Positive pressure-assisted pleural aspiration: A case report of a novel procedure and a review of literature.

Drainage of a pleural effusion is done either by inserting an intercostal tube or by aspirating pleural fluid using a syringe. The latter is a time-consuming and labour-intensive procedure. The serious complications of pleural aspiration are the development of a pneumothorax and re-expansion pulmonary oedema. We describe an observation made during a pleural aspiration in a patient who was on positive pressure ventilation. We explain the physiological basis for the observation, the safety of the procedure and its potential to reduce complications by reviewing the literature. A 56-year-old Sri Lankan female patient with end-stage kidney disease presented with fluid overload and bilateral pleural effusions. She was found to have concurrent COVID pneumonia. The patient was on bilevel positive airway pressure, non-invasive ventilation when pleural aspiration was done. The pleural fluid drained completely without the need for aspiration, once the cannula was inserted into the pleural space. One litre of fluid drained in 15 min without the patient developing symptoms or complications. Positive pressure ventilation leads to a supra-atmospheric (positive) pressure in the pleural cavity. This leads to a persistent positive pressure gradient throughout the procedure, leading to complete drainage of pleural fluid. Pleural fluid drainage in mechanically ventilated patients has been proven to be safe, implying the safety of positive pressure ventilation in pleural fluid aspiration and drainage. It further has the potential to reduce the incidence of post-aspiration pneumothorax by reducing the pressure fluctuations at the visceral pleura. Re-expansion pulmonary oedema is associated with a higher negative pleural pressure during aspiration, and the use of positive pressure ventilation can theoretically prevent re-expansion pulmonary oedema. Positive pressure ventilation can reduce the re-accumulation of the effusion as well. We suggest utilizing positive pressure ventilation to assist pleural aspiration in suitable patients.

Positive pressure–assisted pleural aspiration: A case report of a novel procedure and a review of literature

Drainage of a pleural effusion is done either by inserting an intercostal tube or by aspirating pleural fluid using a syringe. The latter is a time-consuming and labour-intensive procedure. The serious complications of pleural aspiration are the development of a pneumothorax and re-expansion pulmonary oedema. We describe an observation made during a pleural aspiration in a patient who was on positive pressure ventilation. We explain the physiological basis for the observation, the safety of the procedure and its potential to reduce complications by reviewing the literature. A 56-year-old Sri Lankan female patient with end-stage kidney disease presented with fluid overload and bilateral pleural effusions. She was found to have concurrent COVID pneumonia. The patient was on bilevel positive airway pressure, non-invasive ventilation when pleural aspiration was done. The pleural fluid drained completely without the need for aspiration, once the cannula was inserted into the pleural space. One litre of fluid drained in 15 min without the patient developing symptoms or complications. Positive pressure ventilation leads to a supra-atmospheric (positive) pressure in the pleural cavity. This leads to a persistent positive pressure gradient throughout the procedure, leading to complete drainage of pleural fluid. Pleural fluid drainage in mechanically ventilated patients has been proven to be safe, implying the safety of positive pressure ventilation in pleural fluid aspiration and drainage. It further has the potential to reduce the incidence of post-aspiration pneumothorax by reducing the pressure fluctuations at the visceral pleura. Re-expansion pulmonary oedema is associated with a higher negative pleural pressure during aspiration, and the use of positive pressure ventilation can theoretically prevent re-expansion pulmonary oedema. Positive pressure ventilation can reduce the re-accumulation of the effusion as well. We suggest utilizing positive pressure ventilation to assist pleural aspiration in suitable patients.

Symptomatology of COVID-19 - Lessons from a meta-analysis across 13 countries

Background: COVID-19 pandemic has resulted in varying clinical manifestations and mortality rates. There is no consensus on the symptomatology that would guide researchers and clinicians. Aims and Objectives: The objective was to identify symptoms and their frequencies of COVID-19 with a meta-analysis of studies from several countries. Materials and Methods: Data sources: A systematic review using PubMed and Google Scholar data sources and reference tracing were used to identify 7176 articles. Eligibility criteria: Suitable articles were selected manually with selection criteria and 14 original articles included in meta-analysis. Data abstraction and analysis: PRISMA guidelines used for data abstraction and a table was generated by feeding it with numbers and proportions of each symptom described. A meta-analysis was carried out using random effect models on each symptom separately across the studies and their prevalence rates and 95% confident intervals were calculated. Results: Selected 14 studies, either cross-sectional or cohort studies are analyzed. There were 2,660 confirmed cases of COVID-19. The majority were from China (n=2,439, 91.7%) and remainder from the Netherlands, Italy, Korea, and India and one article from Europe. There were a total of 32 symptoms identified from the meta-analysis and additional 7 symptoms were identified from reference searching. The most common symptoms were (prevalence >50%): fever (79.56%, 95% CI: 72.17-86.09%), malaise (63.3%, 95% CI: 53.1-73.0%), cough (56.7%, 95% CI: 48.6-64.6%), and cold (55.6%, 95% CI: 45.2-65.7%). Symptoms of intermediate incidence (5-49%) were anosmia, sneezing, ocular pain, fatigue, sputum production, arthralgia, tachypnea, palpitation, headache, chest tightness, shortness of breath, chills, myalgia, sore throat, anorexia, weakness, diarrhea, rhinorrhea, dizziness, nausea, altered level of consciousness, vomiting, and abdominal pain. Rare symptoms (<5%): tonsil swelling, hemoptysis, conjunctival injection, lymphadenopathy, and rash. Conclusion: We found (25/32, from meta-analysis) symptoms to be present in =5% of cases which could be considered as "typical" symptoms of COVID-19. The list of symptoms we identified is different from those documents released by the WHO, CDC, NHS, Chinese CDC, Institute Pasteur and Mayo Clinic. The compiled list would be useful for future researchers to document a comprehensive picture of the illness. [ABSTRACT FROM AUTHOR] Copyright of Asian Journal of Medical Sciences is the property of Manipal Colleges of Medical Sciences and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

COVID-19 and future pandemics: a global systems approach and relevance to SDGs.

BACKGROUND: The COVID-19 pandemic is adversely impacting modern human civilization. A global view using a systems science approach is necessary to recognize the close interactions between health of animals, humans and the environment. DISCUSSION: A model is developed initially by describing five sequential or parallel steps on how a RNA virus emerged from animals and became a pandemic: 1. Origins in the animal kingdom; 2. Transmission to domesticated animals; 3. Inter-species transmission to humans; 4. Local epidemics; 5. Global spread towards a pandemic. The next stage identifies global level determinants from the physical environments, the biosphere and social environment that influence these steps to derive a generic conceptual model. It identifies that future pandemics are likely to emerge from ecological processes (climate change, loss of biodiversity), anthropogenic social processes (i.e. corporate interests, culture and globalization) and world population growth. Intervention would therefore require modifications or dampening these generators and prevent future periodic pandemics that would reverse human development. Addressing issues such as poorly planned urbanization, climate change and deforestation coincide with SDGs such as sustainable cities and communities (Goal 11), climate action (Goal 13) and preserving forests and other ecosystems (Goal 15). This will be an added justification to address them as global priorities. Some determinants in the model are poorly addressed by SDGs such as the case of population pressures, cultural factors, corporate interests and globalization. The overarching process of globalization will require modifications to the structures, processes and mechanisms of global governance. The defects in global governance are arguably due to historical reasons and the neo-liberal capitalist order. This became evident especially in the aftermath of the COVID-19 when the vaccination roll-out led to violations of universal values of equity and right to life by some of the powerful and affluent nations. A systems approach leads us to a model that shows the need to tackle several factors, some of which are not adequately addressed by SDGs and require restructuring of global governance and political economy.

Lessons from the frontlines: a junior doctor's experience of the first wave of the COVID-19 pandemic in a resource-limited setting.

COVID-19 has stressed healthcare systems across the globe. We present the experience of an intern medical officer working in a tertiary care hospital during the first wave of the pandemic in Sri Lanka. Her narrative describes how the stress of the pandemic brought into sharp focus the strengths and weaknesses in the health system. We suggest some strategies to improve our health services as the world faces the second wave and an uncertain future. These include structural changes in healthcare services at institutional and national levels, focused educational programmes for healthcare professionals to impart generic skills of disaster management, and the development of telehealth services and computerisation of health systems. We believe that we must maintain this focus to ensure that our patients can be guaranteed quality healthcare in the future.

Features of Covid-19 patients detected during community screening: A study from a rural hospital in Sri Lanka.

ABSTRACT: We studied the clinical course and virus shedding of all patients referred to Welikanda Hospital, in one month. There were 53 positives for Covid-19 by PCR. 24 (45%) were male, with an age range of 11-94 years. Of these, 41 (77%) were asymptomatic, 9 had cough, 4 had sore throat and six had fever. Pulse, blood pressure, respiratory rate and capillary oxygen were normal in all. A proportion of them had poor prognostic factors: asthma (n=4), hypertension (n=11), age above 60 years (n=9), and diabetes (n=11). Lymphopenia was seen in 20 and elevated CRP in 14. Viral shedding continued beyond 14 days in several persons and continued in symptomatic patients for a significantly longer time than asymptomatic patients. Covid-19 was an asymptomatic or mild illness in this group of people. Several of them continued to be RT-PCR positive even after 14 days. Such cases are an important source of community spread.

Ethical Responses to the COVID-19 Pandemic-Lessons from Sri Lanka.

The COVID-19 pandemic has undoubtedly become an era-defining challenge for the entire world. It has implications not only in the public health sector but also in the global economy and political landscape. The prevention strategy that has been followed in Sri Lanka is unique. Early action taken by the government and the ministry of health, being one of pre-emptive quarantining and isolation of suspected contacts even before they developed symptoms, was vital to contain the spread of the disease. During the early phase, a nationwide lockdown in the form of a curfew was imposed which helped mitigate the spread of the virus. However, due to several lapses, there was a threat of community transmission; this was swiftly brought under control through ongoing government interventions. Thus, strict social/physical distancing measures enforced by the government, together with an increase in testing capacity, prevented widespread community transmission. Strictly containing the outbreaks as and when they were identified made it easier to bring the spread under control through contact tracing. In this article, we give an account of the strategy taken by Sri Lanka to mitigate the pandemic and comment on the lessons learned concerning the ethical responses to the COVID-19 crisis.

Non-invasive assessment of endothelial dysfunction: A novel method to predict severe COVID-19?

The COVID-19 pandemic caused by the SARS-CoV-2 virus has infected millions and overburdened the healthcare infrastructure globally. Recent studies show that the endothelial dysfunction caused by the virus contributes to its high morbidity and mortality. A parameter that can identify patients who will develop complications early will be valuable in patient management and reducing the burden on medical resources. An emerging technology is currently being tested to predict the cardiovascular risk via non-invasively measuring the endothelial dysfunction. This paper reviews how the assessment of endothelial dysfunction using this technology can be used as a potential parameter in the prognostication and management of COVID-19 patients.

Hydroxychloroquine for post-exposure prophylaxis of COVID-19 among naval personnel in Sri Lanka: study protocol for a randomized, controlled trial.

BACKGROUND: The first case of a coronavirus 2019 (COVID-19) infection in a Sri Lankan was reported on March 11, 2020. The situation in Sri Lanka changed with the rapid increase of personnel contracting COVID-19 in a naval base camp that housed more than 4000 people. This provided a unique opportunity to study the effectiveness of hydroxychloroquine (HCQ) for post-exposure prophylaxis (PEP), while taking stringent, non-pharmacologic, public health measures to prevent spread. Our aim is to study the effectiveness and safety of HCQ for PEP among naval personnel with exposure to COVID-19-positive patients. METHODS/DESIGN: This is a placebo-controlled, randomized, clinical trial carried out in the naval base camp and quarantine centers of the Sri Lanka Navy, Ministry of Defense, Sri Lanka. Navy personnel who are exposed to a patient with confirmed COVID-19 infection but test negative for the virus on reverse real-time polymerase chain reaction (rRT-PCR) at recruitment will be randomized, 200 to each arm, to receive HCQ or placebo and monitored for the development of symptoms or rRT-PCR positivity for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus for 14 days. DISCUSSION: This trial will provide high-quality evidence of the effectiveness and safety of HCQ as PEP for COVID-19. The study design is unique due to the circumstances of the outbreak in a confined area among otherwise healthy adults, at a relatively early stage of its spread. TRIAL REGISTRATION: Sri Lanka Clinical Trials Registry (SLCTR) SLCTR/2020/011 . Registered on 04 May 2020.

Is the anti-filarial drug diethylcarbamazine useful to treat COVID-19?

SARS-CoV-2 virus has resulted in a devastating pandemic of COVID-19. Exploring compounds that could offer a breakthrough in treatment is the need of the hour. Re-positioning cheap, freely available and safe drugs is a priority. The paper proposes evidence for the potential use of diethylcarbamazine (DEC) in the treatment of COVID-19. DEC has inhibitory effects on arachidonic acid metabolism to prostaglandins, little known anti-viral effects on animal retroviruses and demonstrated anti-inflammatory actions in animal models of lung inflammation indicating the need to explore this hypothesis further. We believe this is the first time DEC is being proposed to treat COVID-19.

Slum Health: Arresting COVID-19 and Improving Well-Being in Urban Informal Settlements.

The informal settlements of the Global South are the least prepared for the pandemic of COVID-19 since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing are already in short supply or non-existent. Further, space constraints, violence, and overcrowding in slums make physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely. Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Here, we offer a set of practice and policy suggestions that aim to (1) dampen the spread of COVID-19 based on the latest available science, (2) improve the likelihood of medical care for the urban poor whether or not they get infected, and (3) provide economic, social, and physical improvements and protections to the urban poor, including migrants, slum communities, and their residents, that can improve their long-term well-being. Immediate measures to protect residents of urban informal settlements, the homeless, those living in precarious settlements, and the entire population from COVID-19 include the following: (1) institute informal settlements/slum emergency planning committees in every urban informal settlement; (2) apply an immediate moratorium on evictions; (3) provide an immediate guarantee of payments to the poor; (4) immediately train and deploy community health workers; (5) immediately meet Sphere Humanitarian standards for water, sanitation, and hygiene; (6) provide immediate food assistance; (7) develop and implement a solid waste collection strategy; and (8) implement immediately a plan for mobility and health care. Lessons have been learned from earlier pandemics such as HIV and epidemics such as Ebola. They can be applied here. At the same time, the opportunity exists for public health, public administration, international aid, NGOs, and community groups to innovate beyond disaster response and move toward long-term plans.