Early Versus Late Endotracheal Intubation in Subjects with COVID-19 Pneumonia Treated with High-Flow Oxygen: A Retrospective Observational Study.

INTRODUCTION: The availability of high-flow oxygen (HFO) machines allowed patients with COVID-19 pneumonia to be comfortably treated for longer periods of time until endotracheal intubation became inevitable. Patients treated with invasive mechanical ventilation (MV) preceded by HFO treatment may continue to progress and die. Hence there is a belief in physicians that patients treated with HFO might have delayed invasive MV. METHODS: The study was conducted as a retrospective review of subjects with confirmed COVID-19 admitted to the Dubai Hospital ICU. Study variables included time to intubation, duration of HFO, and cumulative duration of tachypnea and tachycardia while on HFO usage. Early intubation was defined as within 24 hours of the start of HFO, and late intubation was defined as after seven days on HFO. Groups were compared for outcome measures; mortality and length of stay (LOS) in the ICU and hospital. RESULTS: Clinical outcomes of mortality and LOS in ICU and hospital were not significantly different among patients intubated early versus late. Duration of tachypnea and tachycardia was also not different comparing patients intubated early versus late. CONCLUSION: There was no significant difference in clinical outcomes in patients intubated early versus late in patients treated with HFO for COVID-19 pneumonia.

The optimal time for endotracheal intubation in subjects with coronavirus disease 2019 pneumonia: A retrospective observational study.

Background: The optimal timing of intubation has been debated among healthcare professionals, current studies do not show any differences between early and late intubation. most studies failed to show any significant difference in clinical outcomes between early or late intubation. Methods: The study was conducted as a retrospective review of subjects with confirmed coronavirus disease 2019 admitted to the Dubai Hospital intensive care unit (ICU). Study variables included time to intubation, duration of supplemental oxygen requirement >15 L/min, and cumulative duration of tachypnea and tachycardia while on the aforementioned oxygen requirement on this oxygen usage level. Each time duration was assessed for correlation with clinical variables including mortality and length of stay in ICU and hospital. Results: Subjects who require endotracheal intubation within 4 h after the start of oxygen >15 L/min have lower survival (P = 0.03). Subjects who have tachypnea on the aforementioned oxygen requirement for 6-19.5 h (P = 0.01) before they require intubation have better survival. No duration of tachycardia has any significant effect on survival. Only the duration of invasive mechanical ventilation (MV) correlated with the hospital length of stay. Conclusions: Subjects who require endotracheal intubation within 4 h after the start of oxygen >15 L/min have lower survival. The optimal time for intubation is after tachypnea of 6 h but before 19.5 h. No duration of tachycardia has any significant effect on survival. Only the duration of invasive MV correlated with the hospital length of stay.

Predictors of Pneumothorax in People With COVID-19 Pneumonia: A Multicenter Retrospective Investigation.

This multicenter retrospective investigation aimed to identify predictors of pneumothorax (PTX), pneumomediastinum (PM), and subcutaneous emphysema (SE) in patients with COVID-19 pneumonia admitted to the ICU. A total of 256 patients were included, with 128 in the case group and 128 in the control group. The study sample consisted of predominantly male patients with a mean age of around 53 years and a high prevalence of comorbidities. Significant predictors of PTX, PM, and SE included the presence of coronary artery disease, non-rebreather mask usage, high-flow oxygen therapy, mechanical ventilation, pressor usage, inpatient dialysis, steroid usage, sedative usage, narcotic usage, paralytic usage, elevated C-reactive protein levels, increased lung infiltration, the presence of PM and SE, mode of ventilation, duration of various respiratory support interventions, and severity of illness as indicated by APACHE and SOFA scores. These findings have important implications for the clinical management of patients with COVID-19 pneumonia, as they may help identify and closely monitor at-risk individuals, allowing for timely intervention and potentially improving clinical outcomes. Future research should focus on validating these predictors in larger cohorts and investigating the underlying mechanisms to develop targeted preventive and therapeutic strategies.

Impact of Non-viral Coinfections on Mortality of Severely Ill COVID-19 Patients in Dubai.

BACKGROUND: Coronavirus disease 2019 (COVID-19) infections may have been associated with secondary infection. Community-acquired or hospital-acquired such infections affect clinical outcomes. We performed a retrospective study to evaluate the impact of these infections on clinical outcomes. METHODS: This was a retrospective analysis of all consecutive patients with COVID-19 admitted to the intensive care unit (ICU) of Dubai hospital. RESULTS: Patients with secondary non-viral infections (SNIs) have higher mortality than patients without SNIs (57.3% vs. 43.7%, p=0.037). Patients with SNIs had more days on mechanical ventilation (MV) 19(11-27) vs. 5(2-10) p<0.001, more LOSICU 22 (15-33) vs. 7 (2-11) p<0.001, and more length of stay in hospital (LOSH) 28 (18-45) vs. 11.5 (6-19), p<0.001. Multiple logistic regression analyses showed that SNIs do not predict mortality. Linear logistic regression analysis showed patients with SNIs have increased length of stay in ICUs (LOSICUs), length of stay in hospitals (LOSHs), and prolonged needs for MV. CONCLUSION: SNIs are high in patients admitted to ICU for COVID-19 acute respiratory distress syndrome (ARDS). Although they do not impact mortality, they prolong the need for MV, LOSICU, and LOSH.

Principle of Hot and Cold and Its Clinical Application in Persian Medicine.

Persian Medicine (PM) or Humoral Medicine is a traditional school of medicine with thousands of years of prolific history. The concept of Mizaj (temperament) and hot-cold theory is one of PM's most important foundations. In the clinical setting, Mizaj represents individual differences in phenotypical, psychological, spiritual, and physiological functions. Mizaj has a crucial role in determining the treatment plan, to the point that a similar disease in patients with different Mizaj types may demand different treatments. In this chapter, the role of hot and cold theory in the diagnosis and treatment of diseases to develop an integrative medical approach is discussed.

Carnosic acid ameliorates depressive-like symptoms along with the modulation of FGF9 in the hippocampus of middle carotid artery occlusion-induced Sprague Dawley rats.

The increased survival rate of stroke patients has led to the higher incidences of post-stroke depression. Carnosic acid has the ability to cross blood brain barrier with good neuro-modulatory actions. Recently, inclined level of fibroblast growth factor 9 (FGF9) in the postmortem brain of the depressed patients was noted. Therefore, in the present study, the effect of carnosic acid on post-stroke depression-like behavior, and the expression of FGF9 were evaluated. After 3 weeks of middle carotid artery occlusion in Sprague Dawley rats, carnosic acid (20 and 40 mg/kg) was administered for 2 weeks. Sucrose preference test, forced swimming test, and open field test were performed and hippocampi were analyzed for FGF9 and FGFR-3. In comparison to post-stroke depressed rats, carnosic acid increased the sucrose preference, and reduced the immobility time of the rats by ~2×. The speed and distance-covered were also increased. At 40 mg/kg, FGF9 was reduced by ~3× while FGFR-3/Actin was increased by ~1.5×. Altogether results suggest anti-depressant-like activity of carnosic acid in post-stroke depressed rats with decreased expression of hippocampal FGF9.

Hydrochemical characterization and pollution assessment of groundwater in Jammu Siwaliks, India.

Physico-chemical groundwater (GW) parameters were evaluated to understand the hydrogeochemical processes in the Siwalik plains of Jammu and Kashmir, India. During the 2012-2013 post-monsoon (POM) and pre-monsoon (PRM) seasons, GW samples (n = 207) from deep bore wells and shallow open wells were chemically analysed. Cations (Ca2+, Mg2+, Na+, K+ and Fe2+) and anions (HCO3-, Cl-, SO42- and F-) showed a wide spatio-temporal variation. Results suggest that weathering and dissolution of carbonates and silicate rocks is the main source of water mineralization. The major hydrochemical facies is characterized by Ca-Mg-HCO3 and Ca-HCO3 during the PRM and POM seasons respectively. The presence of sulphate-bearing water in a large number of the samples indicates a significant role of gypsum dissolution and anthropogenic contamination of the GW. Factor analysis (FA) and hierarchical cluster analysis (HCA) revealed that the variability of hydrochemistry is mainly related to rock-water interaction, dissolution of carbonates and other lithological units as well as the influence of anthropogenic activities in the area. Overall, it was found that the GW quality is within the limits of human consumption. The higher concentration of a few chemicals indicates an increasing trend of industrial contamination of the GW. For sustainable development of the portable GW in Siwaliks, it is necessary to minimize the adverse impacts of the anthropogenic and industrial contamination on the GW resources through best management practices and prevent its further contamination to a level that could make GW unsuitable for human uses.

Spatio-temporal patterns and factors controlling the hydrogeochemistry of the river Jhelum basin, Kashmir Himalaya.

River Jhelum is a major source of water for growing population and irrigation in the Kashmir Himalaya. The region is trending towards water scarcity as well as quality deterioration stage due to its highly unregulated development. The existence of few literature on various aspects of the basin prompts us to study the spatio-temporal variability of its physicochemical parameters and thereby to understand the regulating hydrogeochemical mechanisms based on 50 samples collected during high flow (June 2008) and low flow (January 2009) periods. The water chemistry exhibited significant spatial variability reflecting the mixing processes in the basin. The seasonal effect does change the concentration of ions significantly with modest variability in the order of ionic abundance. The Ca(2+) ion among cations and HCO3 (-) ion among anions dominate the ionic budget and correlates significantly with the diverse lithology of the basin. Three major water types, i.e., Ca-Mg-HCO3 (72 %), Ca-HCO3 (12 %), and Mg-Ca-HCO3 (16 %), suggest that the chemical composition of water is dominantly controlled by carbonate lithology, besides a significant contribution from silicates. However, at certain sites, the biological processes and anthropogenic activities play a major role. Relatively, the lower ionic concentration during high flow period (summer season) suggested the significant influence of higher discharge via dilution effect. The higher discharge due to higher rainfall and snow melting in response to rising temperature in this period leads to strong flushing of human and agricultural wastes into the river. The factor analysis also reflected the dominant control of varied lithology and anthropogenic sources on the water quality based on the four significant factors explaining collectively about 70-81 % of the total data variance. A two-member chloride mixing model used to estimate the discharge contribution of tributaries to the main river channel showed reliable results. It may be mentioned that the regular and continuous contamination through anthropogenic sources is likely to jeopardize and degrade the water quality in the near future. Thus, critical management approaches and strategies are very imperative for its future sustainability.

Protection of CCl4-Induced Liver and Kidney Damage by Phenolic Compounds in Leaf Extracts of Cnestis ferruginea (de Candolle).

BACKGROUND: The chemoprevention of chemically-induced hepatotoxicity is a crucial means of minimizing susceptibility to hepatic carcinogenesis and plants remain a rich source of anti-hepatotoxicants with antioxidant properties. OBJECTIVE: The protective role of defatted-methanol (MECF) and ethyl acetate fractions (EF), obtained from Leaves of Cnestis ferruginea in rats induced with carbon tetrachloride (CCl4) toxicity was investigated. MATERIALS AND METHODS: Adult male Wistar rats were orally administered MECF or EF (125 - 500 mg/kg bwt/5mL) or silymarin (25 mg/kg bwt/5 mL) separately for three days before intervention with an intraperitoneal dose of CCl4. Biomarkers of liver and kidney toxicity as well as Ca(2+) regulation were evaluated. RESULTS: Pre-treatment with MECF and EF significantly (P < 0.05) decreased the activities of serum alanine and aspartate aminotransferases, levels of urea, creatinine and cholesterol. A significantly (P < 0.05) enhanced Ca(2+) -ATPase activity and lowered levels of membrane cholesterol: Phospholipid ratio were observed in liver microsomes of pre-treated as compared to CCl4 -only treated rats. Rat liver superoxide dismutase activity was enhanced by 125 mg/kg and 250 mg/kg of EF and MECF, while decreases were observed at 500 mg/kg. MECF and EF, like silymarin, attenuated CCl4 -induced hepatotoxicity, microsomal membrane Ca(2+) -ATPase inactivation and renal dysfunction. Phytochemistry of MECF revealed the presence of anthraquinones, cardiac and flavone glycosides, tannins and trihydroxyl phenol. CONCLUSION: These findings suggest that the mechanism of hepatoprotection elicited by MECF and EF, involve its antioxidative properties and regulation of Ca(2+) homeostasis.

Anti-inflammatory and antinociceptive activities of Homalium letestui.

CONTEXT: Homalium letestui Pellegr (Flacourtiaceae) is used in various decoctions traditionally by the Ibibios of the Niger Delta of Nigeria to treat stomach ulcer, malaria and other inflammatory diseases, as well as an aphrodisiac. OBJECTIVE: To investigate the anti-inflammatory and antinociceptive activities of the stem extract of the plant. MATERIALS AND METHODS: The ethanol stem extract (500, 750, 1000 mg/kg, i.p.) of H. letestui was investigated for anti-inflammatory activity using carrageenan, egg albumin-induced and xylene-induced ear edema models and analgesic activity using acetic acid-induced writhing, formalin-induced paw licking and thermal-induced pain models. The ethanol extract was administered to the animals orally, 30 min to 1 h depending on the model, before induction of inflammation/pain. The LD50 was also determined. GC-MS analysis of dichloromethane fraction was carried out. RESULTS: The extract caused a significant (p < 0.05-0.001) reduction of inflammation induced by carrageenan (8.3-70.0%), egg albumin (10.0-71.42%) and xylene (39.39-84.84%). The extract also reduced significantly (p < 0.05-0.001) pain induced by acetic acid (44.22-73.65%), formalin (55.89-79.21%) and hot plate (93.0-214.5%). The LD50 was determined to be 4.38 ± 35.72 g/kg. DISCUSSION AND CONCLUSION: The results of this study suggest that the ethanol stem extract of H. letestui possesses anti-inflammatory and analgesic properties which may in part be mediated through the chemical constituents of the plant as revealed by the GC-MS.

Cellular antioxidative, cytotoxic, and antileishmanial activities of Homalium letestui.

OBJECTIVE: Homalium letestui Pellegr (Flacourtiaceae) is used in traditional medicine in parts of Nigeria for the treatment of malaria, ulcer, and inflammatory diseases and as an aphrodisiac. This investigation was aimed to evaluate the cytotoxic, immunomodulatory, and antileishmanial properties of stem extract and fractions of Homalium letestui (H. letestui). MATERIALS AND METHODS: Cytotoxic activity against HeLa cells was done using sulphorhodamine (SRB) method and DNA interaction activity using gel electrophoresis. Immunomodulatory activity of the extract in whole blood, neutrophils, and macrophages was also investigated using luminol/lucigenin-based chemiluminescence assay. The extract and fractions were similarly screened for antileishmanial activity against promastigotes of Leishmania major in vitro. The GCMS analysis of the most active fraction against HeLa cells was carried out. RESULTS: The stem extract exerted prominent cytotoxic activity with the dichloromethane fraction exhibiting the most pronounced effect (GI50 -5.12±1.45 µg/ml, LC50- 57.3±2.33 µg/ml, TGI -12.6±0.87 µg/ml). The crude extract and the fractions did not interact with DNA when investigated using electrophoresis. The extract significantly ((p<0.05 - 0.001) inhibited oxidative burst activity in whole blood (-27.90-66.90%), isolated polymorphonuclear cells (PMNs) (16.50-67.0%), and mononuclear cells (MNCs) (4.31-98.50%) when two different phagocytosis activators (serum opsonizing zymosan-A and PMA) were used. The extract also exhibited moderate antileishmanial activity against promastigotes of Leishmania major in vitro. GCMS analysis of active fraction revealed pharmacologically active compounds. CONCLUSION: These results suggest that the stem extract/fractions of H. letestui possess cytotoxic, immunomodulatory, and antileishmanial activities.

Role of liberal primary fasciotomy in traumatic vascular injury.

BACKGROUND: Vascular injury represents less than 1% of all injuries, but deserves special attention because of its severe complications. Amputation or retention of a painful functionless limb is the most untoward result of severe vascular injury or inadequate treatmet. Thus, vascular injury needs a judicious and multidimensional approach. OBJECTIVES: This retrospective study was done to asess the outcome of minor modifications of the methodology of extremity fasciotomy by making it liberal with respect to incision and definition. MATERIALS AND METHODS: Out of 55 patients in 2008, 45 patients (Group A) had either no fasciotomy or limited primary fasciotomy, 10 patients (Group B) had primary liberal fasciotomy. Another group from 2008 onwards had undergone primary liberal fasciotomy in all the 45 patients (Group C). RESULTS: In group A, we had 5 amputations and one death. In group B, there were no amputations or deaths and from group C, we had one amputation and no deaths. CONCLUSIONS: Blunt and distal traumatic vascular injury of the extremities and its repair should always combined with primary liberal fasciotomy, which although increases manageable morbidity, avoids disability (functional as well as anatomical).

Mucocele of the appendix: an unusual cause of disturbed bowel habits.

There are many causes of disturbed bowel habits. In this rare case of mucocele of appendix, patient presented with disturbed bowel habits of increased frequency, urgency and semisolid stool. Ultrasound of abdomen revealed fusiform cyst just below umbilicus. Differential diagnoses included mesenteric cyst, duplication cyst and mucocele of appendix. Coronal and saggital reformats of CT abdomen confirmed its origin from ceacum. Its tip was in contact with sigmoid colon. Surgical resection was carried out and histopathology revealed mucinous cyst adenoma.

Iatrogenic bile duct injuries in kashmir valley.

Cholecystectomy is one of the commonest operations performed throughout the world and bile duct injury is the worst complication of this procedure. In a prospective and retrospective study 25 patients were seen in a tertiary care hospital over a period of 10 years. 72% of patients were referred from other hospitals. 48% of patients presented within one month of injury. Pain was the commonest presentation (92%) followed by jaundice (80%). Liver functions were deranged in 70% of patients, USG revealed biliary dilatation in 69.6% of patients. ERCP was done in 16 patients and revealed cut off of the common hepatic duct in 43.8% of patients. Intraoperative findings revealed adhesions in 96% of patients. 48% of patients had bile duct stricture. Roux-en-Y hepaticojejunostomy was the commonest procedure performed. All patients showed improvement in liver function after surgery. Wound infection was the commonest complication seen in 32% patients. 3 patients died in our series.

Popliteal artery embolism by Ascaris lumbricoides: a case report.

Arterial occlusive diseases are highly prevalent and constitute the leading overall cause of death. Adverse events are due to the effects of impaired circulation on critical end organs, namely the brain, heart, abdominal viscera or extremities. Acute thromboembolism remains a major surgical challenge. Even with optimal surgical management, acute lower extremity ischemia resulting from thromboembolic ds continues to cause significant morbidity and mortality. We report a case of thromboembolism of the left popliteal artery by an Ascaris worm in a patient with oriental cholangiohepatitis.

Prevalence of diabetes mellitus and other abnormalities of glucose tolerance in young adults aged 20-40 years in North India (Kashmir Valley).

AIMS: To assess the burden of type 2 diabetes mellitus (T2DM) and other abnormalities of glucose tolerance in young-adult (20-40 years) men and non-pregnant women. METHODS: Prevalence of diagnosed T2DM, undiagnosed T2DM and other abnormalities of glucose tolerance studied in 3032 subjects from Kashmir Valley of India. The study included a questionnaire, anthropological measurements, blood sampling, and a standard OGTT. RESULTS: Eight (0.3%) of surveyed subjects were previously diagnosed to have diabetes. Of 3024 subjects screened, prevalence of diabetes, impaired glucose tolerance (IGT), and impaired fasting glycemia [IFG, World Health Organization, Definition, Diagnosis, and Classification of Diabetes Mellitus and its Complications. Part 1. Diagnosis and Classification of Diabetes Mellitus, World Health Organization, Geneva, 1999], IFG [American Diabetes Association, Diagnosis and classification of diabetes mellitus, Diabetes Care 27 (Suppl. 1) (2004) S5-S10] was 2.5%, 2.0%, 11.9% and 26.7%, respectively. Overall, age-adjusted prevalence of T2DM (known plus unknown), IGT, IFG (WHO) and IFG (ADA) was 2.4% (95% CI: 1.9-3.0), 1.6% (95% CI: 1.3-2.2), 11.1% (95% CI: 10.0-12.3), and 25.2% (95% CI: 23.7-26.8), respectively. The difference in diabetes prevalence was significant by age, habitat, family history of diabetes and BMI. The ratio of known-to-unknown diabetes was 1:10. CONCLUSIONS: This is the first large scale study from North India on prevalence of type 2 diabetes in the younger age group of 20-40 years. Abnormal glucose tolerance including undiagnosed T2DM is common in young adults.

Umbilical endometriosis.

A case of umbilical endometriosis in a 36 years old Saudi female is described.The patient presented with 4 months history of bleeding and discharge from the umbilicus and was treated with local and systemic antibiotics. Histopathology of tissues collected from the umbilicus revealed endometrial stroma and glands. The patient underwent umbilectomy at a tertiary centre as definitive management.

Prevalence of gestational diabetes mellitus in Kashmiri women from the Indian subcontinent.

This prospective study was carried out to determine the prevalence of gestational diabetes mellitus (GDM) in Kashmiri women and to assess the effect of various demographic factors. Two thousand pregnant women (divided into groups A and B, being the first and last 1000 consecutive women) attending various antenatal clinics in six districts of Kashmir valley were screened for GDM by 1 h 50 g oral glucose challenge test. Four hundred and fourteen (20.8%) women (216 from group A and 198 from group B) had an abnormal screening test and proceeded to oral glucose tolerance testing. Women from group A had a 3 h 100 gram oral glucose tolerance test (OGTT) and GDM was as classified by Carpenter and Coustan. A 2 h 75 g OGTT was performed on group B subjects and WHO criteria applied for diagnosis of GDM. The overall prevalence of GDM was 3.8% (3.1% in group A versus 4.4% in group B-P-value 0.071). GDM prevalence steadily increased with age (from 1.7% in women below 25 years to 18% in women 35 years or older). GDM occurred more frequently in women who were residing in urban areas, had borne three or more children, had history of abortion(s) or GDM during previous pregnancies, had given birth to a macrosomic baby, or had a family history of diabetes mellitus. Women with obesity, hypertension, osmotic symptoms, proteinuria or hydramnios had a higher prevalence of GDM.

Copper, zinc and magnesium levels in type-1 diabetes mellitus.

OBJECTIVE: Alterations in plasma concentrations of several trace elements have been reported to occur in type-1 diabetes mellitus. These micronutrients are suspected to have a role in pathogenesis and progression of the disease. METHODS: In a comparative analysis, the plasma concentration of copper, zinc and magnesium was estimated in 37 patients with type-1 diabetes mellitus and 25 healthy non-diabetic subjects at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India. Trace elements were estimated using a GBC 902 double beam atomic absorption spectrophotometer. RESULTS: Mean plasma concentrations of copper and magnesium were comparable between diabetic patients and control subjects. Plasma zinc levels were significantly higher (P=0.022) in diabetic patients (17.78 0.6 micromol/L) as compared to controls (15.80 0.75 micromol/L). Glycemic control and presence of microalbuminuria did not influence the plasma levels of copper, zinc and magnesium. CONCLUSION: Plasma zinc levels are significantly higher in type-1 diabetes mellitus patients, while plasma copper and magnesium levels are not significantly altered. No effect of sex, glycemic control or presence of microalbuminuria could be demonstrated on plasma concentration of trace elements in type-1 diabetes mellitus patients.