Critical care service delivery across healthcare systems in low-income and low-middle-income countries: protocol for a systematic review.

INTRODUCTION: Critical care in low-income and low-middle income countries (LLMICs) is an underdeveloped component of the healthcare system. Given the increasing growth in demand for critical care services in LLMICs, understanding the current capacity to provide critical care is imperative to inform policy on service expansion. Thus, our aim is to describe the provision of critical care in LLMICs with respect to patients, providers, location of care and services and interventions delivered. METHODS AND ANALYSIS: We will search PubMed/MEDLINE, Web of Science and EMBASE for full-text original research articles available in English describing critical care services that specify the location of service delivery and describe patients and interventions. We will restrict our review to populations from LLMICs (using 2016 World Bank classifications) and published from 1 January 2008 to 1 January 2020. Two-reviewer agreement will be required for both title/abstract and full text review stages, and rate of agreement will be calculated for each stage. We will extract data regarding the location of critical care service delivery, the training of the healthcare professionals providing services, and the illnesses treated according to classification by the WHO Universal Health Coverage Compendium. ETHICS AND DISSEMINATION: Reviewed and exempted by the Stanford University Office for Human Subjects Research and IRB on 20 May 2020. The results of this review will be disseminated through scholarly publication and presentation at regional and international conferences. This review is designed to inform broader WHO, International Federation for Emergency Medicine and partner efforts to strengthen critical care globally. PROSPERO REGISTRATION NUMBER: CRD42019146802.

ECG Case of the Month: ECG in a 20-Year-Old Woman with Dyspnea. Sinus tachycardia (104 beats/minute), slight right axis deviation of the QRS (+92°), an R/S ratio greater than 1 in lead V1 with ST depression and T wave inversion in leads V1 - V4, and a prominent S wave in lead I, Q wave in lead III, and inverted T wave in lead III(S1 Q3 T3). These findings suggest right ventricular hypertrophy or strain and are consistent with pulmonary emboli.

A 20-year-old Hispanic woman presented to the emergency department complaining of six months of progressive dyspnea on exertion associated with intermittent palpitations. Her only past medical history was a stillbirth at 32 weeks gestation about two years ago. Her vital signs in the emergency department were a heart rate of 120 beats/minute, a blood pressure of 145/86 mmHg, and an arterial oxygen saturation of 98 percent with her breathing air. Significant laboratory values included a blood hemoglobin of 14.5 gm/dL, a hematocrit of 49 percent, a brain naturetic peptide (BNP) level of 177 pg/mL, a D-dimer level of 330 ng/ml, a prothrombin time of 12.85 s with an INR of 1.2, and a partial thromboplastin time of 45.7s. Urine pregnancy test was positive, and serum beta-human chorionic gonadotropin level was 81 MIU/mL consistent with a fetus of 3-4 weeks gestational age. An electrocardiogram was recorded.

Clinical Case of the Month. A 44-Year-Old HIV-Infected Man With Righ-Shoulder Swelling.

Immunocompromised patients are susceptible to various joint infections with less-common pathogens, such as mycobacterium. Physicians should have a low threshold to investigate the cause of an arthropathy further. An aspiration of the effusion is usually warranted to identify the possible pathogen and target treatment. We report an unusual presentation of a human immunodeficiency virus-infected patient with a chronic effusion arthropathy of his right shoulder due to Mycobacterium kansasii. We review the risk factors, transmission, clinical manifestations, and management of Mycobacterium kansasii.

Photoperiod alters phase difference between activity onset in vivo and mPer2::luc peak in vitro.

Photoperiod is a significant modulator of behavior and physiology for many organisms. In rodents changes in photoperiod are associated with changes in circadian period and photic resetting of circadian pacemakers. Utilizing rhythms of in vivo behavior and in vitro mPer2::luc expression, we investigated whether different entrainment photoperiods [light:dark (L:D) 16:8 and L:D 8:16] alter the period or phase relationships between these rhythms and the entraining light cycle in Per2::luc C57BL/6J mice. We also tested whether mPer2::luc rhythms differs in anterior and posterior suprachiasmatic nucleus (SCN) slices. Our results demonstrate that photoperiod significantly changes the timing of the mPer2::luc peak relative to the time of light offset and the activity onset in vivo. In both L:D 8:16 and L:D 16:8 the mPer2::luc peak maintained a more stable phase relationship to activity offset, while altering the phase relationship to activity onset. After the initial cycle in culture, the period, phase, and peaks per cycle were not significantly different for anterior vs. posterior SCN slices taken from animals within one photoperiod. After short-photoperiod treatment, anterior SCN slices showed increased-amplitude Per2::luc waveforms and posterior SCN slices showed shorter-duration peak width. Finally, the SCN tissue in vitro did not demonstrate differences in period attributable to photoperiod pretreatment, indicating that period aftereffects observed in behavioral rhythms after long- and short-day photoperiods are not sustained in Per2::luc rhythms in vitro. The change in phase relationship to activity onset suggests that Per2::luc rhythms in the SCN may track activity offset rather than activity onset. The reduced amplitude rhythms following long-photoperiod treatment may represent a loss of coupling of component oscillators.