade 3) infl ammation. Twenty-three (45%), 19 (37%), 8(16%) and 1(2%) patient had stage 0, 1, 2 and 3 fi brosis respectively on index biopsy and none had cirrhosis. On univariate analysis, triglyceride levels more than 150 mg % (OR = 7.1; 95% CI: 1.6-31.5, P = 0.002) and AST/ALT ratio > 1 (OR = 14.3; 95% CI: 1.4-678.5, P = 0.008) were associated with high grades of inflammation and none was associated with advanced fibrosis. On multivariate logistic regression analysis, hypertriglyceridemia >150 mg% was the only factor independently associated with presence of high grade of infl ammation (OR = 1.6; 95% CI: 1.3-22.7, P = 0.02), while none was associated with advanced fi brosis. Triglyceride levels correlated positively with infl ammatory grade (r = 0.412; P = 0.003). Conclusion: NAFLD in North Indian patients is a disease of young over-weight males, most of whom are insulin resistant and they tend to have a mild histological disease at presentation