Trends in Mortality after Intensive Care of Patients with Aneurysmal Subarachnoid Hemorrhage in Finland in 2003–2019: A Finnish Intensive Care Consortium study

Background Previous studies suggest that case mortality of aneurysmal subarachnoid hemorrhage (aSAH) has decreased during the last decades, but most studies have been unable to assess case severities among individual patients. We aimed to assess changes in severity-adjusted aSAH mortality in patients admitted to intensive care units (ICUs). Methods We conducted a retrospective, register-based study by using the prospectively collected Finnish Intensive Care Consortium database. Four out of five ICUs providing neurosurgical and neurointensive care in Finland participated in the Finnish Intensive Care Consortium. We extracted data on adult patients admitted to Finnish ICUs with aSAH between 2003 and 2019. The primary outcome was 12-month mortality during three periods: 2003–2008, 2009–2014, and 2015–2019. Using a multivariable logistic regression model—with variables including age, sex, World Federation of Neurological Surgeons grade, preadmission dependency, significant comorbidities, and modified Simplified Acute Physiology Score II—we analyzed whether admission period was independently associated with mortality. Results A total of 1,847 patients were included in the study. For the periods 2003–2008 and 2015–2019, the mean number of patients with aSAH admitted per year increased from 81 to 123. At the same time, the patients’ median age increased from 55 to 58 years (p = 0.001), and the proportion of patients with World Federation of Neurological Surgeons grades I–III increased from 42 to 58% (p < 0.001). The unadjusted 12-month mortality declined from 30% in 2003–2008 to 23% in 2015–2019 (p = 0.001), but there was no statistically significant change in severity-adjusted mortality. Conclusions Between 2003 and 2019, patients with aSAH admitted to ICUs became older and the proportion of less severe cases increased. Unadjusted mortality decreased but age and case severity adjusted–mortality remained unchanged.

Pyoderma Gangrenosum after Cardiac Surgery

Background Pyoderma gangrenosum after cardiac surgery is a rare, noninfectious ulcerating skin disease mimicking sternal wound infection. Methods A systematic search of literature for pyoderma gangrenosum complicating cases of cardiac surgery was conducted between September 1985 and September 2020 on PubMed and Cochrane databases. A systematic review and detailed overview of clinical presentation, diagnostic, treatment, and outcome is provided. Results A total of 15 studies enclosing 15 patients suffering from pyoderma gangrenosum following cardiac surgery were identified. Onset of symptoms was observed after a median of 5 days. Patients were predominantly male (81.3%) with a median age of 64 years. Typical clinical presentation mimicked sternal site infection, mainly by means of mediastinitis. Specific signs were rapid progression, erythematous to violaceous color of the wound border, accompanied by unspecific symptoms including fever, malaise, and severe pain. Additionally, pathergy (development of ulcers at the sites of minor cutaneous trauma) was reported frequently. Biopsy is mandatory with a cutaneous neutrophilic inflammation confirming the diagnosis. Initial treatment mostly (75.0% of reported cases) was misled, addressing suspicion of surgical site infection. After correct diagnosis, the treatment was switched to an immunosuppressive therapy. Full sternal wound closure took between 5 weeks and 5 months. Reported case mortality was 12.5% in actually low-risk surgeries. Conclusion Despite pyoderma gangrenosum has typical signs, it remains an exclusion diagnosis. The treatment is completely opposite to the main differential diagnosis—the typical surgical site infection. Knowledge about diagnosis and treatment is essential in the context of avoiding fatal mistreatment.

The isolated effect of age on the risk of COVID-19 severe outcomes: a systematic review with meta-analysis

IntroductionIncreased age has been reported to be a factor for COVID-19 severe outcomes. However, many studies do not consider the age dependency of comorbidities, which influence the course of disease. Protection strategies often target individuals after a certain age, which may not necessarily be evidence based. The aim of this review was to quantify the isolated effect of age on hospitalisation, admission to intensive care unit (ICU), mechanical ventilation and death.MethodsThis review was based on an umbrella review, in which Pubmed, Embase and preprint databases were searched on 10 December 2020, for relevant reviews on COVID-19 disease severity. Two independent reviewers evaluated the primary studies using predefined inclusion and exclusion criteria. The results were extracted, and each study was assessed for risk of bias. The isolated effect of age was estimated by meta-analysis, and the quality of evidence was assessed using Grades of Recommendations, Assessment, Development, and Evaluation framework.ResultsSeventy studies met our inclusion criteria (case mortality: n=14, in-hospital mortality: n=44, hospitalisation: n=16, admission to ICU: n=12, mechanical ventilation: n=7). The risk of in-hospital and case mortality increased per age year by 5.7% and 7.4%, respectively (effect size (ES) in-hospital mortality=1.057, 95% CI 1.038 to 1.054; ES case mortality=1.074, 95% CI 1.061 to 1.087), while the risk of hospitalisation increased by 3.4% per age year (ES=1.034, 95% CI 1.021 to 1.048). No increased risk was observed for ICU admission and intubation by age year. There was no evidence of a specific age threshold at which the risk accelerates considerably. The confidence of evidence was high for mortality and hospitalisation.ConclusionsOur results show a best-possible quantification of the increase in COVID-19 disease severity due to age. Rather than implementing age thresholds, prevention programmes should consider the continuous increase in risk. There is a need for continuous, high-quality research and ‘living’ reviews to evaluate the evidence throughout the pandemic, as results may change due to varying circumstances.

Prospective and Concurrent Effects of Traits, Coping Beliefs, Social Support, Preventive Beliefs and Behaviors, and Sickness Experiences on Coronavirus Vaccine Inclination

The present study examined prospective and concurrent associations between traits, political orientation, well-being, coping and positive social relations, infection and preventive behavior beliefs, preventive behaviors, symptoms, exposure, viral testing, and coronavirus vaccine intention and likelihood following the FDA emergency use authorization for the Pfizer-BioNTech vaccine. The pre-registered study used a stratified online U.S. sample assessed from March, 2020, to January, 2021 (N = 500). Three assessments were aligned with “15 days to slow the spread” in March 2020; the first mortality surge in April/May, 2020; and the overlapping FDA EUA in mid-December, 2020, and major case/mortality surge during December, 2020 and January, 2021. Consistent with contemporaneous polling, 66.4 % of participants agreed a little or strongly agreed that they intended to receive an approved vaccine. Modeling results showed less education (β = .11, p &lt; .01), child(ren) in the household (β = -.14, p &lt; .001), baseline conservative political orientation (β = -.17, p &lt; .001), weaker concurrent perceived health consequences (β = .13, p &lt; .05), weaker concurrent norms for preventive behaviors (β = .23, p &lt; .001), and less frequent concurrent mask wearing (β = .23, p &lt; .001) were associated with weaker vaccine inclination. None of the trait, coping, or sickness experience variables was associated with vaccine inclination in the model. The results clarify the parental, political, and preventive factors associated with vaccine inclination and suggest the need for a multi-pronged vaccination campaign immediately before approval and upon availability of a novel vaccine.

The isolated effect of age on the risk of COVID-19 severe outcomes: a systematic review with meta-analysis

Introduction Increased age has been reported to be a factor for COVID-19 severe outcomes. However, many studies do not consider the age-dependency of comorbidities, which influence the course of disease. Protection strategies often target individuals after a certain age, which may not necessarily be evidence-based. The aim of this review was to quantify the isolated effect of age on hospitalization, admission to ICU, mechanical ventilation, and death. Methods This review was based on an umbrella review, in which Pubmed, Embase, and pre-print databases were searched on December 10, 2020 for relevant reviews on COVID-19 disease severity. Two independent reviewers evaluated the primary studies using predefined inclusion and exclusion criteria. The results were extracted, and each study was assessed for risk of bias. The isolated effect of age was estimated by meta-analysis, and the quality of evidence was assessed using GRADE. Results Seventy studies met our inclusion criteria (case mortality n=14, in-hospital mortality n=44, hospitalization n=16, admission to ICU n=12, mechanical ventilation n=7). The risk of in-hospital and case mortality increased per age year by 5.7% and 7.4%, respectively (Effect Size (ES) in-hospital mortality=1.057, 95% CI:1.038-1.054; ES case mortality= 1.074, 95% CI:1.061-1.087), while the risk of hospitalization increased by 3.4% per age year (ES=1.034, 95% CI:1.021-1.048). No increased risk was observed for ICU admission and intubation by age year. There was no evidence of a specific age threshold at which the risk accelerates considerably. The confidence of evidence was high for mortality and hospitalization. Conclusions Our results show a best-possible quantification of the increase in COVID-19 disease severity due to age. Rather than implementing age thresholds, prevention programs should consider the continuous increase in risk. There is a need for continuous, high-quality research and living reviews to evaluate the evidence throughout the pandemic, as results may change due to varying circumstances.

A RARE CASE MORTALITY OF DIABETIC KETOACIDOSIS- CEREBRAL EDEMA WITH TONSILLAR HERNIATION- A CONTRADICTORY OPINION.IS SODIUM BICARBONATE A REAL CULPRIT?

Diabetic ketoacidosis (DKA) is the most common complication seen in uncontrolled diabetes mellitus. DKA is most commonly seen with patients of type 1 diabetes. Depletion of Insulin leads to high blood sugars which in turn leads osmotic diuresis, production of ketone bodies i.e, βhydroxybutyric acid and acetoacetic acid, dysregulation of sodium hydrogen exchange mechanism[2]. As a consequence to the above stated mechanisms, cerebral edema has been documented as a fatal complication in DKA. Mortality documented due to cerebral edema is 21-25%[4].

Impact of altitude on COVID-19 infection and death in the United States: A modeling and observational study

Background COVID-19, the disease caused by SARS-CoV-2, has caused a pandemic, sparing few regions. However, limited reports suggest differing infection and death rates across geographic areas including populations that reside at higher elevations (HE). We aimed to determine if COVID-19 infection, death, and case mortality rates differed in higher versus low elevation (LE) U.S. counties. Methods Using publicly available geographic and COVID-19 data, we calculated per capita infection and death rates and case mortality in population density matched HE and LE U.S. counties. We also performed population-scale regression analysis to investigate the association between county elevation and COVID-19 infection rates. Findings Population density matching of LA (< 914m, n = 58) and HE (>2133m, n = 58) counties yielded significantly lower COVID-19 cases at HE versus LE (615 versus 905, p = 0.034). HE per capita deaths were significantly lower than LE (9.4 versus 19.5, p = 0.017). However, case mortality did not differ between HE and LE (1.78% versus 1.46%, p = 0.27). Regression analysis, adjusted for relevant covariates, demonstrated decreased COVID-19 infection rates by 12.82%, 12.01%, and 11.72% per 495m of county centroid elevation, for cases recorded over the previous 30, 90, and 120 days, respectively. Conclusions This population-adjusted, controlled analysis suggests that higher elevation attenuates infection and death. Ongoing work from our group aims to identify the environmental, biological, and social factors of residence at HE that impact infection, transmission, and pathogenesis of COVID-19 in an effort to harness these mechanisms for future public health and/or treatment interventions.

Role of Nutrition therapy during COVID 19

Nutrition is a vital element of health. More decisively, nutrition is part of the treatment routine for acute and chronic diseases and applies mainly to conditions for which an etiologic treatment has not yet been discovered. Ebola virus outbreak Western Africa in the 2014–2016 proved that immediate supportive care significantly reduces case mortality rates [1]. This may relate as well to the current COVID-19 pandemic that is disturbing the world. Emerging evidence shows that COVID-19 is associated with negative outcomes in older, comorbid, and hypoalbuminemia patients. These features are not specific to the Chinese residents because they have been testified also in North American patients with COVID-19. When measured together, the emerging literature on patients with COVID-19 indirectly highlights the applicability of nutrition in possibly determining their outcomes. Older age and the presence of comorbid conditions are almost consistently associated with impaired nutritional status and sarcopenia, independently of body mass index. Fascinatingly, a high body mass index score appears to be related to a poor prognosis in comorbid patients with COVID-19, which further points to a possible role of sarcopenic obesity in influencing the outcome [2].

Surgeon-Level Variation in Outcome following Esophageal Atresia Repair Is Not Explained by Volume

Introduction To assess whether there is a difference in operative outcome for esophageal atresia (EA) depending on a surgeon's seniority as defined by years in consultant practice or number of cases performed. In addition a Clavien–Dindo score was used to sequentially analyze the outcome of each surgeon's EA procedure. Materials and Methods All repairs performed over 22 years in an English regional center were analyzed. Outcomes were: death, anastomotic leak, need for dilatation, need for more than three dilatations, need for fundoplication, and a Clavien–Dindo adverse outcome of ≥3b. Possible explanatory variables were: number of prior repairs by the surgeon, surgeon's years of consultant experience. We also examined the effect of variables intrinsic to the infant as possible confounding variables and as independent predictors of outcome. Results A total of 190 repairs were performed or supervised by 12 consultants. There was no significant association between consultant experience and any objective outcome. However, sequential analysis suggests there is variation between surgeons in the incidence of Clavien–Dindo events of ≥3b. Performance showed deterioration in one case. Mortality was explicable by cardiac and renal anomalies. Conclusion There are surgeon-level variations in outcomes for the procedure of EA repair, but they are not explained by volume. Surgeon performance can deteriorate. Our study would not support the concept that patient outcomes could be improved by concentrating the provision of this surgery to fewer hospitals or surgeons.

Predicting the Spread of the Corona Virus (COVID-19) in Indonesia: Approach Visual Data Analysis and Prophet Forecasting

The development trend of the coronavirus pandemic (COVID-19) in various countries has become a global threat, including in Southeast Asia, such as Indonesia, the Philippines, Brunei, Malaysia, and Singapore. In this paper, we propose an Exploratory Data Analysis (EDA) model approach and a time series forecasting model using the Prophet method to predict the number of confirmed cases and cases of death in Indonesia in the next thirty days. We apply the EDA model to visualize and provide an understanding of this pandemic outbreak in various countries, especially in Indonesia. We present the trends in the spread of epidemics from the countries of China from which the virus originates, then mark the top ten countries and their development and also present the trends in Asian countries. We present an analytical framework comparing the predicted results with the actual data evaluated using the MAPE and MAE models, where the prophet algorithm produces good performance based on the evaluation results, the relative error rate of our estimate (MAPE) is around 6.52%, and the model average false 52.7% (MAE) for confirmed cases, while case mortality was 1.3% for the MAPE and MAE models around 236.6%. The results of the analysis can be used as a reference for the Indonesian government in making decisions to prevent its spread in order to avoid an increase in the number of deaths