Metal phosphide poisoning in a disaster-stricken area. Can early hemodialysis improve outcomes?

BACKGROUND: Phosphide metal poisoning results in tens of thousands of fatalities per year worldwide. The mortality in critically ill patients often exceeds 50%. The available treatment is supportive and there is no antidote. Dialysis is recommended to treat advanced complications but has not been prescribed early in the process. In this study we report our experience in using dialysis in the early hours of presentation of the patients and suggest it can favorably improve the prognosis. We also draw attention to the risk of suicide under conditions of chronic conflict such as those in northwestern Syria, and to the lack of necessary mental health support for patients after suicide attempts. METHODS: Retrospective review of records of patients poisoned with aluminum phosphide and admitted to critical care facilities in northwestern Syria between July 2022 and June 2023. RESULTS: During the observation period 16 cases were encountered. Suicide was the reason of the poisoning in 15 patients, the median patient age was 18 years and over two thirds of the patients were female. Early dialysis was used in 11 patients who were critically ill and their mortality rate was 18%. CONCLUSIONS: Phosphide metal poisoning is common in the disasters stricken area of northwestern Syria. Most cases are suicidal and impact young females. Early dialytic interventions may favorably impact the outcomes.

Removal of benzophenone-4 via chlorination and advanced oxidation processes in aqueous solution: kinetics, by-product identification, and mechanistic studies.

Benzophenone-4 (BP-4) is one of the UV filters widely used in personal care products (PCPs). BP-4 has been identified as an emergent contaminant detected in influent and effluent of wastewater treatment plants (WWTPs) at high concentrations showing that conventional treatment is unable to remove it, subsequently, the presence of BP-4 in surface water is inevitable. In this study, we focus on the degradation of this compound by chlorine, and we report the efficiency of its removal from water by applying two advanced oxidation processes UV/TiO2 and UV/H2O2 aiming to achieve a superior mineralization result. The study was performed in purified water (pH = 6.5, temperature = 25 °C) with an initial concentration of BP-4 similar to that detected in WWTPs (10 mg/L). The results showed that 76% of BP-4 was degraded after 80 min of reaction with chlorine leading to the formation of one by-product persistent in the solution. The oxidation by UV/TiO2 and UV/H2O2 led to a total removal of BP-4 and their generated by-products after 50 and 10 min of reactions, respectively. The kinetic study showed that BP-4 degradation by UV/H2O2 and UV/TiO2 followed pseudo-first-order reaction kinetics and the apparent rate constants (kapp) were determined to be 0.48 min-1 and 0.08 min-1, respectively. The degradation of BP-4 by chlorine followed first-order reaction kinetics with kapp = 0.02 min-1. The identification of by-product structures was performed using liquid chromatography with electrospray ionization and tandem mass spectrometry (MS/MS. The fragmentation of BP-4 and by-product ions at different collision energies allowed to propose the pathways of degradation and to predict the toxicity using a silico toxicity program which confirmed a higher toxicity of all generated by-products.

Geographical Origin, WASH Access, and Clinical Descriptions for Patients Admitted to a Cholera Treatment Center in Northwest Syria between October and December 2022.

Background On September 10, 2022, a cholera outbreak was declared in Syria for the first time in over a decade of protracted conflict. As of May 20, 2023, 132,782 suspected cases had been reported, primarily in northwest and northeast Syria. We aim to provide a detailed description of water sources and clinical status of a patient cohort seen at a cholera treatment center (CTC) in northwest Syria. Methods We retrospectively identified patients with confirmed cholera who presented to the CTC in Idlib governorate between October 8 and December 18, 2022. Data were obtained from clinical case records and analyzed in R v4.0.4. Results Ninety-four patients (55.3% men) were treated at the CTC. Thirty-five patients were severely dehydrated (Plan C treatment), 54 had some dehydration (Plan B), and 5 had no dehydration (Plan A). Most patients were between 11 and 20 years old ( n = 25, 26.6%) or 31 and 40 years old ( n = 19, 20.2%). Note that 70.2% ( n = 66) of patients were seen in November 2022 and most were from Harim district ( n = 44, 46.8%). Public wells ( n = 46, 48.9%) and water trucking ( n = 41, 43.6%) were the most commonly used water sources. Note that 76.6% ( n = 72) did not have access to chlorine-treated water. Forty-seven patients (50%) had more than five water, sanitation, and hygiene (WASH)-related cholera risk factors. Following treatment, six patients were transferred to another treatment center, three died (case fatality rate: 3.2%), and the remainder were discharged. Conclusion Most patients reported WASH-related risk factors for cholera, reflecting the poor state of WASH in northwest Syria after over a decade of conflict. This relates to the direct and indirect impacts of urban and periurban violence as well as the underfunded humanitarian response. Strengthening WASH and health promotion are important components to control the outbreak.

Glomerulonephritis Associated With Infected Cardiac Pacemaker Lead Mimics Infective Endocarditis-Associated Glomerulonephritis With Resolution After Lead Removal: A Case Report and Literature Review.

The incidence of cardiac pacemaker lead infections is increasing due to the rise in cardiac implantable device use. These infections mimic infective endocarditis (IE) and cause a variety of complications. However, there is a scarcity of knowledge regarding glomerulonephritis (GN) resulting from cardiac pacemaker-lead infections. This report describes a 71-year-old female who presented with GN associated with a cardiac pacemaker-lead infection. The patient was successfully treated with intravenous (IV) antibiotics, IV steroids, and early surgical removal of the cardiac pacemaker lead, resulting in the resolution of GN. Current guidelines do not address cardiac pacemaker lead infection-associated GN as an indication for lead removal. Given the success of our treatment approach and the rising incidence of cardiac pacemaker infections, we suggest the consideration of early surgical removal of the cardiac lead, in conjunction with antibiotics and steroids, for the treatment of cardiac lead infection associated with GN. Further research is necessary to determine the prevalence and optimal management of this complication.

Cutaneous Leukocytoclastic Vasculitis Induced by Apixaban and/or Rivaroxaban With Seronegative Anti-Neutrophil Cytoplasmic Antibody (ANCA) Titers: A Case Report and Literature Review.

A 45-year-old man presented with a diffuse petechial rash and a non-blanching palpable purpura, mainly on his lower extremities, some of which had coalesced, blistered, and ulcerated. The patient had a history of hypercoagulability and was chronically on anticoagulant medication. The rash appeared a week after starting apixaban 5 mg twice daily by mouth. Prior to that, he was receiving rivaroxaban. The rash was biopsied, which demonstrated cutaneous leukocytoclastic vasculitis (LCV). Serum anti-neutrophil cytoplasmic antibody (ANCA) titers were negative. Complement levels of C3, C4, and CH50 were normal. Hepatitis C antibodies were negative. HIV antibodies were non-reactive. Titers for Lyme disease and Rocky Mountain spotted fever were nonreactive. It is unusual for a drug to induce cutaneous LCV with negative ANCA titers. Although rare, it usually requires aggressive therapy. Our case resolved after the discontinuation of apixaban and rivaroxaban and the initiation of warfarin for hypercoagulability in conjunction with a short course of steroids. As the use of apixaban and rivaroxaban increases, we may see a consequent increase in cutaneous LCV that is specifically ANCA-negative.

Renal Endometriosis in a Postmenopausal Female Mimics Renal Cell Carcinoma.

A 61-year-old postmenopausal female with a past medical history of type 2 diabetes, nephrolithiasis, and recurrent urinary tract infections presented to an outpatient urology clinic with a chief complaint of urinary frequency, urgency, and burning after micturition. Associated symptoms included nausea, a low-grade fever with chills, and right flank pain. After treatment with antibiotics did not relieve all of her symptoms, imaging was obtained, showing a cystic mass with calcifications in the right kidney. Following laparoscopic partial right nephrectomy and total hysterectomy with bilateral salpingo-oophorectomy, pathological examination of the right kidney mass highlighted endometrial stromal cells consistent with endometriosis of the right kidney. The left ovary also contained endometrial stromal cells, confirming another diagnosis of endometriosis of the left ovary. This case highlights the importance of considering renal endometriosis in the differential diagnosis of renal masses in women, even if they are postmenopausal.

Retrospective analysis of operative time and time to discharge for laparoscopic vs robotic approaches to appendectomy and cholecystectomy.

Robotic-assisted appendectomies and cholecystectomies are believed to increase cost compared to the gold standard laparoscopic approach. Two equally qualified surgeons performed both approaches over 2 years to evaluate intraoperative duration, time to discharge, conversion to open procedure, and readmission within 30 days. 110 laparoscopic, 81 robotic-assisted appendectomies; and 105 laparoscopic and 165 robotic-assisted cholecystectomies were performed. Intraoperative time; laparoscopic appendectomy was 1.402 vs 1.3615 h for robotic-assisted (P value = 0.304); laparoscopic cholecystectomy was 1.692 vs 1.634 h for robotic-assisted (P value = 0.196). Time to discharge, was 38.26 for laparoscopic vs 28.349 h for robotic-assisted appendectomy (P value = 0.010), and 35.95 for laparoscopic vs 28.46 h for robotic-assisted cholecystectomy (P value = 0.002). Intraoperative conversion to open; only laparoscopic procedures were converted, one appendectomy and nine cholecystectomies. None in the robotic-assisted procedures. Readmissions, none in the appendectomy group and three in the cholecystectomy group. One laparoscopic and two robotic-assisted cholecystectomy patients were readmitted. Intraoperative times for robotic appendectomy and cholecystectomy were not longer than laparoscopic approach. Robotic approach shortened the time to discharge and the likelihood for conversion to open procedure.

Successful Surgical Management of Urethral Prolapse in a Postmenopausal Female.

Urethral prolapse is a rare and benign condition where the inner urethral lining protrudes through the external urethral opening. This condition is mostly seen in prepubertal and postmenopausal women. Risk factors include obesity, multiparity, and the onset of menopause. It has a low occurrence, resulting in frequent underdiagnosis. This is compounded by its typical delayed diagnosis. We present a case of a 71-year-old postmenopausal woman who presented with persistent urinary symptoms. After multiple failed conservative treatments, she underwent a successful urethral prolapse excision. Our case highlights the importance of considering urethral prolapse as a differential diagnosis in a postmenopausal woman with continual urinary symptoms.

A Rare Presentation of Rhodococcus Equi Bacteremia as a Result of Right Upper Arm Cellulitis: A Case Report and Literature Review.

Rhodococcus equi is an emerging opportunistic pathogen in immunocompromised patients. Owing to its resemblance to Mycobacterium, Nocardia, and Corynebacterium, R. equi is frequently misdiagnosed as a contaminant, which can result in treatment delays. A 65-year-old man with a history of end-stage renal disease (ESRD) presented to the emergency room with pain and increased swelling in his right upper extremity. Shortly after he arrived in the emergency room, his condition deteriorated. Intravenous vancomycin was administered after collecting blood cultures. The blood cultures grew Rhodococcus equi, and oral azithromycin and oral rifampin were added for a 14-day course of treatment. The patient recovered without any further complications and was subsequently discharged home.  R. equi is a partially acid-fast actinomycete that spreads through contact with grazing animals and contaminated soil. R. equi invades macrophages to survive and causes infection within a host. In this particular case, the patient worked on a farm taking care of goats. He was exposed to the bacteria after falling and sustaining multiple lacerations to the right arm. This case is unique due to the development of bacteremia with R. equi, an uncommon cause of bacteremia that led to cardiopulmonary arrest. The treatment with oral azithromycin combined with oral rifampin and intravenous vancomycin was effective for the complete resolution of the infection.

Antitubular Basement Membrane Antibody Disease Associated with Nivolumab Infusion and Concomitant Acute Pyelonephritis Leading to Acute Kidney Injury : a Case Report and Literature Review.

Antitubular basement membrane (anti-TBM) antibody disease is an extremely rare disorder. It may be idiopathic or secondary to exposure of the proximal tubular basement membrane, triggered by tubular injury due to acute pyelonephritis, acute allergic interstitial nephritis, or kidney allograft rejection. The histopathology of anti-TBM antibody disease is characterized by strong linear deposits of IgG with complement C3 along the proximal tubular cell basement membranes. The staining is restricted to proximal tubules. Currently, a kidney biopsy with these pathognomonic findings is the only diagnostic method. Serological testing and titers for anti-TBM antibodies are not clinically standardized. Our patient had pyelonephritis and possibly acute allergic interstitial nephritis as a result of nivolumab infusion. The kidney biopsy demonstrated dense interstitial infiltrates of neutrophil-rich interstitial inflammation, neutrophilic casts, and neutrophilic tubulitis consistent with acute pyelonephritis, as well as areas of mixed inflammation with lymphocytic tubulitis suggesting concurrent acute interstitial nephritis. The presence of linear IgG staining along proximal but not distal tubular basement membranes was diagnostic of anti-TBM antibody disease, favored to be due to both triggers. The patient was treated with discontinuation of nivolumab, intravenous antibiotics, and corticosteroids and was supported with hemodialysis. After 6 weeks, the patient's kidney function recovered enough to discontinue hemodialysis and had significant renal improvement.

Psychological Distress and Physical Adverse Events of COVID-19 Vaccination among Healthcare Workers in Taiwan.

The COVID-19 pandemic places high pressure on everyone, including healthcare workers (HCWs), thus causing them to experience psychological distress. HCWs have priority in receiving the COVID-19 vaccine. However, few studies have identified adverse events (AEs) and psychological distress in the HCWs group. Therefore, we investigated the association between psychological distress and AEs and the determinants of protective behaviors in Taiwanese HCWs. A longitudinal measurement was conducted among HCWs at National Cheng Kung University Hospital (NCKUH), Tainan, Taiwan (n = 483, mean age = 37.55 years). All HCWs completed an online questionnaire on psychological distress, COVID-19 vaccination AEs, and protective behaviors. We used generalized estimating equations (GEE) to analyze the correlation between psychological distress and AEs, and used multivariable logistic regressions to explore the predictors of protective behaviors. Depression and distress and anger were significantly associated with various physical AEs (p = 0.045 to p < 0.001). Suicidal thoughts became a significant independent variable of systemic AEs after COVID-19 vaccination (p = 0.014 to p < 0.001). People of older ages or females engaged more in washing their hands, wearing masks, and reducing their presence in crowded places. Suicidal thoughts were related to the occurrence of systemic AEs among HCWs. Doctors performed better at preventive behaviors compared to nurses and other HCWs. HCWs who experienced anxiety and nervousness tended to avoid crowds.

Hepatitis delta virus infection prevalence, diagnosis and treatment in the Middle East: A scoping review.

Hepatitis D virus (HDV) infection is a global public health concern, especially because of its unique existence in the presence of hepatitis B virus infection. HDV infection is estimated to affect 12 million people globally. Having a clearer understanding of its prevalence in all regions of the world is essential for helping direct preventive and early interventional treatment. This mini-review assessed the literature over the last 10 years to determine the prevalence, diagnostic means and treatment guidelines available for HDV in the Middle East. The search found limited data available in 21 articles, of which 18 were studies focused on Iran. Prevalence rates ranged dramatically among the countries, and none of the 12 countries included in the search had specific HDV guidelines. This review highlights the urgent need for more precise data for the Middle East region to help establish early diagnosis and treatment options for HDV.

A Fatal Case of Isolated Renal Mucormycosis in an Immunocompetent Male.

Mucormycosis (MM) is an angio-invasive fungal infection that often presents in immunocompromised patients. Isolated renal MM is an uncommon presentation that has been documented as a life-threatening condition in immunocompetent patients due to its poor prognosis. Here, we present a rare case of isolated renal MM in a 27-year-old male who presented with left flank pain, nausea, and vomiting. Upon further investigation, a renal infarct was discovered, and he underwent a subsequent nephrectomy. A renal biopsy revealed MM. The patient's infection spread, and he ultimately succumbed to his illness. Isolated renal involvement of this pathogen is extremely rare in healthy individuals and has poor outcomes. The ubiquitous nature of MM increases the risk of exposure to humans. Comorbidities such as coronavirus disease 2019 and immunosuppressive states are risk factors for the deleterious outcomes of MM. It is unusual for an immunocompetent patient with no underlying conditions to die despite early diagnosis and prompt treatment. This example calls attention to the unpredictable clinical presentation of isolated renal MM. Our case highlights MM as a differential diagnosis in patients with unilateral flank pain and identifies the importance of a prompt clinical diagnosis and treatment due to the rapid progression and poor health outcomes associated with MM infection.

Hernia Causing Ureteral Obstruction With Hydronephrosis and Subsequent Urinary Tract Infection and Sepsis.

Inguinal hernias are common anatomic defects, especially among men. Complications of inguinal hernias include incarceration, but incarcerated hernias rarely cause other disturbances. An 86-year-old man with a history of chronic kidney disease (stage IIIb) presented with recurrent urinary tract infections and acute kidney injury with sepsis. Physical examination revealed a right inguinal hernia, and non-contrast abdominal computed tomography revealed right ureteral obstruction and distal entrapment by the inguinal hernia, with hydronephrosis. The patient underwent right retrograde pyelography and ureteral stent placement, followed by laparoscopic inguinal herniorrhaphy with mesh, which restored renal function. Our case is unique among obstructive uropathies due to inguinal hernias because the distal ureter was entrapped within the bowel mesentery communicating between the peritoneal cavity and retroperitoneum. Both inguinal hernias and obstructive uropathy are common among elderly men. While the latter is often secondary to prostate malfunction, other causes of obstructive uropathy or hydronephrosis should be considered, especially if unilateral.

The Motors of COVID-19 Vaccination Acceptance Scale (MoVac-COVID19S): Measurement Invariant Evidence for Its Nine-Item Version in Taiwan, Indonesia, and Malaysia.

Background: As the number of COVID-19 cases grows worldwide, one solution to the global pandemic is vaccination. Unfortunately, the hesitancy of receiving vaccines is still high, particularly among younger age groups (eg, students). Because the hesitancy of receiving vaccines is an important issue, instruments have been developed to assess vaccine hesitancy. Moreover, the use of these instruments among specific groups such as students is of critical importance. Aim: The present study examined the psychometric properties of the nine-item MoVac-COVID19S (also known as the DrVac-COVID19S) including its measurement invariance among university students in three different countries (ie, Taiwan, Indonesia, and Malaysia). Methods: A multi-country, web-based cross-sectional survey study was conducted among 1809 university students, recruited from the three countries from May to September 2021. The nine-item scale was translated into Traditional Chinese, Bahasa Indonesian, and Malay. Results: The results of the confirmatory factor analysis indicated that the one-factor structure of the MoVac-COVID19S was fully supported among Indonesian and Malay participants (comparative fit index [CFI] = 0.991 and 0.998; Tucker-Lewis index [TLI] = 0.997 and 0.987; root mean sqaure error of approximation [RMSEA] = 0.040 and 0.071; and standardized root mean square residual [SRMR] = 0.014 and 0.039). Moreover, the four-factor structure was supported among Indonesian, Malay, and Taiwanese participants (CFI = 0.998, 0.998, and 0.985; TLI = 0.997, 0.996, and 0.973; RMSEA = 0.044, 0.038, and 0.091; and SRMR = 0.013, 0.018, and 0.049). Conclusion: The MoVac-COVID19S has good construct validity among university students from three different countries (ie, Taiwan, Indonesia, and Malaysia). The four-factor structure of the MoVac-COVID19S was supported. Therefore, health-care providers may want to assess the four underlying constructs to better understand why a university student accepts or declines COVID-19 vaccine uptake in the three countries. Using the findings, government policymakers and health-care authorities can design appropriate programs to help decrease vaccine hesitancy.

Short Single-Lead ECG Signal Delineation-Based Deep Learning: Implementation in Automatic Atrial Fibrillation Identification.

Physicians manually interpret an electrocardiogram (ECG) signal morphology in routine clinical practice. This activity is a monotonous and abstract task that relies on the experience of understanding ECG waveform meaning, including P-wave, QRS-complex, and T-wave. Such a manual process depends on signal quality and the number of leads. ECG signal classification based on deep learning (DL) has produced an automatic interpretation; however, the proposed method is used for specific abnormality conditions. When the ECG signal morphology change to other abnormalities, it cannot proceed automatically. To generalize the automatic interpretation, we aim to delineate ECG waveform. However, the output of delineation process only ECG waveform duration classes for P-wave, QRS-complex, and T-wave. It should be combined with a medical knowledge rule to produce the abnormality interpretation. The proposed model is applied for atrial fibrillation (AF) identification. This study meets the AF criteria with RR irregularities and the absence of P-waves in essential oscillations for even more accurate identification. The QT database by Physionet is utilized for developing the delineation model, and it validates with The Lobachevsky University Database. The results show that our delineation model works properly, with 98.91% sensitivity, 99.01% precision, 99.79% specificity, 99.79% accuracy, and a 98.96% F1 score. We use about 4058 normal sinus rhythm records and 1804 AF records from the experiment to identify AF conditions that are taken from three datasets. The comprehensive testing has produced higher negative predictive value and positive predictive value. This means that the proposed model can identify AF conditions from ECG signal delineation. Our approach can considerably contribute to AF diagnosis with these results.

Edwardsiella tarda: A Classic Presentation of a Rare Fatal Infection, with Possible New Background Risk Factors.

BACKGROUND Edwardsiella tarda is a facultative anaerobic bacterium that is rarely pathogenic to humans, but, in patients with certain risk factors, it can lead to severe, disseminated infections. Humans are inoculated through the gastrointestinal tract while consuming undercooked or raw seafood or through skin penetration. E. tarda has been isolated from marine environments, including lakes, rivers, wells, and sewage water. Although the bacterium has not been directly isolated from seawater, it has been cultured from animals inhabiting seawater environments. In the United States, E. tarda is predominantly localized along the coastline of the Gulf of Mexico. Complications from this bacterium usually arise in patients with liver disease, iron overload, or cirrhosis or in those who are immunocompromised or on immunosuppressive therapy. CASE REPORT Our patient was a 59-year-old woman with a history of advanced lung cancer, pulmonary hypertension, liver cirrhosis, hepatitis C, and alcoholism. She initially presented to the Emergency Department in the Florida Panhandle on June 16 with colitis, which then progressed to fulminant sepsis with septic shock. Despite aggressive interventions, including intravenous hydration, broad-spectrum antibiotics, and vasopressor support, our patient succumbed to her illness approximately 34 h after initial presentation. CONCLUSIONS Although severe cases of E. tarda have been reported in patients with liver dysfunction, we believe this is the first reported case potentially complicated by concomitant lung cancer. The rise in sea water temperature, increased human consumption of raw seafood, and increased prevalence of nonalcoholic steatohepatitis may increase the incidence and mortality of E. tarda in the near future.

Optimizing biologic therapy in inflammatory bowel disease: a Delphi consensus in the United Arab Emirates.

BACKGROUND: Inflammatory bowel diseases (IBD) are chronic, relapsing-remitting inflammatory conditions with a substantial negative impact on health-related quality of life and work productivity. Treatment of IBD has been revolutionized by the advent of biologic therapies, initially with anti-TNF agents and more recently with multiple alternatives targets, and yet more under development. OBJECTIVES: Approximatively one third of patients do not respond to biologic therapy and more importantly a significant proportion experiences partial response or loss of response during treatment. The latter are common clinical situations and paradoxically are not addressed in the commercial drug labels and available guidelines. There is therefore a clinical need for physicians to understand when and how eventually to optimize the biologic therapy. DESIGN: This consensus using a Delphi methodology was promoted and supported by the Emirates Society of Gastroenterology and Hepatology to close this gap. DATA SOURCES AND METHODS: Following an extensive systematic review of over 60,000 studies, 81 studies with dose escalation and five addressing drug monitoring were selected and in addition five systematic reviews and three guidelines. RESULTS AND CONCLUSION: after three rounds of voting 18 statements were selected with agreement ranging from of 80% to 100.