Comparing Important and Well-documented Potential Drug-Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center.

Introduction: Drug-drug interaction (DDI) is one of the major healthcare challenges in intensive care units (ICUs). The prevalence of DDIs and interacting drug pairs may vary between different types of ICUs. This study aimed to compare the frequency and nature of important and well-documented potential DDIs (pDDIs) in three types of ICUs. Materials and methods: A prospective study was conducted in medical (M), surgical (S), and emergency (E) ICUs of a tertiary referral center for respiratory diseases. A pharmacist checked the patients' files three days in a week for 6 months. The pDDIs were identified using the Lexi-Interact database. Interactions with a severity rating of D (modify regimen) and X (avoid combination) and with a reliability rating of good and excellent were considered important and well-documented. These pDDIs were evaluated in terms of drug combinations, mechanisms of interaction, and clinical management. Results: One hundred eighty-nine patients admitted to MICU, SICU, and EICU were included in the study. The percentage of patients who experienced at least one important and well-documented pDDI was 18.8% in MICU, 11.1% in SICU, and 11.8% in EICU. The most common drug pairs causing important and well-documented interactions were atracurium + hydrocortisone in MICU, meropenem + valproic acid in MICU and EICU, and aspirin + warfarin in SICU. Conclusion: The current study shows different frequency and nature of pDDIs between three types of ICUs. We recommend conducting similar studies in other settings to develop evidence-based guidance on clinically relevant pDDIs in different types of ICUs. How to cite this article: Hosseinpoor Z, Farzanegan B, Baniasadi S. Comparing Important and Well-documented Potential Drug-Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center. Indian J Crit Care Med 2022;26(5):574-578.

Impact of Religiosity on Delirium Severity Among Critically Ill Shi'a Muslims: A Prospective Multi-Center Observational Study.

This study assesses the impact of religiosity on delirium severity and patient outcomes among Shi'a Muslim intensive care unit (ICU) patients. We conducted a prospective observational cohort study in 21 ICUs from 6 Iranian academic medical centers. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU) tool. Eligible patients were intubated, receiving mechanical ventilation (MV) for ≥ 48 h. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. A total of 4200 patients were enrolled. Patient religiosity was categorized as more (40.6%), moderate (42.3%), or less (17.1%) based on responses to patient and surrogate questionnaires. The findings suggest that lower pre-illness religiosity may be associated with greater delirium severity, MV duration, and ICU and hospital LOS. The lower mortality in the less religiosity group may be related in part to a greater proportion of female patients, but it remains unclear whether and to what extent greater religiosity impacted treatment decisions by patients and families. Further investigation is needed to validate and clarify the mechanism of the mortality findings.

Extracorporeal membrane oxygenation and COVID-19: The causes of failure.

INTRODUCTION: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a therapeutic strategy for the coronavirus disease 2019 (COVID-19) induced acute respiratory distress syndrome (ARDS). There are inconclusive data in this regard and causes of VV-ECMO failure are not yet understood well. CASE SERIES: Here, seven patients with COVID-19-induced ARDS who underwent VV-ECMO introduced and causes of VV-ECMO failure discussed. Medical records of seven COVID-19 patients treated with VV-ECMO were retrospectively evaluated to determine the clinical outcomes of VV-ECMO. Oxygenator failure occurred in four patients whom needed to oxygenator replacement. Successful VV-ECMO decannulation was done in three patients, however finally one patient survived. CONCLUSIONS: Hypercoagulability state and oxygenator failure were the most main etiologies for VV-ECMO failure in our study. All patients with COVID-19 undergoing VV-ECMO should be monitored for such problems and highly specialized healthcare team should monitor the patients during VV-ECMO.

An Observational Study of QTc Prolongation in Critically Ill Patients: Identification of Incidence and Predictors.

AIMS: Despite the importance of abnormal QTc interval values in intensive care unit (ICU) patients, there is a paucity of information on this topic. The current study was designed to identify the incidence and predictors of QTc prolongation in medical (M), surgical (S), and emergency (E) ICUs. MATERIALS AND METHODS: A prospective observational study was conducted for 6 months. Patients more than 18 years old who admitted to MICU, SICU, and EICU were included in the study. Electrocardiogram (ECG) was taken on day 1, 3, and 5 of ICU admission. The QTc intervals >460 ms in male and >470 ms in female and increased >60 ms above baseline were considered QTc prolongation. Comparative analysis was done between two groups of patients (normal vs prolonged QTc). Logistic regression models were carried out to determine the predictors of QTc prolongation. RESULTS: Incidence of QTc prolongation was 6.5, 9.8, and 15.7% on day 1, 3, and 5 of ICU admission, respectively. On day 1, the history of alcohol addiction and the reason of ICU admission were associated with a prolonged QTc. A significant association was demonstrated between administration of azithromycin and QTc prolongation on day 3. High serum creatinine and hospitalization in EICU were predictors of QTc prolongation on day 5 of ICU admission. CONCLUSION: The QTc prolongation is relatively common among patients admitted to ICUs and its incidence increases with increasing length of hospital stay. Predictors of QTc prolongation may be affected by the duration of ICU admission. Physicians should consider these predictors particularly before prescribing QTc-prolonging drugs. HOW TO CITE THIS ARTICLE: Farzanegan B, Hosseinpoor Z, Baniasadi S, Seyyedi SR, Rajabi M. An Observational Study of QTc Prolongation in Critically Ill Patients: Identification of Incidence and Predictors. Indian J Crit Care Med 2020;24(4):270-275.

Spiritual Health and Outcomes in Muslim ICU Patients: A Nationwide Cross-Sectional Study.

The aim of the present study is to describe how religiosity and spirituality affect the psychiatric morbidity of Muslim intensive care unit (ICU) patients. We conducted a prospective nationwide cross-sectional study of ICU patients discharged from 45 medical centers spanning 31 proivinces in Iran. Adults (age ≥ 18 years) admitted to the ICU and treated with invasive mechanical ventilation were eligible. Nine validated survey tools were administered to detect direct and indirect associations between spiritual health (SH) and depression, anxiety, and post-traumatic disorder. The Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale-Revised (IES-R), Post-Traumatic Stress Syndrome 14 question (PTSS-14) quality-of-life (QoL), and quality of patient to physician or nurse communication (PP-QoC and PN-QoC) scales were modeled through two mediators by structural equation modeling (SEM). Sex, ICU type, LOS, and APACHE II score were added in the independent variable list. 338 eligible patients were discharged from the ICUs during the study period. 56 were excluded (clinical status), and 282 were administered the survey. 278 returned it, with 272 complete and 6 partial responses. SH displayed no direct or indirect association to QoL. SH was indirectly associated with decreased depression and anxiety (B = - 0.081, p < 0.05) via PP-QoC mediator. Both direct and indirect positive associations were observed between SH and IES-R (B = 0.293, p < 0.05; via PP-QoC) and PTSS-14 scores (B = 0.267, p < 0.001; via PP-QoC). Medical ICU location was associated with decreased PTSS-14 scores via the same mediator. In this survey of Muslim ICU patients treated with invasive mechanical ventilation, SH correlated with decreased depression and anxiety, but paradoxically increased post-traumatic stress. The most influential mediator was patient-physician quality-of-communication.

Evaluation of cerebral oxygen saturation during hypotensive anesthesia in functional endoscopic sinus surgery.

BACKGROUND AND AIMS: Controlled hypotensive anesthesia in endoscopic sinus surgery would provide a clean surgical field. Cerebral oxygen saturation (ScO2) is important in endoscopic sinus surgery patients and it may be low during controlled hypotension. The aim of the present study was to assess ScO2 in these patients. MATERIAL AND METHODS: In this observational study, 41 patients who underwent endoscopic sinus surgery with hypotensive anesthesia were enrolled for the study and all of the patients received the same anesthetic medication, nitroglycerin for controlled hypotension. Variables were measured prior to surgery, after induction of anesthesia, 5 min, and every 30 min after controlled hypotension. Near-infrared spectroscopy was used for ScO2 evaluation. Mean arterial blood pressure (MAP) was maintained at 55-60 mmHg in the surgical duration. We used t-test, Wilcoxon, and repeated measures analysis of variance (ANOVA). We examined the cross-correlation functions of the time series data between end-tidal carbon dioxide (ETCO2)/MAP and ScO2. RESULTS: The mean of intraoperative ScO2 was not significantly different from the baseline evaluation (P > 0.05). ETCO2 was cross correlated with current ScO2 [r: 0.618, confidence interval (CI) 95%: 0.46-0.78]. We found moderate cross correlation between the MAP and current ScO2 (r: 0.728, CI 95%: 0.56-0.88). About 92% of the patients recovered within 30 min. Recovery time was associated with intraoperative MAP (P: 0.004, r: 0.438), intraoperative ETCO2 (P: 0.003, r: 0.450), and ScO2 (P: 0.026, r: 0.348). CONCLUSIONS: Based on our findings, the assessment of ScO2 and maintained MAP >55 mmHg may provide safe conditions for endoscopic sinus surgery.

Effectiveness of Short-term Use of Gabapentin as Pre-emptive Analgesia in Reducing Pain after Video Assisted Thoracoscopic Surgery.

Background: Pain control after thoracoscopy is one of the important issues in patient health care. Pre-emptive analgesia can reduce acute postoperative pain and also prevent chronic pain. This study aimed to evaluate the effectiveness of gabapentin (GABA analog) as pre-emptive analgesia in reducing pain and reducing opiate consumption after video-assisted thoracoscopic surgery (VATS) surgery. Materials and Methods: In this study, 67 patients undergoing thoracoscopic surgery were randomly divided into two groups (31 placeboes and 36 gabapentin). Patients received two capsules (300 mg gabapentin capsules or placebo) on the night before surgery and again one hour before surgery. After completion of the operation, all patients were transferred to the recovery. Evaluation of postoperative pain was performed using the visual analog scale (VAS) every 30 minutes and then after 2, 4, 6, 10, 24 hours. If patients had pain (VAS above 3), intravenous morphine was injected to relieve pain and the number of injections and the total dose of morphine administered was recorded. Results: There was no significant difference between the two groups regarding VAS, blood pressure (BP), heart rate (HR), respiratory rate (RR) and saturated oxygen level (SaO2), urea, creatinine, and adverse effects. Conclusion: Preoperative gabapentin administration did not affect postoperative pain reduction, but morphine consumption in the gabapentin group was decreased during the first 24 hours after VATS.

Expression of miRNA1, miRNA133, miRNA191, and miRNA24, as Good Biomarkers, in Non-Small Cell Lung Cancer Using Real-Time PCR Method.

BACKGROUND: Lung cancer has recently shown the highest incidence among all cancers. microRNAs (miRNAs) are the molecules playing a role in regulating gene expression and contributing to many pathogenic mechanisms. Therefore, these molecules could be used as biomarkers for the detection, anticipation, and treatment of cancer. With this in mind, we decided to investigate and compare the expression of miR-1, miR-133, miR-191, and miR-24 and also the expression differences in these four RNA molecules between lung cancer patients and the controls. METHODS: A total of 50 patients with lung cancer participated in this study. In addition, 50 healthy blood samples were selected as the control group. Real-time PCR determined the expression levels of miRNA. The RNAs extracted from the patients' white blood cells were initially synthesized, and then cDNA was extracted. Finally, the synthesized cDNA was amplified using real-time PCR, and its expression was compared with the control group. RESULTS: The result indicated a low expression level of miR-1 and miR-133, and a high expression level of miR-191 and miR-24 in the blood of patients with lung cancer compared to the healthy subjects. CONCLUSION: Our findings revealed that miR-1, miR-133, miR-191, and miR-24 are oncogenes, and their expression could result in cancer. It appears that a therapy to overexpress miR-1 and miR-133 and downexpress miR-191 and miR-24 could contribute to the treatment of lung cancer.

Stress and burnout in health care workers during COVID-19 pandemic: validation of a questionnaire.

Aim: To validate a questionnaire to assess stress and burnout in healthcare workers during COVID-19 pandemic. Subjects and methods: In this study, content validity, Cronbach's alpha, and test-retest reliability method were utilized among 60 HCWs to evaluate the validity, internal consistency, and reliability of the questionnaire respectively. The final questionnaire was composed of four parts asking for the background information, questions about the stress caused by the COVID-19, the Depression, Anxiety and Stress Scale - 21 (DASS-21), and six questions from the Copenhagen Burnout Inventory (CBI). Results: The CVR of 46 questions was equal to 1, making them acceptably valid (CVR > 0.78), so that the items could be arranged into a final questionnaire. Moreover, all items could successfully attain CVI values above 0.79, confirming the content validity of the questionnaire. The Cronbach's alpha was between 0.80-0.95 for different sections of questionaire, confirming the stable reliability and high repeatability of the questionnaire. Conclusion: The results of this study showed that the DASS-21 offers adequate levels of validity and reliability for assessing the stress, anxiety, and depression among the HCWs engaged with the COVID-19 pandemic. Moreover, the six items adapted from the Copenhagen burnout inventory (CBI) were found to provide a good instrument for investigating the job burnout among the HCWs at Masih Daneshvari Hospital during the outbreak of the COVID-19 epidemic.

National Research Institute of Tuberculosis and Lung Disease (NRITLD) Protocol for the Treatment of Patients with COVID-19.

More than a year after the onset of the coronavirus disease pandemic in 2019, the disease remains a major global health issue. During this time, health organizations worldwide have tried to provide integrated treatment guidelines to control coronavirus disease 2019 (COVID-19) at different levels. However, due to the novel nature of the disease and the emergence of new variants, medical teams' updating medical information and drug prescribing guidelines should be given special attention. This version is an updated instruction of the National Research Institute of Tuberculosis and Lung Disease (NRITLD) in collaboration with a group of specialists from Masih Daneshvari Hospital in Tehran, Iran, which is provided to update the information of caring clinicians for the treatment and care of COVID-19 hospitalized patients.

Evaluation of the efficacy and safety of inhaled magnesium sulphate in combination with standard treatment in patients with moderate or severe COVID-19: A structured summary of a study protocol for a randomised controlled trial.

OBJECTIVES: Basic and clinical studies have shown that magnesium sulphate ameliorates lung injury and controls asthma attacks by anti-inflammatory and bronchodilatory effects. Both intravenous and inhaled magnesium sulphate have a clinical impact on acute severe asthma by inhibition of airway smooth muscle contraction. Besides, magnesium sulphate can dilate constricted pulmonary arteries and reduce pulmonary artery resistance. However, it may affect systemic arteries when administered intravenously. A large number of patients with covid-19 admitted to the hospital suffer from pulmonary involvement. COVID-19 can cause hypoxia due to the involvement of the respiratory airways and parenchyma along with circulatory impairment, which induce ventilation-perfusion mismatch. This condition may result in hypoxemia and low arterial blood oxygen pressure and saturation presented with some degree of dyspnoea and shortness of breath. Inhaled magnesium sulphate as a smooth muscle relaxant (natural calcium antagonist) can cause both bronchodilator and consequently vasodilator effects (via a direct effect on alveolar arterioles in well-ventilated areas) in the respiratory tract. We aim to investigate if inhaled magnesium sulphate as adjuvant therapy to standard treatment can reduce ventilation-perfusion mismatch in the respiratory tract and subsequently improve arterial oxygen saturation in hospitalized patients with COVID-19. TRIAL DESIGN: A multi-centre, open-label, randomised controlled trial (RCT) with two parallel arms design (1:1 ratio) PARTICIPANTS: Patients aged 18-80 years hospitalized at Masih Daneshvari Hospital and Shahid Dr. Labbafinejad hospital in Tehran and Shahid Sadoughi Hospital in Yazd will be included if they meet the inclusion criteria of the study. Inclusion criteria are defined as 1. Confirmed diagnosis of SARS-CoV-2 infection based on polymerase chain reaction (PCR) of nasopharyngeal secretions or clinical manifestations along with chest computed tomography (chest CT) scan 2. Presenting with moderate or severe COVID-19 lung involvement confirmed with chest CT scan and arterial oxygen saturation below 93% 3. Length of hospital stay ≤48 hours. Patients with underlying cardiovascular diseases including congestive heart failure, bradyarrhythmia, heart block, the myocardial injury will be excluded from the study. INTERVENTION AND COMPARATOR: Participants will be randomly divided into two arms. Patients in the intervention arm will be given both standard treatment for COVID-19 (according to the national guideline) and magnesium sulphate (5 cc of a 20% injectable vial or 2 cc of a 50% injectable vial will be diluted by 50 cc distilled water and nebulized via a mask) every eight hours for five days. Patients in the control (comparator) arm will only receive standard treatment for COVID-19. MAIN OUTCOMES: Improvement of respiratory function and symptoms including arterial blood oxygen saturation, dyspnoea (according to NYHA functional classification), and cough within the first five days of randomization. RANDOMISATION: Block randomisation will be used to allocate eligible patients to the study arms (in a 1:1 ratio). Computer software will be applied to randomly select the blocks. BLINDING (MASKING): The study is an open-label RCT without blinding. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): The trial will be performed on 100 patients who will be randomly divided into two arms of control (50) and intervention (50). TRIAL STATUS: The protocol is Version 5.0, January 05, 2021. Recruitment of the participants started on July 30, 2020, and it is anticipated to be completed by February 28, 2021. TRIAL REGISTRATION: The trial was registered in the Iranian Registry of Clinical Trials (IRCT) on July 28, 2020. It is available on https://en.irct.ir/trial/49879 . The registration number is IRCT20191211045691N1. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting the dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Measurement of Gastric Residual Volume via Ultrasound after Receiving Intravenous Ondansetron, Metoclopramide, and Neostigmine in Critically Ill Patients: A Double-Blind Clinical Trial.

Background: Gastric residual volume (GRV) is considered an important parameter for gastric emptying and nutrition tolerance. This volume is measured before any nutrition and has a direct effect on the volume and timing of the next nutrition. The present study aimed to examine the GRV via ultrasound after receiving intravenous ondansetron, metoclopramide, and neostigmine. Materials and Methods: In the present study, 40 patients were included in the study, 10 patients were excluded from the study due to death during treatment, and 30 patients were divided into three groups of 10(10 patients in each group).The first, second, and third groups received 2.5, 10, and 8 mg neostigmine, metoclopramide, and ondansetron every 8 h, respectively. The drugs were infused as a micro set in 100 ml normal saline into patients within 30 min. The patients underwent ultrasound imaging and GRV measurement by an intensive care unit (ICU) subspecialty fellow, who was not aware of the drugs received by the patients, in the 1st h of hospitalization, 6 h after drug injection, and once daily for 4 days. Results: A total of 40 patients entered the study based on inclusion and exclusion criteria. The effect of neostigmine on reducing GRV (Gastric residual volume) in ICU patients was better than those of the other two drugs, which was significant. Conclusion: The results of this study showed that neostigmine has a better and significant effect on reducing GRV in ICU patients, compared to those of ondansetron and metoclopramide.

Residency Education Reform Program in Department of Anesthesiology and Critical Care: An Academic Reform Model.

BACKGROUND: Reform in medical education is a basic process in every academic department, especially in residency programs. OBJECTIVES: This study was designed to assess the indices of education and research as part of the Medical Education Reform program (MERP) in the Department of Anesthesiology and Critical Care (DACC), Shahid Beheshti University of Medical Sciences (SBMU) for four years. METHODS: MERP in DACC, SBMU was designed and implemented as a modern academic reform model; different outcome measures in education and research were assessed to demonstrate the effects of the reform plan in academic improvements. RESULTS: there were significant improvements regarding education indices (i.e., teaching methods, passing comprehensive exams, mentorship, assessment methods, faculty development, professionalism in medical education, integration in education, and crisis management) and research indices (targeted research activities, innovation in research approaches, increasing the impact of research). CONCLUSIONS: Based on the experiences of DACC, SBMU regarding clinical anesthesiology residency, reform could be achieved using painstaking plans and continuous efforts with tangible documented outcomes. Often, the management period is not durable, and these reforms require meticulous care to sustain.

Pulmonary Alveolar Proteinosis in Children: Diagnosis and Treatment Outcomes.

Background: Pulmonary Alveolar Proteinosis (PAP) is an uncommon pulmonary disease characterized by the accumulation of surfactant composed of proteins and lipids due to disruption of surfactant clearance by alveolar macrophages. The current standard treatment is lung lavage. There are no specific criteria for lavage, but in case of observing these signs it is recommended to perform lavage for the patient: progressive respiratory failure, no labored breathing at rest, and drop in oxygen level during activity (>5%). Materials and Methods: In this study, patients with PAP admitted to Pediatric ward of Masih Daneshvari Hospital were studied. The required data were collected including the patient's demographic data, clinical signs and radiographic data, the number of admissions, the age of diagnosis, detection and treatment methods, number of lavage, current condition of the patient, and in case of death, the cause of death. Results: In this study, 17 patients with PAP who were admitted during the past 15 years were examined; among which 7 patients were boys (41.2%) and 10 were girls (58.8%). The mean age of population was 11.79±7.21 years. Transbronchial Lung Biopsy (TBLB) (47.1%) and open lung biopsy (52.9%) were used for diagnosis of patients. Lung lavage was used to treat patients, 15 of whom were treated by this method. Five of the patients died because of their serious conditions. Conclusion: Therapy method in the present study was lavage for both lungs, and it was performed for all patients except for two patients due to their anatomical complications. This method is still considered as the gold standard for PAP. Considering the findings from previous studies and the present study, it seems that Whole Lung Lavage (WLL) was fruitful for patients who had the indication for using this therapy and it played a significant role in improving the prognosis of patients. Besides, it is recommended to do follow-up regularly in order to have more therapeutic efficacy and increased patient longevity.

No clinical benefit of high dose corticosteroid administration in patients with COVID-19: A preliminary report of a randomized clinical trial.

The aim of this study was to evaluate the clinical effects of dexamethasone administration in patients with mild to moderate acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). The study included 50 patients who were randomly assigned to the dexamethasone group or control group. Dexamethasone was administered at a dose of 20 mg/day from day 1-5 and then at 10 mg/day from day 6-10. The need for invasive mechanical ventilation, death rate, duration of clinical improvement, length of hospital stay, and radiological changes in the computed tomography scan were assessed. The results revealed that 92% and 96% of patients in the dexamethasone and control groups, respectively, required noninvasive ventilation (P = 0.500). Among them, 52% and 44% of patients in the dexamethasone and control groups, respectively, required invasive mechanical ventilation (P = 0.389). At the end of the study, 64% of patients in the dexamethasone group and 60% of patients in the control group died (P = 0.500); the remaining patients were discharged from the hospital during the 28-day follow-up period. The median length of hospital stay was 11 days in the dexamethasone group and 6 days in the control group (P = 0.036) and the median length of hospital stay was 7 days in the dexamethasone group and 3 days in the control group (P < 0.001). No significant differences were observed in the other outcomes. This study showed that corticosteroid administration had no clinical benefit in patients with COVID-19-induced mild to moderate ARDS.

Prediction of Patient's Adherence to the Post-Intubation Tracheal Stenosis Follow-up Plan in Iran: Application of two Data Mining Techniques.

BACKGROUND: Timely diagnosis of post-intubation tracheal stenosis (PITS), which is one of the most serious complications of endotracheal intubation, may change its natural history. To prevent PITS, patients who are discharged from the intensive care unit (ICU) with more than 24 hours of intubation should be actively followed-up for three months after extubation. This study aimed to evaluate the abilities of artificial neural network (ANN) and decision tree (DT) methods in predicting the patients' adherence to the follow-up plan and revealing the knowledge behind PITS screening system development requirements. MATERIALS AND METHODS: In this cohort study, conducted in 14 ICUs during 12 months in ten cities of Iran, the data of 203 intubated ICU-discharged patients were collected. Ten influential factors were defined for adherences to the PITS follow-up (P<0.05). A feed-forward multilayer perceptron algorithm was applied using a training set (two-thirds of the entire data) to develop a model for predicting the patients' adherence to the follow-up plan three months after extubation. The same data were used to develop a C5.0 DT in MATLAB 2010a. The remaining one-third of data was used for model testing, based on the holdout method. RESULTS: The accuracy, sensitivity, and specificity of the developed ANN classifier were 83.30%, 72.70%, and 89.50%, respectively. The accuracy of the DT model with five nodes, 13 branches, and nine leaves (producing nine rules for active follow-up) was 75.36%. CONCLUSION: The developed classifier might aid care providers to identify possible cases of non-adherence to the follow-up and care plans. Overall, active follow-up of these patients may prevent the adverse consequences of PITS after ICU discharge.

COVID-19 in Iran: A model for Crisis Management and Current Experience.

In February 2020, the first sample test was confirmed as positive for corona virus in Masih Daneshvari Hospital that is the reference center in Iran for all pulmonary and respiratory diseases. The decisions made in a hospital or organization to manage a crisis is very vital. Success in managing any crisis requires a scientific and scholarly attitude. This paper was distilled from experiences gained in Masih Daneshvari Hospital in Tehran, capital of Iran, in March 2020 at the stubborn time of coping and managing corona virus crisis. This study was conducted using participatory action research, a methodology which identifies problems in practice, and finds methods to solve them. This Action research involves five stages: statement of the problem, planning, data interpretation and analysis, action, and evaluation of the research process during performing the study. The whole hospital was equipped for corona virus patients in 10 phases during one week and 250 active beds were equipped for these patients. Three models, namely, "corona virus crisis management model", "Pharmaceutical care management in coronavirus crisis model" and "nursing in coronavirus crisis model" were planned and implemented. During one month of implementing these three models, the supervision team monitored the accurate implementation of instructions and resolving or revising the possible deficiencies and faults. The Masih Daneshvari crisis management model in coronavirus, can be a useful and applicable model in other corona virus centers.

Clinical Features and Outcomes of ICU Patients with COVID-19 Infection in Tehran, Iran: a Single-Centered Retrospective Cohort Study.

BACKGROUND: The clinical characteristics of the novel coronavirus disease (COVID-19) were diverse and unspecific. Here, we identified the associated factors with surviving of COVID-19 ICU patients based on the clinical characteristics of patients admitted to one of the Corona Centre Hospitals of Iran. MATERIALS AND METHODS: This cohort study was performed retrospectively from February to June 2020 on 133 COVID-19 patients admitted to 4 intensive care units of Masih Daneshvari Hospital in Tehran, Iran. Demographic, medical, clinical manifestation at admission, laboratory parameters and outcome data were obtained from medical records. Also the SOFA and APACHE II scores were calculated. All data were analyzed using SPSS (version 23, IBM Corp.) software. RESULTS: The median (IQR) age of the patients was 62.0 (54.0-72.0) years in total. RT-PCR of throat swab SARS-CoV-2 in 80 patients (60.2%) was positive. Total mortality rate was 57.9 percent (77 patients). Dyspnea, hypertension and chronic pulmonary diseases were significantly common in non-survivors than survivors (p<0.05). Both SOFA and APACHE II scores were significantly higher in the non-survivors (p<0.05). Also other significant differences were observed in other parameters of the study. CONCLUSION: The mortality rate of COVID-19 patients admitted to ICU is generally high. Dyspnea as initial presentation and comorbidity, especially hypertension and pulmonary diseases, may be associated with higher risk of severe disease and consequent mortality rate. Also, higher SOFA and APACHE II scores could indicate higher mortality in patients admitted to ICU.

Diffuse alveolar damage and thrombotic microangiopathy are the main histopathological findings in lung tissue biopsy samples of COVID-19 patients.

BACKGROUND: Since the outbreak of the novel coronavirus disease-2019 (COVID-19) in December 2019, limited studies have investigated the histopathologic findings of patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). MATERIAL AND METHODS: This study was conducted on 31 deceased patients who were hospitalized for COVID-19 in a tertiary hospital in Tehran, Iran. A total of 52 postmortem tissue biopsy samples were obtained from the lungs and liver of decedents. Clinical characteristics, laboratory data, and microscopic features were evaluated. Reverse transcription polymerase chain reaction (RT-PCR) assay for SARS-CoV-2 was performed on specimens obtained from nasopharyngeal swabs and tissue biopsies. RESULTS: The median age of deceased patients was 66 years (range, 30-87 years) and 25 decedents (81 %) were male. The average interval from symptom onset to death was 13 days (range, 6-34 days). On histopathologic examination of the lung specimens, diffuse alveolar damage and thrombotic microangiopathy were the most common findings (80 % and 60 %, respectively). Liver specimens mainly showed macrovesicular steatosis, portal lymphoplasmacytic inflammation and passive congestion. No definitive viral inclusions were observed in any of the specimens. In addition, 92 % of lung tissue samples tested positive for SARS-CoV-2 by RT-PCR. CONCLUSIONS: Further studies are needed to investigate whether SARS-CoV-2 causes direct cytopathic changes in various organs of the human body.

Clinical Manifestations of Patients with Coronavirus Disease 2019 (COVID-19) in a Referral Center in Iran.

BACKGROUND: Following the recent epidemic of coronavirus disease 2019 (COVID-19) in Wuhan, China, a novel betacoronavirus was isolated from two patients in Iran on February 19, 2020. In this study, we aimed to determine the clinical manifestations and outcomes of the first confirmed cases of COVID-19 infection (n=127). MATERIALS AND METHODS: This prospective study was conducted on all COVID-19-suspected cases, admitted to Masih Daneshvari Hospital (a designated hospital for COVID-19), Tehran, Iran, since February 19, 2020. All patients were tested for COVID-19, using reverse transcription-polymerase chain reaction (RT-PCR) assay. Data of confirmed cases, including demographic characteristics, clinical features, and outcomes, were collected and compared between three groups of patients, requiring different types of admission (requiring ICU admission, admission to the general ward, and transfer to ICU). RESULTS: Of 412 suspected cases, with the mean age of 54.1 years (SD=13.4), 127 (31%) were positive for COVID-19. Following the patients' first visit to the clinic, 115 cases were admitted to the general ward, while ten patients required ICU admission. Due to clinical deterioration in the condition of 25 patients (out of 115 patients), ICU admission was essential. Based on the results, the baseline characteristics of the groups were similar. Patients requiring ICU admission were more likely to have multiorgan involvement (liver involvement, P<0.001; renal involvement, P<0.001; and cardiac involvement, P=0.02), low O2 saturation (P<0.001), and lymphopenia (P=0.05). During hospital admission, 21 (16.5%) patients died, while the rest (83.5%) were discharged and followed-up until March 26, 2020. Also, the survival rate of patients, who received immunoglobulin, was higher than other patients (60.87% vs. 39.13%). CONCLUSION: The mortality rate of COVID-19 patients was considerable in our study. Based on the present results, this infection can cause multiorgan damage. Therefore, intensive monitoring of these patients needs to be considered.