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Background: In early 2020, severe acute respiratory syndrome-corona virus 2 (SARS-CoV-2) pandemics caused previously unheard of health, social, and economic problems worldwide. The disease can affect different organs such as the lungs, heart, pancreas, kidney, and unusual symptoms can be seen. Information on the clinical impact of SARS-CoV-2 infection on renal function among pediatric age groups is scarce. Case Report: In this report, we presented a 13-year-old boy who was admitted to our hospital with the relapse of nephrotic syndrome caused by COVID-19. The patient had mild upper respiratory tract symptoms, eyelid edema and progressive swelling of the lower extremities. Clinical remission was achieved with oral prednisolone therapy without the use of any antiviral drugs. Conclusion(s): Patients with nephrotic syndrome presenting with relapse should be evaluated for potential COVID-19 infection during the pandemic. The use of routine doses of prednisolone appears to be safe in mild disease. Copyright © 2023 by Erciyes University Faculty of Medicine.
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Recent reports highlight potential inaccuracies of pulse oximetry in patients with various degrees of skin pigmentation. We summarise the literature, provide an overview of potential clinical implications, and provide insights into how pulse oximetry could be improved to mitigate against such potential shortcomings.
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While medical technology is typically considered neutral, many devices rely upon racially biased algorithms that prioritize care for white patients over Black patients who may require more urgent medical attention. Sudat et al. document striking inaccuracies in pulse oximeter readings among Black patients, with significant clinical implications. Findings suggest that this resulted in racial differences in delivering evidence-based care during COVID-19, impacting admissions and treatment protocols. Despite the medical community's growing awareness of the pulse oximeter's significant design flaw, they are still in use. In this article, I contextualize Sudat et al.'s study results within the larger history of racial bias in medical devices by highlighting the consequences of the continued underrepresentation of diverse populations in clinical trials. I probe the implications of racially biased assessments within clinical practice and research and illustrate the disproportionate impact on patients of color by examining two medical tools, the pulse oximeter and pulmonary function tests. Both cases result in the undertreatment and underdiagnosis of Black patients. I also demonstrate how the social underpinnings of racial bias in medical technology contribute to poor health outcomes and reproduce health disparities and propose several recommendations for the field to rectify the harms of racial bias in medical technology.
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Some publications suggest that pulse oximetry measurement (SpO2) might overestimate arterial oxygen saturation (SaO2) measurement in COVID-19 patients. This study aims to evaluate the agreement between SpO2 and SaO2 among COVID-19 and non-COVID-19 patients. We conducted a multicenter, prospective study including consecutive intensive care patients from October 15, 2020, to March 4, 2021, and compared for each measurement the difference between SpO2 and SaO2, also called the systematic bias. The primary endpoint was the agreement between SpO2 and SaO2 measured with the Lin concordance coefficient and illustrated using the Bland and Altman method. Factors associated with systematic bias were then identified using a generalised estimating equation. The study included 105 patients, 66 COVID-19 positive and 39 COVID-19 negative, allowing for 1539 measurements. The median age was 66 [57; 72] years with median SOFA and SAPSII scores of, respectively, 4 [3; 6] and 37 [31; 47]. The median SpO2 and SaO2 among all measurements was respectively 97 [96-99] and 94 [92-96] with a systematic bias of 0.80 [- 0.6; 2.4]. This difference was, respectively, 0.80 [- 0.7; 2.5] and 0.90 [- 0.3; 2.0] among COVID-19 positive and negative patients. Overall agreement measured with the Lin correlation coefficient was 0.65 [0.63; 0.68] with 0.61 [0.57; 0.64] and 0.53 [0.45; 0.60] among the COVID-19 positive and negative groups, respectively. Factors independently associated with the variation of the SpO2-SaO2 difference were the PaO2/FiO2 ratio and need for mechanical ventilation. In our population, agreement between SpO2 and SaO2 is acceptable. During the COVID-19 pandemic, SaO2 remains an efficient monitoring tool to characterise the level of hypoxemia and follow therapeutic interventions. As is already known about general intensive care unit patients, the greater hypoxemia, the weaker the correlation between SpO2 and SaO2.
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In this paper, a preliminary implementation of a system monitoring the fetus's heart rate (FHR) has been designed and implemented as a mobile wearable measuring system with remote sensing specifically developed on Node MCU ESP8266 (ESP). In particular, the proposed system uses sensors for heart rate, humidity, temperature, and a transceiver module. The transceiver module is capable of efficient data transmission to a remote server station using an IEEE 802.11 b/g/n protocol - based on the wireless network. A major benefit is that the patient's data is monitored at distance using an IoT device. Hence, it complies with the health safety distance measures required due to various situations, including that of the COVID-19 pandemic. The proposed implementation has been proven to be efficient in terms of hardware simplicity and cost-effectiveness and is accompanied by preliminary accurate measurements of the FHR. © 2022 IEEE.
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Background and Objectives: Photoplethysmography (PPG) sensors have been increasingly used for remote patient monitoring, especially during the COVID-19 pandemic, for the management of chronic diseases and neurological disorders. There is an urgent need to evaluate the accuracy of these devices. This scoping review considers the latest applications of wearable PPG sensors with a focus on studies that used wearable PPG sensors to monitor various health parameters. The primary objective is to report the accuracy of the PPG sensors in both real-world and clinical settings. Methods: This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Studies were identified by querying the Medline, Embase, IEEE, and CINAHL databases. The goal was to capture eligible studies that used PPG sensors to monitor various health parameters for populations with a minimum of 30 participants, with at least some of the population having relevant health issues. A total of 2,996 articles were screened and 28 are included in this review. Results: The health parameters and disorders identified and investigated in this study include heart rate and heart rate variability, atrial fibrillation, blood pressure (BP), obstructive sleep apnea, blood glucose, heart failure, and respiratory rate. An overview of the algorithms used, and their limitations is provided. Conclusion: Some of the barriers identified in evaluating the accuracy of multiple types of wearable devices include the absence of reporting standard accuracy metrics and a general paucity of studies with large subject size in real-world settings, especially for parameters such as BP.
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Background. The morbidity of new coronavirus infection remains high (in children as well). Children with bronchial asthma are not at risk this disease development and severe course of COVID-19 according to the previous studies results. Objective. The aim of the study is to compare the morbidity rate of COVID-19 among children with and without bronchial asthma between May 2020 and October 2021 with the results from the beginning of pandemics. Methods. Online questionnaires in Google form have been developed and sent to parents of 83 patients aged from 7 to 17 years who have been interviewed at the beginning of the pandemics. The main group includes 49 patients diagnosed with bronchial asthma, and the control group includes 25 children without bronchial asthma. Results. 45% (22) of patients had COVID-19 in the main group and 32% (8) — in the control group (p = 0.636). 80% of patients had mild course of disease and 20% — moderate in the main group, and 62% and 37% in the control group respectively. Febrile fever was observed in 40% of respondents in the main group and in 33% — in the control group;anosmia — in 35% in the main and in 14% — in the control group;pulse oximetry was used by 44% of patients in the main group (SpO2 94–98%) and 42% in the control group (SpO2 98–99%);66% of patients had baseline therapy and 6% had rescue medications in the main group. No one from both groups has been hospitalized. Conclusion. Pediatric patients both with and without bronchial asthma have COVID-19 more often compared to the pandemics beginning. The disease in most cases had mild course and did not require hospitalization, aggravations of bronchial asthma were rare and saturation values did not decrease below 94%.
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Background: The application of methylprednisolone in ARDS patients has led to a sustained reduction in inflammatory plasma cytokines and chemokines and has recently been used in the treatment of patients with SARS-CoV-2 infection. Objectives: In this study, the effect of methylprednisolone on clinical symptoms and antioxidant changes of patients with COVID-19 has been investigated. Methods: In the present study, patients with moderate to severe COVID-19 who required hospitalization were entered into the study phase. Then, in addition to standard treatment, patients received methylprednisolone at a dose of 250 mg intravenously over three days. Necessary evaluations include analysis of arterial blood gases, pulse oximetry, monitoring of patient clinical signs, examination of inflammatory biomarkers, and also receiving 10 cc of peripheral blood samples to check for antioxidant changes, at the beginning of the study, after 24 hours, and 72 hours after receiving methylprednisolone was on the agenda. Results: Changes in fever, superoxide dismutase (SOD, Glutathione-S-Transferase (GST, the ferric reducing ability of plasma (FRAP, malondialdehyde (MDA, Nitric oxide, Ferritin, and TNF-α before treatment and 72 hours after treatment were significantly different between the two stages (P < 0.05). Conclusions: The use of methylprednisolone improves the balance of antioxidants and immunological factors in patients with COVID-19 and thus improves some clinical indicators in these patients.
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Patients with Chiari I malformations present with tonsillar herniation below the foramen magnum causing abnormal spinal anatomy. Anesthesia challenges in this population include difficult airway management, monitoring intraoperative autonomic dysfunction, avoiding increased intracranial pressure, and accommodating sensitivity to neuromuscular blockade. We present a case with an additional airway management challenge due to morbid obesity with a BMI of 62. A 23 year old female with a history of Covid pneumonia and morbid obesity who presented with syringomyelia and Chiari I malformation. She initially presented with bilateral numbness, tingling, weakness, and pain in her hands. Imaging with MRI at the time showed downward displacement of the cerebellar tonsils with the tips reaching the lower portion of C1 and overall 10-12 mm displacement below the level of the foramen magnum. Syrinx was also visualized from the level of C1-C2 extending down to the level of T5-T6. Repeat MRI a year later showed no significant changes. However, she has worsening symptoms of pain in her right arm preventing her from working. She is agreeable to surgical decompression of the posterior fossa through a suboccipital craniotomy with resection of the posterior arch of C1 with duraplasty. Significant findings on the physical exam include Mallampati III, shorter thyromental distance, and limited range of motion of her cervical spine due to pain in her arms. We chose awake fiberoptic intubation due to difficult airway from morbid obesity and limited cervical spine range of motion and the consideration of hypercapnia induced from brief apnea the patient may not tolerate. She was premedicated with versed, glycopyrrolate, and dexmedetomidine, and given a 5% lidocaine paste lollipop to topicalize oropharynx. She was also started on a low dose remifentanil infusion for sedation during the awake fiberoptic approach. Blood pressure, heart rate, respiratory rate with continuous end-tidal capnography, and pulse oximetry were monitored during the awake fiberoptic intubation. A 7.0 endotracheal tube was lubricated with viscous lidocaine and placed over a fiberoptic scope. Once there was visualization of the vocal cords, additional 2% lidocaine was administered directly at the vocal cords. She was intubated smoothly on the first attempt. She was then immediately induced to general anesthesia with propofol and non-depolarizing muscle relaxant to avoid using succinylcholine due to the possible hypersensitivity caused by denervation. Intraoperatively, a conventional air warmer was used to prevent hypothermia. Invasive arterial blood pressure monitoring was applied. Normotensive blood pressure and normocapnia were maintained throughout the surgery. Muscular blockade was reversed with sugammadex at the end of surgery to ensure adequate ventilation especially with the patient's body habitus. Upon extubation, the patient had acute hypertension which was managed by nicardipine infusion and hydralazine boluses. Patient was taken to a neurosurgical intensive unit and monitored for two days. She was discharged home without any complication. In conclusion, anesthetic considerations for patients with Chiari I malformation include airway management, monitoring for autonomic dysfunction, avoiding increase in ICP, and optimizing postoperative neurological status with balanced anesthetic management.
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SESSION TITLE: Pathology Identifying Chest Infections Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pulmonary histoplasmosis typically affects immunocompromised individuals. Symptomatic infection in immunocompetent patients is rare, however, important risk factors include living in an endemic region and the size of inoculation. We present a case of subacute pulmonary histoplasmosis in a healthy young male and discuss how availability bias during the COVID-19 pandemic may pose challenges in the diagnosis. CASE PRESENTATION: A healthy 30-year-old male presented to our hospital complaining of left flank and bilateral chest pain for one week. The patient returned from Veracruz, Mexico three weeks prior after spending two months there studying to become a chef. While in Mexico, the patient experienced low-grade fevers, night sweats, and pleuritic chest pain for which he was treated with steroids and antibiotics for presumed COVID-19 infection despite negative testing. Treatment provided the patient temporary relief, however, some of his symptoms returned prompting him to present to the emergency department. Upon presentation, the patient was afebrile and had a normal resting pulse oximetry. CT angiogram of the chest demonstrated three lung nodules and prominent mediastinal lymphadenopathy. A complete infectious and rheumatologic workup was performed. BAL, transbronchial biopsies and EBUS-TBNA were performed. Lung biopsy showed reactive pneumocytes, focal intra-alveolar fibrinous material, congestion, and hemorrhage. Lymph node cytology revealed an aggregate of necrotizing and nonnecrotizing granulomas and GMS stain was positive for yeast. Fungitell and Histoplasma antibodies returned positive. The patient was discharged on Itraconazole and followed up with infectious disease specialists two months later in stable condition. DISCUSSION: Patients with subacute pulmonary histoplasmosis and viral pneumonia may present with similar clinical and radiological findings making the diagnosis arduous. In addition, the prevalence of COVID-19 pneumonia makes clinicians susceptible to using availability bias and further obscuring diagnosis. Some clues that help differentiate subacute pulmonary histoplasmosis include a longer duration of symptoms, pulmonary nodules, and mediastinal and hilar adenopathy. CONCLUSIONS: While pulmonary histoplasmosis is an uncommon finding in immunocompetent patients, suspicion should be raised in patients from endemic regions. Despite the COVID-19 pandemic, clinicians should avoid anchoring biases and keep differential diagnoses in mind. Reference #1: Azar MM, Hage CA. Clinical Perspectives in the Diagnosis and Management of Histoplasmosis. Clin Chest Med. 2017;38(3):403-415. doi:10.1016/j.ccm.2017.04.004 Reference #2: Staffolani S, Buonfrate D, Angheben A, et al. Acute histoplasmosis in immunocompetent travelers: a systematic review of literature. BMC Infect Dis. 2018;18(1):673. Published 2018 Dec 18. doi:10.1186/s12879-018-3476-z DISCLOSURES: No relevant relationships by Steven Douedi No relevant relationships by Justin Ilagan No relevant relationships by TAIMOOR KHAN No relevant relationships by Romany Nightingale No relevant relationships by Mihir Odak No relevant relationships by Noor Salam No relevant relationships by Kameron Tavakolian
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SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The most dangerous complication of amiodarone use is amiodarone-induced pulmonary toxicity (AIPT) (1). AIPT has no pathognomonic findings & is therefore diagnosed based on clinical suspicion & exclusion of other possible pulmonary diseases (2) CASE PRESENTATION: A 91-year-old female with history of CHF & atrial fibrillation on amiodarone 200mg once daily for approximately 10 years, presented for worsening shortness of breath for 3 days. On admission vitals were stable & pulse oximetry revealed a SpO2 of 89% on room air which increased to 96% on 4 litres oxygen. Examination revealed decreased breath sounds at bases, bilateral rales right>left. No clinical signs of fluid overload. Chest x-ray (fig 1) showed increased bilateral airspace opacities and computed tomography (CT) of chest (fig 3) revealed diffuse airspace opacities, right > left. Initial lab work was within normal limits. She was admitted with a working diagnosis of acute hypoxemic respiratory failure due to community acquired pneumonia (CAP) versus COVID-19 pneumonia due to high suspicion based on her clinical picture. She received remdesvir, empiric antibiotics and amiodarone was discontinued. COVID-19 PCR was negative, patient did not spike fevers or had any leukocytosis & pneumonia workup was negative. Therefore we now considered AIPT. Gallium scan for AIPT revealed abnormal uptake involving lungs bilaterally consistent with AIPT. Patient was continued on dexamethasone, after which patient's oxygen requirement subsequently decreased & repeat chest x-ray (fig 2 ) showed a significant decrease in bilateral infiltrates on steroids. She was discharged home on 2 litres oxygen & prednisone taper for 4 months. DISCUSSION: The advent of the highly contagious SARS-CoV-2 has made it further essential to diagnose AIPT correctly & to differentiate between these two entities. They have similar & non-specific features which makes this an even a greater challenge. Our elderly patient on long-term amiodarone use represents an at-risk group for AIPT (1). Her clinical picture was non-specific, initially suggesting CAP versus COVID-19 pneumonia. In our case, the consistent gallium scan findings confirmed the diagnosis of AIPT & enabled prompt anti-inflammatory treatment along with cessation of amiodarone which resulted in improved prognosis & outcome. AIPT should be suspected in patients taking amiodarone who have new or worsening symptoms with an insidious onset &/or new infiltrates on chest x-ray. Greater parenchymal activity on gallium scintigraphy scanning & the presence of lung biopsy findings can help further confirm the diagnosis (1) CONCLUSIONS: In the era of the COVID-19 pandemic, it becomes even more challenging to diagnose and differentiate AIPT from SARS-CoV-2 pneumonia, which can have a similar presentation (3). Early recognition of AIPT is critical to prevent or minimize its potentially devastating pulmonary effects. Reference #1: Martin, W. J., & Howard, D. M. (1985). Amiodarone-induced lung toxicity: In vitro evidence for the direct toxicity of the drug. American Journal of Pathology, 120(3), 344–350. Reference #2: Benassi, F., Molardi, A., Righi, E. et al. ECMO for pulmonary rescue in an adult with amiodarone-induced toxicity. Heart Vessels 30, 410–415 (2015). Reference #3: Macera M, De Angelis G, Sagnelli C, Coppola N, Vanvitelli Covid-Group. Clinical Presentation of COVID-19: Case Series and Review of the Literature. Int J Environ Res Public Health. 2020 Jul 14;17(14):5062. DISCLOSURES: No relevant relationships by Nayaab Bakshi No relevant relationships by Navjot Kaur Grewal No relevant relationships by Talha Munir No relevant relationships by Anusha Singhania
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SESSION TITLE: Diagnosis of Lung Disease through Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Usual interstitial pneumonia (UIP) is a histological term used to describe a pattern of interstitial fibrosis with alternating areas of the normal lung with temporal fibrosis and architectural alteration due to chronic scarring or honeycomb change. It is a subset of idiopathic interstitial pneumonias (IPF) that usually presents in the sixth and seventh decades of life with progressive dyspnea on exertion and productive cough. CASE PRESENTATION: We present a 46 y/o man with a history of thyroid disease, hypertension and a former smoker of 20 pack-year smoking. Presented to ED complaining of low oxygen saturation with pulse oximetry at home with readings between 60-80%. Accompanied with progressive dyspnea on exertion and unintentional weight loss of 80 pounds in the last year. Also referred productive cough of white sputum that was worse in the morning. Home nebulized Albuterol therapy did not provide improvement. Denied recent viral respiratory infections, night sweats, environmental exposures nor family history of lung disease. DISCUSSION: Physical exam demonstrated bilateral expiratory dry crackles and pulse oximetry oxygen saturation at room air of 78%. RBBB evidenced on EKG. Bloodwork showed polycythemia with hemoglobin of 17.8;ABG's with pH: 7.40, Pco2: 42.2, PO2: 59.8, HCO3: 26, O2 sat: 90.8 and ideal PO2: 85.6 consistent with metabolic alkalosis with BMP CO2 of 30, A/a gradient: 43.0. Mycoplasma IgM, Influenza A & B and COVID-19 antigen test were negative. CXR with increased vascular markings, chest CT demonstrated small pericardial effusion, bilateral coarse interstitial pulmonary markings and bronchiectasis suggestive of chronic interstitial lung disease with no specific pattern. Left heart catheterization revealed right ventricular hypertrophy, normal EF >55%, and no evidence of coronary disease. Alpha-1 antitrypsin: 158, EPO: 6.5, HIV, and hepatitis panel were all negative. Rheumatology work up with only an ANA antibody positive, with titer 1:160. Patient underwent VATS procedure with wedge biopsy of the right upper and middle lobe that revealed usual interstitial pneumonia pattern. Patient improved and was discharged on home oxygen 3L. At follow-up, treatment was started with Nintedanib and Sildenafil Citrate. He had clinical improvement and oxygen requirements decreased to intermittent oxygen. CONCLUSIONS: Patients with interstitial pulmonary fibrosis experience slow progressive decline with typical clinical presentation over 60 years of age. This case remarks the importance of the need for stratification of interstitial lung disease classification, when pattern and history are non specific, with the use of VATS procedure for early start of treatment. Our patient with no environmental exposure or connective tissue disease had an uncommon early presentation of usual interstitial pneumonia. Reference #1: Tibana, R.C.C., Soares, M.R., Storrer, K.M. et al. Clinical diagnosis of patients subjected to surgical lung biopsy with a probable usual interstitial pneumonia pattern on high-resolution computed tomography. BMC Pulm Med 20, 299 (2020). https://doi.org/10.1186/s12890-020-01339-9 DISCLOSURES: No relevant relationships by Jesse Aleman No relevant relationships by Carlos Martinez Crespí no disclosure submitted for Jean Ramos;No relevant relationships by Alexandra Rodriguez Perez No relevant relationships by Paola Vazquez No relevant relationships by Nahomie Veguilla Rivera
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SESSION TITLE: Critical Thinking SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Cephalosporins have been known to cause hypo-prothrombinemia and prothrombin prolongation (1). The proposed mechanism of this coagulopathy is secondary to a N-methylthiotetrazole side chain interfering with vitamin-k metabolism (1). Current literature supporting the association between cefazolin and hypo-prothombinemia have only been reported through case reports. As cefazolin is a commonly used antibiotic, it is important that healthcare professionals are aware of its potential bleeding risk. We present a case of a 72 year old female with cefazolin-induced hypo-prothrombinemia. CASE PRESENTATION: A malnourished 72-year old female with a past medical history of recent methicillin-susceptible Staphyloccocus aureus (MSSA) bacteremia and COVID-19 pneumonia presented to the emergency department from a skilled nursing facility (SNF) due to shortness of breath. The patient was previously discharged to SNF to complete a 14 day course of IV cefazolin due to her MSSA bacteremia. On admission, vital signs were significant for a respiratory rate of 22 and a pulse oximetry reading of 78% on room air. Laboratory findings were significant for an elevated prothrombin time of >100 seconds, an INR >15, and a D-dimer of 42,344 ng/mlL. A computed tomography angiography (CTA) of the chest revealed a small segmental pulmonary embolus in the right lower lobe of the lung. The patient was started on a heparin drip, placed on a non-rebreather mask, and admitted to the ICU for closer monitoring. Infectious disease was consulted and cefazolin was discontinued. Due to the patient's risk of bleeding her heparin drip was stopped. It was decided not to reverse the patient's coagulopathy with vitamin K as there were no signs of an acute bleed in the setting of an acute pulmonary embolus. The patient was started on nafcillin in place of cefazolin. Four days after discontinuation of cefazolin, the patient's INR had trended down from >15 to 1.6 and she was started on Lovenox 1mg/kg for the treatment of her acute PE. DISCUSSION: Due to the timing of the discontinuation of cefazolin and the correction of the hypo-prothrombinemia, a clear association between the two can be made. It has been proposed that cefazolin's side chain, heterocyclic thiol, 2-methyl-1,3,4-thiadiazole-5-thiol (MTD), causes a similar reaction that other cephalosporins have on the metabolism of Vitamin K (2). This altered Vitamin K metabolism was also likely exacerbated due to the patient's malnourishment and likely depleted vitamin k reserves (2). CONCLUSIONS: Although rare, this case demonstrates the need for clinicians to be aware of the potential bleeding risk associated with cephalosporins and cefazolin in particular. In the future, routine monitoring of PT/INR levels may be recommended when initiating cephalosporins. Reference #1: Park GH, Kim S, Kim MS, Yu YM, Kim GH, Lee JS, Lee E. The Association Between Cephalosporin and Hypoprothrombinemia: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2019 Oct 16;16(20):3937 Reference #2: Shearer, M. J., Bechtold, H., Andrassy, K., Koderisch, J., McCarthy, P. T., Trenk, D., Jähnchen, E., & Ritz, E. (1988). Mechanism of cephalosporin-induced hypoprothrombinemia: relation to cephalosporin side chain, vitamin K metabolism, and vitamin K status. Journal of clinical pharmacology, 28(1), 88–95 DISCLOSURES: no disclosure on file for John Abernathy;No relevant relationships by Ethan Goldberg No relevant relationships by Renee Miu No relevant relationships by Luis Osorio no disclosure on file for Satesh Saroop;no disclosure on file for Oliver Sevilla;no disclosure on file for Kristen Zubel;
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The article discusses the racial disparity shown when considering the accuracy of pulse oximetry readings. Topics include the Veteran Health Administration, a US governmental body that provides primary care;pulse oximetry measurement discrepancies according to race, and systemic racial or ethnic biases in pulse oximetry, in particular in relation to COVID-19 patients.
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The emergency department (ED) is a key point of entry for most of these patients.1 In the setting of an ongoing pandemic, emergency medicine clinicians are forced to make disposition decisions with incomplete information and significant uncertainty regarding the disease course both on an individual and community level.2 From clinical experiences in China, Italy, and New York, it is clear that patients with minor symptoms could subsequently develop severe hypoxia with rapid progression to respiratory failure days to weeks later.3 Furthermore, while certain population-based risk factors for serious illness were known (advanced age, obesity and hypertension), there are no definitive guidelines to identify which of the patients are at highest risk of disease progression, and therefore, warranting early hospital admission. The CO-POP leveraged the availability of medical students withdrawn from clinical rotations to provide emergency medicine physicians an opportunity to discharge patients with COVID-19 with the outpatient pulse oximetry monitoring protocol and close structured follow-up. [...]we have identified the medical student body as one of the few resources that has become more available as pandemic volumes increase.
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[...]in early July 2021 the longperforming Hubble Space Telescope (HST) ceased working. With NASA engineers of all kinds trying to seek answers, much hope is being placed on HST's replacement, the James Webb Space Telescope (JWST) which is scheduled to be launched (tentatively, after many years of delays) sometime in late 2021. [...]was the increase in drug overdose deaths and homicides related to social and personal tension?
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Background: Covid-19 is an acute health emergency to human beings all over the world. This pandemic has destabilised the day-to-day life of almost everyone. It is a challenge to scientists and politicians to initiate a return to normal human life from the grip of Covid-19 so that the economies of countries do not stop growing. Objective: To study the characteristics of Covid-19 deaths in a regional hospital in Mthatha in the Eastern Cape, South Africa. Method: It is a retrospective record review study of the cases of patients in Mthatha Regional Hospital (MRH) in South Africa who were not able to be saved. Results: There were 100 deaths in MRH. Of these 57 (57%) were females and 43 (43%) males. The average age was 63.3 years. Shortness of breath was the most common presenting symptom followed by weakness, a cough and fever. More than half of the Covid-19 cases had associated co-morbidity such as hypertension (50%), diabetes (37%) and HIV (15%). The mean oxygen saturation (SpO2) at the time of admission was 75.5±17 on pulse oximetry. Conclusion: The covid-19 mortality was 1.3 times higher among females in the regional hospital under study. The majority of the victims were suffering hypertension and diabetes.
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STATEMENT OF PROBLEM/QUESTION: In the spring of 2020 during the initial outbreak of COVID-19, the Rocky Mountain Regional VA (RMR) was tasked with ensuring the health of infected veterans. The RMR COVID-19 Telehealth Clinic was developed to support veterans in the community diagnosed with COVID-19, identify those with clinical deterioration requiring a higher level of care, and encourage appropriate isolation protocols. DESCRIPTION OF PROGRAM/INTERVENTION: Patients were stratified by risk factors (obesity, CHF, DM, cancer, CAD, HTN, age > 64) and clinical status into 3 tiers, with high-risk (Tier 3) receiving daily telehealth, moderate-risk (Tier 2) telehealth every other day, and low-risk (Tier 1) telehealth every three or more days. Providing care seven days a week, Tier 1 veterans were contacted by nurses and advanced practitioners, while Tier 2 and 3 veterans were managed predominantly by resident physicians and attendings, who provided clinical care for exacerbations of chronic disease as well as comprehensive care of COVID-19 infection. Hypoxic patients were provided oxygen and closely monitored with pulse oximeters. MEASURES OF SUCCESS: Between April 13 to October 5, 2020, 351 veterans testing positive for COVID-19 were followed. Thirty-eight were excluded (26 were outside study dates, 7 covid negative, 5 never received care). Charts for the remaining 313 patients were retrospectively evaluated for demographic data, comorbid conditions, duration of follow-up, and interventions provided, including prescribing and managing medications, referrals for emergency services, and escalating tiers. FINDINGS TO DATE: Of the cohort, 88% were male, 43% obese, 34% over age 64, 40% HTN, and 27% DM. Veterans were followed for 10.4 days on average. Approximately 54% were assigned to Tier 1, 29% to Tier 2, and 16% to Tier 3. Medications were prescribed for 45% and 27% of Tier 3 and Tier 2 patients respectively, and emergency care was advised for 22% and 20% of Tier 3 and Tier 2 veterans. Of Tier 1 patients, medications were ordered on 5%, emergency care recommended for 3%, and only 7% were escalated to Tier 2. Of the five deaths that occurred, two were directly attributed to COVID-19. KEY LESSONS FOR DISSEMINATION: A dedicated telehealth clinic for veterans with Covid-19 appropriately identified patients into low, moderate, and high-risk categories based on risk factor assessment. Low-risk patients were safely followed with intermittent telehealth emphasizing self-care and isolation, avoiding unnecessary Emergency Department visits. More frequent monitoring of symptoms and pulse oximetry in moderate to high-risk patients facilitated identification of patients with clinical deterioration requiring emergency evaluation and avoiding admissions for at-risk clinically stable patients. Tiered management resulted in judicious utilization of health care resources during a critical time marked by scarcity of hospital beds and personal protective equipment.
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BACKGROUND: Reports of silent hypoxia in patients with Covid-19 have raised concerns that patients monitored at home should receive pulse oximeters to objectively measure oxygen saturation rather than relying on subjective dyspnea as an indicator of clinical deterioration. METHODS: In this pragmatic randomized control trial, patients with suspected or confirmed Covid-19 were randomly assigned (1:1) to receive a text message based remote monitoring program (“Covid Watch”) or the program supplemented with SpO2 monitoring using a home pulse oximeter (“COVID Watch + Pulse Oximetry”). Covid Watch is a an automated 14-day text program that enquires about patients' symptoms of dyspnea. The primary outcome was days alive and out of hospital (DAOH) at 30 days. RESULTS: A total of 1056 patients (611 Covid-19 positive) were assigned to receive automated remote monitoring of both peripheral oxygen saturation (SpO2) levels and self-reported symptoms of dyspnea and 1041 (606 Covid-19 positive) to receive symptom monitoring alone. Among Covid-19 patients, the addition of SpO2 monitoring provided no significant difference in mean DAOH at 30 days (29.38 vs 29.46;difference -0.08;95% CI, -0.37 to 0.21). Patients in the intervention arm were more likely to use more clinical resources such as telephone calls and telemedicine visits. These finding were consistent across subgroups defined by race, age, and clinical status. CONCLUSIONS: SpO2 monitoring added no clinical value to subjective assessments of dyspnea in an automated text-message remote monitoring program of Covid-19 patients, while simultaneously increasing utilization of clinical resources. These findings reveal that home pulse oximetry may be ineffective and inefficient in supporting the management of Covid-19 patients in outpatient settings relative to remotely monitoring symptoms of dyspnea alone.
ABSTRACT
BACKGROUND: During the COVID-19 pandemic, there have been concerns regarding potential bias in pulse oximetry measurements for people with high levels of skin pigmentation. We systematically reviewed the effects of skin pigmentation on the accuracy of oxygen saturation measurement by pulse oximetry (SpO2) compared with the gold standard SaO2 measured by CO-oximetry. METHODS: We searched Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform (up to December 2021) for studies with SpO2-SaO2 comparisons and measuring the impact of skin pigmentation or ethnicity on pulse oximetry accuracy. We performed meta-analyses for mean bias (the primary outcome in this review) and its standard deviations (SDs) across studies included for each subgroup of skin pigmentation and ethnicity and used these pooled mean biases and SDs to calculate accuracy root-mean-square (Arms) and 95% limits of agreement. The review was registered with the Open Science Framework ( https://osf.io/gm7ty ). RESULTS: We included 32 studies (6505 participants): 15 measured skin pigmentation and 22 referred to ethnicity. Compared with standard SaO2 measurement, pulse oximetry probably overestimates oxygen saturation in people with the high level of skin pigmentation (pooled mean bias 1.11%; 95% confidence interval 0.29 to 1.93%) and people described as Black/African American (1.52%; 0.95 to 2.09%) (moderate- and low-certainty evidence). The bias of pulse oximetry measurements for people with other levels of skin pigmentation or those from other ethnic groups is either more uncertain or suggests no overestimation. Whilst the extent of mean bias is small or negligible for all subgroups evaluated, the associated imprecision is unacceptably large (pooled SDs > 1%). When the extent of measurement bias and precision is considered jointly, pulse oximetry measurements for all the subgroups appear acceptably accurate (with Arms < 4%). CONCLUSIONS: Pulse oximetry may overestimate oxygen saturation in people with high levels of skin pigmentation and people whose ethnicity is reported as Black/African American, compared with SaO2. The extent of overestimation may be small in hospital settings but unknown in community settings. REVIEW PROTOCOL REGISTRATION: https://osf.io/gm7ty.