Hypocalcemia in COVID-19: A prognostic marker for severe disease

Background & Objective: Previous studies have addressed the electrolyte abnormalities such as hypocalcemia in COVID-19 patients. We aimed to compare the laboratory findings especially the electrolyte levels among COVID-19 patients and healthy controls and evaluate their prognostic values. Methods: This case-control study included 91 COVID-19 patients and 169 healthy individuals. Their laboratory parameters including electrolytes, albumin, liver enzymes, complete blood count, vitamin D, and parathyroid hormone (PTH) were compared. We also analyzed the association between these markers and the major outcomes including severity, mortality and hospitalization. Results: Among patients with COVID-19, 59.3 of the patients had hypocalcemia on admission while in control group only 32.5 had low calcium level (OR=3.02, 95 CI: 1.79-5.13, P<0.001). The rates of death and ICU admission were significantly higher among the patients in hypocalcemic group than those of eucalcemic group (85.7 vs 14.3 and 33.3 Vs 9.1, respectively). However, there was no significant difference in the mean PTH and vitamin D levels between the two groups. In terms of the severity of the infection, 74.1 of patients in hypocalcemic group had a severe infection while 24.3 of the patients in eucalcemic group were diagnosed with severe infection (OR=8.89, 95 CI: 3.38-23.37, P<0.001). Conclusion: Patients with COVID-19 may present with considerable laboratory abnormalities including hypocalcemia. The hypocalcemia would be also associated with worse major clinical outcome and higher mortality risk

Conceptualization of category-oriented likelihood ratio: a useful tool for clinical diagnostic reasoning

<p>Abstract</p> <p>Background</p> <p>In the diagnostic reasoning process medical students and novice physicians need to be made aware of the diagnostic values of the clinical findings (including history, signs, and symptoms) to make an appropriate diagnostic decision. Diagnostic reasoning has been understood in light of two paradigms on clinical reasoning: <it>problem solving </it>and <it>decision making</it>. They advocate the reasoning strategies used by expert physicians and the statistical models of reasoning, respectively. Evidence-based medicine (EBM) applies <it>decision theory </it>to the clinical diagnosis, which can be a challenging topic in medical education.</p> <p>This theoretical article tries to compare evidence-based diagnosis with expert-based strategies in clinical diagnosis and also defines a novel concept <it>of category-oriented likelihood ratio (LR) </it>to propose a new model combining both aforementioned methods.</p> <p>Discussion</p> <p>Evidence-based medicine advocates the use of quantitative evidence to estimate the probability of diseases more accurately and objectively; however, the published evidence for a given diagnosis cannot practically be utilized in primary care, especially if the patient is complaining of a nonspecific problem such as abdominal pain that could have a long list of differential diagnoses. In this case, expert physicians examine the key clinical findings that could differentiate between broader categories of diseases such as organic and non-organic disease categories to shorten the list of differential diagnoses. To approach nonspecific problems, not only do the experts revise the probability estimate of specific diseases, but also they revise the probability estimate of the <it>categories of diseases </it>by using the available clinical findings.</p> <p>Summary</p> <p>To make this approach analytical and objective, we need to know how much more likely it is for a key clinical finding to be present in patients with one of the diseases of a specific category versus those with a disease not included in that category. In this paper, we call this value <it>category-oriented LR</it>.</p

Evidence-based history taking under “time constraint”

Physicians all through the world visit patients under time limitations. The most important troubled clinical skill under “time constraint” is the diagnostic approach. In this situation, clinicians need some diagnostic approaches to reduce both diagnostic time and errors. It seems that highly experienced physicians utilize some special tactics in this regard. Evidence-based medicine (EBM) as a relatively new paradigm for clinical practice stresses on using research evidences in diagnostic evaluations. The authors aimed to evaluate experts’ strategies and assess what EBM can add to these tactics. They reviewed diagnostic strategies of some veteran internists in their busy outpatient clinics and proposed an evidence-based diagnostic model engaging clinical experience and research evidence. It appears that every clinician utilizes a set of “key pointer” questions for decision-making. In addition to use of evidence-based resources for making differential diagnosis and estimating utility of various diseases, clinicians should use “key pointers” with significant likelihood ratios and from independent systems to reduce time and errors of history taking. Clinical trainees can improve their practice by constructing their own set of pointers from valid research evidences. Using this diagnostic model, EBM can help physicians to struggle against their “time constraint”

The Ethical Considerations in the Main Practices of the Iranian Legal Medicine Organization: A Qualitative Study

Background: Effective and acceptable practice in Legal Medicine (LM) requires special attention to ethical and professional behaviors. In LM, the importance of practitioners’ compliance with ethical standards is higher. LM covers a wide range of practices, requiring specific ethical considerations. This study aims to identify the ethical principles for considerations in Iranian Legal Medicine Organization (ILMO) from the perspective of experts in LM. Methods: This is an applied and qualitative study using in-depth interviews and conventional content analysis. The study was conducted in three steps: 1) Determination of the main areas of work by reviewing academic texts، surveying 131 experts in this field with a questionnaire. 2) Qualitative Study for determination of ethical considerations of these areas by structured and in-depth interviews with 49 owner’s Forensic and medical ethics experts obtained by purposive sampling and theoretical saturation and analysis of interviews by the conventional approach of content analysis to specify propositions and confirm the reliability of 80% research in coding through the double-coder agreement method. 3) Drafting ethical guidelines by the research group (students، supervisors، and consultants) in the focus group meetings based on the results of the second step.Results: The ethical principles of LM were categorized as general and specific principles according to the perspective of experts in LM. General ethical principles included virtue ethics, professional and ethical behavior, and proper environment and working conditions. The specific ethical principles included six principles related to the entire organization, legal physical examinations, legal mental examinations, dissection rooms and crime scenes, LM laboratories, and LM commissions.Conclusion: Developing and implementing general and specific ethical guidelines for ILMO is recommended. The comprehensive and holistic view of ethical considerations for main practices of LM in Iran provided by this study can be seen as a good taxonomy and a preliminary step to develop local ethical guidelines

Integration of Cognitive Skills as a Cross-Cutting Theme Into the Undergraduate Medical Curriculum at Tehran University of Medical Sciences

Nowadays, improvement of thinking skills of students is one of the universally supported aims in the majority of medical schools. This study aims to design longitudinal theme of reasoning, problem-solving and decision-making into the undergraduate medical curriculum at Tehran University of Medical Sciences (TUMS). A participatory approach was applied to design the curriculum during 2009-2011. The project was conducted by the contribution of representatives of both basic and clinical faculty members, students and graduates at Tehran University of Medical Sciences. The first step toward integrating cognitive skills into the curriculum was to assemble a taskforce of different faculty and students, including a wide variety of fields with multidisciplinary expertise using nonprobability sampling and the snowball method. Several meetings with the contribution of experts and some medical students were held to generate the draft of expected outcomes. Subsequently, the taskforce also determined what content would fit best into each phase of the program and what teaching and assessment methods would be more appropriate for each outcome. After a pilot curriculum with a small group of second-year medical students, we implemented this program for all first-year students since 2011 at TUMS. Based on findings, the teaching of four areas, including scientific and critical thinking skills (Basic sciences), problem-solving and reasoning (Pathophysiology), evidence-based medicine (Clerkship), and clinical decision-making (Internship) were considered in the form of a longitudinal theme. The results of this study could be utilized as a useful pattern for integration of psycho-social subjects into the medical curriculum