COVID-19 Infection Presenting as an Isolated Severe Acute Liver Failure.

The clinical features of severe acute respiratory syndrome-coronavirus disease 2019 (SARS-COVID-19) infection range from mild upper respiratory symptoms to severe acute respiratory failure. Among other less common features are diarrhea, nausea, vomiting, elevated liver enzymes, and acute kidney injury. We present a case of a 49-year-old female with no preexisting liver disease who presented with weakness and dizziness for one week. Initial investigations revealed acute liver failure (ALF) and positive COVID-19 on polymerase chain reaction (PCR) testing. The patient did not have any upper or lower respiratory symptoms, and extensive workup to look for other etiologies of acute liver failure was unremarkable. She eventually deteriorated to decompensated liver failure and was transitioned to comfort measures only. Liver injury is a well-documented phenomenon associated with COVID-19 infection. Some of the common pathophysiological mechanisms include direct liver injury, immune-mediated liver damage due to the severe inflammatory response, ischemic injury, endothelial disruption, and coagulopathy. Our case uniquely highlights that SARS-COVID-19 infection may have the potential to solely affect hepatocytes without the classic severe acute respiratory distress syndrome. This case demonstrates that a diagnosis of COVID-19 may be considered if no other etiology of ALF is identified.

Accuracy of lung ultrasound and chest X-rays in diagnosing acute pulmonary oedema in patients presenting with acute dyspnoea in emergency department.

To determine the diagnostic accuracy of lung ultrasound and chest X-ray in diagnosing Acute Pulmonary Oedema in patients presenting with acute dyspnoea in emergency department, a study was conducted at the emergency department of Shifa International Hospital, Islamabad, from July 31, 2018 to January 31, 2019. A total of 225 patients presenting with dyspnoea and satisfying the inclusion criteria were assessed through clinical examination, lung ultrasound (LUS) and chest X-ray. The results of chest X-ray and lung ultrasound were compared with clinical diagnosis. The study revealed sensitivity of chest X-ray and LUS (60.16% versus 91.05%), specificity (66.67% versus 91.18%), positive predictive value (68.52% versus 92.56%) and the negative predictive values (58.12% versus 89.42%) respectively. The present study revealed that the LUS has better accuracy than chest X-ray for diagnosis of acute pulmonary oedema.

Knowledge and attitudes of Pakistani intensive care unit nurses regarding oral care delivery to mechanically ventilated patients.

OBJECTIVE: To assess the knowledge and attitudes of intensive care unit nurses regarding oral care delivery to mechanically ventilated patients. METHODS: The cross-sectional study was conducted from January to July 2018 across four hospitals in the twin cities of Rawalpindi and Islamabad, Pakistan. Data was obtained from randomly selected nurses with the help of a 14-item self-reporting questionnaire. Data was analysed using SPSS 23. RESULTS: Out of 81 nurses, 76(93.8%) were female, and 47(58%) had experience up to 10 years. When the participants were asked if disease can be transmitted from other patients, 23(28.4%) said it was likely, 22(27.2%) said it was most likely and 16(19.8%) said they did not know. When asked if the disease can be transmitted from the aspiration of contaminated secretions from the oropharynx, 32(39.5%) nurses said it was likely, 31(38.3%) said it was not likely and 9(11.1%) did not know. Knowledge level was significantly associated with level of education (p<0.05). In terms of attitude, 54(66.7%) nurses disagreed that there were more important tasks to do for unstable patients than oral care, indicating a good attitude. CONCLUSIONS: Knowledge and attitude among the subjects were found to be good regarding oral care delivery to mechanically ventilated patients.

Knowledge and attitude of health workers regarding catheter-associated urinary tract infection in tertiary care hospitals, Pakistan.

OBJECTIVE: To assess the knowledge and attitude of house officers, residents, specialists and nurses regarding urinary catheterisation and catheter-associated urinary tract infection in tertiary care hospitals. METHODS: The cross-sectional study was conducted from February to July 2018 at 9 hospitals in Rawalpindi and Islamabad, Pakistan, and comprised doctors and nurses. Data were collected using an interviewer-administered questionnaire. Knowledge and attitude regarding urinary catheterisation were compared between doctors and nurses. Data was analysed using SPSS 23. RESULTS: Of the768 individuals approached, 485(63%) agreed to participate. Of them, 358(74%) were doctors and 127(26%) were nurses. Among the doctors, 261(73%) were house officers, 58(16%) residents and 39(11%) specialists. When asked if avoiding catheter kinking was an effective way to prevent CAUTI, 194(54.19%) doctors got it correct as opposed to 102(80.31%) nurses. When the doctors and nurses were asked if the catheter should be removed whenever it is convenient for healthcare personnel, 354(98.88) doctors and 112(88.18) nurses gave the correct answer (p=0.041). CONCLUSIONS: There was reasonable knowledge and attitude among nurses and doctors towards urinary catheterisation and preventive measures related to catheter-associated urinary tract infection.

Predictors of prolonged mechanical ventilation in patients admitted to intensive care units: A systematic review.

OBJECTIVE: Although intensive care medicine has evidenced a significant growth in recent decades, the number of patients requiring prolonged mechanical ventilation (PMV) still represents a considerable burden on health-care expenditure. The prediction of the need for PMV seems to provide a plausible cost-effective intervention. The objective of this study is to systematically review the predictors of the need for PMV of adult patients admitted to intensive care units (ICUs) due to medical and surgical needs. METHODS: We conducted a systematic search on three online databases (PubMed, Embase, and MEDLINE) till February 20, 2019. The search process employed several combinations of specific keywords and Boolean operators. RESULTS: A total of 15 articles were included in the study. Based on pooling the outcomes of odds ratios (ORs) and their respective 95% confidence intervals (CIs) as reported from logistic regression analyses, the pooled PMV incidence in 8220 patients (69.59% males) was 17.67 cases per 100 ICU admissions (95% CI 13.69-21.65). We could not conduct a meta-analysis of ORs and 95% CIs due to the significant heterogeneity observed between the included studies (P < 0.001, I2 = 97%). Pre-operative/preadmission kidney dysfunction and chronic obstructive pulmonary disease were the most significant independent predictors of the need for PMV. Following cardiac surgeries, repeated or emergency surgery, prolonged cardiopulmonary bypass time, and the need for blood transfusion were predictors of the need for PMV. CONCLUSION: Within the study limitations, several predictors were identified, which could be further investigated using a unified PMV definition. Successful prediction of the need for PMV would assist clinicians in identifying and adjusting a "weaning strategy" as well as improving patient care to reduce morbidity. Furthermore, establishing specialized weaning units could be warranted based on PMV incidence and prediction in the local settings.

Assessment of Academic Motivation Level of Undergraduate Medical Students of Azad Kashmir, Pakistan.

Objective To assess the academic motivation level of undergraduate medical students of Azad Kashmir, Pakistan. Methods A total of 378 Poonch Medical College (PMC) students were included in this cross-sectional study. The academic motivation scores of the study subjects were measured using a 28-item, five-point Academic Motivation Scale (AMS) questionnaire originally developed by Deci and Ryan (1985). The tool was checked for internal consistency and was interviewer-administered. Motivation level was quantitatively presented and compared across gender and medical years. Results The highest mean motivation score (4.04 ± 2.71) was observed for the statement "Because this will help me make a better choice regarding my career orientation." The following statements showed a statistically significantly higher mean motivation level in females as compared to males: "Because eventually, it will enable me to enter the job market in a field that I like" (p .008) and "for the pleasure that I experience when I read interesting authors" (p .001). But for the statement, "I once had good reasons for going to college; however, now I wonder whether I should continue," males showed a higher motivation level (p. 0.19). A statistically significant difference in mean motivation level was seen across medical years for the following statements: "For the intense feelings I experience when I am communicating my own ideas to others," "For the pleasure that I experience when I read interesting authors," "Because this will help me make a better choice regarding my career orientation," "For the satisfaction I feel when I am in the process of accomplishing difficult academic activities," and "Because I want to show myself that I can succeed in my studies" (p-value <.05). Conclusion This study analyzed mean motivation scores for all AMS questions. The study identified that the most common motivational factor for pursuing medical education was because the students thought this will help them make a better choice regarding their career orientation.

Bicarbonate Therapy for Critically Ill Patients with Metabolic Acidosis: A Systematic Review.

The management of acid-base disorders always calls for precise diagnosis and treatment of the underlying disease. Sometimes additional means are necessary to combat systemic acidity itself. In this systematic review, we discuss the concept and some specific aspects of bicarbonate therapy for critically ill patients with metabolic acidosis (i.e., patients with blood pH < 7.35). We conducted a systematic literature review of three online databases (PubMed, Google Scholar, and Cochrane) in November 2018 to validate usage of bicarbonate therapy for critically ill patients with metabolic acidosis. Twelve trials and case series were included in the final analysis, from which we assessed population, intervention, comparison, and outcome data. The current literature suggests limited benefit from bicarbonate therapy for patients with severe metabolic acidosis (pH < 7.1 and bicarbonate < 6 mEq/L). However, bicarbonate therapy does yield improvement in survival for patients with accompanying acute kidney injury.