A prospective study correlating fluid balance and outcome in critically ill patients

Background: Fluid administration can be lifesaving as fluid accumulation after initial resuscitation and stabilization of hemodynamics can lead to avoidable adverse effects and less favorable outcomes.Objective: The aim of the work was to evaluate whether even fluid balance in comparison to negative or even fluid status is correlated with increased morbidity and mortality rates in critically ill patients.Patients and Methods: An observational prospective study was done on 145 patients older than eighteen years, admitted to the general intensive care (Medical & Surgical ICU) units in Helwan University Hospitals and Ain Shams University Hospitals during the period from November 2020 till May 2021.Results: One hundred twenty-four patients (85.5%) who survived, having the median cumulative fluid balance of -110ml (IQR-2.1 – 2.2L) after four days following randomization while the median cumulative fluid balance of the 21 patients (14.5%) who didn’t survive was 3800 ml (IQR 1.7-5.2L), after four days of ICU admission. Fluid balance more than 1.2 liters per day in our study had higher ICU complications: Increased risk of AKI, longer ICU and hospital stays, mechanical ventilation and fluid balance was an independent factor associated with increased mortality.Conclusion: It could be concluded that negative fluid balance for 4 days in critically ill patients was associated with less length of stay in the general ICU, and less mechanical ventilation duration, while positive fluid balance, leads to higher mechanical ventilation duration, vasopressors requirements, and significantly associated with higher mortality

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

Employing 18F-FDG PET/CT for distinguishing benign from metastatic adrenal masses

Background: Metastatic adrenal disease can occur in a wide diversity of malignancies. Distinguishing benign from metastatic adrenal masses in oncologic patients is vital. Objective: To appraise the 18F-FDG PET/CT performance for distinguishing benign from metastatic adrenal masses. Material and methods: In the current prospective study, 21 patients with proven extra-adrenal primary malignancy, having adrenal masses ≥10 mm on the axial CT images of their PET/CT examinations, were enrolled. Positive PET findings for malignancy were considered if the mass showed FDG uptake equivalent to or more prominent than the FDG liver uptake. Alternatively, negative PET findings for malignancy were considered if the mass showed FDG uptake not as much of the FDG liver uptake. Afterward, the obtained results were correlated with serial imaging follow-up or histopathological diagnosis by surgery or percutaneous biopsy as the diagnostic standard of reference. Results: An overall number of 24 adrenal masses was diagnosed. Positive PET/CT results were found in 14 adrenal masses. All were finally considered to be metastases by serial imaging follow-up (n = 8) and histopathological analysis by surgery (n = 1) and percutaneous biopsy (n = 5). Accordingly, no false positive result was obtained. Negative PET/CT results were observed in 10 adrenal masses, 9 of them were finally confirmed to be benign by serial imaging follow-up. The remaining mass was finally confirmed to be metastasis by percutaneous biopsy and hence, it represented the false negative result. 93% sensitivity, 100% specificity and 96% accuracy for identifying adrenal metastases were obtained. Conclusion: 18F-FDG PET/CT is a precise, non invasive modality for distinguishing benign from metastatic adrenal masses in oncologic patients

Psoriasis: is it a risk factor for cardiovascular diseases?

Background/objectives Psoriasis, newly considered as a systemic inflammatory condition, has a high prevalence of cardiovascular diseases (CVDs), including atherosclerosis and myocardial infarction. Measurement of carotid artery intima-media thickness (C-IMT) represents a noninvasive diagnostic tool for predicting cardiovascular disorders. We aimed to determine if psoriatic patients have an increased risk for the development of cardiovascular disorders by assessment of the presence of subclinical atherosclerosis in psoriasis patients. Methods Forty adult psoriatic patients and 40 matched healthy controls were selected in this study. All participants were subjected to full history, examination, assessment of the severity of psoriasis using psoriasis area and severity index (PASI) score, measuring serum lipid profile (cholesterol, low density lipoprotein (LDL) and triglycerides) and C-IMT. Results Psoriatic patients showed significantly higher serum lipid profile findings and C-IMT. There was a positive statistically significant correlation between C-IMT and each of age of the patients (r = 0.760, p<.001) and severity of psoriasis (PASI score). Conclusions There is increased susceptibility to CVDs in psoriatic patients represented by increased incidence of subclinical atherosclerosis and dyslipidemia in our patients

40. Optical coherence tomography correlates of complex lesions evaluated by coronary angiography in patients with acute coronary syndromes

Plaque rupture (PR) and superimposed thrombosis have been shown as the most frequent underlying substrate in acute coronary syndromes (ACS). Coronary angiography is a luminogram that is not able to define in-vivo features of the culprit plaques. The aim of the study was to use optical coherence tomography (OCT) to investigate the pathology underlying complex (CL) and non-complex angiographic lesions (NCL). Methods: We retrospectively enrolled 107 ACS patients admitted to our institution; 83 with Non-ST elevation ACS (NSTE-ACS) and 24 with ST-elevation myocardial infarction (STEMI). Coronary angiography was performed and culprit lesions were classified according to Ambrose criteria into NCL (n = 47) and CL (n = 60). In STEMI patients, angiographic and OCT analysis were performed after mechanical thrombus aspiration. OCT analysis of these culprit lesion was performed to identify plaque morphology; either PR or intact fibrous cap (IFC), as well as the presence of superimposed thrombosis, lipid rich plaque, thin cap fibroatheroma (TCFA), and minimal lumen area (MLA). Results: OCT analysis showed that 58 lesions (54.2%) were classified as PR and 48 lesions (44.9%) were associated with thrombi. Lipid rich plaques were identified in 62 culprit plaques (57.9%). PR, intracoronary thrombi, lipid rich plaques and thin cap fibroatheroma (TCFA) were more frequent in CL compared with NCL (71.7% vs 31.9%, 63.3% vs 21.3%, 71.7% vs 40.4% and 46.7% vs 21.3% respectively). PR (31.9%) with superimposed thrombus (21.3%) may be also detected in NCL. In STEMI patients, there was no significant difference regarding OCT plaque features between NCL and CL. Conclusion: In conclusion, OCT demonstrates PR and thrombosis in the majority of ACS patients presenting with CL. Of note, one third of NCL has PR and thrombosis by OCT. In STEMI, coronary angiography is of limited utility in identifying PR by means of CL and should be implemented with OCT to tailor future therapies