Emergency presentations of melioidosis in Hospital USM : a ten-year review

Introduction Melioidosis emerged as a global problem, however, few studies have specifically described the clinical characteristics and outcomes when patients with melioidosis are treated at an Emergency Department (ED). Melioidosis is a tropical infectious disease caused by Gram-negative bacteria Burkholderia pseudomallei. The prompt diagnosis of melioidosis is a great challenge to ED physicians because of the disease’s diverse clinical presentations. The most common organ affected by this organism is lungs. However, it is very difficult to differentiate clinically the pneumonia causes by melioidosis with other organisms. It is postulated that heavy rainfall with strong winds brings buried B. pseudomallei isolates to the soil surface; thereafter, they are more likely to be inhaled at high concentrations of the bacteria resulted in severe septic shock and early mortality. This study aimed to determine the clinical characteristics and laboratory profiles of patients with melioidosis that attended ED, Hospital Universiti Sains Malaysia(HUSM), Kelantan. Methodology This is a retrospective cohort study (record review). All patients presented to ED, HUSM from January 2001 till December 2011 with positive culture for melioidosis were included in the study. Data collected via hospital’s computerized microbiology database (WHO-net program) for candidate individuals with melioidosis. Data entered and analyzed by using SPSS version 19.0 to generate descriptive and analytical statistics. Results A total of 86 patients were reviewed. Median age of the cases was 51 years old, males (79.1%) and Malays (96.5%). About 91.9% of the patients presented with fever, followed with cough (62.8%), and shortness of breath (25.6%). Majority of the organ involved were lung (65.1%), soft tissue (19.8%), liver (18.6%), and joints (11.6%). Base on symptoms, there were significant association for cough (p=0.02), shortness of breath (p=0.001) and abscess (p=0.030) with the outcomes. Even though the most common risk factors were diabetes (79.1%), followed with rainy season (55.8%) and soil exposure (36%), there was no significant associations between risk factors and outcomes. All physical findings is significantly associated with the outcomes except for temperature (p>0.05). Overall, all laboratory profiles of melioidosis patients were deranged or prolonged. The only significant association were urea (p=0.001), creatinine (p=0.001), AST (p=0.002) and PT/INR (p=0.001). In term of empirical antibiotic usage and time lag before initiation of therapy,there was no significance associations (p>0.05) with the outcomes. The absence of shortness of breath (p=0.017), systolic blood pressure (p=0.049), diastolic blood pressure (p=0.018) and PT/INR (p=0.012) were the main predictor for the patients to recover from melioidosis. Therefore, predictor model for recovery among melioidosis patient is: Recovery (z) = 5.161 (No SOB) -0.074 (SBP) + 0.186 (DBP) – 7.010 (PT/INR) The Nagelkerke R Square shows that about 76% of the variation in the outcome variable (recovery) is explained by this logistic model and the overall accuracy of this model to predict subjects to recover (with a predicted probability of 0.5 or greater) is 87.7%. Conclusion The clinical presentations and laboratory profiles can predict the outcomes of patient with melioidosis. There was no significant association between empirical usage of antibiotics and time lag before initiation of antimelioid therapy with the outcomes of melioidosis patients

Patient Ability to Use Old versus New/Modified Model Adrenaline Autoinjection Emergency Medical Devices for Anaphylaxis in Prehospital Setting: A Systematic Review and Meta-Analysis

Background: The goal of this study was to determine the individual’s ability to use new/modified model AAI compared to old model AAIs devices for anaphylaxis. Methods: The protocol was established a priori and published on PROSPERO (CRD42021229691) and was conducted based on PRISMA guidelines. MEDLINE and CENTRAL were searched until 31 January 2021. Only RCTs were included in this review. Primary studies comparing old model AAI to new/modified model AAI emergency medical devices were included. Primary outcomes included number of successful administrations, and number of individuals to complete all steps. Secondary outcomes included successful removal of device safety guards, placement of correct end of the device against the thigh and holding of the device in place for adequate time after administration; the frequency of an adverse event (digital injection); individual preferences in terms of size, individual preference in terms of ease for carrying, overall patient preference; and the mean time of delivery. Results: Overall, seven trials consisting of 1359 patients were analyzed. Reporting of adverse events was limited to digital injection, which was significantly higher in the old model AAI (RR 6.90, 95% CI 3.27 to 14.57; I2 statistic = 0%; p < 0.001; four trials, 610 participants; high quality evidence). No significant difference was found regarding successful administration between the old model AAI and new/modified model AAI (RR 0.76, 95% CI 0.52 to 1.11; I2 statistic = 96%; p = 0.16; seven trials, 2196 participants; low quality evidence). Conclusions: We cannot make any new recommendations on the effectiveness of different models of AAIs regarding successful administration. However, considering the aspect of safety, we think that mew/modified model AAI can be chosen as the old model AAI was associated with a higher frequency of the adverse event (digital injection)

Norepinephrine in Septic Shock: A Systematic Review and Meta-analysis

Introduction: Most experts recommend norepinephrine as the first-line agent in septic shock. Our objective was to determine the effectiveness and safety of norepinephrine in patients with septic shock.Methods: We searched the Cochrane Central Register of Controlled Trials and Epistemonikos, as well as MEDLINE from 1966 till August 2019. Screening of full texts, evaluation for eligibility, and data extraction were done by four independent reviewers. We estimated risk ratios (RR) and mean differences (MD) using a random-effects model with 95% confidence intervals (CI). The primary outcomes included the number of participants who achieved the target mean arterial pressure (MAP), time to achieve the target MAP, and number of participants with all-cause 28-day mortality. The secondary outcomes included the length of stay in the intensive care unit, length of hospital stay, incidence of arrhythmia and myocardial infarction, vasopressor-free days, and number of participants with all-cause 90-day mortality.Results: We identified 11 randomized controlled trials with a total of 4,803 participants. There was no difference in the number of participants who achieved the target MAP between those patients receiving norepinephrine and other vasopressors (RR 1.44; 95% CI, 0.32 to 6.54; P = 0.640; I2 = 94%; two trials, 116 participants). There was no significant difference in time to achieve the target MAP (MD -0.05; 95%, CI, -0.32 to 0.21; P = 0.690; I2 = 26%; two trials, 1763 participants) and all-cause 28-day mortality (RR 0.95; 95% CI, 0.89 to 1.02; P = 0.160; I2 = 0%; seven trials, 4,139 participants). Regarding the secondary outcome, norepinephrine may significantly reduce the incidence of arrhythmia as compared to other vasopressors (RR 0.64; 95% CI, 0.42 to 0.97; P = 0.030; I2 = 64%; six trials, 3974 participants). There was no difference in the incidence of myocardial infarction (RR 1.28; 95% CI, 0.79 to 2.09), vasopressor-free day (RR 0.46; 95% CI, -1.82 to 2.74) and all-cause 90-day mortality (RR 1.08; 95% CI, 0.96 to 1.21) between norepinephrine and vasopressors.Conclusion: In minimizing the occurrence of an arrhythmia, norepinephrine is superior to other vasopressors, making it safe to be used in septic shock. However, there was insufficient evidence concerning mortality and achievement of the target MAP outcomes

Patient-controlled analgesia morphine for the management of acute pain in the emergency department: a systematic review and meta-analysis

Abstract Background The ideal pain control approach is typically viewed as titration of analgesia for pain reduction and periodic pain evaluation. However, this method takes time and is not always possible in the crowded Emergency Department. Therefore, an alternative way to improve pain care in the Emergency Department is needed to avoid this unpleasant sensation in the patients. The best solution to tackle this situation is using Patient Controlled Analgesia (PCA), in the form of a PCA pump. Study objectives This systematic review and meta-analysis was designated to evaluate the efficacy of PCA morphine in treating acute pain at Emergency Department. Methods We searched databases Cochrane Central Register of Controlled Trials (CENTRAL), Medline, and Google Scholar up to February 2022 and identified randomized controlled trials with English language only that compare PCA morphine to IV morphine in treating patients presenting with acute pain at Emergency Department. Results Eight trials were included in our review, comprising 1490 participants. We compared PCA morphine vs. IV morphine. There were no differences in the pain score between PCA and IV morphine (standard mean difference [SMD] = -0.20, p = 0.25). Further subgroup analyses (origin of the pain, time of assessment and the durations) showed no difference except for the dosages as the PCA morphine reduced the pain compared to IV morphine in low and high dosages but only two studies were involved. However, the analysis showed PCA morphine increased patient satisfaction and reduced the number of patients who required additional analgesia compared to IV morphine (MD 0.12, P < 0.001), (MD 0.47, P < 0.001) respectively. Data obtained in this review pertaining to adverse effects such as nausea, vomiting, pruritus, and drowsiness is limited since not all the trials reported the events. Conclusions PCA morphine do appear to have a beneficial effect on the outcome of patient satisfaction and the number of patients who required additional analgesia. However, further studies targeting a larger sample size is required to increase the certainty of the evidence