Chest X-ray Findings and Hyponatremia in COVID-19 Pneumonia Patients.

BACKGROUND: The World Health Organization declared the coronavirus disease-2019 (COVID-19) a pandemic in December 2019. COVID-19 can affect most organs of the body but predominantly affects the lungs. Chest infection is associated with hyponatremia primarily due to inappropriate ectopic secretion of antidiuretic hormone. We conducted a six-month retrospective observational study to evaluate the relationship between chest X-ray (CXR) radiological findings and serum sodium levels. Our secondary goal was to assess the relationship between CXR findings and patient outcomes. AIM OF THE STUDY: To assess the relationship between the initial CXR findings, hyponatremia severity, and outcome in COVID-19 infected patients. MATERIALS AND METHODS: We conducted a retrospective review of CXR findings of COVID-19 patients aged > 18 years. The patients were healthy and had no history of hyponatremia before COVID-19 infection. All recruited patients were admitted to one of four hospitals in Qatar (Hazm Mebaireek General Hospital, Communicable Disease Center, and all affiliated quarantine centers managed under the Communicable Disease Centre, Mesaieed Hospital, and Ras Laffan Hospital) between March and June 2020. We excluded patients with factors that contributed to hyponatremia. Three score grades were established to describe the CXR findings. Patients were divided into three groups by the principal researcher according to their serum sodium levels. A radiologist evaluated the CXR findings with the patient and group information obscured. The principal researcher collected the X-ray scores for analysis with the serum sodium levels. We used SPSS for Windows, Version 15.0. (SPSS Inc., Chicago, IL, USA) and STATA Package Version 12.0 (StataCorp, College Station, TX, USA) to analyze the data. A p-value ≤  0.05 was considered significant. RESULTS: A total of 414 CXR patients with COVID-19 were recruited; 275 patients had hyponatremia and 139 had normal sodium levels and were used as the control group. Patients with normal serum sodium and hyponatremia were classified into three categories based on the CXR findings. Grade 0 (95), Grade 1 (43), and Grade 2 (137) hyponatremic patients were reported. The mean sodium levels were 133.6, 131.3, and 127.2 mmol/L for Grades 0, 1, and 2, respectively (p < 0.001). More than 95% of the patients who developed hyponatremia were >30 years. Moderate and severe hyponatremia was more prevalent in patients with Grade 1 or Grade 2 CXR findings and were >30 years. CONCLUSION: Serum sodium levels in COVID-19 patients correlated well with the severity of the CXR findings observed at the early disease stage. Furthermore, simple CXR scores can be used to identify COVID-19 patients at a higher risk of hyponatremia, length of hospital stay, medical care support type, and mortality.

Reducing Unnecessary Complete Blood Count Ordering Through Education and Standardization: A Quality Improvement Initiative.

BACKGROUND AND OBJECTIVES: The American Board of Internal Medicine's Choosing Wisely campaign recommends against ordering repetitive complete blood counts (CBC) in the face of clinical and laboratory stability. METHODS: Consecutive patients admitted to a teaching team were included. Intervention 1 was an educational lecture outlining costs of and indications for CBC ordering. Intervention 2 added a simplified algorithm to help providers determine the need for a daily CBC. The primary outcome measure was the number of CBCs ordered per number of patients per day. The secondary outcome measure was net cost saved. The process measures were lecture/poster and algorithm utilization rates. The balancing measure was emergency department visits/readmissions within 7 days of discharge. A statistical process control chart was generated to assess special cause variation. Using R software version 3.5.2, a 2-sample t test and Fisher exact test differences between groups in the outcome and balancing measures. RESULTS: One hundred ten patients were included over a 62-day period. The difference between the pre-intervention group and both interventions combined was significant ( P = .000317). Special cause variation was observed after institution of both interventions in conjunction. Net costs saved totaled $43 482. Emergency department visits/readmissions within 7 days were similar between the groups ( P = .1403). CONCLUSIONS: Complete blood count ordering patterns and costs were improved through education and providing a decision support tool in the form of a simplified algorithm, without increasing 7-day emergency department visits/readmissions. The algorithm, far less detailed than that previously published, still resulted in significant improvement without unintended consequences, making for a safe and potentially sustainable intervention.

Increased procoagulant platelet levels are predictive of death in COVID-19.

Prior research has identified abnormal platelet procoagulant responses in COVID-19. Coated-platelets, a form of procoagulant platelets, support thrombin formation and are elevated in ischemic stroke patients with increased risk for recurrent infarction. Our goal was to examine changes in coated-platelet levels over the course of COVID-19 infection and determine their association with disease severity, thrombosis, and death. Coated-platelet levels were assayed after admission and repeated weekly in COVID-19 patients, and in COVID-19 negative controls. Receiver operator characteristic (ROC) analysis was used to calculate area under the curve (AUC) values for a model including baseline coated-platelets to predict death. Kaplan-Meier and Cox proportional hazards analysis was used to predict risk for death at 90 days. We enrolled 33 patients (22 with moderate and 11 with severe infection) and 20 controls. Baseline coated-platelet levels were lower among moderate (mean ± SD; 21.3 ± 9.8%) and severe COVID-19 patients (28.5 ± 11.9%) compared to controls (38.1 ± 10.4%, p < 0.0001). Coated-platelet levels increased during follow-up in COVID-19 patients by 7% (relative) per day from symptom onset (95% CI 2-12%, p = 0.007). A cut-off of 33.9% for coated-platelet levels yielded 80% sensitivity and 96% specificity for death at 90 days, with resulting AUC of 0.880 (95% CI 0.680-1.0, p = 0.0002). The adjusted hazard ratio for death in patients with coated-platelet levels > 33.9% was 40.99 when compared to those with levels ≤ 33.9% (p < 0.0001). Platelet procoagulant potential is transiently decreased in most patients during COVID-19; however, increased baseline platelet procoagulant levels predict death. Defining the mechanisms involved and potential links with aging may yield novel treatment targets.

War-related ocular injuries in Damascus during the Syrian Crisis.

BACKGROUND: . Ocular injuries constitute a major cause of visual morbidity, and they have a significant socioeconomic impact worldwide. We aimed to document the types and causes of Syrian War related ocular injuries in Damascus, Syria. METHODS: . Medical records were retrospectively reviewed to evaluate all patients in Al-Mouwasat University Hospital and Damascus Hospital, whose ocular injuries were caused by war-related activities during the period extending between January of 2016 and December 2017. RESULTS: . 150 eye injuries in 127 patients were reviewed, in which 46 (31%) were bilateral and 87 (58%) were open globe injuries. The leading cause of the observed ocular injuries was improvised explosive devices (IED) [37 eyes (41%)]. The majority of patients presented with an initial best corrected visual acuity (BCVA) of "light perception" (LP) to "hand movement" (HM) [51 eyes (34%)]. Information on the final BCVA was available for 69 injured eyes only, and it was "no light perception" (NLP) in 20 eyes (29%). CONCLUSION: . Explosive weaponry is the main culprit in most war-related ocular injuries in Syria. The high incidence of open globe injuries caused many of the cases to be severe in nature. Education on the precautionary measures that protect the eyes such as the use of combat eye protection during wartimes ought to be enforced, so that future ocular injuries can be prevented.

Utilization of guideline-directed medical therapy in patients with de novo heart failure with reduced ejection fraction: A Veterans Affairs study.

BACKGROUND: The utilization of guideline-directed medical therapy (GDMT) significantly reduces morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). Previous studies have documented the underutilization of GDMT in HFrEF. The present study aimed to determine reasons for underutilization and achievement of target doses of GDMT in patients with de novo diagnosis of HFrEF. METHODS: Patients presenting with de novo HFrEF at the Veterans Affairs Medical Center were included. Baseline demographic, clinical, and echocardiographic data were collected. The utilization of target doses of GDMT was assessed at the time of discharge and 1-, 3-, 6-, and 12-month follow-up. RESULTS: Of the 95 patients who met the criteria for de novo HFrEF, 48 were included in the final analysis. Dose titration of either beta-blocker or angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) was attempted in 20 patients (42%) at 1 month, 21 patients (44%) at 3 months, 13 patients (27%) at 6 months, and 14 patients (29%) at 12 months. Nine (19%) patients were on a target dose of beta-blockers and three (6%) patients were on a target dose of an ACEi/ARB at 12 months. The most common reasons for underutilization were patient-level factors, such as hypotension, acute kidney injury/hyperkalemia, and patient noncompliance. CONCLUSIONS: Utilization and achievement of target doses of GDMT were suboptimal among patients discharged with de novo HFrEF during a 1-year follow-up. Although patient factors may limit the up-titration of therapies, concerted efforts are needed to support primary care physicians in improving adherence to target doses of GDMT in patients with HFrEF.

Prevalence, clinical manifestations, and biochemical data of type 2 diabetes mellitus versus nondiabetic symptomatic patients with COVID-19: A comparative study.

BACKGROUND: There is a scarcity of data regarding the effect of Type 2 diabetes mellitus (T2DM) and associated comorbidities on the clinical presentation and outcome of symptomatic patients with -COVID-19 infection in comparison with non-diabetic patients. AIM OF THE STUDY: We described and compared the clinical presentation and radiological and hematological data of a cohort of symptomatic COVID19 positive T2DM diabetic patients (n = 59) versus another cohort of non-diabetic symptomatic COVID19 positive patients (n =244) diagnosed at the same time from January 2020 to May 2020. Associated comorbidities were -assessed, and the Charlson Comorbidity Index was calculated. The outcomes including duration of hospitalization, duration of Intensive Care Unit (ICU) stay, duration of mechanical ventilation, and duration of O2 -supplementation were assessed. RESULTS: Prevalence of T2DM in symptomatic COVID19 positive patients was 59/303 (=19.5%).  Diabetic patients had higher prevalence of hypertension, chronic kidney disease (CKD) and cardiac dysfunction [coronary heart disease (CHD)], and congestive heart failure (CHF). Charlson Comorbidity score was significantly higher in the T2DM patients (2.4± 1.6) versus the non-diabetic -patients (0.28 ± 0.8; p: < 0.001). Clinically and radiologically, T2DM patients had significantly higher percentage of pneumonia, severe pneumonia and ARDS versus the non-diabetic patients. Hematologically, diabetic patients had significantly higher C-reactive protein (CRP), higher absolute neutrophilic count (ANC) and lower counts of lymphocytes and eosinophils compared to non-diabetic patients. They had significantly higher systolic and diastolic blood pressures, longer duration of hospitalization, ICU stay, mechanical ventilation and oxygen therapy. CRP was correlated significantly with the duration of stay in the ICU and the duration for oxygen supplementation (r = 0.37 and 0.42 respectively; p: <0.01). CONCLUSIONS: T2DM patients showed higher inflammatory response to COVID 19 with higher absolute neutrophilic count (ANC) and CRP with lower lymphocytic and eosinophilic counts. Diabetic patients had more comorbidities and more aggressive course of the disease with higher rate of ICU admission and longer need for hospitalization and oxygen use.

Computed tomography pulmonary angiography using high-pitch dual-source scanner technology.

OBJECTIVES: To compare use of ultra-fast high-pitch dual-source free-breathing computed tomography pulmonary angiogram (CTPA) with conventional standard-pitch single-source breath-hold CTPA. Methods: This retrospective comparative study was conducted in Radiology Department at King Fahad Military Medical Complex Dhahran, Saudi Arabia from July 2016 to December 2017. Patients (N=130) were divided into 2 groups, each having 65 consecutive patients; Group-1 (single-source CT) and Group-2 (dual-source CT). Previously treated pulmonary embolism cases, pregnant patients and those with incomplete data were excluded. Image quality was subjectively assessed by 2 readers for adequacy of contrast opacification and pulmonary vessel outline, and presence of artifacts (breathing motion, cardiac pulsation, and contrast related). Scan acquisition times and radiation doses were also compared. Chi-square and t-test were used to determine association. Results: Improved image quality (optimal studies without artifacts 91%) was seen in Group-2 compared to Group-1 (optimal studies without artifacts 75.4%). Also, reduced scan time (1-2 sec.) and radiation dose (mean dose length product (DLP)-248 mGy-cm) were observed in Group-2 compared to Group-1 (scan time- 6.5 sec, mean DLP-375). Results were found significant (p less than 0.05). Conclusion: High-pitch dual-source CT with free-breathing yields better image quality, reduces image acquisition time and radiation doses.

Diagnostic accuracy of Focused Assessment with Sonography for Trauma for blunt abdominal trauma in the Eastern Region of Saudi Arabia.

OBJECTIVES: To determine the diagnostic accuracy of  Focused Assessment with Sonography for Trauma (FAST) in blunt abdominal trauma caused by motor vehicle accidents at our Hospital in Dhahran city. METHODS: This descriptive, observational study was conducted in the Radiology Department at King Fahad Military Medical Complex   Dhahran, Saudi Arabia between September 2016 and September 2017.  All adult patients (n=105) involved in motor vehicle accidents with blunt abdominal injury on presentation were retrospectively reviewed for FAST and CT scans for detection of free fluid. Focused assessment with sonography for trauma studies were conducted or supervised by senior registrar of general surgery (trauma team leader). Computed tomography findings were reviewed by 2 experienced radiologists. High and low-grade solid abdominal visceral (liver, spleen, kidney) injuries were identified on CT scans. Focused assessment with sonography for trauma and CT scan findings were identified as 'positive' and 'negative' for presence and absence of free fluid respectively. Outcomes of FAST were presented on a 2x2 contingency table. RESULTS: Sensitivity of FAST in detecting intraperitoneal free fluid was calculated as 76.1% (95% confidence interval [CI], 64.14-85.69%), specificity 84.2% (95% CI, 68.75-93.98%) and accuracy 79% (95% CI, 70.01-86.38%). Focused assessment with sonography for trauma detected free fluid in most cases of high-grade solid visceral injuries. Nearly half of true-negative cases were having low grade visceral or other injuries. CONCLUSION: Focused assessment with sonography for trauma is an important tool in initial assessment of suspected blunt abdominal injury patients with high sensitivity and specificity. A negative FAST does not exclude low grade solid visceral or other injuries.