Convalescent plasma transfusion in severe COVID-19 patients: Clinical and laboratory outcomes.

INTRODUCTION: The objective of this study was to investigate the effect of convalescent plasma (CP) transfusion on clinical and serial laboratory parameters in severe COVID-19 patients. The Coronavirus Disease 2019 (COVID-19) pandemic presents a challenge to the healthcare system worldwide due to the limited treatment options available. The body of evidence reported that CP containing anti- COVID-19 antibodies could be effective against the infection. MATERIALS AND METHODS: This was a cross-sectional study that involved retrospective data collection of severe COVID-19 adult patients who received CP transfusion along with the best-of-care (CP group, n: 53) and best-of-care only (control group, n: 53). An age, gender, and comorbidity were manually matched approximately at a 1:1 ratio. RESULTS: The prevalence of adverse transfusion reactions was 5.7%. A shorter duration of oxygen support (median: 12 days vs 14 days, P=0.030) and a shorter duration of mechanical ventilation (median: 6 days vs 10 days, P=0.048) were found in the CP group. The laboratory parameters were also improved. However, there was no significant difference in the mechanical ventilation rate, length of hospital stay, length of intensive care unit (ICU) stay, and mortality rate across both groups (P = 0.492, 0.614, 0.793, 0.374). CONCLUSION: CP transfusion is safe and effective in the treatment of severe COVID-19 patients. However, a revision of our approaches such as early CP transfusion and use of a high-titre anti-COVID-19 neutralising antibody (nAb) unit is necessary to unlock the full potential benefits of CP transfusion among COVID-19 patients.

Convalescent plasma as an adjunctive therapy for COVID-19: A single centre experience in Malaysia.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic posed a significant and urgent threat to global health and economy. Currently, there is no effective treatment known to alter the course of COVID-19. Convalescent plasma (CP) has been used previously to treat several types of infections during pandemics. The aim of our study is to evaluate the efficacy of CP in the treatment of severe COVID-19 infections at Hospital Sultanah Bahiyah, Kedah, Malaysia. MATERIALS AND METHODS: A retrospective cross-sectional study of all severe COVID-19 patients who received CP treatment from 1st August 2020 until 31st December 2020 was conducted. Clinical outcomes were compared before and after CP transfusion. RESULTS: Thirty-four patients were enrolled and received CP transfusion during the study period. The most common presenting complaints were fever (64.7%) and cough (58.8%). Fourteen patients showed improvement in oxygen support after CP transfusion. Several laboratory parameters also improved such as increased lymphocyte count (1.48 vs 1.98, p=0.008) and decreased C-reactive protein levels (28.1 vs 10.6, p=0.004), and these were statistically significant. Median time from symptoms onset to CP transfusion was 6 days (range 1-11) while median time from PCR diagnosis to CP transfusion was 5 days (range 1-11). One patient developed urticaria after CP transfusion and no severe adverse events were observed. Two of our patients passed away due to secondary causes. CONCLUSION: This study showed CP treatment was well tolerated and could potentially prevent progression of COVID-19 to a severe disease if administered early during the viraemic phase. Further evaluation with randomized control trial should be conducted to help ascertain the optimal dose and effectiveness of CP treatment, in correlation with the IgG titer of the donated CP.

Emergency Laparotomy in a COVID-19 patient with acute abdomen.

We describe here the first laparotomy involving a COVID-19 patient in Malaysia. A 60-year-old man screened positive for SARS-CoV-2 in March 2020 and developed acute abdomen in the ward in Hospital Sultanah Bahiyah, Kedah. He underwent laparotomy and cholecystectomy for gangrenous cholecystitis. All personnel adhered to infectious control precautions, donning full personal protective equipment (PPE) throughout the surgery. Post-operatively, due to raised septic parameters, he was carefully diagnosed with and treated empirically for superimposed bacterial sepsis instead of cytokine release syndrome, with confirmed blood culture of Klebsiella pneumoniae. Patient was discharged well later. None of the staff involved in his care developed COVID-19 infection.

Collaboration between a tertiary pain centre and community teams during the pandemic.

People with chronic pain faced potential treatment disruption during the COVID-19 pandemic in Singapore, as the focus of healthcare shifted. A model of rapid integration of a pain centre with community healthcare teams was implemented to care for vulnerable older patients with chronic pain and multiple comorbidities. Telemedicine and home visits by community nurses were used, with risk-mitigation measures, ensuring comprehensive assessment and treatment compliance. Medications from pain physicians were delivered at home through a hospital pharmacy. A secure national electronic health records system used by all teams ensured seamless access and documentation. Potential emergency department visits, admissions and delayed discharges were thus avoided. Integration of community teams with chronic pain management services can be recommended to ensure pandemic preparedness.

A systematic review of nudge theories and strategies used to influence adult health behaviour and outcome in diabetes management.

BACKGROUND: Diabetes is a chronic disease associated with a variety of complications, and nudging may be a potential solution to improve diabetes control. Since nudging is a new concept, no review of literature on nudging diabetic patients into improving their health behaviour has been done. Therefore, we aim to collate a list of nudge intervention and determine the context in which nudging is successful. METHODS: We adopted a two-arm search strategy comprising the search of literature databases and snowballing using relevant search terms. We summarized patient characteristics, the nudge intervention, according to nudging strategies, delivery mode and their outcomes. The conditions present in effective nudge interventions were assessed and reported. RESULTS: We retrieved 11,494 studies from our searches and included 33. An additional five studies were added through snowballing. Studies included utilized framing (n=5), reminders (n=10), gamification (n=2), social modelling (n=5) and social influence (n=16). Studies on reminders and gamification were more likely to have a statistically significant outcome. The targeted health behaviours identified were medication adherence, physical activity, diet, blood glucose monitoring, foot care, self-efficacy, HbA1c and quality of life. Of these, studies with adherence to medication, foot care practice and quality of life as targeted health behaviours were more likely to show a statistically significant outcome. CONCLUSION: Nudging has shown potential in changing health behaviour of patients with diabetes in specific context. We identified two possible factors (delivery mode and patient characteristics) that may affect the effectiveness of nudge intervention.

The association between distance to public amenities and cardiovascular risk factors among lower income Singaporeans.

Existing evidence on the association between built environment and cardiovascular disease (CVD) risk factors focused on the general population, which may not generalize to higher risk subgroups such as those with lower socio-economic status (SES). We examined the associations between distance to 5 public amenities from residential housing (public polyclinic, subsidized private clinic, healthier eatery, public park and train station) and 12 CVD risk factors (physical inactivity, medical histories and unhealthy dietary habits) among a study sample of low income Singaporeans aged ≥ 40 years (N = 1972). Using data from the Singapore Heart Foundation Health Mapping Exercise 2013-2015, we performed a series of logistic mixed effect regressions, accounting for clustering of respondents in residential blocks and multiple comparisons. Each regression analysis used the minimum distance (in km) between residential housing and each public amenity as an independent continuous variable and a single risk factor as the dependent variable, controlling for demographic characteristics. Increased distance (geographical inaccessibility) to a train station was significantly associated with lower odds of participation in sports whereas greater distance to a subsidized private clinic was associated with lower odds of having high cholesterol diagnosed. Increasing distance to park was positively associated with higher odds of less vegetable and fruits consumption, deep fried food and fast food consumption in the preceding week/month, high BMI at screening and history of diabetes, albeit not achieving statistical significance. Our findings highlighted potential effects of health-promoting amenities on CVD risk factors in urban low-income setting, suggesting gaps for further investigations.

A forgotten clinical sign making a comeback.

We report a case of Staphylococcus aureus infective endocarditis in a patient presenting with fever and rare cutaneous manifestations of Osler Nodes and Janeway Lesions. There had not been any distinct risk factors. His echocardiography subsequently revealed vegetation at the anterior mitral valve leaflet. As Staphylococcus aureus infective endocarditis is of utmost significance in morbidity and mortality, a sharp clinical acumen and follow up investigations is required alongside a prolonged course of antibiotics. Our patient was then started on intravenous cloxacillin for 28 days and gentamicin for 5 days to which he made good progress and recovery.

Computer vision syndrome: a study of knowledge and practices in university students.

INTRODUCTION: Computer vision syndrome (CVS) is a condition in which a person experiences one or more of eye symptoms as a result of prolonged working on a computer. OBJECTIVES: To determine the prevalence of CVS symptoms, knowledge and practices of computer use in students studying in different universities in Malaysia, and to evaluate the association of various factors in computer use with the occurrence of symptoms. MATERIAL AND METHODS: In a cross sectional, questionnaire survey study, data was collected in college students regarding the demography, use of spectacles, duration of daily continuous use of computer, symptoms of CVS, preventive measures taken to reduce the symptoms, use of radiation filter on the computer screen, and lighting in the room. RESULTS: A total of 795 students, aged between 18 and 25 years, from five universities in Malaysia were surveyed. The prevalence of symptoms of CVS (one or more) was found to be 89.9%; the most disturbing symptom was headache (19.7%) followed by eye strain (16.4%). Students who used computer for more than 2 hours per day experienced significantly more symptoms of CVS (p=0.0001). Looking at far objects in-between the work was significantly (p=0.0008) associated with less frequency of CVS symptoms. The use of radiation filter on the screen (p=0.6777) did not help in reducing the CVS symptoms. CONCLUSION: Ninety percent of university students in Malaysia experienced symptoms related to CVS, which was seen more often in those who used computer for more than 2 hours continuously per day.

Validity and reliability of the SF-36: the Malaysian context.

Results of construct validity and reliability of the SF-36 are described, based on data from a multi-centre study on asthmatics and a population based survey. Questionnaire refinement was carried out between the two studies. Quality of data was good, with all items having less than 0.5% missing values. Floor and/or ceiling effects were observed for REE, REP, PF and SF. For scaling assumptions, correlations between each items and its hypothesized scale were all above 0.50, except for one item in PF. and for both items in SF. Item discriminant validity was an issue for items in VT, SF and MH scales. Cronbach's as for all scales exceeded the recommended 0.70 level, except for SF. Only one latent dimension was identified in principal component analysis, and only 52-53% of variance accounted for. As expected, PF shows high correlations with the physical component while MH was highly correlated with the mental component. Contrasting findings in the loadings of other scales were observed in the asthma data. Age, disease severity and presence of self-reported handicap/disability significantly affect PF, while MH demonstrates no obvious pattern with declining age. In essence, the Malay version of SF-36 could be used in Malaysia, with its generally acceptable internal consistency and validity. The caveat is in the call for additional domains of importance to Malaysians that is not covered by the instrument, and in the caution to be employed when using and construing the instrument.

Quality of life of the Malaysian general population: results from a postal survey using the SF-36.

Population norms for Health Related Quality of Life using SF-36 are described. A national sample was canvassed in 2000 using a self-administered SF-36 in Bahasa Malaysia and English. Response rate was 30.6%, with 3072 usable data. Male: Female ratio was 1.04 and mean age was 39.8 years. Quality of life was affected by age and sex. Older population and women had a poorer quality of life. Population norms for Malaysia differed from those of US, Canada and Australia. The malaysian general population norm described is useful as reference point for studies in Malaysia. Variability in scores by age and sex emphasize the need to use appropriate age- or sex-specific normative data.

Quality of life--how do Malaysian asthmatics fare?

Asthma can place considerable restrictions on the physical, emotional and social aspects of the lives of patients. The assessment of quality of life aims to provide a means of measuring the impact of this disease on patients' lives, from the patients' perspective. A cross sectional multi-centre study was conducted in six government hospitals throughout the country. Self-administered SF-36 was used, and clinical information obtained through interviews and examination. 1612 asthmatics responded. Females constituted 63% of the respondents; mean age was 40.9 years; Malays were the majority ethnic group, while 70.8% had secondary level education and 53.7% were employed. Half had suffered from asthma for at least 13 years, while 46.8% and 23.6% have moderate and severe disease respectively. Quality of life was affected by severity of disease. Asthmatics, had a significantly poorer quality of life than the general US population. Severe asthma disease was associated with a compromised quality of life, similar to that of COPD.

Medical futility and the critically ill patient.

Today, the world of critical care medicine has given us the capabilities to accomplish things that were only dreamed of a few decades ago. When combined with the increasing importance of patient autonomy and economics in healthcare, these new capabilities have caused conflicts about what is too little, and what is too much. Medical futility becomes an issue whenever these conflicts arise. Understanding how to deal with issues surrounding futility begins with defining it. A firm definition is not possible or desirable, but revolves around the probability of being able to achieve a patient's goal with modern medicine. Establishing this understanding between the patient and their family (team), and the healthcare team, is dependent on trust between the two. It must be recognized that there are many reasons for families to not trust healthcare professionals and that these reasons need to be explored and dealt with. Sometimes conflicts regarding predictions and economics need to be addressed. Once trust is established a goal for a course of medical treatment should be discussed from the patient's perspective. This discussion should involve the physician's best judgement as to the chances of achieving this goal, and what type of discomfort or indignity, if any, the patient may experience. Only after these have been clearly discussed can decisions regarding medical futility be made. To date, the U. S. Courts have refused to grant physicians and hospitals the power to override the opinions of family members on matters of futility. However, with time, a consensus of public opinion should influence decisions regarding medical futility.

The effect of arterial lines on blood-drawing practices and costs in intensive care units.

STUDY OBJECTIVE: To determine whether the presence of an indwelling arterial access line leads to differences in blood-drawing practices and costs, in patients with similar APACHE II scores, in the ICU. DESIGN: Prospective, observational. SETTING: Adult surgical and medical ICUs at a large military tertiary care hospital. PATIENTS: Twenty-five adult (ie, above 18 years old) patients with arterial access lines and 25 adult patients without arterial access lines. Each had APACHE II of 9 to 20 and none had any central venous access. MEASUREMENTS AND RESULTS: A survey of the arterial line blood-drawing habits of critical care nurses at our hospital revealed a 2.99-mL mean discard blood volume to clear an arterial line, with only 9.4% not discarding any blood. For each patient enrolled in the study, the number of blood tests and blood draws were recorded during the first two 24-h periods after admission to the ICU. The amount of blood required by the laboratory for each blood test was totalled. In the arterial line group, the mean discard volume was added to the total for each blood-drawing procedure. Increases were found in the number of blood tests (29% increase, p = 0.013), blood-drawing procedures (30% increase, p = 0.014), and the amount of blood volume (44% increase, p < 0.001) sent from patients with arterial lines compared to those without. CONCLUSION: When APACHE II scores are similar, the presence of an arterial access line may lead to increased blood drawing from patients in ICUs.

Non-operative management of gastric perforation secondary to cardiopulmonary resuscitation.

We report the case of a 72-year-old male who suffered a cardiac arrest during an early positive treadmill stress test. After successful resuscitation the patient had evidence of a gastric perforation. Because of his hemodynamic stability, lack of peritoneal signs, and prohibitively high surgical risk, a non-operative management approach was successfully administered. Although not the standard approach to traumatic gastric perforation, this case is not unlike the management of peptic ulcer perforations. A non-operative approach should be considered as an option in selected patients.