MIST-based Tuning of Cyber-Physical Systems Towards Holistic Healthcare Informatics

The entire world seems shaken and disrupted since the strike of Covid-19 ever since its outbreak towards the end of 2019 and its continued perils. During this unprecedented event of the century, people's health emerged as the most vulnerable and affected area either directly or indirectly by the coronavirus and its new variants. Disrupting almost all spheres of life, patients' health and care systems required timely support from healthcare professionals to provide the needed medical advice on one hand and a prescriptive mechanism to avoid another impending casualty. Similarly, a proactive approach became desirable from the health ministry, pharmaceutical firms, medical insurance companies, and other stakeholders in fine-tuning their offerings to the patients as per the recommender systems. The devices to measure the vitals of a person, became more efficient and ergonomically sound with the advent of wearable gadgets. These devices monitored the physical activities of the user and transferred the vital signals wirelessly to any base computing device and cloud-based repositories. This mechanism, however, was reported to fail in addressing the issues with non-communicating or stand-alone devices that were used by the masses in developing countries including India. If the real-time data could be used from these devices, the healthcare diagnosis and analysis of a patient's medical condition could have taken a progressive dimension with the addition of missing data points. This research thus aims to fill the information gap and proposes a transforming approach towards existing non-communicating devices used to measure the vitals like blood pressure, oxygen level, blood sugar, etc. The proposed MIST-based Cyber-Physical System shall create extensive scalability towards the retrieval of the vital details from the devices which were otherwise captured offline previously and were unused at multiple critical points of healthcare processes. © 2022 IEEE.

Managing Drilling Real-Time Center Remotely Amid Covid-19 Pandemic in Compliance to 100% HSE

COVID-19 pandemic shifted the conventional working paradigms, forcing an accelerated adaptability to remote working, ensuring the wellbeing of the employees without sacrificing the effectiveness, in compliance to 100% HSE. To overcome this challenge, Drilling Real Time Operations Center (RTOC) transformed the conventional Monitoring Onsite Hub into a full virtual collaborative remote center operated from each individual's place. This paper describes how RTOC successfully, continued to support drilling operations off-site through secure portal during work-from-home period. RTOC ensured to have the sufficient connectivity resources and security protocols to access the IT company environment and execute the tasks at the same productivity level, as operating from the hub. The platform design involved virtual machine remoting in an integrated communication environment, in synergy with the conventional ways of communication. Several data access points were developed to ensure an unstoppable link between operational teams and the data deliverables. To grantee productivity, KPIs were established and closely monitored, e.g. active rigs count, connectivity issues, software support, real-time drilling performance reporting, engineering computations, with continuous quality audits. Despite several challenges at start due to change in the nature of the work, RTOC successfully overcame the difficulties by having proper procedures and infrastructure in place. The virtual collaborative environment allowed the team to operate the center remotely and meet the targets for deliverables. Defining a clear communication protocol created efficiency when addressing data aggregation problems. As a result, RTOC was able to maintain the resolution time for data aggregation issues and continue to produce drilling performance reports within time. RTOC launched a mobile application for drilling real-time monitoring to support user mobility prior to the mandate of work-from-home policy. RTOC continued to support drilling operations during work-from-home period by providing real-time computations for drilling operations, doing real-time interactions for drilling events and introducing data analytics platform for users to analyze drilling performance. In summary, systematic implementation of the workflows and following clear chain of command have proven to be effective in ensuring business continuity of RTOC. Building trust and respect helped boost the morale and productivity of the team while ensuring their safety and wellbeing. The pandemic has been, indeed, a tough period for the world but the shift of working lifestyle was indeed a unique experience. It broadened the horizon for RTOC to develop advanced collaboration tools and upgrade the infrastructure to be future-ready for higher mobility. This novelty can also be adopted as standard procedure for Emergency Response Plan. © Copyright 2021, Society of Petroleum Engineers

Spontaneous pneumothorax in a patient with covid-19

The coronavirus disease 2019 (COVID-19) frequently involves the respiratory system causing pneumonia. The disease started in December 2019 and is now a global pandemic. The disease is not limited to the respiratory system and cardiac, cutaneous, and neurological involvement has been reported. Psychiatric features of agitation and delirium have also been described in COVID-19. It is yet to be determined whether this will have any long term effect on the quality of life of these patients. We report a case of delirium in a COVID-19 patient who had also developed spontaneous pneumothorax on the day 15 of illness. Few of such case reports have been reported internationally but to the best of authors' knowledge, no such case has been reported in Pakistan. © 2021, Army Medical College. All rights reserved.

Feasibility and safety of bronchoscopy and ultrasonography guided bedside percutaneous dilatational tracheostomy performed by non-intensivists in a community icu

Introduction: Many ICU's in the United States do not have intensivist coverage and all procedures typically performed by intensivists are done by other specialties. Percutaneous dilatational tracheostomy (PDT) is commonly performed in the intensive care unit (ICU) at bedside for long-term ventilator support. In this study, we aim to describe our experience with PDT with both endoscopic and USG guidance with the primary operator being a hospitalist or internal medicine residents or pulmonary(non critical care) medicine fellow with the supervisor being an intensivist with training in PDT Methods: A total of 26 PDTs were performed using both bronchoscopy and USG guidance. Prior to the procedure, anatomical landmarks, including the thyroid cartilage, crico-thyroid membrane and tracheal rings, were identified using USG. The distance of the trachea from skin was checked and absence of a high innominate artery as well as other vascular anomalies was confirmed with USG. A bronchoscope inserted through the endotracheal tube (ETT) was used to pull the ETT out just distal to the vocal cords. Bronchoscopic visualization was also used to confirm a midline puncture and to avoid puncture of the posterior tracheal wall. After cannulation, the bronchoscope was inserted through the tracheostomy tube to confirm adequate distance from the carina. A post-procedure USG was performed to check for the absence of a pneumothorax. Results:The average BMI of patients was 28 with an average age of 72. 2 patients were therapeutically anticoagulated and three patients were on clopidogrel. 5 patients had COVID 19 ARDS. Accidental decannulation was noted in 2 patients early on in the course and the procedure modified to include sutures through the tracheostomy holder along with a tracheostomy tie, following which there were no recurrences. 1 patient had persistent oozing which needed treatment with lidcoaine with epinephrine. No pneumothorax, tracheoinnominate fistula or stenosis post decannulation was noted. There was a 46% in hospital mortality but not related to procedural complications Discussion: Conventional/surgical tracheostomy involves more personnel and increases cost. Bronchoscopy and USG guidance help ensure reduction in major complications described with the procedure when compared to surgical tracheostomies. This pilot feasibility and safety analysis paves the way for teams without full time intensivists to perform more PDTs and collect further data to prove the safety and cost effective performance of PDTs.

COVID-19-RELATED ARDS PHENOTYPES AND PROGRESSION BETWEEN THEM: A CASE REPORT

SESSION TITLE: Fellows' COVID-19 SESSION TYPE: Fellow Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: Since January 20th, 2020 when the first case of the novel coronavirus SARS-CoV-2 was confirmed in the United States [1], there have been several reports of the disease caused by the virus known as COVID19. In the recent literature there have been descriptions of two different phenotypes of the virus presentation among hospitalized patients and particularly those requiring mechanical ventilation. These phenotypes, known as “L type” and “H type”, report what appear to be two distinct presentations with drastically different management which a patient can transition between [2]. We present a case of a patient with confirmed COVID19 who progressed through both phenotypes during his treatment consistent with these theorized phenotypes. CASE PRESENTATION: A 40 year old male presented to the hospital with shortness of breath and cough. Medical and social history was unremarkable. Workup initially showed patchy bilateral infiltrates, negative procalcitonin, fever of 103, and sats of 93% on 4L. The patient’s respiratory status quickly degraded and he required mechanical ventilation. He tested positive for SARS-CoV-2 via PCR. Initially the patient had subpleural ground glass opacities and low peep requirements before stress index became >1. He developed dyssynchrony and required more peep causing higher pressure with worse compliance. Standard supportive care for ARDS was followed. After several days the peak and plateau pressures continued to be elevated. The patient was started on nitric oxide and flolan with paralytics. He returned to a high compliance state and was ultimately extubated and discharged. DISCUSSION: There are two phenotypes with COVID-19 ARDS. The first, L-type, has high compliance, low V/Q ratio, and low lung recruitability. It has been theorized that viral infection leads to interstitial edema with vasoplegia accounting for the severe hypoxemia. This leads to increased minute volume and a more negative intrathoracic pressure with little dyspnea. The increased negative intrathoracic pressure and high tidal volumes likely lead to edema due to inflammation and increased lung permeability. This leads to dependent atelectasis and increased work of breathing. It is unclear if this is from the virus itself versus and/or high-stress ventilation. The second, H-type, has decreased compliance and high recruitability. One of the crucial things to prevent progression from L to H type is controlling work of breathing. In community hospital settings this is hard to monitor. The patient's dyssynchrony caused a significantly negative intrathoracic pressure and resulted in a form of patient-self inflicted lung injury that caused the transition from L to H phenotype. Once this was controlled with paralytics, the patient returned to L-type and recovered. CONCLUSIONS: Control of the work of breathing in a patient with COVID-19 ARDS is critical in preventing progression between L and H phenotypes. Reference #1: 1. Holshue LH, DeBolt C, Lindquist S, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;382:929-936. Reference #2: 2. Gattinoni DC, Caironi P, Busana M, et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes?. J Intens Care Med. 2020;DOI: 10.1007/s00134-020-06033-2. Reference #3: 3. Yoshida T, Grieco DL, Brochard L, Fujino Y. Patient self inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathing. Curr Opin Crit Care. 2020;26(1):59-65. DISCLOSURES: No relevant relationships by Muhammad Ahmed, source=Admin input no disclosure on file for Nisarfathima Kazimuddin;No relevant relationships by Ahmed Qadir, source=Web Response No relevant relationships by karan Singh, source=Web Response No relevant relationships by Rodney Steff, source=Web Response