Left brachial plexopathy after prone positioning with COVID-19: a case series

Prone positioning is a strategy shown to reduce mortality in patients who are mechanically ventilated for acute respiratory distress syndrome and has been used in the COVID-19 pandemic. It is not, however, without complications. Barotrauma, pressure sores, ventilator associated pneumonia and peripheral nerve injuries have all been implicated as complications of prone positioning. There have also been several reports of brachial plexopathy in patients who have undergone prolonged mechanical ventilation with prone positioning. Patient characteristics including body weight index, degree of critical illness, and suboptimal prolonged positioning have all been suggested as possible contributing factors, although, there has been less discussion concerning the action of rolling patients, and how it may contribute to the development of injuries. We describe 3 cases of left brachial plexus injury in patients who were consistently rolled on their left sides. Patients presented with isolated left upper extremity weakness without any structural etiology found on imaging. Electrodiagnostic studies subsequently confirmed a left brachial plexopathy in each of the cases. We suggest that the action of proning patients may contribute to injury. This observation has not yet been suggested in the literature, and carries clinical relevance, as greater attention and meticulous care may need to be employed when moving these individuals

Association between glial fibrillary acidic protein, glial- derived neurotrophic factor, and fatty acid-binding protein-2 at birth in the incidence of necrotizing enterocolitis in preterm infants

Abstract Background This study aimed to analyze the relationship between glial fibrillary acidic protein (GFAP), glial-derived neurotrophic factor (GDNF), and fatty acid-binding protein-2 (FABP-2) in preterm infants on the incidence of NEC. Methods Preterm infants with a birth weight <1,500 g and gestational age <34 weeks were included in this study. Biomarker examination was performed using the umbilical vein blood at birth (first sample). Biomarker examination was repeated if the infant developed symptoms of NEC using peripheral vein blood (second sample). Infants were observed for 14 days. If NEC did not exist, a biomarker examination was performed at 14 days. Results This study included 30 preterm infants, nine infants experienced NEC. The values of GFAP, GDNF, and FABP-2 (median and range) in the group with NEC were higher than those in the group without NEC in both the first samples {GFAP [1.40 (0.20–6.50) vs. 0.30 (0.10–1.30) P = 0.014], GDNF [2.84 (1.05–14.11) vs. 1.56 (1.07–3.48) P = 0.050], and FABP-2 [621.70 (278.40–2,207.00) vs. 294.20 (211.40–597.50) P = 0.002]} and second samples {GFAP [2.40 (0.30–3.10) vs. 0.30 (0.10–0.60) P = 0.003], GDNF [2.99 (0.56–10.30) vs. 1.46 (0.85–2.24) P = 0.019], and FABP-2 [646.8 (179.20–1,571.00) vs. 314.90 (184.70–521.60) P = 0.040]}. In infants with NEC, the median values of GFAP [2.40 (0.30–3.10) vs. 1.40 (0.20–6.50) P = 0.767], GDNF [2.99 (0.56–10.30) vs. 2.84 (1.05–14.11) P = 0.859], and FABP-2 [646.80 (179.20–1,571.00) vs. 621.70 (278.40–2,207.00) P = 0.953] in the second sample were higher than those in the first sample. Logistic regression demonstrated that GFAP at birth (Odds Ratio [OR] = 15.629, 95% Confidence Interval [CI] = 1.697–143.906, P = 0.015) and FABP-2 levels at birth (OR = 1.008, 95% CI = 1.001–1.015, P = 0.033) were significantly associated with an increased risk of NEC. Conclusion Increased GFAP, GDNF, and FABP-2 at birth are associated with NEC occurrence within two weeks of birth. These findings suggest that early-onset NEC is associated with intestinal injury that occurs during the perinatal or even prenatal period

Association Between Depression, Anxiety, and Stress with Sleep Quality in Indonesian People During the COVID-19 Pandemic

Background: To prevent the spread of COVID-19, authorities implemented health protocols such as quarantine, large-scale social restrictions, and lockdowns. Data on the psychological effects and sleep quality as a result of these health protocols are still limited.Objective: This study was aimed to determine the association between depression, anxiety, and stress with sleep quality during the COVID-19 pandemic in Indonesia.Methods: An online survey was used to do a cross-sectional study among students in Indonesia. Sociodemographic information, including age, gender, religion, level of education, and regions, was analyzed. Levels of depression, anxiety, and stress were measured using the DASS-21 questionnaire. Sleep quality was determined using Pittsburgh Sleeping Quality Index (PSQI) questionnaire. Chi-square was used to evaluate the variables for bivariate analysis and logistic regression for multivariate analysis.Results: A total of 913 participants from across Indonesia included to this study. Adolescent (OR=0.367, 95% CI=0.199-0.679), female (OR=1.437, 95% CI=1.095-1.886), and high school students (OR= 0.737, 95% CI=0.544-0.999) had a higher risk for having poor sleep quality. In the multivariate analysis there were significant relationship between sleep quality with depression (Adjusted OR= 1.887, 95% CI=1.330-2.679), anxiety (Adjusted OR=1.731, 95% CI=1.221-2.455), stress (Adjusted OR= 2.577, 95% CI=1.617-4.107), use of sleeping medication (Adjusted OR=9.070, 95% CI=2.062-39.896) and age (Adjusted OR= 0.414, 95% CI= 0.205-0.837).Conclusion: There was an association between depression, anxiety, stress, consumption of sleeping medication, age, and poor sleep quality during the pandemic in Indonesia

A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity.

Objective To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. Design We used the Delphi method. Setting A multiquestion electronic survey. Participants Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. Interventions After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. Main Outcome Measures Not applicable. Results When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. Conclusions These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature