Advancement in pleura effusion diagnosis: a systematic review and meta-analysis of point-of-care ultrasound versus radiographic thoracic imaging.

BACKGROUND: Pleural effusion is a fluid buildup in the pleural space that mostly result from congestive heart failure, bacterial pneumonia, malignancy, and pulmonary embolism. The diagnosis of this condition can be challenging as it presents symptoms that may overlap with other conditions; therefore, imaging diagnostic tools such as chest x-ray/radiograph (CXR), point-of-care ultrasound (POCUS), and computed tomography (CT) have been employed to make an accurate diagnosis. Although POCUS has high diagnostic accuracy, it is yet to be considered a first-line diagnostic tool as most physicians use radiography. Therefore, the current meta-analysis was designed to compare POCUS to chest radiography. METHODS: n extended search for studies related to our topic was done on five electronic databases, including PubMed, Medline, Embase, Scopus, and Google Scholar. A quality assessment using the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) was performed on all eligible articles obtained from the databases. Moreover, the diagnostic accuracy of POCUS and CXR was performed using STATA 16 software. RESULTS: Our search yielded 1642 articles, of which only 18 were eligible for inclusion and analysis. The pooled analysis showed that POCUS had a higher diagnostic accuracy compared to CXR (94.54% (95% CI 91.74-97.34) vs. 67.68% (95% CI 58.29-77.08) and 97.88% (95% CI 95.77-99.99) vs. 85.30% (95% CI 80.06-90.54) sensitivity and specificity, respectively). A subgroup analysis based on the position of patients during examinations showed that POCUS carried out in supine and upright positions had higher specificity than other POCUS positions (99%). In comparison, lateral decubitus CXR had higher sensitivity (96%) and specificity (99%) than the other CXR positions. Further subgroup analyses demonstrated that CXR had higher specificity in studies that included more than 100 patients (92.74% (95% CI 85.41-100). Moreover, CXR tends to have a higher diagnostic accuracy when other CXR positions are used as reference tests (93.38% (95% CI 86.30-100) and 98.51% (95% CI 94.65-100) sensitivity and specificity, respectively). CONCLUSION: POCUS as an imaging modality has higher diagnostic accuracy than CXR in detecting pleural effusion. Moreover, the accuracy is still high even when performed by physicians with less POCUS training. Therefore, we suggest it is considered a first-line imaging tool for diagnosing pleural effusion at the patients' bedside.

The role of point-of-care ultrasound (POCUS) imaging in clinical outcomes during cardiac arrest: a systematic review.

BACKGROUND: Cardiac arrest in hospital and out-of-hospital settings is associated with high mortality rates. Therefore, a bedside test that can predict resuscitation outcomes of cardiac arrest patients is of great value. Point-of-care ultrasound (POCUS) has the potential to be used as an effective diagnostic and prognostic tool during cardiac arrest, particularly in observing the presence or absence of cardiac activity. However, it is highly susceptible to "self-fulfilling prophecy" and is associated with prolonged cardiopulmonary resuscitation (CPR), which negatively impacts the survival rates of cardiac arrest patients. As a result, the current systematic review was created to assess the role of POCUS in predicting the clinical outcomes associated with out-of-hospital and in-hospital cardiac arrests. METHODS: The search for scientific articles related to our study was done either through an electronic database search (i.e., PubMed, Medline, ScienceDirect, Embase, and Google Scholar) or manually going through the reference list of the relevant articles. A quality appraisal was also carried out with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2), and the prognostic test performance (sensitivity and sensitivity) was tabulated. RESULTS: The search criteria yielded 3984 articles related to our topic, of which only 22 were eligible for inclusion. After reviewing the literature, we noticed a wide variation in the definition of cardiac activity, and the statistical heterogeneity was high; therefore, we could not carry out meta-analyses. The tabulated clinical outcomes based on initial cardiac rhythm and definitions of cardiac activity showed highly inconsistent results. CONCLUSION: POCUS has the potential to provide valuable information on the management of cardiac arrest patients; however, it should not be used as the sole predictor for the termination of resuscitation efforts.

Plasma exchange (PE) versus intravenous immunoglobulin (IVIG) for the treatment of Guillain-Barré syndrome (GBS) in patients with severe symptoms: A systematic review and meta-analysis.

Background and purpose: Guillain- Barré syndrome (GBS) is a neuropathic condition that leads to the rapid development of impairments and is characterized by weakness and numbness or tingling sensation in the legs and arms and sometimes loss of movement and feeling in the legs, arms, upper body, and face. Currently, the cure for the disease is yet to be developed. However, treatment options such as intravenous immunoglobulin (IVIG) and plasma exchange (PE) have been used to minimize the symptoms and duration of the disease. Therefore, this systematic review and meta-analysis compared the efficacy of IVIG and PE in treating GBS patients with severe symptoms. Methodology: Six electronic databases, including PubMed, Embase, Scopus, ScienceDirect, Medline, and Google scholar, were scoured for articles related and relevant to our research. Additionally, more studies were obtained through the reference lists of the studies retrieved from these electronic databases. Quality assessment and statistical data analysis were conducted using Review Manager software (RevMan 5.4.1). Results: The search for relevant articles resulted in 3253 articles, of which only 20 were included for review in the current study. A sub-group analysis indicated no significant difference in the curative effect (Hughes score reduces by at least one score 4 weeks after GBS treatment; OR: 1.00; 95% CI: 0.66-1.52; p = 1.00 and Achieving grade 0 or 1 on Hughes scale; OR: 1.03; 95% CI: 0.27-3.94; p = 0.97). Similarly, the statistical showed that the difference in length of hospitalization and duration of mechanical ventilation was insignificant between the IVIG and PE group (Standard Mean Difference (SMD): -0.45; 95% CI: -0.92, 0.02; I2 = 91%; p = 0.06 and SMD: -0.54; 95% CI: -1.67, 0.59; I2 = 93%; p = 0.35, respectively). Moreover, the meta-analysis did not find any significant difference in the risk of GBS relapse (RR: 0.47; 95% CI: 0.20-1.14; p = 0.10) and risk of complications related to the treatment regimens (RR: 1.03; 95% CI: 0.71-1.48; p = 0.89). However, the statistical analysis of outcomes from 3 studies showed that the risk of discontinuation was significantly lower in the IVIG group than in the PE group (RR: 0.22; 95% CI: 0.06-0.88; p = 0.03). Conclusion: Our study suggests that IVIG and PE have similar curative effects. Similarly, IVIG seems easier to use and thus can be preferred for treating GBS.

Comparison between transthoracic echocardiography and transoesophageal echocardiography in the diagnosis of acute aortic dissection from an emergency perspective. A systematic review and meta-analysis.

Background: Acute aortic dissection (AAD) is a life-threatening medical condition with high early fatality. Therefore, a prompt and precise diagnosis, which can be achieved through invasive and non-invasive techniques is vital. Echocardiography, unlike MRI and CT, is accessible in emergency units and bedside-compatible. The recommended echocardiographic techniques for AAD are transthoracic and transoesophageal echocardiography (TTE and TOE). Therefore, our review compares their diagnostic roles in AAD. Methods: Studies relevant to our topic were attained through a database search and manual scrutiny of references lists of articles obtained from the electronic databases. The Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) has been used for quality assessment. All quantitative analyses were performed using either STATA 16 or Comprehensive Meta-Analyst software. Results: The search strategy yielded 1,798 articles, of which only 11 were eligible for inclusion. Our subgroup analysis showed that conventional TTE had a sensitivity and specificity of 85.35% and 84.51% for the diagnosis of Stanford type A AAD and was 45.89% sensitive and 87.05% specific for the diagnosis of type B AAD. However, the subgroup analysis shows that contrast-enhancement of TTE results in a sensitivity and specificity of 93.30% and 97.60% for diagnosis of type A AAD, and 83.60% and 94.50% for diagnosis of type B AAD, respectively. On the other hand, conventional TOE was 93.64% sensitive and 95.50% specific for the diagnosis of type A AAD, 99.80% sensitive and 99.87% specific for the diagnosis of type B AAD. Moreover, our analyses show that TTE has pooled false negative and positive rates of 28.6% and 18.6%, while TOE has shown false negative and positive rates of 2.4% and 4.3%, respectively. Conclusion: TOE is the more favorable diagnostic tool for AAD diagnosis than TTE. However, it cannot be used as a stand-alone diagnostic tool since misdiagnosis cases are being reported. Contrast-enhanced TTE can also diagnose AAD since it provides similar results to conventional TOE.

The effect of exposure to MoO3-NP and common bean fertilized by MoO3-NPs on biochemical, hematological, and histopathological parameters in rats.

Nanotechnologies has been used to introduce several beneficial tools in the agricultural field. Herein, the effect of molybdenum oxide nanoparticles (MoO3-NPs) was investigated by evaluating the hematological, biochemical, and histopathological parameters in rats orally exposed to MoO3-NPs or fed common beans (CB) fertilized by MoO3-NPs. In the first study, 18 rats were randomly divided into 3 groups: G1 (control group) was given water orally, while G2 and G3 were administered 10 and 40 ppm MoO3-NPs by oral gavage tube, respectively. There was a significant increase in the levels of alanine aminotransferase (ALT), albumin, and total protein; however, there was a a significant decrease in body weight change (BWC), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), creatinine, creatine kinase-MB (CK-MB), thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), and testosterone levels in G3 compared to G1. In the second study, 24 rats were divided into 4 groups: the control (C) group was fed a balanced diet, and three groups were fed on a balanced diet plus 10% CB that was fertilized with 0, 10, and 40 ppm MoO3-NPs, resulting in nCB, CB10, and CB40 groups, respectively. This revealed a significant increase in BWC and total food intake (TFI) but a significant decrease in relative kidney weight in all the CB groups compared to the control group. In CB10 and CB40 groups ALT, LDH, TSH, FT3, and testosterone levels were significantly lower than the respective levels in the control group. We concluded that high doses of MoO3-NPs caused more side effects than low doses in both experiments.

Interpretation of Cardiac and Non-Cardiac Causes of Elevated Troponin T Levels in Non-Acute Coronary Syndrome Patients in the Emergency Department.

The definition of myocardial infarction was updated in 2000 to include an elevation of cardiac troponin T or I (cTnT or xTnI) alongside clinical evidence of myocardial infarction. The redefinition was jointly done by the American College of Cardiology Committee and the European Society of Cardiology. Since then, cardiac troponin T and I have assumed the position as the primary biochemical markers for diagnosing myocardial infarction. The high sensitivity of cardiac troponin for myocardial necrosis influenced the decision to include cardiac troponins (cTn) in the diagnostic pathway. An elevated cTn level indicates the presence of myocardial injury. However, it does not give the underlying reason for the damage. Apart from acute myocardial infarction (AMI), a range of potential diseases feature troponin release, including heart failure, acute pulmonary embolism, end-stage renal disease, and myocarditis. However, regardless of the mechanism that triggers the release from cardiac myocytes, elevated cTnI and cTnT typically implies a poor prognosis. This review attempts to explain both the cardiac and non-cardiac causes of increased cTnT in emergency department patients.

A Rare Case of Idiopathic Gonadal Vein Thrombosis.

Gonadal vein thrombosis, also known as ovarian vein thrombosis, is a rare medical condition presenting mostly in the postpartum period. Gonadal vein thrombosis is associated with conditions such as inferior vena cava thrombosis, sepsis, and pulmonary emboli which can lead to high morbidity and mortality. This report illustrates the case of a 25-year-old female patient who presented to the emergency department with a history of abdominal pain for over three days. The pain initially started centrally for a day, gradually, without radiation, and then became more localized in the right lower area and radiated to the genital area. The patient had a history of a cesarean section two years ago. Based on the presentation, an abdominal computed tomography scan demonstrated thickened tortuous right gonadal vein with the possibility of right gonadal vein thrombophlebitis and thrombosis. Having been examined by the general surgery and gynecology teams, a treatment plan was drawn involving thrombophilia workup and therapeutic anticoagulation. Although a rare entity, idiopathic gonadal vein thrombosis can present in the emergency department with vague abdominal pain and unclear diagnosis with a lack of risk factors. A high index of suspicion and imaging might be helpful to make this unique diagnosis.

Laparoscopic Exploration Converted to Laparotomy in a Case of Rectal Perforation and Peritonitis After Administration of Enema.

Laparoscopy is the preferred surgical approach to several ailments because it permits accurate and efficient diagnosis and treatment. In abdominal conditions, the clinician may accomplish both treatment components - exploration for identification of the causative pathology and the conduction of a proper operation - through laparoscopy. There is an ongoing debate of peritonitis as a contraindication to this approach. Laparoscopy has been widely accepted in many subspecialties over the last decade. Peritonitis is usually treated by a conventional open surgery which has a significantly high morbidity and mortality rate. In the present case, a 24-year-old male presented to the emergency unit of our facility with constipation for the past week, along with the inability to urinate with suprapubic pain and tenderness. The patient developed severe abdominal pain within an hour of receiving an enema injection. The patient was started on broad-spectrum antibiotics due to suspected peritonitis and later sent for imaging studies with urgent surgical consultation. The patient remained in the hospital for a few days and was then discharged after a week of hospital administration. It is worth mentioning that therapeutic laparoscopy may be considered in select cases of abdominal trauma. It offers more advantages over laparotomy, including reduced complication rate, length of stay, and mortality.

Atrial Fibrillation With Decompensated Heart Failure Complicated With Non-ST Elevation Myocardial Infarction.

Non-ST-elevation myocardial infarction (NSTEMI) has a less severe ratio of acute coronary syndromes compared with ST-segment elevation myocardial infarction (STEMI), arising from complete occlusion of a major coronary artery. The name implies a syndrome that does not exhibit the dramatic ST-elevation seen in the traditional 12-lead ECG in chest pain patients with a confirmed diagnosis of STEMI. The crucial clinical significance of NSTEMI is that delay in diagnosis can lead to increased morbidity, risk of arrhythmia, and death. It was recently reported that atrial fibrillation (AF) correlates with the risk rise of myocardial infarction (MI), although the mechanism underlying this association is currently unknown. Does atrial fibrillation with decompensated heart failure (DHF) get complicated with NSTEMI? In this article, we describe the case of a 77-year-old male patient diagnosed and admitted as NSTEMI complicated by DHF.

Influence of GSTM1, T1 genes polymorphisms on oxidative stress and liver enzymes in rural and urban pesticides-exposed workers.

Several studies discussed the relationship between the toxicity of organophosphates (OPs) and carbamates pesticides and oxidative stress which affects human health. This study aimed to evaluate the effects of pesticides on the induction of oxidative stress and hepatotoxicity. It was also focused on glutathione-S-transferase gene polymorphism in the modulation of these effects. In addition, the role of the educational level of exposed workers was studied. Acetylcholinesterase (AChE), butyrylcholinesterase (BuChE), liver enzymes, malondialdehyde (MDA), reduced glutathione (GSH), superoxide dismutase (SOD), and glutathione S transferase (GST) were estimated at 100 pesticide-exposed workers (50 urban researchers (UE) and 50 rural sprayers (RE)), and 100 matched controls (50 urban controls (UC)and 50 rural controls (RC)). AChE and BuChE were decreased in RE and UE compared to RC. Aspartate aminotransferase (AST) and alkaline phosphatase (ALP) activity were elevated in UE and UC compared to the RE and RC. Alanine aminotransferase (ALT) was elevated in UE compared to RE. MDA in RE and UE showed elevation compared to RC. There was a significant reduction in the levels of GSH, GST, and GPx in UE compared to RE and RC. The most sensitive pesticide-induced hepatotoxicity group were exposed workers with the GSTT1 genotype. Within these workers, ALT and ALP were significantly correlated with MDA and inversely correlated with AChE and BuChE, while AST was inversely correlated with AChE and BuChE only in UE. Conclusion: GST gene polymorphisms appeared to have a significant role in workers' susceptibility to hepatotoxic effects due to occupational exposure to pesticides; GSTT1 was the most sensitive genotype.

An integrative comparative study between ultrasound-guided regional anesthesia versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: A systematic review and meta-analysis.

Background: Emergency physicians play a major role in managing patients with hip fractures. The most commonly used pain management option is parenteral opioids. However, parenteral opioids are subjected to several adverse effects. New pain management techniques such as regional anesthesia are used as alternatives to parenteral opioids. Anatomical landmarks were used to administer regional anesthesia; however, ultrasound guidance has shown promising results with regional anesthesia. Objective: of the Review: The present study compares the efficacy of ultrasound-guided regional anesthesia (USGRA) to parenteral opioids in analgesia of hip fractures patients. Methods: A literature search for original and relevant articles carried out through six electronic databases, yielded 710 articles which were then assessed using the eligibility criteria resulting in 8 studies eligible for inclusion. Results: A Meta-analysis of the seven studies showed that ultrasound-guided femoral nerve block was more effective than parenteral opioids in relieving pain. Similarly, meta-analysis of data from two studies shows that US-guided FICB significantly reduced pain scores than parenteral opioids. A subgroup analysis of adverse events showed no significant difference in nausea/vomiting and respiratory complications. However, a subgroup analysis on hypotension showed that the incidence of hypotension was significantly lower in USGRA than parenteral opioids. The present study also revealed that patients in the USGRA group required less frequent rescue analgesia than the patients in the parenteral opioids group. Conclusion: Results of the present study show that USGRA is superior to parenteral opioids in reducing pain and the need for rescue analgesia in patients with hip fractures.

Camel Bite Injury to the Face in an Adult Patient: Skin Closure Controversy.

Animal bite injuries are prevalent worldwide. Camel bites, as a cause, are relatively rare. Male camels are particularly aggressive, especially during the rutting season. These injuries, when inflicted over the face, have a disfiguration effect with possible psychological repercussions to the patient. The surgical management of facial camel bite is described sporadically and remains a source of deliberation. Our paper reports the mechanism and management of facial soft tissue injury inflicted by camel bite over the face in an adult male with long-time follow-up for the patient post surgical repair without any documented complications. This case report demonstrates the complex nature of camel bite injuries over the face. Inappropriate wound management may result in long-term sequelae, which may affect the patient's quality of life. Individuals should apply caution when dealing with camels, mainly in the rutting season. Primary skin closure, especially to the face or neck, and proper wound management will decrease the risk of permanent scars and infections.

High Troponin-T in Acute Biliary Pancreatitis: Is it a Real Myocardial Injury?

Acute pancreatitis (AP) is characterized by abdominal pain and elevated levels of pancreatic enzymes in the serum. Pain is the hallmark of this condition, and as a presenting symptom, is localized in the epigastrium in at least 60% of patients having the mild or severe form of the disease. Thus, the differential diagnosis may be difficult in some cases due in part to the fact that the disease may mimic other diseases, and in particular, acute coronary syndrome. We present the case of a patient who presented to our facility with epigastric pain, normal electrocardiogram (ECG), elevated high-sensitive troponin-T and elevated lipase, and amylase. Laboratory investigations and ultrasonography confirmed AP, with further serial ECGs being within the normal limits and normal echocardiography. The patient underwent laparoscopic cholecystectomy and intraoperative cholangiogram. Postoperative diagnosis confirmed biliary pancreatitis with chronic cholecystitis.

Normal D-Dimer Plasma Level in a Case of Acute Thrombosis Involving Intramuscular Gastrocnemius Vein.

Venous thromboembolism (VTE) is a major cause of morbidity and mortality among hospitalized patients. Studies have reported an incidence of deep venous thrombosis to be as high as 50%, especially after craniotomy. Several factors are involved in the alteration of the specificity and sensitivity of D-dimer testing. These include symptom duration, the extent of fibrinolytic and thrombosis activity, anticoagulant therapy, comorbidity associated with medical or surgical illness, cancer, inflammatory diseases, old age, postpartum, and pregnancy period, as well as previous VTE. Several studies have shown the high sensitivity of the D-dimer test (>95%) in pulmonary embolism or acute deep venous thrombosis. The cut-off value is usually within the 500 µg FEU/L range, ruling out acute VTE, especially in patients with low or intermediate clinical probability. Patients who present with a high D-dimer level may necessitate an intense diagnostic approach, the pretest probability notwithstanding. Herein, we present a case of a 52-year-old male patient who presented with a normal D-dimer level in deep venous thrombosis.

A Rare Presentation of Small Bowel Obstruction Due to Obstructed Indirect Inguinal Hernia.

Inguinal hernia is the most common hernia that affects the anterior abdominal wall. It is important to note that increased intra-abdominal pressure is a major risk factor of inguinal hernia formation. An indirect inguinal hernia in the right groin region causing small bowel obstruction is rare in elderly females. The current report illustrates the case of a 53-year-old female presenting with a history of abdominal pain (colicky) with vomiting and nausea, which required diagnostic laparoscopy plus open mesh repair of right inguinal hernia. Operative findings reveal a hernia in the right groin extended to the right labia containing fat and a segment of distal ileum that shows decreased wall enhancement with the surrounding fluid, leading to small bowel dilatation up to proximal jejunum with a maximum diameter of about five cm. This case highlights the importance of obstipation imperative to the diagnosis of small bowel obstruction due to obstructed indirect inguinal hernia.

A Case of Complicated Traumatic Generalized Surgical Emphysema, Pneumomediastinum, Pneumopericardium, Pneumothorax, and Pneumoperitoneum Due to Accidental Dislodgement of Tracheostomy Tube.

A tracheostomy tube (TT) is usually taken out in a well-planned and coordinated manner after the underlying condition that necessitated the procedure is resolved. The inadvertent removal or dislodgement of the TT from the stroma is known as accidental extubation or decannulation. This event may prove fatal in a stable patient. Like other respiratory procedures, tracheostomy with the long-term placement of tracheal tube comes with several risks, including scarring of the trachea, pneumothorax, tracheal rupture, and tracheoesophageal fistula. Other complications may include pneumomediastinum (PM) or the escape of air into the surrounding tissue. This may be attributed to several reasons, including mispositioning of the tracheal tube, barotrauma, or tracheal rupture. In some cases, PM presents with free air into cavities such as the thorax, peritoneum, or subcutaneous tissue. Although not fatal, it may require complex treatments such as ventilator management, high-flow oxygen, or, in some cases, surgical intervention. In this article, we describe a rare case of PM and generalized surgical emphysema due to mispositioning of the tracheal tube.

The effect of white kidney bean fertilized with nano-zinc on nutritional and biochemical aspects in rats.

This study aims to estimate the safety of white kidney bean (WKB) fertilized by zinc oxide nanoparticles (ZnO-NPs) via studying changes of liver and kidney function, lipid profile and histological examination for the liver and kidney tissue in rats fed on it. Twenty Four male albino rats were used in this study divided into four groups; the first fed balanced diet (control group), the second fed WKB treated with normal ZnO (nWKB), the third fed WKB treated with 20 ppm ZnO-NPs (tWKB-1), and the fourth fed WKB treated with 40 ppm ZnO-NPs (tWKB-2). The results revealed that WKB treated with ZnO-NPs reduced body weight, food efficiency ratio, relative liver weight, and relative spleen weight were increased as well as the most biochemical parameters exhibited non-significant changes as compared to control group. Meanwhile, tWKB-2 group demonstrated a decrease in alkaline phosphatase and aspartate transaminase activities as compared to nWKB group.

Protective effects of zinc and selenium against benzene toxicity in rats.

The presented study investigates the protective role of zinc (Zn) and selenium (Se) in attenuating benzene-induced toxicity in rats. Male Sprague-Dawley rats were injected with benzene (0.5 mL/kg body weight ip) and received a diet supplement containing Zn and Se. Several hematological and biochemical parameters (representing antioxidant status) were estimated. Histopathological examinations were performed. Results showed that food intake and body weight gain of benzene-injected rats were significantly lower than that of the control rats. Benzene-injected rats showed increased plasma malondialdehyde (MDA) and decreased activity of: glutathione peroxidase (GSH-Px), catalase, superoxide dismutase (SOD) enzymes, as well as reduced glutathione (GSH) when compared to the control group. Histopathological investigations revealed structural changes in benzene-injected rats' liver. Supplementation with Zn and Se resulted in a significant decrease in MDA, elevation in GSH, GSH-Px, SOD and catalase levels. This study shows that Zn and Se supplementation can improve the activity of antioxidant enzymes in rats and decrease the histological anomalies induced by benzene toxicity as well.