Early Doffing among Frontline Healthcare Workers Working in the COVID Areas in Resource-Limited Settings: Lessons Learned and Interventions Taken.

Background: In the fight against the pandemic, personal protective equipment (PPE) has played a vital role. However, working with PPE has its own difficulties and problems. The aim of this study was to find out the reasons of early doffing, that is, in doffing in emergency situations before the shift among healthcare workers (HCWs) working in PPE in the COVID areas in resource-limited settings. Methods: This cross-sectional, survey-based study was carried out on healthcare workers involved in direct care of patients with COVID-19 in tertiary care COVID center, India. The questionnaire was sent as a Google form through email and social media platforms like WhatsApp and Facebook. The data was reported as the mean ± SD for continuous variables and as the percentage for categorical variables. Findings: Among 252 healthcare workers who participated in the survey, 145 (57.5%) participants doffed early on 300 occasions. Out of these 145, 50% doffed early only once and rest doffed early multiple times. The most common reason of early doffing was found to be breach in PPE (15.33%) followed by fogging (14%) and headache (12%), and most commonly, breach was in mask or coverall/gown (32.6% each). Conclusion: Although PPE decreases the risk of infection, it is challenging for HCWs to work in PPE leading to instances of early doffing. The most common reason for early doffing in our study was the breach in PPE and the most common component of breach was found to be mask and coverall/gown. Therefore, we suggest that the proper sizes of the PPE should be made available and proper training in donning should be imparted to HCWs working in PPE.

Upper Thoracic Erector Spinae Plane Block-A Win-Win Deal For Polytrauma Victims Undergoing Surgeries in the Shoulder Region: A Case Report.

Polytrauma victims are usually in severe pain with difficulty in breathing. There are limited regional analgesia options that cover the shoulder region as well as the rib and other associated fractures. The erector spinae plane block (ESPB) is a versatile block which has established a role in the management of rib fracture pain and has emerging indications for managing pain in the shoulder and upper humerus regions. We examined the efficacy of ultrasound guided ESPB at the T2 level in two polytrauma patients with unilateral scapular, humerus, and rib fractures undergoing surgery in the shoulder region. It provided excellent postoperative analgesia and helped to alleviate pain of associated rib and other fractures, thereby facilitating early postoperative recovery and rehabilitation.

Bilateral continuous serratus anterior plane block: An effective alternative for bilateral multiple rib fracture analgesia.

Pain due to rib fracture leads to respiratory impairment and bilateral fractures impact respiratory mechanics in the worst manner. Thoracic epidural analgesia is the gold standard for bilateral rib fractures but is technically difficult, entails potentially serious complications, and necessitates patient repositioning. Ultrasound-guided serratus anterior plane block (SAPB) has recently gained favor for alleviating thoracic pain and can be performed in patients lying supine, rendering it particularly useful in polytrauma patients who are unable to sit up or turn lateral for regional blocks on the back. Use of continuous bilateral SAPB for rib fractures has been underutilized. We report a case of a polytrauma patient who had bilateral multiple rib fracture along with vertebral and pelvic fractures due to which she was in severe pain and was unable to move to provide any kind of positioning for the blocks. Bilateral SAPB provided effective pain relief and facilitated early recovery and pulmonary rehabilitation of the patient.

Clinical Characteristics and Outcomes of Coronavirus Disease 2019 Infection of In-center Hemodialysis Patients: An Experience of a Dialysis Center from Pakistan.

Much has now been learned about the coronavirus disease 2019 (COVID-19) in the general population, but data for hemodialysis (HD) patients are limited. This is the first study of COVID-19 disease in patients undergoing maintenance HD in Pakistan. We studied the epidemiological, clinical, laboratory, radiological characteristics, and outcomes of a cohort of HD patients that contracted COVID-19 in our HD center from the first confirmed case on May 12, 2020, until September 9, 2020. Out of the total 423 patients being dialyzed in our center, 87 were suspected and 50 (11.8%) were confirmed for COVID-19. Male:Female ratio was nearly equal. The median age was 59.5 ± 9.99 years. Most patients developed mild disease. The most common symptoms were fever (82%). Ten (20%) had patchy bilateral opacity (ground-glass opacity) on the chest radiograph. Major complications were lymphocytopenia (36%), thrombocytopenia (30%), pneumonia (28%), and septic shock (6%). Eleven (22%) patients were hospitalized. Five required mechanical ventilation. Ten (20%) patients died. The relative risk of death with COVID-19 in HD patient was 1.46 with 95% confidence interval 1.15-1.84, (P = 0.003). The patients aged ≥60 years had 4.3 times more severe disease (P = 0.044) and died 3.3 times (P = 0.164) more than patients aged <60 years. HD patients have a high susceptibility to COVID-19 compared to the general population with an increased mortality rate and prolonged recovery time. Patients with age >60 years, female gender, diabetics, and those presented with more severe symptoms and laboratory parameters, had a higher fatal outcome.

Frequency of pregnancy-related complications causing acute kidney injury in pregnant patients at a tertiary care hospital.

Acute kidney injury (AKI) in pregnancy is associated with significant maternal morbidity and mortality. Several studies from worldwide have shown different frequencies of the causes of pregnancy-related AKI (PRAKI). The present study aimed to provide local data on frequency of causes of PRAKI. A total of 111 pregnant women using nonprobability consecutive sampling technique, with the age group of 18-45 years, admitted with the diagnosis of PRAKI were included in the study. The information regarding age, duration of pregnancies, serum creatinine levels, and outcome variables (complications) were collected from each patient. Effect modifiers were controlled by stratification. The mean age was 29.90 ± 5.40 years. Out of 111 cases, 10 (9%) developed AKI in the 1st trimester, 12 (10.8%) in the 2nd trimester, 13 (11.7%) cases in the 3rd trimester, and rest of the 76 (68.4%) cases were of the postpartum period. The etiology of PRAKI was multifactorial in several patients. The frequencies of complication leading to AKI were observed individually. The results showed that 21 (18.9%) had antepartum hemorrhage, 41 (36.9%) postpartum hemorrhage, 33 (29.7%) puerperal sepsis, 11 (9.9%) preeclampsia, 13 (11.7%) eclampsia, 11 (9.9%) hemolysis, elevated liver enzymes, and low-platelet count syndrome, 7 (6.3%) hemolytic uremic syndrome, and 5 (4.5%) had hyperemesis gravidarum. The results of the present study showed no statistically significant association of age with the individual complications with P >0.05. AKI during pregnancy was mostly due to prerenal causes. The most common cause was postpartum hemorrhage followed by puerperal sepsis and antepartum hemorrhage.

Prevalence of subclinical hypothyroidism in patients with chronic kidney disease on maintenance hemodialysis.

The prevalence of subclinical hypothyroidism (SHT) has been reported to be much higher in patients with chronic kidney disease (CKD) than in the general population. SHT has been identified as a strong predictor of mortality and a risk factor for cardiovascular disease in CKD. The study aimed to provide local data on the prevalence of SHT in CKD patients on maintenance hemodialysis (MHD). A total of 72 patients with CKD on MHD were enrolled. Nonprobability consecutive sampling was performed on patients of either gender aged 14-50 years who met the inclusion and exclusion criteria. Thyroid-stimulating hormone and free thyroxine four levels were obtained and interpreted for the presence of SHT. SHT was present in 22 patients (30.6%). When stratified according to age, 22.7% of patients were younger than 30 years, 20.8% between 30 and 40 years and 46.2% were above 40 years. The percentage of patients above 40 years with SHT was much higher, but not statistically significant (P = 0.096). When stratified according to gender, 21.6% were male, and 46.2% were female (P = 0.03). When stratified according to duration on hemodialysis (HD), 4.5% of patients on HD for two years or less had SHT; 25.9% on HD for three to five years and, 60.9% on HD for more than five years had SHT (P <0.01). The study shows a considerably high prevalence of SHT in CKD patients on HD. Routine screening of thyroid functions in these patients, especially in females and those on HD for >5 years, may help in reducing the morbidity and mortality associated with SHT through early detection and timely intervention.

Reusing dialyzer in low income countries: A good cost saving tactic with complex ethics.

Despite almost universal practice of dialyzer reuse from the earliest days of haemodialysis, reusing dialyzer always remains a controversial issue and several ethical concerns have been raised. Some of the important are safety of reuse over single use, informed consent of the patient, conflict of interest on the part of physician or manufacturer, fiscal responsibility and environmental stewardship. Indeed, at the beginning of this century, there was a drastic shift of practice in favour of single use in developed countries due to availability of biocompatible haemodialyzers, at favourable price. Despite this mega shift, dialyzer reuse is still widely practised in low-income countries. Considering cost inflation and limited medical resources in such countries, dialyzer reuse may be justified as a cost-saving strategy for this part of world. However, it poses the same ethical questions to us which were a matter of debate for the western world in the 1980s and 1990s. This review of literature was planned to revisit and highlight these concerns.

Clinico-laboratory findings in male lupus patients from a tertiary care hospital, Pakistan.

This study was conducted to delineate the clinical pattern of a cohort of Pakistani male patients with systemic lupus erythematosus (SLE). Clinical and laboratory data were collected of 24 male patients who were diagnosed with SLE and admitted to a tertiary care hospital between 1986 and 2001. Imaging and invasive studies (including aspirations and biopsies) were also recorded. Fourteen patients (58%) had renal involvement, with WHO class 4 and 5 comprising 89% of the cases. Eight patients (33%) had neurological involvement. Out of these 8 patients, 3 presented with psychosis (12.5%) and 4 (17%) with seizures. Twenty three patients (96%) had hematological involvement, 6 (25%) had serosal and 10 (41%) had articular involvement. Cutaneous lesions were noted in 10 (41%) patients. A majority of the patients were noncompliant and were lost to follow-up; therefore, ultimate outcome could not be clearly delineated. A high index of suspicion for SLE in males may permit early diagnosis and dictate the need for more aggressive therapy.