Spatiotemporal variability of COVID-19 pandemic in relation to air pollution, climate and socioeconomic factors in Pakistan.

Information on the spatiotemporal variability of respirable suspended particulate pollutant matter concentrations, especially of particles having size of 2.5 µm and climate are the important factors in relation to emerging COVID-19 cases around the world. This study aims at examining the association between COVID-19 cases, air pollution, climatic and socioeconomic factors using geospatial techniques in three provincial capital cities and the federal capital city of Pakistan. A series of relevant data was acquired from 3 out of 4 provinces of Pakistan (Punjab, Sindh, Khyber Pakhtunkhwa (KPK) including the daily numbers of COVID-19 cases, PM2.5 concentration (µgm-3), a climatic factors including temperature (°F), wind speed (m/s), humidity (%), dew point (%), and pressure (Hg) from June 1 2020, to July 31 2020. Further, the possible relationships between population density and COVID-19 cases was determined. The generalized linear model (GLM) was employed to quantify the effect of PM2.5, temperature, dew point, humidity, wind speed, and pressure range on the daily COVID-19 cases. The grey relational analysis (GRA) was also implemented to examine the changes in COVID-19 cases with PM2.5 concentrations for the provincial city Lahore. About 1,92, 819 COVID-19 cases were reported in Punjab, Sindh, KPK, and Islamabad during the study period. Results indicated a significant relationship between COVID-19 cases and PM2.5 and climatic factors at p < 0.05 except for Lahore in case of humidity (r = 0.175). However, mixed correlations existed across Lahore, Karachi, Peshawar, and Islamabad. The R2 value indicates a moderate relationship between COVID-19 and population density. Findings of this study, although are preliminary, offers the first line of evidence for epidemiologists and may assist the local community to expedient for the growth of effective COVID-19 infection and health risk management guidelines. This remains to be seen.

Spot Sign in Acute Intracerebral Hemorrhage in Magnetic Resonance Imaging: A Case Report and Review of the Literature.

INTRODUCTION: Intracranial hemorrhage (ICH) is associated with significant mortality and morbidity. Current treatment paradigms focus on correcting hypertension and coagulopathy to prevent hematoma expansion. Magnetic resonance imaging (MRI) is becoming more common in the hyperactive phase of ICH management. The finding of contrast extravasation (ie, spot sign) on MRI may be a marker of active bleeding. We present a case of MRI spot sign and review of the literature. CASE REPORT: We present a patient on oral coumadin for history of deep venous thrombosis and pulmonary embolus who presented with a right basal ganglia hemorrhage. She had a computed tomography angiography showing contrast extravasation and also had a hyperacute MRI showing similar contrast extravasation. Follow-up imaging showed hematoma enlargement. DISCUSSION: We present here a case of corroboration of the computed tomography angiography spot sign with the MRI spot sign. The prognostic value of the MRI spot sign is unclear. Future studies should evaluate the prognostic value of the hyperacute MRI in ICH management.

An Evaluation of Complications in Femoral Arterial Sheaths Maintained Post-Neuroangiographic Procedures.

BACKGROUND: Digital subtraction angiography (DSA) is a frequently used technique in the neuro-diagnosis and treatment of cerebrovascular diseases. The routine use of femoral arterial sheaths (FAS) peri-procedurally has become standard. The maintenance of a FAS post-procedure may be warranted while awaiting the normalization of coagulopathy or to reaccess emergently. We retrospectively reviewed our stroke dataset to evaluate for complications associated with the prolonged use of FAS post-procedure. METHODS: A retrospective chart review was performed over a five-month period, including adult patients admitted to the neuroscience intensive care unit (NSICU) following a neuro-endovascular procedure at a tertiary healthcare facility. The patients' age and sex along with catheter size, duration of sheath placement, coagulation status, usage of heparinized-saline, reuse of FAS for angiographic interventions, and closure technique employed when sheath was removed were recorded. FAS were maintained and evaluated by the neurocritical care team for vascular complications according to protocols. Furthermore, patients were categorized as delayed extubation when they remained intubated post-procedure. A spontaneous breathing trial was performed once FAS could be removed following evaluation. Data were expressed with descriptive statistics. RESULTS: One hundred and seventy-eight neuro-endovascular procedures were reviewed. Fourteen patients in which the sheaths were left in place for a prolonged period of time after the procedure were identified with seven (50%) having complications. The most common complication was delayed extubation, which was noted in all seven of the patients with complications. Bleeding complications were noted in four (28.6%). None had thromboembolic complications. Only one FAS was reaccessed for the evaluation of vasospasm and the introduction of intra-arterial verapamil. There was a linear increase in complications with the duration the catheter remained in place after the procedure. CONCLUSION: The practice of keeping FAS in for a prolonged period of time following procedures should be evaluated given the association with direct and indirect complications and minimal need to reaccess the catheter after the procedure.

Extubating the Neurocritical Care Patient: A Spontaneous Breathing Trial Algorithmic Approach.

BACKGROUND: Delaying extubation in neurologically impaired patients otherwise ready for extubation is a source for significant morbidity, mortality, and costs. There is no consensus to suggest one spontaneous breathing trial (SBT) over another in predicting extubation success. We studied an algorithm using zero pressure support and zero positive end-expiratory pressure (ZEEP) SBT followed by 5-cm H2O pressure support and 5-cm H2O positive end-expiratory pressure (i.e., 5/5) SBT in those who failed ZEEP SBT. METHODS: This is a retrospective analysis of intubated patients in a neurosciences intensive care unit. All eligible patients were initially challenged with ZEEP SBT. If failed, a 5/5 SBT was immediately performed. If passed either the ZEEP SBT or the subsequent 5/5 SBT, patients were liberated from mechanical ventilation. RESULTS: In total, 108 adult patients were included. The majority of patients were successfully liberated from mechanical ventilation using ZEEP SBT alone (82.4%; p = 0.0007). Fifteen (13.8%) patients failed ZEEP SBT but immediately passed 5/5 SBT (p = 0.0005). One patient (0.93%) required reintubation. We found high sensitivity of this extubation algorithm (100; 95% CI 95.94-100%) but poor specificity (6.67; 95% CI 0.17-31.95%). CONCLUSION: This study showed that the majority of patients could be successfully liberated from mechanical ventilation after a ZEEP SBT. In those who failed, a 5/5 SBT increased the successful liberation from mechanical ventilation.

Finger Flexion to Noxious Stimulation in a Brain-dead Patient: A Case Report and Review of Literature.

Several guidelines and definitions for brain death have been proposed. The Uniform Determination of Death Act (UDDA) in 1980, the American Academy of Neurology (AAN) guidelines in 1995 and the later update in 2010 have all described standards for diagnosing brain death. As brain death testing became more commonly performed, several abnormal reflexive movements were recognized and led to ambiguities that falsely suggested retained brain function. Movements in the upper extremities have been under-recognized. We report a brain-dead patient with finger flexion in the upper extremities with noxious stimulation and suspect a pathogenesis similar to that of Hoffman's reflex sign. We present a case of an asthmatic patient who presented with pulseless electrical activity (PEA). The patient was managed emergently and subsequently deteriorated to a comatose state. She remained in a comatose state following management and showed diffuse cerebral edema secondary to anoxic brain injury on computed tomography (CT) scan. Subsequent apnea testing, transcranial Doppler studies (TCD) and detailed neurological examinations were performed. She was eventually declared brain dead. On nailbed pressure to her fourth finger, she had flexion of her third finger, similar to the finding of a Hoffman's sign in an upper motor neuron injury. We have described this case in detail and reviewed the literature on abnormal movements in brain-dead patients.

Risk factors for complicated varicella infection in pediatric oncology patients at a tertiary health care facility in Pakistan.

INTRODUCTION: Varicella zoster infection (VZI) is well recognized as a potential cause of morbidity and mortality in immunocompromised pediatric oncology patients (POP). The purpose of this study was to describe the clinical profile and risk factors for complications and outcomes of VZI in POP treated with acyclovir. METHODOLOGY: Medical records of all POP with a discharge diagnosis of VZI over a period of seven years (2005-2011) were reviewed. The demographic features, underlying malignancy, risk factors for VZI, complications, and outcomes were recorded. RESULTS: Thirty-six POP with VZI were identified. Leukemia was the most common underlying malignancy (n = 20, 58.8%), followed by lymphoma (n = 7, 20.6%) and solid organ tumors (n = 7, 20.6%). Most of the cases (41%) were observed in children under five. All patients were treated with acyclovir. Varicella-related complications developed in 10 (29%) patients. The most frequent complication was bloodstream infection (n = 3, 8.8%), followed by pneumonia (n = 2, 5.9%), skin infection (n = 2, 5.9%), hepatitis, renal failure, and encephalitis. Independent risk factors associated with complications were age < five years, weight for age < fifth percentile, delay in seeking care (> seven days after onset of symptoms) and severe neutropenia (ANC < 500/cm). One child died secondary to varicella encephalitis. CONCLUSION: Our data suggests that young age, poor health-seeking behavior, severe neutropenia, and being underweight are the major risk factors for the development of varicella-related complications in POP in developing countries. These complications could be favorably modified through active immunization of immunocompetent children.