Bladder trauma: a guideline of the guidelines.

OBJECTIVES: To identify and review the most up-to-date guidelines pertaining to bladder trauma in a unifying document as an updated primer in the management of all aspects relating to bladder injury. METHODS: In accordance with the PRISMA statement, the most recent guidelines pertaining to bladder injury were identified and subsequently critically appraised. An electronic search of PubMed and Scopus databases was carried out in September 2023. RESULTS: A total of six guidelines were included: European Association of Urology (EAU) guidelines on urological trauma (2023), EAU guidelines on paediatric urology (2022), Urotrauma: American Urological Association (AUA) (2020), Kidney and Uro-trauma: World Society of Emergency Surgery and the American Association for the Surgery of Trauma (WSES-AAST) guidelines (2019), Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST) (2019), and EAU guidelines on iatrogenic trauma (2012). Recommendations were summarised with the associated supporting level of evidence and strength of recommendation where available. CONCLUSION: Several widely recognised professional organisations have published guidelines relating to the diagnosis, investigation, classification, management, and follow-up related to bladder injury. There is consensus amongst all major guidelines in terms of diagnosis and management but there is some discrepancy and lack of recommendation with regards to the follow-up of bladder injuries, iatrogenic bladder injury, paediatric bladder trauma, and spontaneous bladder rupture. The role of increasing minimally invasive techniques seem to be gaining traction in the select haemodynamically stable patient. Further research is required to better delineate this treatment option.

Spontaneous (idiopathic) rupture of the urinary bladder: a systematic review of case series and reports.

OBJECTIVES: To perform a systematic review of all cases of spontaneous rupture of the urinary bladder (SRUB) and to describe the demographic data, associated comorbidities, clinical presentation, diagnosis, relevant laboratory findings, associated factors, management, morbidity and mortality associated with the presentation of SRUB. METHODS: The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). A search was carried out across the following electronic databases: PubMed, Web of Science, Scopus, Google Scholar and the Cochrane Database of Systematic Reviews. Full texts of selected studies were analysed, and data extracted. The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS: A total of 278 articles comprising 240 case reports and 38 case series, with a total of 351 patients were included. The median (interquartile range [IQR]) age of all included patients was 47.5 (33-65) years. The median (IQR) time to presentation was 48 (24-96) h, with the major presenting symptom being abdominal pain (76%). In patients in whom the diagnosis was made prior to any intervention, the condition was misdiagnosed in 64% of cases. The diagnosis was confirmed during explorative open surgery in 42% of cases. Pelvic radiation (13%) and alcohol intoxication (11%) were the most common associated factors. Intraperitoneal rupture (89%) was much more common, with the dome of the bladder being most frequently involved (55%). The overall mortality was 15%. CONCLUSION: This review identified a number of key factors that appear to be associated with an increased incidence of SRUB. It also emphasized the high rate of misdiagnosis and challenge in confirming the diagnosis. Overall, it highlighted the importance of the need for increased awareness and maintaining a high index of suspicion for this condition.

Development and internal validation of the HIV In-hospital Mortality Prediction (HIV-IMP) risk score.

BACKGROUND: Despite advances in availability and access to antiretroviral therapy (ART), HIV still ranks as a major cause of global mortality. Hence, the aim of this study was to develop and internally validate a risk score capable of accurately predicting in-hospital mortality in HIV-positive patients requiring hospital admission. METHODS: Consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult emergency department between 7 July 2017 and 18 October 2018 were prospectively enrolled. Multivariate logistic regression was used to determine parameters for inclusion in the final risk score. Discrimination and calibration were assessed by means of the area under the receiver operating curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test, respectively. Internal validation was conducted using the regular bootstrap technique. RESULTS: The overall in-hospital mortality rate was 13.6% (n = 166). Eight predictors were included in the final risk score: ART non-adherence or not yet on ART, Glasgow Coma Scale < 15, respiratory rate > 20 breaths/min, oxygen saturation < 90%, white cell count < 4 × 109 /L, creatinine > 120 µmol/L, lactate > 2 mmol/L and albumin < 35 g/L. After internal validation, the risk score maintained good discrimination [AUROC 0.83, 95% confidence interval (CI): 0.78-0.88] and calibration (Hosmer-Lemeshow χ2 = 2.26, p = 0.895). CONCLUSION: The HIV In-hospital Mortality Prediction (HIV-IMP) risk score has overall good discrimination and calibration and is relatively easy to use. Further studies should be aimed at externally validating the score in varying clinical settings.

Secondary asthma prevention measures are not adequately addressed prior to emergency department discharge!

BACKGROUND: Exacerbations of acute asthma are frequent presentations to the Emergency Department (ED) and contribute to ED overcrowding and healthcare cost. The purpose of this study was to evaluate whether ED clinicians are implementing secondary asthma prevention measures prior to discharging patients after an acute asthma exacerbation and also to determine whether ED clinicians are able to correctly demonstrate how to use an asthma metered dose inhaler (MDI) device. METHODS: Consenting doctors employed at four EDs situated in the Gauteng province of South Africa were asked to complete a questionnaire and thereafter demonstrate the technique of using an MDI device. Collected data was presented using descriptive statistics. RESULTS: Eighty-six doctors were included in the study. Of these, 18 (20.9%) routinely checked that inhaler technique was correct, 50 (58.1%) routinely enquired regarding adherence to their asthma treatment, 8 (9.3%) routinely informed patients of the side effects of asthma medication, 16 (18.6%) routinely provided patients with a written asthma action plan, 7 (8.1%) routinely evaluated for the presence of concurrent allergic rhinitis and 53 (61.6%) routinely counselled patients regarding smoking cessation. With regards to correctly demonstrating how to use an MDI device, only 23 (26.74%) physician participants performed all eight steps correctly. CONCLUSION: This study indicates that secondary asthma prevention measures are not adequately addressed by clinicians prior to discharging patients from the ED after an acute asthma attack. It is recommended that ED clinicians are educated with regards to the importance of these measures.

Modified Two-Rescuer CPR With a Two-Handed Mask-Face Seal Technique Is Superior To Conventional Two-Rescuer CPR With a One-Handed Mask-Face Seal Technique.

BACKGROUND: Bag-valve-mask (BVM) ventilation using a two-handed mask-face seal has been shown to be superior to a one-handed mask-face seal during cardiopulmonary resuscitation (CPR). OBJECTIVE: We aimed to compare CPR quality metrics during simulation-based two-rescuer CPR with a modified two-handed mask-face seal technique and two-rescuer CPR with the conventional one-handed mask-face seal technique. METHODS: Participants performed two-rescuer CPR on a simulation manakin and alternated between the modified and conventional CPR methods. For the modified method, the first rescuer performed chest compressions and thereafter squeezed the BVM resuscitator bag during the ventilatory pause, while the second rescuer created a two-handed mask-face seal. For the conventional method, the first rescuer performed chest compressions and the second rescuer thereafter delivered rescue breaths by creating a mask-face seal with one hand and squeezing the BVM resuscitator bag with the other hand. RESULTS: Among the 40 participants that were enrolled, the mean ± standard deviation (SD) delivered respiratory volume was significantly higher for the modified two-rescuer method (319.4 ± 71.4 mL vs. 190.2 ± 50.5 mL; p < 0.0001). There were no statistically significant differences between the two methods with regard to mean ± SD compression rate (117.05 ± 9.67 compressions/min vs. 118.08 ± 10.99 compressions/min; p = 0.477), compression depth (52.80 ± 5.57 mm vs. 52.77 ± 6.77 mm; p = 0.980), chest compression fraction (75.92% ± 2.14% vs. 76.57% ± 2.57%; p = 0.186), and ventilatory pause time (4.62 ± 0.64 s vs. 4.56 ± 0.43 s; p = 0.288). CONCLUSIONS: With minor modifications to the conventional method of simulated two-rescuer CPR, rescuers can deliver significantly higher volumes of rescue breaths without compromising the quality of chest compressions.

Mechanically Ventilating the Severe Asthmatic.

The management of the critically ill patients with asthma can be rather challenging. Potentially devastating complications relating to this presentation include hypoxemia, worsening bronchospasm, pulmonary aspiration, tension pneumothorax, dynamic hyperinflation, hypotension, dysrhythmias, and seizures. In contrast to various other pathologies requiring mechanical ventilation, acute asthma is generally associated with better outcomes. This review serves as a practical guide to the physician managing patients with severe acute asthma requiring mechanical ventilation. In addition to specifics relating to endotracheal intubation, we also discuss the interpretation of ventilator graphics, the recommended mode of ventilation, dynamic hyperinflation, permissive hypercapnia, as well as the role of extracorporeal membrane oxygenation and noninvasive mechanical ventilation.

First-presentation with psychotic behavior to the Emergency Department: Meningitis or not, that is the question.

INTRODUCTION: Meningitis is a potentially life threatening medical emergency. Psychotic behavior may be a presenting feature in patients with meningitis. We aimed to determine the value of various clinical and laboratory features at ruling-out meningitis in the patient presenting with a first-episode of psychotic behavior. METHODS: Medical records of 159 subjects presenting to a tertiary academic hospital over a 6-month period with one or more psychotic features for the first time were prospectively gathered. Pathological cerebrospinal fluid findings as well as clinical and other laboratory findings were tabulated and discussed retrospectively. RESULTS: Cerebrospinal fluid was obtained in 153/159 (96.2%) subjects. Meningitis was confirmed in twenty-eight (18.3%) subjects. Of these, a) one or more clinical feature of meningitis (headache, neck stiffness, photophobia or focal neuropathy) was present in 21 subjects (75.0%), b) visual hallucinations in 15 subjects (53.6%), c) pyrexia >37.5 °C in 7 subjects (25.0%), d) CRP >10 mg/L in 21 subjects (75.0%), e) HIV seropositive status in 19 subjects (67.9%) and f) an absence of illicit substances on urinalysis in 23 subjects (82.1%). Various combinations of these variables, where the presence of ≥1 variable was regarded as positive, were unable to rule-out meningitis in all study subjects. CONCLUSION: The absence of these six parameters; alone or in various combinations, was unable to rule-out meningitis in all patients presenting to our ED with a first-episode of psychotic behavior. When the underlying etiology of psychotic behavior is not obvious, the clinician should adopt a low threshold to perform a lumbar puncture.

First Presentation with Psychotic Symptoms to the Emergency Department.

BACKGROUND: Mental health conditions account for 52.8 million (4.9-6.3%) emergency department (ED) visits in the United States. Psychotic conditions are responsible for approximately 10% of all mental health presentations. OBJECTIVE: We aimed to determine the underlying etiology and characteristics of patients presenting to the ED with a first episode of psychotic symptoms. METHODS: Medical records of 159 African, Asian, white, and mixed-race patients were prospectively reviewed. Subjects were classified into one of three groups; psychosis due to an underlying medical condition (UMC), substance-induced psychotic disorders (SIPDs), and psychosis due to other primary psychiatric disorders (OPD). Demographic details and presenting features were described and compared. RESULTS: Overall mean (standard deviation [SD]) age of all study subjects was 34.3 (13.4) years. A UMC was responsible for a first presentation with psychotic features in more than half of the study subjects (n = 87 [54.7%]), while SIPD (n = 37 [23.3%]) and OPD (n = 35 [22.0%]) were responsible for the remainder of cases. The majority of subjects were male (n = 95 [59.7%]), unemployed (n = 105 [66.0%]), and had not completed secondary school (n = 109 [68.6%]). More than one-third of subjects tested positive for human immunodeficiency virus infection (n = 63 [39.6%]). Mean (SD) duration of psychotic symptoms before ED presentation was 16.6 (26.3) days. CONCLUSIONS: UMC is a common etiology in patients presenting to the ED with a first episode of psychotic symptoms.

The ultrasonographic "whirlpool sign" in testicular torsion: valuable tool or waste of valuable time? A systematic review and meta-analysis.

PURPOSE: A positive whirlpool sign (WS) is defined as the presence of a spiral-like pattern when the spermatic cord is assessed during ultrasonography (US), using standard, high-resolution ultrasonography (HRUS) and/or color Doppler sonography (CDS), in the presence of testicular torsion. The objective of this review was to assess the validity and accuracy of this sign by performing a comprehensive systematic literature review and meta-analysis. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive literature search was performed (August, 2017), using the following databases: BMJ Best Practice, Cochrane Library, Embase, PubMed, Scopus, and Web of Science. Selected studies were further assessed for relevance and quality using the Oxford 2010 Critical Appraisal Skills Program (CASP). RESULTS: Of the studies assessed, a total of 723 participants were included, with a mean of 72.3 (SD 71.9) participants. Of the participants, 226 (31.3%) were diagnosed with testicular torsion (TT). Meta-analysis of the studies that provided sufficient data resulted in a pooled sensitivity and specificity of the WS of 0.73 (95% CI, 0.65-0.79) and 0.99 (95% CI, 0.92-0.99), respectively. Removal of all neonates increased the pooled sensitivity to 0.92 (95% CI, 0.70-0.98) while the pooled specificity remained almost unchanged at 0.99 (95% CI, 0.95-1.00). The estimated summary effect of all studies with sufficient data was 4.34 (95% CI, 1.01-7.67; n = 394; p = 0.001). A large degree of heterogeneity was suggested by an I2 statistic of 88.27% (95% CI, 68.60-98.68%). Removal of neonatal subjects increased the estimated summary effect to 5.32 (95% CI, 1.59-9.05; n = 375; p = 0.001). CONCLUSION: The WS, when correctly diagnosed, may be viewed as a very definitive sign for TT in the pediatric and adult populations. However, its role in neonates is limited.

A review of hemodynamic monitoring techniques, methods and devices for the emergency physician.

The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end-organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini-fluid challenge, the end-expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.

Finding the mental foramen.

The mental foramen and mental nerve are clinically important landmarks for clinicians across various disciplines including dentists, oral maxillofacial surgeons, emergency physicians and plastic and reconstructive surgeons. To minimize complications related to procedures in the vicinity of the mental foramen and nerve, knowledge of its anatomy and anatomical variations is cardinal to concerned clinicians. In this review, basic anatomy, procedural complications, hard and soft tissue relations, variations between population groups, asymmetry, accessory mental foramina and the use of various radiological modalities to determine the position of the mental foramen are reviewed to provide a more thorough understanding of this important landmark.

Utilization of barley and parsley for the management of urolithiasis among the Saudi Arabian population.

Objective: To determine the utilization of barley and parsley for managing urolithiasis among the Saudi Arabian population. Methods: This is a prospective cross-sectional survey-based study. The survey comprised questions about the use of barley, parsley, and other therapies for managing urolithiasis. A WhatsApp® message with the link to the study survey was sent out to family, friends, patients, and other acquaintances residing in the Kingdom of Saudi Arabia (KSA). Results: A total of 1014 respondents completed the survey, of which 44.8% indicated that they utilized barley, 38.3% stated that they used parsley, and 4.2% indicated that they utilized other non-medical remedies to treat or prevent kidney stones. In contrast, only 29.5% stated that they utilized potassium citrate and/or magnesium citrate, and only 14.4% indicated that they consumed greater amounts of water to treat or prevent kidney stones. Conclusion: Our study findings indicate that among the Saudi Arabian population, non-conventional therapies such as barley and parsley are more commonly utilized for managing urolithiasis rather than established therapies such as increasing water intake and the use of potassium-citrate/ magnesium-citrate. There is a need to conduct large-scale clinical studies to evaluate the efficacy and safety of barley, parsley, and other non-conventional therapies for treating urolithiasis.

Critical illness due to infection in people living with HIV.

People living with HIV comprise a substantial number of the patients admitted to intensive care. This number varies according to geography, but all areas of the world are affected. In lower-income and middle-income countries, the majority of intensive care unit (ICU) admissions relate to infections, whereas in high-income countries, they often involve HIV-associated non-communicable diseases diagnoses. Management of infections potentially resulting in admission to the ICU in people living with HIV include sepsis, respiratory infections, COVID-19, cytomegalovirus infection, and CNS infections, both opportunistic and non-opportunistic. It is crucial to know which antiretroviral therapy (ART) is appropriate, when is the correct time to administer it, and to be aware of any safety concerns and potential drug interactions with ART. Although ART is necessary for controlling HIV infections, it can also cause difficulties relevant to the ICU such as immune reconstitution inflammatory syndrome, and issues associated with ART administration in patients with gastrointestinal dysfunction on mechanical ventilation. Managing infection in people with HIV in the ICU is complex, requiring collaboration from a multidisciplinary team knowledgeable in both the management of the specific infection and the use of ART. This team should include intensivists, infectious disease specialists, pharmacists, and microbiologists to ensure optimal outcomes for patients.

Knowledge, Attitudes, and Perceptions Regarding CPR Among Non-medical Staff at a Medical School in South Africa.

Background Sudden cardiac arrest can occur unexpectedly in any person and at any place including at medical schools. Improved outcomes after cardiac arrest are dependent on the initiation of early first responder high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. There is a lack of data pertaining to the knowledge, attitudes, and perceptions of non-medical staff at medical schools regarding CPR. The aim of this study was to determine the knowledge, attitudes, and perceptions of non-medical staff employed at a medical school in South Africa regarding CPR. Methods In this cross-sectional survey study, a paper-based questionnaire was administered to non-medical staff (i.e., all staff without a medical [MBBCh or equivalent] or nursing degree) employed at the medical school. Data were collected between August 1 and October 25, 2020. Results The final study sample comprised 150 participants. Of these, 103 (68.7%) were female, 109 (72.7%) were ≤ 40 years old, 62 (41.3%) had a postgraduate university degree, 72 (48.0%) had witnessed a medical emergency at the medical school premises and 46 (30.7%) had previously undertaken first aid or CPR training. The mean (SD) knowledge score was 4.4 ± 1.6 out of 10 with only 25 (16.7%) participants knowing what the first thing was to look out for during a medical emergency and 28 (18.7%) participants knowing the location of the automated external defibrillator. Most participants (n=136, 90.7%) indicated that CPR training should be mandatory for all employees. Conclusion Non-medical staff surveyed displayed suboptimal knowledge but positive attitudes and perceptions toward CPR. Although this was a single-center study, these results can be used to motivate CPR training of non-medical staff at all medical schools.

mHealth app usage amongst paediatric department doctors in South Africa.

Background: Smartphone and mobile health (mHealth) applications (apps) have become an integral part of the day-to-day function of healthcare professionals, allowing quick, comprehensive, and up-to-date access to current clinical guidelines and other reference material. Objective: To evaluate the extent and nature of use of mHealth apps by paediatric department doctors in South Africa. Methods: E-mails requesting study participation were sent out to 285 paediatric department doctors employed at six hospitals affiliated to the University of the Witwatersrand. Willing participants were directed to complete the online study questionnaire. Results: A total of 150 respondents completed the questionnaire. All respondents owned a mobile device and already had one or more mHealth apps, 95.3% were unaware of any regulatory body responsible for regulating the use of mHealth apps, 86.0% did not have access to free Wi-Fi at work and 87.3% used an mHealth app at least once daily. Drug dosing (81.3%), diagnostic (59.3%) and clinical decision-making (44.7%) apps were the most common app categories with Medscape® (62.0%) and EMGuidance® (41.3%) being the most frequently used apps. Peer recommendation (76.0%), app credibility (74.0%) and app functionality (66.0%) were the most common factors that were considered by respondents prior to downloading or using an mHealth app. Conclusion: Medical apps are frequently used among paediatric medical doctors of all ranks. Drug dosing, diagnostic and clinical decision-making apps are the most common app categories in use. Improved awareness of the regulations pertaining to the use of mHealth apps amongst doctors is required.

Financial burden associated with attendance at a public hospital emergency department in Johannesburg.

INTRODUCTION: More than half of South Africans live below the poverty line. Indirect medical costs can contribute significantly to the financial burden of patients seeking medical care. The aim of this study was to determine the expenses incurred by patients and/or their escorts during a visit to the emergency centre (EC). METHODS: Patients and/or their escorts presenting to an EC in Johannesburg were asked to complete the study questionnaire relating to expenses incurred during a visit to the EC. RESULTS: Of the total 396 participants that completed the questionnaire, 108 (27.2%) did not have any source of income, 146 (36.9%) were the sole breadwinner in their household and 36 (9.1%) belonged to zero-income households. Among those earning ≤R2000 per month, the mean expenses relating to the EC visit was R240 (SD R372), equating to an average of 33.2% of mean monthly income. Transport costs were the most common expense (n=302, 76.3%), while general practitioner (GP) fees incurred prior to the EC visit accounted for the bulk of the expenses (median R450, IQR 350-820). Participants that earned >R2000 per month were significantly more likely to incur GP fees (p =0.012), while those earning ≤R2000 per month were significantly more likely to take a loan to cover EC related expenses (p =0.014). CONCLUSION: A visit to the EC can have a substantial financial impact on patients and their accompanying escorts in South Africa. Strategies should be aimed at identifying and assisting those that are in need of financial assistance to cover indirect healthcare costs.

Prevalence and presentation of neonatal sepsis at a paediatric emergency department in Johannesburg, South Africa.

Background: Despite a significant reduction in the prevalence of neonatal sepsis over the past three decades, the prevalence still remains high, especially in low- and middle-income countries. The aim of this study was to determine the prevalence and presenting features of neonatal sepsis at a paediatric emergency centre (PEC). Methods: Medical records of all neonates presenting to an academic hospital PEC over a six-month period were analysed. Data was compared between neonates with and without sepsis. The odds ratio was calculated to determine factors associated with neonatal sepsis. Results: Of the 210 neonates who were included, 43 (20.5%) were diagnosed with neonatal sepsis. Of these, 19 (44.2%) presented within the first 72 hours of life (early-onset neonatal sepsis) and 4 (9.3%) died prior to hospital discharge. A history of maternal employment (odds ratio (OR) 2.38, p=0.021), preterm birth (OR 3.24, p=0.019), low birth weight (<2.5kg) (OR 2.67, p=0.026), perinatal human immunodeficiency virus exposure (OR 3.35, p=0.002), not being breast fed (OR 4.36, p=0.001), and signs of lethargy (OR 14.01, p<0.001), dehydration (or 11.14, p<0.001), poor feeding (OR 7.20, p<0.001), irritability (OR 6.93, p<0.001), fever (OR 5.50, p<0.001), vomiting (OR 4.14, p<0.001) and respiratory distress (OR 4.12, p<0.001) were significantly associated with neonatal sepsis. Conclusion: Among neonates presenting to the PEC, various clinical features on history and examination may be useful in predicting the diagnosis of neonatal sepsis. Clinicians working in the PEC must adopt a high index of suspicion when attending to neonates presenting with these features.

Hypernatremia at a Tertiary Hospital Intensive Care Unit in South Africa.

Background Hypernatremia in the critical care setting is a major cause of morbidity and mortality. However, data pertaining to this has not been evaluated in South African hospitals. The aim of this study was to evaluate hypernatremia with regards to its prevalence, associated factors, and outcomes at an academic hospital intensive care unit (ICU) in Johannesburg, South Africa. Methods The ICU charts of patients admitted to the Charlotte Maxeke Johannesburg Academic Hospital adult general ICU from June 1, 2016 to May 31, 2017 were retrospectively reviewed. Subjects were categorized into three groups namely, ICU-acquired hypernatremia (IAH), pre-admission hypernatremia (PAH), and normonatremia. Data was compared between the three groups. Results Of the 833 subjects that were enrolled, 310 (37.2%) were hypernatremic. IAH was present in 144 (17.2%) and PAH in 166 (19.9%) subjects. Hypernatremia was significantly (p <0.05) associated with a higher rate of altered mental status, higher Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) scores, a higher rate and duration of mechanical ventilation, a greater need for inotropic/vasopressor support, longer ICU stay and higher ICU mortality. Conclusion Hypernatremia in ICU patients remains a significant contributor to morbidity, mortality, and ICU length of stay. The prevalence of hypernatremia was much higher than that reported in higher-income countries.

Anterograde Mini-Percutaneous Retropelvic Extra-Luminal Endopyelotomy: A Novel Approach to Uretero-Pelvic Junction Obstruction.

Background Uretero-pelvic junction obstruction (UPJO) is a common cause of upper tract urinary obstruction. This condition is generally treated with various surgical options which include endoscopic (retrograde or anterograde), laparoscopic, open or robotic-assisted approaches. Herein, we describe a novel endoscopic retropelvic extra-luminal approach using a mini (14 Fr) nephroscope. Methods A 30-year-old male presented with symptomatic left UPJO and inferior pole renal stones, which were identified on computed tomography (CT) imaging. Mercaptuacetyltriglycine (MAG3) renogram demonstrated a functioning left kidney. With the patient positioned supine, a mini-perc (Karl-Storz) nephroscope was used to access the renal pelvis via the percutaneous route. The retropelvic space was thereafter accessed. Using a Holmium-YAG laser, the UPJO was splayed using an extra-luminal approach. Results Clear endoscopic vision, minimal bleeding, and overall satisfactory identification of the UPJO were achieved. At the 12-month follow-up, the patient remained stent and symptom-free. On follow-up CT imaging and MAG3 renogram, the system remained dilated with no obstruction noted. Conclusion Percutaneous anterograde retropelvic extra-luminal endopyelotomy is a novel approach that should be considered in patients with secondary renal calculi. This is the first report of the procedure being successfully performed utilizing the mini-perc access route.

Coronavirus disease 2019 (COVID-19) and priapism: An unexplored association.

Background: Coronavirus disease 2019 (COVID-19) has an established impact on multiple organ systems, including the vascular and urogenital systems. Vascular effects may include venous thromboembolic disease, which could theoretically be a precursor to priapism-a urological emergency defined as an abnormal condition of prolonged penile erection lasting >4 hours. To better explore this association, we critically appraised all the published COVID-19 cases associated with priapism. Materials and methods: After PROSPERO registration (CRD42021245257), a systematic search of Google Scholar, Scopus, Embase, Web of Science, PubMed, Cumulative Index to Nursing and Allied Health Literature, Global Index Medicus, and Cochrane Database of Systematic Reviews was performed using specific search terms. The following study metadata were extracted: age, requirement for respiratory support, cavernous blood gas findings, management of priapism, and patient outcomes. Results: Fifteen single-patient case reports were included in this review. Of these, all of the patients presented with ischemic priapism, 9 patients (60.0%) were >60 years of age, 4 (26.7%) reported more than a single episode of priapism, 11 (73.3%) presented with pneumonia, 8 (53.3%) required mechanical ventilation, D-dimer was elevated in 5 of the 6 (83.3%) patients in whom this was reported, and among the 13 patients in whom mortality was reported, 4 (30.8%) died. Conclusions: Early reports suggest a prognostic relationship between COVID-19 and coexisting priapism. However, owing to commonalities in their pathophysiology and the small dataset reported in the literature, the probable association between COVID-19 and priapism is still theoretical. Further research is needed to confirm this association.