Tabindeh J. Khalid

Acute Management and Long-Term Survival Among Subjects With Severe Middle East Respiratory Syndrome Coronavirus Pneumonia and ARDS

BACKGROUND: Data on the management, clinical course, and outcome of critical patients with Middle East Respiratory Syndrome coronavirus are scarce. We report here our experience and long-term outcome of such patients. METHODS: Subjects intubated for management of ARDS from Middle East Respiratory Syndrome coronavirus pneumonia and ARDS during the April-May 2014 outbreak were included. Their characteristics, ICU course, management, and outcome were evaluated. RESULTS: Fourteen subjects, including 3 health-care workers, met study criteria. Besides 2 health-care workers, all subjects had comorbidities. Predominant symptoms were fever, cough, and dyspnea. The worst median PaO2/FIO2 ratio of 118 post-intubation was seen on the third day, and median APACHE II score was 27. All subjects received lung-protective ventilation and 1 mg/kg/d methylprednisolone infusion for ARDS. Eleven subjects received ribavirin and peginterferon α-2a. Subjects had a critical ICU course and required neuromuscular blockade (n = 11; 79%), required rescue therapy for respiratory failure (n = 8; 57%), developed shock (n = 10; 71%), and required renal replacement therapy (n = 8; 57%). Declining C-reactive protein levels correlated with clinical improvement despite continued positive real-time polymerase chain reaction results. Nine subjects died in ICU. Five subjects, including 3 health-care workers, were discharged from hospital and were alive after 1 y. CONCLUSIONS: Middle East Respiratory Syndrome coronavirus pneumonia with ARDS has high mortality in subjects with comorbidities. The mainstay of treatment is meticulous ARDS management. Those who survived the acute infection and its complications remained well after 1 y in our study. The role of ribavirin and interferon warrants urgent further evaluation.

End-of-Life Care in Muslim Brain Dead Patients: A 10-Year Experience

Background: In Muslim countries, end-of-life practices in Muslim brain-dead patients are unknown. We conducted this study to evaluate this issue. Results: We identified 42 brain-dead patients between 2001 and 2011. The expectant terminal extubation occurred only in 5. Largely due to family opposition, 2 patients remained “full code,” and rests were “do not attempt resuscitation” with varying usage of “life-sustaining” therapies. Only 2 out of 24 eligible patients donated organs. There was minimal involvement of social worker, palliative team, or Muslim chaplain in the end-of-life discussions. Conclusion: In Muslim patients, the concept of terminal withdrawal and organ donation after brain death is still not well accepted. Future multicenter studies, involving palliative teams, should focus on improving these issues.

Outcomes of Patients Treated With Noninvasive Ventilation by a Medical Emergency Team on the Wards

BACKGROUND: Initiation of noninvasive ventilation (NIV) on the wards is not universally accepted. Medical emergency teams (METs) provide acute care and monitoring to deteriorating patients on the general wards. Whether it is safe for an MET to start NIV in ward patients with respiratory distress remains unclear. METHODS: We evaluated 1,123 MET calls in 30,217 ward patients between January 2009 and June 2011 from the prospectively maintained MET database in our tertiary care hospital. We identified ward patients with acute desaturation (< 90%) and tachypnea (breathing frequency > 28 breaths/min), for whom an MET was called. Subjects transferred to the ICU at the end of an MET call were excluded. The remaining ward subjects were divided into 2 groups: patients who were not started on NIV by the MET; versus patients who were started on NIV by the MET. The primary outcome was endotracheal intubation or ICU transfer within 48 hours of MET activation. Secondary outcome measures were 28-day mortality and ICU mortality. RESULTS: Two hundred thirty-eight MET subjects met the study criteria, and 109 immediate ICU transfers were excluded. Of the remaining 129 ward subjects, 54 were in the NIV group, and 75 in the no-NIV group. The NIV group subjects were sicker (mean Acute Physiology and Chronic Health Evaluation II score 17.6 ± 5.1 versus 14.4 ± 5, P < .001). Subjects with pulmonary edema, COPD exacerbation, or asthma exacerbation were more likely, while those with pneumonia were less likely to be placed on NIV. The primary outcome was reached in 2/54 (3.7%) of the NIV subjects and 12/75 (16%) of the no-NIV subjects (P = .03). There was no significant difference (P > .30) between the groups in 28-day mortality (7.4% vs 13.3%) or ICU mortality (3.7% vs 8%). CONCLUSIONS: In selected ward patients, especially those with COPD or pulmonary edema, NIV can be safely initiated by an MET.

Healthcare Workers Emotions, Perceived Stressors and Coping Strategies During a MERS-CoV Outbreak

Objective Healthcare workers (HCWs) are at high risk of contracting Middle East respiratory syndrome coronavirus (MERS-CoV) during an epidemic. We explored the emotions, perceived stressors, and coping strategies of healthcare workers who worked during a MERS-CoV outbreak in our hospital. Design A cross-sectional descriptive survey design. Setting A tertiary care hospital. Participants HCWs (150) who worked in high risk areas during the April–May 2014 MERS-CoV outbreak that occurred in Jeddah, Saudi Arabia. Methods We developed and administered a “MERS-CoV staff questionnaire” to study participants. The questionnaire consisted of 5 sections with 72 questions. The sections evaluated hospital staffs emotions, perceived stressors, factors that reduced their stress, coping strategies, and motivators to work during future outbreaks. Responses were scored on a scale from 0–3. The varying levels of stress or effectiveness of measures were reported as mean and standard deviation, as appropriate. Results Completed questionnaires were returned by 117 (78%) of the participants. The results had many unique elements. HCWs ethical obligation to their profession pushed them to continue with their jobs. The main sentiments centered upon fear of personal safety and well-being of colleagues and family. Positive attitudes in the workplace, clinical improvement of infected colleagues, and stoppage of disease transmission among HCWs after adopting strict protective measures alleviated their fear and drove them through the epidemic. They appreciated recognition of their efforts by hospital management and expected similar acknowledgment, infection control guidance, and equipment would entice them to work during future epidemics. Conclusion The MERS-CoV outbreak was a distressing time for our staff. Hospitals can enhance HCWs experiences during any future MERS-CoV outbreak by focusing on the above mentioned aspects.

Using Spirometry to Rule Out Restriction in Patients with Concomitant Low Forced Vital Capacity and Obstructive Pattern

Background: Different formulas have been proposed to exclude restriction based on spirometry, however none of them have specifically tested the patients whose spirometry show both obstruction and a low forced vital capacity (FVC). Study Objective: The study was designed to create an algorithm that would better predict the absence of restriction in such patients. Design: Retrospective analysis of prospectively collected data. Methods: A cohort of consecutive adults that underwent complete pulmonary function testing from 2002-2004 was analyzed. The data was randomly split into two groups to allow for derivation and then validation of a predictive formula. Patients were randomly assigned into either a “derivation” or “validation” group. In the derivation group, stepwise logistic regression was used to determine a formula and optimal cut-off value for the variable with the best discriminative capacity. The formula was applied subsequently to the validation group to test the results and compared to previously published formula. Results: The study group contained 766 patients. We determined that the variable with the highest association with TLC was [(FEV1/FVC) % predicted/FVC % predicted]. A value of ≥1.11 was found to be the maximal cutoff to predict the absence of restriction. The formula was applied to a validation group (n=397) and performed better than prior published algorithm with a sensitivity, specificity, positive predictive value and negative predictive value of 95%, 44%, 22%, and 98%, respectively. Conclusion: Our formula performs superior to the previously published algorithms in patients with concomitant low FVC and obstruction to exclude restriction.

Outcome of patients treated with noninvasive ventilation by a medical emergency team on the wards: scarce and probably secure and resourceful monitoring in select subjects--reply.

In Reply: We reviewed the comments by Killen H Briones Claudett. Of 238 subjects, we excluded the ones who were immediately transferred to the ICU. These subjects were deemed to be ICU candidates during the initial medical emergency team (MET) evaluation and were not the focus of our study.

A patient with an uncommon complication from insertion of a central venous catheter: A case report

BackgroundA 72 year old male was admitted to the medical intensive care unit with septic shock.Case presentationA left subclavian central venous catheter was inserted on the day of admission whose tip was pushing against the wall of the vessel lumen. The patients condition improved with treatment, but three days later had a new episode of acute hypotension. CT scan of the chest showed that the catheter had eroded through the superior vena cava wall.ConclusionThe catheter was pulled out and patient recovered from the complication with supportive therapy. Care should be taken that the tip of the catheter is in the center of the vessel lumen to avoid this rare, but potentially life threatening, complication.

Perception of nurses regarding influence of local lifestyle on sleep while working in Saudi Arabia

The aim was to investigate the effects of sleep, television use and texting and computer habits on overweight, enjoyment of school and feelings of tiredness at school in school-age children and ado ...I affects 30%-50% of the general population and even more so (63%) among patients with mild cognitive impairments (MCI). Alzheimer’s disease (AD) risk among insomnia patients is approximately 3 fold that of good sleepers. Furthermore, poor sleep quality is associated with faster cognitive decline and may be an early marker of cognitive decline in mid life. Improvement of sleep may be critically important for maintaining or enhancing cognitive function in patients with MCI or AD. Current hypnotic medications (benzodiazepines and benzodiazepines-like) are associated with cognitive and memory impairments, increased risk of falls, accidents and dependency. Melatonin receptors agonists are safe and effective drugs for primary insomnia and circadian rhythm sleep disorders and are potentially useful for cognition and sleep in. Piromelatine is a novel investigational MT1\MT2 and 5HT1A\D receptors agonist developed for primary and co-morbid insomnia. In Phase-I studies it demonstrated good oral bioavailability (Elimination half-life 2.8±1.4 hours), good safety & tolerability profile across a wide dose range and provided the first indication for beneficial effects on sleep maintenance. In a Phase-II study in insomnia patients, piromelatine demonstrated significant improvements in sleep maintenance based on objective assessments (polysomnography recorded wake after sleep onset, sleep efficiency and total sleep time) and good safety profile with no detrimental effects on next-day psychomotor performance and memory. The electroencephalographic (EEG) power spectral density (PSD) profile of piromelatine indicated significant reduction in beta power (p<0.05), a marker of cortical arousal and enhanced delta power (P<0.05), a marker of restorative sleep. In preclinical studies in rats, piromelatine enhanced memory performance, attenuated cellular loss and neuronal and cognitive impairment in intrahippocampal Aβ(1-42) injection-induced neurodegeneration and reversed memory, hippocampal BDNF, CREB and pCREB deficits and hippocampal neurogenesis in chronic mild stress rats. Such unique effects suggest that piromelatine is a promising drug candidate in insomnia patients and particularly those with comorbid MCI or AD.D sleep phase disorder (DSPD) is common among young people and is characterized by a mismatch between the desired timing of sleep and the ability to fall asleep and remain asleep. The underlying cause of this could be related to biological or behavioral reasons. Individuals with DSPS have problems in falling asleep and consequently struggle with waking up in the morning. Sleep difficulties, excessive sleepiness leads to poor performance and they acquire difficulty with school and employment. This may result in adverse medical, psychological and social consequences. Light is the most effective environmental cue for circadian entrainment and light therapy (LT) has been shown effective for treatment of DSPS. Unfortunately, compliance is a concern and also the high amount of relapse. Cognitive behavioural therapy (CBT) might contribute as an adjunct therapy in DSPS. A randomized controlled short and long term trial with DSPS individuals aged 16 to 26 years was performed. Subjects received LT for 2 weeks and thereafter one group received CBT for 4 weeks while the other group received no further treatment at all. LT advanced sleep onset 1 hour 50 min and sleep offset 2 hour 20 min during the second week of LT for all participants and this was maintained at a 6 months follow-up. Insomnia sleepiness score (ISI) was the primary outcome measure for sleep difficulties and there was a significant decrease in ISI over time. Anxiety and depression scores decreased significantly more in the group that has received CBT and subjects in this group were able to retain the effect of LT better compared to the group that only received LT. It was concluded that CBT given after LT can maintain the effect of LT better and can decrease sleep difficulties beyond those improvements observed with light therapy alone.Background: Data regarding sleep patterns in nocturnal enuresis (NE) and its relation to anti-diuretic hormone (ADH) secretion pattern is deficient. Normally, ADH secretion is increased at night compared to morning so that urine volume decreases during sleep. NE can be caused by nocturnal polyuria due to ADH deficiency or detrusor muscle hyperactivity. We aimed to evaluate the ADH secretion pattern in children with primary NE and compare the polysomnography (PSG) findings between children with a normal ADH secretion pattern to those with a reversed secretion pattern.Methods: A self-reported questionnaire that included demographics, work schedule, sleep-wake questions, Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) was formulated and approved for the study by the Institutional Review Board. It was distributed among a convenience sample of 150 nurses working in inpatient and outpatient clinical units of a tertiary care hospital of a major metropolitan city in Saudi Arabia. Study respondents were divided into two groups based on their response; “Influenced” and “Not-Influenced” by local lifestyle. Student t-test and Chi-square test were used as appropriate for data analyses.