Atrial Fibrillation as a Predictor of Mortality in High Risk COVID-19 Patients: A Multicentre Study of 171 Patients.

PURPOSE: Certain patient demographics and biomarkers have been suggested to predict survival in patients infected with COVID-19. However, predictors of outcome in patients who are critically ill are unclear. MATERIALS AND METHODS: We performed a multicentre analysis of 171 consecutive patients with confirmed COVID-19 who were admitted to the intensive care unit (ICU) between 1 March 2020 and 30 April 2020 and were followed until 23 May 2020. Demographic data, past medical history, laboratory values, echocardiographic and telemetry data were analysed. Patient status was classified as either alive or deceased at hospital discharge or the end of follow-up period. RESULTS: Mean patient age was 66±13 and 57% were male. Mortality rate of this ICU cohort at the end of follow-up was 46.2%. A multivariable logistic regression analysis identified the presence or history of atrial fibrillation (Odds Ratio 4.8, p=0.004) as a significant cardiovascular attribute that contributed to increased mortality. CONCLUSION: Mortality of critically ill COVID-19 patients is high. This study suggests a relationship between atrial fibrillation and increased mortality from COVID-19. Early aggressive treatment patients with high risk characteristics, such as atrial fibrillation could improve clinical outcome.

Low vision device requirements among children from two schools for the blind in Tamil Nadu.

PURPOSE: To identify children with low vision from two local schools for the blind, to provide low vision devices (LVD) to those who may benefit from it, and to encourage them to learn print. METHODS: A prospective study was conducted among children from two local schools for the blind. Best-corrected visual acuity (BCVA) was done using the Snellen chart. Children with BCVA of counting finger (CF) 1/2 meter or more in the better eye underwent low vision assessment. Distant vision was assessed using the Feinbloom chart and near vision was assessed using the Lea symbol chart. Low vision devices (LVD) were prescribed as required. RESULTS: Among 185 children enrolled, 31 children had BCVA of >CF ½ meter. Using a telescope, distant vision was better than 3/36 in 48.4%, 3/36-3/12 in 16.2%, and 3/9.5 to 3/3 in 35.4%. Among 23 children who read 1M at <10 cm, 22.6% could read 0.6-0.8M, and 25.8% could read 1M using LVD. CONCLUSION: Regular screening of children in schools for the blind could identify children who might benefit from LVD. A review of protocols for the entry of children in schools for the blind by screening these children by a specialist team prior to admission should be made mandatory.

Safety of bedside lumbar puncture in adult patients with thrombocytopenia.

The risk of lumbar puncture (LP) hemorrhagic complications is believed to be exacerbated by thrombocytopenia, yet evaluations in clinical practice are lacking. We conducted a retrospective cohort study to examine the risk of traumatic tap (TT) and significant hemorrhagic complications in thrombocytopenic patients undergoing bedside LP. Two hundred sixty-two adult patients undergoing initial bedside LP were analyzed. Overall, we observed 37 TTs (14.1%, 95% CI 10.0 to 18.3%). TTs occurred in 11 of 78 LPs performed on patients with thrombocytopenia, compared with 26 of 184 LPs among patients with a normal platelet count (14.1% vs 14.1%; p > 0.99) and 6 of 19 LPs among patients with severe thrombocytopenia compared with 31 of 243 among those without (31.6% vs 12.8%; p = 0.04). For patients with severe thrombocytopenia, the relative risk of TT was 2.5 (95% CI 1.2 to 5.2; p = 0.02). Stratifying this group by operator experience, a higher incidence of TTs was observed in LPs performed by trainees (57.1% vs 15.8%; p = 0.02), an effect which did not reach significance in LPs performed by dedicated procedural operators (16.7% vs 10.8%; p = 0.63). The presence of other bleeding risk factors was not found to be statistically associated with the incidence of TT. There were no significant hemorrhagic complications. TTs occurred significantly more frequently among patients with severe thrombocytopenia, an effect modulated by operator experience. For patients in this higher risk group, LPs should be performed by the most skilled operators available.

Comparison of Visual Parameters Between Normal Individuals and People with Low Vision in a Virtual Environment.

Patients with Low vision are known to experience difficulties in executing activities of daily living and visual search due to reduction in vision. There is a need to translate clinical parameters into a real world that is relevant so as to understand the patient's functional vision; this can be possible with virtual reality (VR). This prospective study included 53 normal and 30 low vision subjects older than 18 years of age in a tertiary care center. The low vision subjects were further classified into peripheral field loss (PFL) and central field loss (CFL). A VR bank environment was developed with multiple tasks that aimed at assessing reading for distance and near, identification of objects against various contrast levels and mobility. Based on the normative data obtained a scoring system was developed to quantify the visual performance between normal and low vision subjects. A significant difference was found in the performance between the normal and low vision subjects in the VR environment. The overall VR performance score was lower in subjects with PFL 56.65 (IQR 19.4) than CFL 63.25 (IQR 10.83); however, both of them were lower compared with normal subjects 87 (IQR 4.6) p < 0.001. These findings suggest that performance of low vision subjects was worse than normal subjects in VR environment and it is important to plan and prioritize assessment and rehabilitation interventions for low vision subjects with a more holistic performance based approach.

Spatio-temporal dynamics of Plasmodium falciparum transmission within a spatial unit on the Colombian Pacific Coast.

As malaria control programmes concentrate their efforts towards malaria elimination a better understanding of malaria transmission patterns at fine spatial resolution units becomes necessary. Defining spatial units that consider transmission heterogeneity, human movement and migration will help to set up achievable malaria elimination milestones and guide the creation of efficient operational administrative control units. Using a combination of genetic and epidemiological data we defined a malaria transmission unit as the area contributing 95% of malaria cases diagnosed at the catchment facility located in the town of Guapi in the South Pacific Coast of Colombia. We provide data showing that P. falciparum malaria transmission is heterogeneous in time and space and analysed, using topological data analysis, the spatial connectivity, at the micro epidemiological level, between parasite populations circulating within the unit. To illustrate the necessity to evaluate the efficacy of malaria control measures within the transmission unit in order to increase the efficiency of the malaria control effort, we provide information on the size of the asymptomatic reservoir, the nature of parasite genotypes associated with drug resistance as well as the frequency of the Pfhrp2/3 deletion associated with false negatives when using Rapid Diagnostic Tests.

Evaluation of a Pharmacist-Driven Protocol to Reduce Inappropriate Use of Acid-Suppressive Medications In the Non-ICU Setting.

PURPOSE: Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2 blockers) continue to be over utilized for stress ulcer prophylaxis (SUP). Our study aims to evaluate the effectiveness and feasibility of a pharmacist-driven termination protocol in a community teaching hospital to limit the inappropriate use of acid-suppressive medications in the non-intensive care unit (ICU) setting. METHODS: Patient charts were evaluated for the appropriate use of PPIs or H2 blockers. A centralized pharmacist contacted healthcare providers for medication discontinuation if the acid suppressant use was deemed inappropriate. The primary outcome of the study was the number of patients who had acid-suppressive medication discontinued after the implementation of the pharmacist-driven termination protocol. RESULTS: Acid-suppressive medication was inappropriately prescribed for nine patients. It was discontinued for eight of those patients based on the pharmacist-driven termination protocol; this was a statistically significant decrease (P < 0.001). The pharmacist spent, on average, less than one minute on each patient's chart. CONCLUSION: Our study revealed that a pharmacist-driven termination protocol resulted in a 6% overall reduction rate in inappropriately used acid-suppressive medications, with little impact on pharmacist workflow. Implementing such a termination protocol could help to decrease the inappropriate use of acid-suppressive medications in an inpatient hospital service.

Rare case of Rhizobium radiobacter bioprosthetic mitral valve endocarditis.

Rhizobium radiobacter is an aerobic, gram negative, rod-shaped, bacterium typically found in the soil. Commonly a plant pathogen, it is also a rare human pathogen causing serious disease. Risk factors for infection include neutropenia, leukopenia, catheters, hospitalization, and low CD4+ lymphocyte count, especially in patients with malignancy or human immunodeficiency virus. There is currently limited literature to establish a definitive guideline for antimicrobial therapy and obtaining susceptibilities from a specialized laboratory is appropriate. We present a successfully treated case of R. radiobacter bioprosthetic mitral valve endocarditis in a patient with previous S. epidermidis endocarditis.

Immune Modulatory Therapy Causing Acute Coronary Syndrome.

Intravenous immunoglobulin (IVIG) is a therapeutic preparation of pooled polyspecific IgG used effectively in immune thrombocytopenic purpura (ITP), autoimmune diseases, and inflammatory diseases. We present a case of a 67-year-old male who presented with diffuse petechiae and was diagnosed with immune thrombocytopenic purpura with platelet count less than 10,000 per milliliter. Treatment was initiated with IVIG. When the third dose of IVIG was being administered he developed hypertensive urgency and non-ST segment elevation myocardial infarction. He was deemed not to be a candidate for cardiac catheterization and was treated conservatively. IVIG can cause major thrombotic adverse events such as deep vein thrombosis, myocardial infarction and stroke, which are attributed to thrombosis and hyperviscocity. Decreasing the dosage of IVIG, administration of anticoagulants are proposed treatments for such events. We propose that patients receiving high-dose IVIG with previous coronary artery disease require meticulous cardiac monitoring. Further research is needed to determine the true adverse effects of high-dose IVIG and prophylaxis regimens to decrease the risk.

Whole genome sequencing of Plasmodium falciparum from dried blood spots using selective whole genome amplification.

BACKGROUND: Translating genomic technologies into healthcare applications for the malaria parasite Plasmodium falciparum has been limited by the technical and logistical difficulties of obtaining high quality clinical samples from the field. Sampling by dried blood spot (DBS) finger-pricks can be performed safely and efficiently with minimal resource and storage requirements compared with venous blood (VB). Here, the use of selective whole genome amplification (sWGA) to sequence the P. falciparum genome from clinical DBS samples was evaluated, and the results compared with current methods that use leucodepleted VB. METHODS: Parasite DNA with high (>95%) human DNA contamination was selectively amplified by Phi29 polymerase using short oligonucleotide probes of 8-12 mers as primers. These primers were selected on the basis of their differential frequency of binding the desired (P. falciparum DNA) and contaminating (human) genomes. RESULTS: Using sWGA method, clinical samples from 156 malaria patients, including 120 paired samples for head-to-head comparison of DBS and leucodepleted VB were sequenced. Greater than 18-fold enrichment of P. falciparum DNA was achieved from DBS extracts. The parasitaemia threshold to achieve >5× coverage for 50% of the genome was 0.03% (40 parasites per 200 white blood cells). Over 99% SNP concordance between VB and DBS samples was achieved after excluding missing calls. CONCLUSION: The sWGA methods described here provide a reliable and scalable way of generating P. falciparum genome sequence data from DBS samples. The current data indicate that it will be possible to get good quality sequence on most if not all drug resistance loci from the majority of symptomatic malaria patients. This technique overcomes a major limiting factor in P. falciparum genome sequencing from field samples, and paves the way for large-scale epidemiological applications.