Single-Breath Counting Test Predicts Non-Invasive Respiratory Support Requirements in Patients with COVID-19 Pneumonia

The use of non-invasive respiratory strategies (NIRS) is crucial to improve oxygenation in COVID-19 patients with hypoxemia refractory to conventional oxygen therapy. However, the absence of respiratory symptoms may delay the start of NIRS. The aim of this study was to determine whether a simple bedside test such as single-breath counting test (SBCT) can predict the need for NIRS in the 24 h following the access to Emergency Department (ED). We performed a prospective observational study on 120 patients with COVID-19 pneumonia. ROC curves were used to analyze factors which might predict NIRS requirement. We found that 36% of patients had normal respiratory rate and did not experience dyspnea at rest. 65% of study population required NIRS in the 24 h following the access to ED. NIRS-requiring group presented lower PaO2/FiO2 (235.09 vs. 299.02), SpO2/FiO2 ratio (357.83 vs. 431.07), PaCO2 (35.12 vs. 40.08), and SBCT (24.46 vs. 30.36) and showed higher incidence of dyspnea at rest (57.7% vs. 28.6%). Furthermore, SBCT predicted NIRS requirement even in the subgroup of patients without respiratory symptoms (AUC = 0.882, cut-off = 30). SBCT might be a valuable tool for bedside assessment of respiratory function in patients with COVID-19 pneumonia and might be considered as an early clinical sign of impending respiratory deterioration.

The Association Between Ventilatory Ratio and Mortality of Adult Patients with ARDS: Systematic Review and Meta-Analysis

Background: Ventilatory ratio is a simple bedside index of impaired efficiency of ventilation and correlates well with physiological dead space fraction in patients with ARDS. So it was regarded as a dead-space marker associated with mortality in mechanically ventilated adults with ARDS. However, the association between VR and outcome of patients with ARDS remains largely unknown. Methods: We searched articles in three electronic databases including PubMed, EMBASE and Web of Science. All the English publications up to 1 st Oct. 2021 will be searched without any restriction of countries. All the observational study that investigated the association between ventilatory ratio and the mortality of ARDS patients were identified in this meta-analysis. The main outcome was mortality. Summary estimates of effect using odds ratio (OR) for dichotomous outcomes with accompanying 95% confidence interval (CI) were expressed. Results: A total of 9 trials enrolling 5638 patients were finally included in this meta-analysis. The results revealed that the use of ventilatory ratio could be significantly related to the mortality in adult ARDS (OR=1.27; 95% CI 1.10 to 1.47; P=0.001). Ventilatory ratio may have the capability of predicting the mortality of NON- COVID-related patients (OR 1.39, 95% CI 1.12 to 1.73 P = 0.003) while it has no predictable significance in patients with COVID (OR 1.18, 95% CI 0.94 to 1.48 P = 0.16). Importantly, the dynamic changes of VR adds more predictable value (OR 1.21 vs 1.19). Conclusion: Our study suggests that ventilatory ratio can be regarded as a valuable marker to predict the mortality of adult patients with ARDS. Compared to patients with COVID, ventilatory ratio is more predictable in patients with NON-COVID. What’s more, the dynamic changes of VR may have the potential to improve the prognostic value.

Agitated Saline Contrast Echocardiogram In Cardio-Pulmonary Evaluation

Agitated saline contrast echocardiogram (ASC) is a very useful technique to detect various intracardiac and extra cardiac shunts in daily cardiology practice . Conventional 2D and color echocardiogram may not be well effective in ruling out various intracardiac shunts especially with patients having poor echo window. The introduction of agitated saline with bubbles formed during the study can help delineate different right to left shunt physiology commonly like patent foramen ovale (PFO) which is often sought for in evaluation of cases with young stroke . Various other etiologies like atrial septal defects, atrial septal aneurysm, large right to left shunts with eisenmengerisation can also be evaluated with this simple bedside study.

Evaluation of Bedside Tests of Attention and Arousal Assessing Delirium in Parkinson’s Disease, Dementia, and Older Adults

Background: Delirium is a serious acute neuropsychiatric condition associated with altered attention and arousal. Objective: To evaluate simple bedside tests for attention and arousal to detect delirium in those with and without Parkinson’s disease (PD) and dementia. Methods: Participants from two prospective delirium studies were pooled comprising 30 with PD without cognitive impairment, 24 with Lewy body cognitive impairment (PD dementia or dementia with Lewy bodies), 16 with another dementia and 179 PD and dementia-free older adults. Participants completed standardised delirium assessments including tests of attention: digit span, Memorial Delirium Assessment Scale (MDAS) attention and months of the year backwards; and arousal: Glasgow Coma Scale (GSC), Observational Scale of Level of Arousal (OSLA), Modified Richmond Agitation Scale and MDAS consciousness. Delirium was diagnosed using the DSM-5 criteria. Results: On their first admission, 21.7%participants had prevalent delirium. Arousal measures accurately detected delirium in all participants (p < 0.01 for all), but only selected attention measures detected delirium in PD and dementia. In PD and dementia-free older adults, impaired digit span and OSLA were the optimal tests to detect delirium (area under the curve [AUC] = 0.838, p < 0.001) while in PD and dementia the optimal tests were MDAS attention and GCS LB. Conclusion: Simple bedside tests of attention and arousal at a single visit could accurately detect delirium in PD, dementia and PD and dementia-free older adults; however, the optimal tests differed between groups. Combined attention and arousal scores increased accuracy, which could have clinical utility to aid the identification of delirium neurodegenerative disorders.

The Utility of Bedside Assessment Tools and Associated Factors to Avoid Antibiotic Overuse in an Urban PICU of a Diarrheal Disease Hospital in Bangladesh

Background: Antibiotic exposure in the pediatric intensive care unit (PICU) is very high, although 50% of all antibiotics may be unnecessary. We aimed to determine the utility of simple bedside screening tools and predicting factors to avoid antibiotic overuse in the ICU among children with diarrhea and critical illness. Methods: We conducted a retrospective, single-center, case-control study that included children aged 2–59 months who were admitted to PICU with diarrhea and critical illness between 2017 and 2020. Results: We compared young children who did not receive antibiotics (cases, n = 164) during ICU stay to those treated with antibiotics (controls, n = 346). For predicting the ‘no antibiotic approach’, the sensitivity of a negative quick Sequential Organ Failure Assessment (qSOFA) was similar to quick Pediatric Logistic Organ Dysfunction-2 (qPELOD-2) and higher than Systemic Inflammatory Response Syndrome (SIRS). A negative qSOFA or qPELOD-2 score calculated during PICU admission is superior to SIRS to avoid antibiotic overuse in under-five children. The logistic regression analysis revealed that cases were more often older and independently associated with hypernatremia. Cases less often had severe underweight, altered mentation, age-specific fast breathing, lower chest wall in-drawing, adventitious sound on lung auscultation, abdominal distension, developmental delay, hyponatremia, hypocalcemia, and microscopic evidence of invasive diarrhea (for all, p < 0.05). Conclusion: Antibiotic overuse could be evaded in PICU using simple bedside screening tools and clinical characteristics, particularly in poor resource settings among children with diarrhea.

What is a tilt table test and why is it performed during the investigation of syncope?

Falls are one of the most common reasons for patients to present to the emergency department. Syncope is a common cause of falls, which disproportionately affects older people. In most cases, syncope can be confirmed with a detailed history and simple bedside tests, but tilt table testing remains an invaluable diagnostic adjunct in more complex cases. Often misunderstood, the tilt table test is a useful way to reproduce a patient’s symptoms in a safe and controlled environment. The tilt table test is considered positive if the patient experiences symptoms associated with a drop in blood pressure or postural tachycardia. The test can support a diagnosis and can direct therapeutic interventions.

PROSPECTIVE STUDY OF BEDSIDE ASSESSMENT OF DIABETIC PERIPHERAL NEUROPATHY

Background: Diabetic peripheral sensorimotor neuropathy is one of the most prevalent neuropathic syndromes affecting around 50 % people with diabetes. Its development is gradual with subtle changes hence ignored. Early diagnosis using simple bedside tools is essential. Methods: The prospective study of evaluation of peripheral neuropathy in diabetes involved examination of 500 diabetic patients for neuropathy. Pinprick, vibration sensation, perception of 5.07 Semmes Weinstein monofilament and Achilles tendon reflex were examined and impairment noted. Results: 39 % patients had impairment of perception of Semmes Weinstein monofilament. Loss of pinprick sensation was found in 65.6 % in patients with diabetes for 5-10 years duration. Abnormal tendon reflex was seen in 64.2 % in patients with diabetes move than 10 years. Loss of Vibration (40.2 %), Wasting (16.6 %), loss of pinprick sensation (44.5%) and loss of abnormal tendon reflex (32.1 %) was found to be more common in type II diabetes. Conclusion: Sensorimotor peripheral neuropathy was more common in long standing diabetes mellitus especially with impaired glycaemic control and type II diabetes mellitus.