Stratifying risk outcomes among adult COVID-19 inpatients with high flow oxygen: The R4 score.

BACKGROUND: High flow oxygen therapy (HFO) is a widely used intervention for pulmonary complications. Amid the coronavirus infectious disease 2019 (COVID-19) pandemic, HFO became a popular alternative to conventional oxygen supplementation therapies. Risk stratification tools have been repurposed -and new ones developed- to estimate outcome risks among COVID-19 patients. This study aims to provide a simple risk stratification system to predict invasive mechanical ventilation (IMV) or death among COVID-19 inpatients on HFO. METHODS: Among 529 adult inpatients with COVID-19 pneumonia, we selected unadjusted clinical risk factors for developing the composite endpoint of IMV or death. The risk for the primary outcome by each category was estimated using a Cox proportional hazards model. Bootstrapping was used to validate the results. RESULTS: Age above 62, eGFR under 60 ml/min, room air SpO2 ≤89 % upon admission, history of hypertension, history of diabetes, and any comorbidity (cancer, cardiovascular disease, COPD/ asthma, hypothyroidism, or autoimmune disease) were considered for the score. Each of the six criteria scored 1 point. The score was further simplified into 4 categories: 1) 0 criteria, 2) 1 criterion, 3) 2-3 criteria, and 4) ≥4 criteria. Taking the first category as the reference, risk estimates for the primary endpoint were HR; 2.94 [1.67 - 5.26], 4.08 [2.63 - 7.05], and 6.63 [3.74 - 11.77], respectively. In ROC analysis, the AUC for the model was 0.72. CONCLUSIONS: Our score uses simple criteria to estimate the risk for IMV or death among COVID-19 inpatients with HFO. Higher category reflects consistent increases in risk for the endpoint.

Identification of SARS-CoV-2 Pneumonia in Chest X-ray Images Using Convolutional Neural Networks

In 2019, COVID-19 disease emerged in Wuhan, China, leading to a pandemic that saturated health systems, raising the need to develop effective diagnostic methods. This work presents an approach based on artificial intelligence applied to X-ray images obtained from Mexican patients, provided by Hospital General de Zona No. 24. A dataset of 612 images with 2 classes: COVID and HEALTHY, were labelled by a radiologist and also verified with positive RT-PCR test. The first class contains X-ray images of patients with pneumonia due to SARS-CoV-2 and the second contains patients without diseases affecting the lung parenchyma. The proposed work aims to classify COVID-19 pneumonia using convolutional neural networks to provide the physician with a suggestive diagnosis. Images were automatically trimmed and then transfer learning was applied to VGG-16 and ResNet-50 models, which were trained and tested using the generated dataset, both achieving an accuracy, recall, specificity and F1-score of over 98%. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Development of a digital tool for home-based monitoring of skin disease for older adults

The COVID-19 pandemic has accelerated the adoption of telemedicine. However, current tools pose substantial barriers for older adults and those with low digital literacy. By implementing user-centered design, we developed a digital tool, Dermatology for Older Adults (DORA), for home-based monitoring of skin disease, specifically designed for older adults. DORA is a virtual assistant based on REDCap and Twilio APIs that automates image and symptom collection and allows communication between patients and the research team. We evaluated the feasibility, usability, patient compliance, retention, and clinical utility of DORA. Eligibility criteria included patients >70 years with any skin disease, access to a smartphone, and no cognitive impairment. We recruited 62 patients aged 70-94 (mean age 77), 39% female, 81% white from Stanford’s Dermatology Clinic from August-December 2021. We asked patients to send weekly photos and answer a questionnaire of a single skin lesion for 4 weeks, then monthly for 4 months. We measured response time, photo quality, and participant satisfaction using mHealth app usability questionnaire (MAUQ). The median response time was 1.4 days (IQR 0.6-3.4). Four participants dropped out. 83% completed photo submission requests (48% at initial request, 19% after 1st reminder and 16% after 2nd reminder). 80% of all questionnaires requested (131 of 163) were completed. Four dermatology clinicians evaluated the quality of the first 88 images and reported good confidence in triaging skin diseases. MAUQ scores were high for ease of use (5.6 SD1.3), interface satisfaction (5.5 SD1.3), and usefulness (5.2 SD1.3). Patients were consistently able to use DORA to submit photos and symptoms and reported high usability and satisfaction. Patient retention was high, and clinicians felt confident making triage recommendations based on DORA images. This approach can be used in other settings where digital literacy barriers and unequal access to dermatologists contribute to healthcare disparities.

Acute arterial and venous thrombosis in patients infected with COVID-19

Background: There are recognized complications in patients infected by COVID-19 and thrombotic processes are closely related to infection. Objective: To describe the factors associated with increased risk in thrombotic events in COVID-19. Material and methods: Case-control study to identify factors associated with thrombotic processes in patients with COVID-19. Descriptive, comparative and inferential statistics were used, as well as logistic regression.The value of p <0.05 was determined as statistically significant and the statistical program IBM SPSS V.25 was used. Results: 15 cases of acute thrombosis were assesed, 17.5% were arterial and 8.8% were venous, 66.7% (n = 10) were men.Therapeutic anticoagulation and surgical procedures were neccesary. There was an association as a risk factor the fact of presenting some comorbidity (p = 0.005), and prolonged aPTT (p = 0.10), as well as abnormalities in the D-dimer. Conclusions: Infected patients suffers from hypercoagulability and confers a high risk of thrombosis. Significant elevation of D-dimer may be one of the markers of inflammation. The condition of presenting COVID-19 is not a contraindication for any revascularization procedure, which encourages us to improve our diagnostic and therapeutic behavior in patients with COVID-19 infection. © 2021 Sociedad Mexicana de Angiología y Cirugía Vascular y Endovascular, A.C. Publicado por Permanyer. Este es un artículo open access bajo la licencia CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

sars-CoV-2 vaccines efficacy in Mexico and the World

The current phase of the pandemic in different regions of the world is complex, a high community transmission of variants adapted to infect more susceptible people, combined with the increasing availability of different vaccines against covid-19, leads to the need to review basic aspects of the vaccines such as their efficacy, dosage and main side effects, among other aspects of interest. It is also important to contrast the covid-19 vaccines currently in use. In this review, an intentional search was carried out by type of vaccine applied and manufacturing laboratory in Mexico. Clinical trials and different secondary sources in PubMed and academic search engines were selected. The primary search variable was vaccine efficacy and its safety profile;secondary variables were viral platforms, dose and site of application. At the time of searching for this information, there were 287 vaccines against covid-19 in development, five different vaccines had been licensed in our country;one based on mrna technology (Pfizer), four based on viral vectors (AstraZeneca, CanSino, Sputnik V, Jennsen) and one based on inactivated virus (Sinovac). With the exception of CanSino which efficacy data are not available, the performance in the other licensed vaccines offers an excellent safety profile and protection against covid- 19. Efforts to improve vaccination coverage in the Mexican population should be reinforced.

Primary headaches in a group of hospital workers during SARS-COV2 infection: An observational study

Background and aims: Headaches represent at the same time the symptom and the disease, while the secondary ones are the expression of an ongoing pathology that can be systemic, locoregional or distant. The aim of this study is to determine the prevalence rate in the workplace in a ward (Nucleo Alzheimer) during the period of Sars-COV2 infection. This survey was carried out using 2 questionnaires: 1 (work activity sheet), 2 (headache sheet according to IHS criteria). Methods: All health personnel belonging to the Alzheimer Nucleus of the IDR S. Margherita di Pavia were subjected to compilation of questionnaires during the Sars-COV2 infection period. Results: From the analysis of the questionnaires administered, it was found that out of 15 workers, 10 were women and 5 were men. 4 (all women had migraines without aura) and 7 tension-type headaches (5 women and 2 men). Before the Sars-COV2 period, only 2 workers had migraine without aura and 2 tension-type headaches (all women). All 11 workers reported stress, insomnia, and concern for family members and their own health. None of the workers at the time of testing had been vaccinated. Conclusions: Factors related to the work environment are able to increase the frequency and/or intensity of pre-existing headaches. It is also likely that particular situations can give rise to or cause some forms of headache under certain working conditions. Excessive responsibility or, on the contrary, disaffection and incongruous work rhythms should be considered among the occupational risk factors.

Case report: atypical migraine as a sentinel symptom for SARS-COV2 infection

Background and aims: Migraine without aura is the most frequent of the forms of migraines (about 60% - 80% of all forms of migraines). There are many causes that can trigger migraines, including infections (IHS ICDH-3). Methods: 69 year old woman. Professional nurse. Family history of migraine (maternal line). Arising in school age. Diagnosis made according to the IHS ICDH-3 criteria. The patient presented 2–3 crises / month with pulsating pain in the bilateral frontotemporal region, medium-strong intensity, associated with photo-phonophobia, nausea, sometimes vomiting. Duration 24–36 h. Triggering factors: menstruation and psychophysical stress. After menopause (49 years) reduction of intensity, duration and frequency with 1–2 cris / month related stress lasting 12–24 h and responsive to NSAID intake. No preventive therapy performed. Results: On 29.11.2020 episode of atypical headache (described as different from other episodes) with very strong, throbbing, stabbing, burning pain in the bilateral front-temporal region, unresponsive to the intake of NSAIDs. Duration 24 h. No other symptoms reported, apiretic. 30.11.2020: TNF fast: +. Molecular TNF: positive for SARS COV 2. During the period of infection headache present whenever the patient had fever and was unresponsive to paracetamol. Conclusions: In our case report, atypical migraine can be considered a sentinel symptom of an initial infection. The patient works as a professional nurse in the ward which had become Covid on 3.11.2020.

Laboratory Abnormalities in Patients with COVID-19 in Mazandaran Province, Iran

Background: Coronavirus is a single-stranded RNA virus, causing an epidemic of pneumonia and acute respiratory distress syndrome (ARDS) worldwide in late 2019. Objectives: In addition to the clinical symptoms, laboratory diagnosis can greatly help diagnose the diseases;therefore, this study aimed to analyze laboratory parameters in patients with COVID-19. Methods: In this cross-sectional study, the laboratory data of 2563 patients with COVID-19 admitted to hospitals affiliated with Mazandaran University of Medical Sciences were extracted from hospital information systems (HIS). The data were recorded on Excel and analyzed through t-test, chi-squared, and Fisher's exact tests in SPSS 19 at the significance level of P < 0.05. Results: Out of 2563 patients with a mean age of 55.1 +/- 16.7 years, 1409 (55%) were male, and 1154 (45%) were female with a mean age of 55.7 +/- 16.8, and 54.3 +/- 16.6 years, respectively. As the most frequent clinical findings, ESR, CRP, and LDH were increased by 83.5%, 71%, and 69.3% of the patients, respectively. Other research findings included lymphopenia, disturbed INR, abnormal SGOT, abnormal alkaline phosphatase (ALP), and increased lactate dehydrogenase (LDH), which were significantly higher in men than in women and was different between age groups. Conclusions: Conducting simple, convenient, and inexpensive laboratory tests can be helpful in the diagnosis of COVID-19.

The role of simulation as an educational strategy in the COVID-19 pandemic

Simulation-based learning has been widely used to improve response to crisis situations. It has played an important role in preparing care teams for patients with infections such as Ebola, influenza, severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS). The recent pandemic caused by the coronavirus (SARS CoV-2) declared by the World Health Organization (WHO) in March of this year 2020, requires special attention in these moments, where the disease has exceeded the response of the health systems in several countries, so it is necessary training of response teams to reduce risks. The objectives proposed in this review through deliberate practice, the clinical scenario and simulation in situ, in the patient with suspected or infected by COVID-19, try to systematize the placement and removal of personal protective equipment (PPE), the management of the airway and the approach of the patient in cardiac arrest, in order to improve technical skills and strengthen non-technical skills. Furthermore, during the development of these strategies, unexpected situations can be identified and addressed, some compromise in patient and/or staff safety can be detected, which allows these deficiencies to be rectified and response capacity to be optimized. Likewise, it allows to reflect and analyze the emotions of the staff to prevent adverse situations regarding the performance of health workers. With this, it seeks to strengthen the safety and quality of patient care during the course of this pandemic. © 2020, Colegio Mexicano de Anestesiologia A.C.. All rights reserved.

Perioperative management of the patient with COVID-19

Currently, the SARS-CoV-2 pandemic has put health systems to the test throughout their world. The impact of surgical stress and anesthesia on predisposition to a new COVID-19 infection or exacerbation of the infection in a COVID-19 infected patient to be operated on is unknown. Although COVID-19 mortality is between 1-5%, most deaths have occurred in elderly patients with underlying cardiopulmonary conditions, most of them hypertensive, diabetic and obese, therefore, it should be specially attention in its handling. Carefull perioperative preparation and planning is key in successfully achieving adequate clinical care and maintaining the safety of the health team in a difficult and high risk moment. An additional role for the anesthesiologist, considering that he has the most experience in the management of the airway, is to support the emergency services for endotracheal intubation of patients who require ventilatory support, being a procedure with very specific protection recommendations. Therefore, there is a commitment as specialists, to know the subject thoroughly and protect ourselves along with the health team involved in saving lives during this contingency.

Evaluation of hepatic enzymes changes and association with prognosis in COVID-19 patients

Background: One of the most critical health issues in the world is the COVID-19 pandemic from the Coronaviridae family. There is a lack of knowledge regarding the disease, and liver involvement is controversial. Objectives: We aimed to analyze the laboratory investigations of COVID-19 patients focusing on liver enzymes and association with outcomes. Methods: We enrolled 93 patients with COVID-19 referring to the Mazandaran University of Medical Sciences’ hospitals and 186 people from the normal population of Tabari Cohort. The laboratory tests included CBC, Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), Alkaline Phosphatase (ALP), direct bilirubin, and total bilirubin. The lengths of hospital stay, critical care transfers, and deaths were the outcome measures investigated with lab results. Results: The counts of lymphocytes (833.3 ± 564.4 vs. 2465.1 ± 796.6 per mm3, P < 0.001) and platelets (209.4 ± 62.7 vs. 255.2 ± 63.8 per mm3, P < 0.001) were significantly lower in patients than in controls. Also, AST (39.5 ± 34.9 vs. 19.9 ± 7.5 U/L, P < 0.001), ALT (40.4 ± 46.5 vs. 21.6 ± 12.7 U/L, P < 0.001), and ALP (192.6 ± 91.2 vs. 222.2 ± 70.6 U/L, P = 0.004) were higher in patients than in controls. The most common hepatic impairment events were increased direct bilirubin (45.8%), ALT (30.3%), AST (29.2%), ALP (17%), and total bilirubin (10.2%), in sequence. The risk of transfer to intensive and critical care units was strongly associated with elevated levels of AST and direct bilirubin, and AST = 30.5 (U/L) had a sensitivity of 71.4% and specificity of 68.5% for critical and intensive care transfer. The mortality rate significantly increased with increased AST levels (P = 0.023). Conclusions: Abnormal liver enzymes are frequent in COVID-19 patients. As AST is not specific for liver damage, the systemic inflammation induced by the virus might be responsible for these findings.