Obesity and Extracorporeal Membrane Oxygenation (ECMO): Analysis of Outcomes.

Traditionally, patients with obesity have been deemed ineligible for extracorporeal life support (ELS) therapies such as extracorporeal membrane oxygenation (ECMO), given the association of obesity with chronic health conditions that contribute to increased morbidity and mortality. Nevertheless, a growing body of literature suggests the feasibility, efficacy, and safety of ECMO in the obese population. This review provides an in-depth analysis of the current literature assessing the effects of obesity on outcomes among patients supported with ECMO (venovenous [VV] ECMO in noncoronavirus disease 2019 and coronavirus disease 2019 acute respiratory distress syndrome, venoarterial [VA] ECMO, and combined VV and VA ECMO), offer a possible explanation of the current findings on the basis of the obesity paradox phenomenon, provides a framework for future studies addressing the use of ELS therapies in the obese patient population, and provides guidance from the literature for many of the challenges related to initiating, maintaining, and weaning ELS therapy in patients with obesity.

Remimazolam in Cardiac Anesthesia: Analysis of Recent Data.

Interest in remimazolam has surged in recent years, thanks to its advantageous pharmacologic profile. This ultra-short-acting benzodiazepine is noted for its rapid onset and termination of action, organ-independent elimination, availability of a reversal agent, and excellent hemodynamic stability. Although the use of remimazolam has been explored in various anesthesia settings and procedures, data on its application in cardiovascular anesthesia and catheterization laboratory procedures remain limited. This review evaluates the latest literature to assess remimazolam's role in cardiovascular anesthesia across different settings and procedures. The analysis shows that remimazolam offers anesthesia without significant hemodynamic instability and a reduced need for vasopressors, with an incidence of perioperative adverse events comparable to that of other agents. These findings are relevant for both the induction and maintenance of general anesthesia in catheterization laboratory procedures and general anesthesia in elective cardiac surgery. Although further research is needed to fully understand remimazolam's role in cardiovascular anesthesia, its favorable hemodynamic and safety profile suggests that it is a promising option for cardiac anesthesiologists in both the catheterization laboratory and the operating room.

Treatment of pain in length-dependent peripheral neuropathy with the use of spinal cord stimulation: a systematic review.

BACKGROUND: Chronic intractable pain from peripheral neuropathy is a debilitating condition that might not respond to conventional medical management and pharmacotherapy. The primary objective of this systematic review was to assess change (or reduction) in pain intensity in patients with length-dependent peripheral neuropathy after spinal cord stimulation (SCS) therapy. METHODS: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was change (or reduction) in pain intensity after 12 months of SCS therapy compared with baseline in participants with length-dependent peripheral neuropathy. Secondary outcomes included change in pain intensity after 6 months and change in opioid consumption after 12 months. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines were used to appraise the quality of evidence. RESULTS: Nineteen studies consisting of 376 participants who underwent SCS implantation met the inclusion criteria. Qualitative synthesis revealed that all eligible studies reported a significant improvement in pain intensity after 12 months of SCS therapy as compared with baseline. Mean differences with 95% confidence intervals were calculated for 4 studies, all of which achieved the minimal clinically important difference for change in pain intensity at 12 months. The GRADE quality of evidence for this outcome was appraised as very low quality. CONCLUSION: This systematic review highlights that SCS could lead to significant improvement in pain intensity for length-dependent peripheral neuropathy, although future well-powered randomized controlled trials are warranted to increase the certainty of evidence in this finding. STUDY REGISTRATION: PROSPERO (https://www.crd.york.ac.uk/PROSPERO/) ID: CRD42022377572.

Incidence of Lead Migration With Loss of Efficacy or Paresthesia Coverage After Spinal Cord Stimulator Implantation: Systematic Review and Proportional Meta-Analysis of Prospective Studies and Randomized Clinical Trials.

OBJECTIVE: The objective of this meta-analysis was to approximate the incidence of overall lead migration, clinically significant lead migration, and asymptomatic lead migration in patients who have undergone spinal cord stimulator implantation. MATERIALS AND METHODS: A comprehensive literature search was performed for studies published before May 31, 2022. Only randomized controlled trials and prospective observational studies with more than ten patients were included. Two reviewers analyzed the articles from the literature search for final inclusion, after which, study characteristics and outcome data were extracted. The primary dichotomous categorical outcome variables were the incidence of overall lead migration, clinically significant lead migration (defined as lead migration resulting in loss of efficacy), and asymptomatic lead migration (defined as lead migration discovered incidentally on follow-up imaging) in patients with spinal cord stimulator implant. Freeman-Tukey arcsine square root transformation for meta-analysis of proportions using random effects (DerSimonian and Laird method) was used to calculate incidence rates for the outcome variables. Pooled incidence rates and 95% CIs were calculated for the outcome variables. RESULTS: Fifty-three studies met the inclusion criteria, with a total of 2932 patients having received spinal cord stimulator implants. The pooled incidence of overall lead migration was 9.97% (95% CI of 7.62%-12.59%). Only 24 of the included studies commented on the clinical significance of reported lead migrations, of which every lead migration was clinically significant. In these 24 studies, 96% of the reported lead migrations required a revision procedure or explant. Unfortunately, no studies that reported lead migration commented on asymptomatic lead migrations; therefore, the incidence of asymptomatic lead migrations could not be defined. CONCLUSIONS: This meta-analysis found that the rate of lead migration in patients who have received spinal cord stimulator implants is approximately one in ten patients. This likely closely approximates the incidence of clinically significant lead migration owing to the included studies not routinely performing follow-up imaging. Therefore, lead migrations were primarily discovered owing to loss of efficacy, and no included studies clearly reported asymptomatic lead migration. The results of this meta-analysis can be used to inform patients more accurately on the risks and benefits of spinal cord stimulator implantation.

A historical delve into neurotrauma-focused critical care.

Neurocritical care is a multidisciplinary field managing patients with a wide range of aliments. Specifically, neurotrauma is a rapidly growing field with increasing demands. The history of how neurotrauma management came to its current form has not been extensively explored before. Our review delves into the history, timeline, and noteworthy pioneers of neurotrauma-focused neurocritical care. We explore the historical development during early times, the 18th-20th centuries, and modern times, as well as warfare- and sports-related concussions. Research is ever growing in this budding field, with several promising innovations on the horizon.

Inhaled volatile anesthetics in the intensive care unit.

The discovery and utilization of volatile anesthetics has significantly transformed surgical practices since their inception in the mid-19th century. Recently, a paradigm shift is observed as volatile anesthetics extend beyond traditional confines of the operating theatres, finding diverse applications in intensive care settings. In the dynamic landscape of intensive care, volatile anesthetics emerge as a promising avenue for addressing complex sedation requirements, managing refractory lung pathologies including acute respiratory distress syndrome and status asthmaticus, conditions of high sedative requirements including burns, high opioid or alcohol use and neurological conditions such as status epilepticus. Volatile anesthetics can be administered through either inhaled route via anesthetic machines/devices or through extracorporeal membrane oxygenation circuitry, providing intensivists with multiple options to tailor therapy. Furthermore, their unique pharmacokinetic profiles render them titratable and empower clinicians to individualize management with heightened accuracy, mitigating risks associated with conventional sedation modalities. Despite the amounting enthusiasm for the use of these therapies, barriers to widespread utilization include expanding equipment availability, staff familiarity and training of safe use. This article delves into the realm of applying inhaled volatile anesthetics in the intensive care unit through discussing their pharmacology, administration considerations in intensive care settings, complication considerations, and listing indications and evidence of the use of volatile anesthetics in the critically ill patient population.

Emotional and psychosocial function after dorsal column spinal cord stimulator implantation: a systematic review and meta-analysis.

BACKGROUND: The efficacy of spinal cord stimulation (SCS) in chronic pain studies is traditionally assessed by pain scores, which do not reflect the multidimensional nature of pain perception. Despite the evidence of SCS's influence on emotional functioning comprehensive assessments of its effect remain lacking. OBJECTIVE: To assess changes in emotional and psychosocial functioning in patients who underwent SCS implantation for chronic pain. EVIDENCE REVIEW: Ovid MEDLINE, EMBASE, PsychINFO, Cochrane CENTRAL and Scopus databases were searched for original peer-reviewed publications reporting emotional functioning after SCS. The primary outcomes were a pooled mean difference (MD) in anxiety, depression, global functioning, mental well-being and pain catastrophizing at 12 months. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) was used to determine the quality of evidence. FINDINGS: Thirty-two studies were included in the primary analysis. Statistically significant improvements were observed in anxiety (MD -2.16; 95% CI -2.84 to -1.49; p<0.001), depression (MD -4.66; 95% CI -6.26 to -3.06; p<0.001), global functioning (MD 20.30; 95% CI 14.69 to 25.90; p<0.001), mental well-being (MD 4.95; 95% CI 3.60 to 6.31; p<0.001), and pain catastrophizing (MD -12.09; 95% CI -14.94 to -9.23; p<0.001). Subgroup analyses revealed differences in Global Assessment of Functioning and mental well-being based on study design and in depression based on waveform paradigm. CONCLUSION: The results highlight the statistically and clinically significant improvements in emotional and psychosocial outcomes in patients with chronic pain undergoing SCS therapy. However, these results need to be interpreted with caution due to the very low certainty of evidence per the GRADE criteria. PROSPERO REGISTRATION: CRD42023446326.

Pain intensity and opioid consumption after temporary and permanent peripheral nerve stimulation: a 2-year multicenter analysis.

OBJECTIVE: Peripheral nerve stimulation (PNS) is an emerging neuromodulation modality, yet there remains limited data highlighting its long-term effectiveness. The objective of this study was to report real-world data on pain intensity and opioid consumption after temporary and permanent PNS for chronic pain up to 24 months postimplantation. METHODS: A retrospective study was conducted on all patients who received PNS implants at a multi-centered enterprise between January 1, 2014 and February 24, 2022. The two co-primary outcomes were: (1) change in pain intensity (11-point Numerical Rating Scale) from baseline to 12 months postimplant; and (2) comparison of the change in pain intensity between temporary and permanent PNS cohorts 12 months postimplant. RESULTS: 126 patients were included in this analysis. Pain intensity significantly decreased 12 months postimplant in the overall cohort (mean difference (MD) -3.0 (95% CI -3.5 to -2.4), p<0.0001). No significant difference in this reduction was identified between temporary and permanent PNS cohorts (MD 0.0 (95% CI -1.1 to 1.0), p=1.00) 12 months postimplantation. Pain intensity significantly decreased in the overall, temporary, and permanent cohorts at all secondary time points (3, 6, and 24 months). No change in daily opioid consumption was observed at 6 and 12 months postimplant in the overall cohort. CONCLUSION: This study found that both temporary and permanent PNS may be effective for reducing pain intensity in patients with chronic pain up to 24 months postimplantation, although no changes in opioid consumption were observed. The decrease in pain intensity was comparable between patients receiving temporary versus permanent implants, highlighting that temporary PNS may achieve long-lasting clinical benefits. However, given the substantial loss to follow-up, further large-scale studies are needed to solidify conclusions about the efficacy of PNS.

An Inquiry-Based Distance Learning Tool for Medical Students Under Lockdown ("COVID-19 Rounds"): Cross-Sectional Study.

BACKGROUND: The COVID-19 pandemic presented significant challenges to both clinical practice and the delivery of medical education. Educators and learners implemented novel techniques, including distance learning and web-based rounds, while trying to stay updated with the surge of information regarding COVID-19 epidemiology, pathogenesis, and treatment. Hence, we designed and implemented a technologically enhanced course called "COVID-19 Rounds" to educate students about the rapidly evolving pandemic. OBJECTIVE: The objectives of this study are to describe a technologically enhanced course called "COVID-19 Rounds" and evaluate the following: (1) student satisfaction and program usefulness in achieving preset objectives, (2) perceived improvement in literacy regarding the pandemic, and (3) the impact of student engagement by designing infographics and initiating COVID-19-related research projects. METHODS: This is a cross-sectional study measuring the impact of the implementation of the web-based "COVID-19 Rounds" course. This program included web-based clinical experiences with physicians on actual rounds in COVID-19 wards in the hospital, weekly updates on evolving data and new research, and engagement in student-led projects. The study population included 47 fourth-year medical students at the Mohamed Bin Rashid University of Medicine and Health Sciences in Dubai, the United Arab Emirates, who attended the course. We designed and administered a 47-item survey to assess student satisfaction, program usefulness, impact on knowledge, and student engagement. Data were collected at the end of program delivery via Microsoft Forms. RESULTS: In total, 38 (81%) out of 47 fourth-year medical students participated in this study. The final course evaluation revealed an overall high satisfaction rate, with a mean rating of 3.9 (SD 0.94) on the 5-point Likert scale. Most students were satisfied with the course format (27/38, 71%), organization (31/38, 82%), and the learning experience (28/38, 74%) that the course offered. The course was particularly appreciated for offering evidence-based talks about aspects of the pandemic (34/38, 90%), providing weekly updates regarding emerging evidence (32/38, 84%), and enhancing understanding of the challenges of the pandemic (34/38, 90%). Satisfaction with distance learning was moderate (23/37, 62%), and a minority of students would have preferred an in-person version of the course (10/37, 27%). Student engagement in the course was high. All students participated in small group presentations of infographics of pandemic-related topics. Perceived advantages included conciseness and visual appeal, and disadvantages included the lack of detail and the time-consuming nature of infographic design, especially for students with no prior design experience. After the course ended, 27 (57%) students began research projects. This resulted in 6 abstracts presented at local meetings and 8 scientific papers published or submitted for publication. CONCLUSIONS: This inquiry-based adaptive approach to educating medical students about updates on COVID-19 via web-based learning was successful in achieving objectives and encouraging engagement in research. However, shortcomings of the course related to the lack of in-person teaching and clinical activities were also highlighted.

Effect of Dapagliflozin in Patients with Heart Failure: A Systematic Review and Meta-Analysis.

Background: Heart failure (HF) is a major cause of recurrent hospitalization and death worldwide. Sodium-glucose cotransporter-2 inhibitors including dapagliflozin are anti-diabetic drugs with promising cardiovascular (CV) effects. We performed systematic review and meta-analysis of randomized controlled trials investigating the effects of dapagliflozin in heart failure patients. Methods: We searched PubMed, Scopus and ScienceDirect databases. A total of 1,567 studies from January 2017 to September 10, 2022, were screened. After applying exclusion criteria, 22 studies were retrieved for full-text screening, and nine of them were eligible for this meta-analysis. Effect estimates for dichotomous variables were expressed as risk ratio (RR) and 95% CI. The primary outcomes were the incidence of all-cause mortality, hospitalization due to HF, and CV death. This review was registered on PROSPERO with ID CRD42022347793. Results: A total of 14,032 patients were included. The overall risk ratio of all-cause mortality favored the dapagliflozin group over the placebo/standard therapy group (RR = 0.89, 95% CI: 0.82-0.97, P = 0.006) and the pooled studies were not heterogenous (I2 = 0%). Additionally, dapagliflozin significantly reduced the hospitalization due to heart failure (RR = 0.76, 95% CI: 0.70-0.84, P > 0.00001, I2 = 0%), cardiovascular death (RR = 0.87, 95% CI: 0.78-0.97, P = 0.01, I2 = 0%) and their composite outcomes. Conclusion: Dapagliflozin reduces the risk of all-cause mortality, heart failure hospitalizations and cardiovascular death in a wide range of heart failure patients.

Physical functioning following spinal cord stimulation: a systematic review and meta-analysis.

BACKGROUND: Spinal cord stimulation (SCS) has emerged as an important treatment for chronic pain disorders. While there is evidence supporting improvement in pain intensity with SCS therapy, efforts to synthesize the evidence on physical functioning are lacking. OBJECTIVE: The primary objective of this meta-analysis was to assess long-term physical function following 12 months of SCS for chronic back pain. EVIDENCE REVIEW: PubMed, EMBASE, Scopus, and CENTRAL databases were searched for original peer-reviewed publications investigating physical function following SCS. The primary outcome was physical function at 12 months following SCS therapy for chronic back pain compared with baseline. A random effects model with an inverse variable method was used. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to determine the certainty of evidence. FINDINGS: A total of 518 studies were screened, of which 36 were included. Twenty-two studies were pooled in the meta-analysis. There was a significant reduction in Oswestry Disability Index (ODI) scores at all time frames up to 24 months following implantation. Pooled results revealed significant improvement in ODI scores at 12 months with a mean difference of -17.00% (95% CI -23.07 to -10.94, p<0.001). There was a very low certainty of evidence in this finding as per the GRADE framework. There was no significant difference in subgroup analyses based on study design (randomised controlled trials (RCTs) vs non-RCTs), study funding, or stimulation type. CONCLUSION: This meta-analysis highlights significant improvements in physical function after SCS therapy. However, this finding was limited by a very low GRADE certainty of evidence and high heterogeneity.

Relevance of Anthropometric Measurements in a Multiethnic Obesity Cohort: Observational Study.

BACKGROUND: The prevalence of obesity is increasing worldwide, and the Middle East is not an exception to this increasing trend. Obesity increases the risk of multiple metabolic complications, such as diabetes mellitus. Measurement of obesity has primarily relied on the BMI to identify risk; however, both bedside and office-based anthropometric measures of obesity can provide more detailed information on risk. OBJECTIVE: This study aimed to investigate the prevalence of obesity-related diseases in a multidisciplinary weight management population and to determine its relationship with obesity anthropometric indices. METHODS: This cross-sectional study was conducted at Mediclinic Parkview Hospital (Dubai, the United Arab Emirates). In total, 308 patients have been evaluated from January to September 2019 as part of a multidisciplinary weight management program. Key demographics, anthropometrics, and clinical data were analyzed using SPSS (version 25, SPSS Inc). RESULTS: Our cohort of 308 patients included 103 (33%) males and 205 (67%) females of 38 nationalities. The mean age of the cohort was 41 (SD 9.6) years, with a median BMI of 34.5 (IQR 6.7) and 33.7 (IQR 7.8) for males and females, respectively. The mean waist circumference (WC) was 113.4 (SD 23.3) cm and 103.5 (SD 16.2) cm, fat percentage was 33.7% (SD 11.6%) and 45% (SD 6.8%), fat mass was 41 (SD 15.2) kg and 41.1 (SD 14.1) kg, and visceral fat mass was 6.5 (SD 3.2) kg and 3.1 (SD 1.8) kg for males and females, respectively. There was a strong correlation between BMI and WC (r=0.65 and r=0.69 in males and females, respectively; P=.01) and visceral fat (r=0.78 and r=0.90 in males and females, respectively). Furthermore, visceral fat was significantly associated with WC in both sexes (r=0.73 and r=0.68 in females and males respectively; P=.01). Furthermore, WC was significantly associated with a risk of diabetes, hypertension, and nonalcoholic fatty liver disease. CONCLUSIONS: BMI and WC are the most representative measures of obesity in our population and correlate with abdominal adiposity- and obesity-related diseases. Further studies are required to assess the benefits of these measures during weight reduction interventions.

COVID-19 under 19: A meta-analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to cause global havoc posing uncertainty to educational institutions worldwide. Understanding the clinical characteristics of COVID-19 in children is important because of the potential impact on clinical management and public health decisions. METHODS: A meta-analysis was conducted for pediatric COVID-19 studies using PubMed and Scopus. It reviewed demographics, co-morbidities, clinical manifestations, laboratory investigations, radiological investigations, treatment, and outcomes. The 95% confidence interval (CI) was utilized. RESULTS: Out of 3927 articles, 31 articles comprising of 1816 patients were selected from December 2019 to early October 2020 and were defined by 77 variables. Of these studies 58% originated from China and the remainder from North America, Europe and the Middle East. This meta-analysis revealed that 19.2% (CI 13.6%-26.4%) of patients were asymptomatic. Fever (57%, CI 49.7%-64%) and cough (44.1%, CI 38.3%-50.2%) were the most common symptoms. The most frequently encountered white blood count abnormalities were lymphopenia 13.5% (CI 8.2%-21.4%) and leukopenia 12.6% (CI 8.5%-18.3%). Ground glass opacities were the most common radiological finding of children with COVID-19 (35.5%, CI 28.9%-42.7%). Hospitalization rate was 96.3% (CI 92.4%-98.2%) of which 10.8% (CI 4.2%-25.3%) were ICU admissions, and 2.4% (CI 1.7%-3.4%) died. CONCLUSION: The majority of pediatric patients with COVID-19 were asymptomatic or had mild manifestations. Among hospitalized patients there remains a significant number that require intensive care unit care. Overall across the literature, a considerable level of understanding of COVID-19 in children was reached, yet emerging data related to multisystemic inflammatory syndrome in children should be explored.

Clinical Characteristics of Children With COVID-19 in the United Arab Emirates: Cross-sectional Multicenter Study.

BACKGROUND: COVID-19 has infected over 123 million people globally. The first confirmed case in the United Arab Emirates (UAE) was reported on January 29, 2020. According to studies conducted in the early epicenters of the pandemic, COVID-19 has fared mildly in the pediatric population. To date, there is a lack of published data about COVID-19 infection among children in the Arabian region. OBJECTIVE: This study aims to investigate the clinical characteristics, laboratory findings, treatment, and outcomes of children with COVID-19. METHODS: This cross-sectional, multicenter study included children with confirmed COVID-19 infection admitted to 3 large hospitals in Dubai, UAE, between March 1 and June 15, 2020. Serial COVID-19 polymerase chain reaction (PCR) testing data were collected, and patients' demographics, premorbid clinical characteristics, and inpatient hospital courses were examined. RESULTS: In all, 111 children were included in our study and represented 22 nationalities. Of these, 59 (53.2%) were boys. The mean age of the participants was 7 (SD 5.3) years. About 15.3% of children were younger than 1 year. Only 4 (3.6%) of them had pre-existing asthma, all of whom had uneventful courses. At presentation, of the 111 children, 43 (38.7%) were asymptomatic, 68 (61.2%) had mild or moderate symptoms, and none (0%) had severe illness requiring intensive care. Fever (23/111, 20.7%), cough (22/111, 19.8%), and rhinorrhea (17/111, 15.3%) were the most common presenting symptoms, and most reported symptoms resolved by day 5 of hospitalization. Most patients had no abnormality on chest x-ray. The most common laboratory abnormalities on admission included variations in neutrophil count (22/111, 24.7%), aspartate transaminase (18/111, 22.5%), alkaline phosphatase (29/111, 36.7%), and lactate dehydrogenase (31/111, 42.5%). Children were infrequently prescribed targeted medications, with only 4 (3.6%) receiving antibiotics. None of the 52 patients tested for viral coinfections were positive. COVID-19 PCR testing turned negative at a median of 10 days (IQR: 6-14) after the first positive test. Overall, there was no significant difference of time to negative PCR results between symptomatic and asymptomatic children. CONCLUSIONS: This study of COVID-19 presentations and characteristics presents a first look into the burden of COVID-19 infection in the pediatric population in the UAE. We conclude that a large percentage of children experienced no symptoms and that severe COVID-19 disease is uncommon in the UAE. Various laboratory abnormalities were observed despite clinical stability. Ongoing surveillance, contact tracing, and public health measures will be important to contain future outbreaks.