Effect of an Albumin Infusion Treatment Protocol on Delayed Cerebral Ischemia and Relevant Outcomes in Patients with Subarachnoid Hemorrhage.

BACKGROUND: An institutional management protocol for patients with subarachnoid hemorrhage (SAH) based on initial cardiac assessment, permissiveness of negative fluid balances, and use of a continuous albumin infusion as the main fluid therapy for the first 5 days of the intensive care unit (ICU) stay was implemented at our hospital in 2014. It aimed at achieving and maintaining euvolemia and hemodynamic stability to prevent ischemic events and complications in the ICU by reducing periods of hypovolemia or hemodynamic instability. This study aimed at assessing the effect of the implemented management protocol on the incidence of delayed cerebral ischemia (DCI), mortality, and other relevant outcomes in patients with SAH during ICU stay. METHODS: We conducted a quasi-experimental study with historical controls based on electronic medical records of adults with SAH admitted to the ICU at a tertiary care university hospital in Cali, Colombia. The patients treated between 2011 and 2014 were the control group, and those treated between 2014 and 2018 were the intervention group. We collected baseline clinical characteristics, cointerventions, occurrence of DCI, vital status after 6 months, neurological status after 6 months, hydroelectrolytic imbalances, and other SAH complication. Multivariable and sensitivity analyses that controlled for confounding and considered the presence of competing risks were used to adequately estimate the effects of the management protocol. The study was approved by our institutional ethics review board before study start. RESULTS: One hundred eighty-nine patients were included for analysis. The management protocol was associated with a reduced incidence of DCI (hazard ratio 0.52 [95% confidence interval 0.33-0.83] from multivariable subdistribution hazards model) and hyponatremia (relative risk 0.55 [95% confidence interval 0.37-0.80]). The management protocol was not associated with higher hospital or long-term mortality, nor with a higher occurrence of other unfavorable outcomes (pulmonary edema, rebleeding, hydrocephalus, hypernatremia, pneumonia). The intervention group also had lower daily and cumulative administered fluids compared with historic controls (p < 0.0001). CONCLUSIONS: A management protocol based on hemodynamically oriented fluid therapy in combination with a continuous albumin infusion as the main fluid during the first 5 days of the ICU stay appears beneficial for patients with SAH because it was associated with reduced incidence of DCI and hyponatremia. Proposed mechanisms include improved hemodynamic stability that allows euvolemia and reduces the risk of ischemia, among others.

Prevalencia de Helicobacter pylori en pacientes llevados a endoscopia de vías digestivas altas en un hospital de referencia en Cali, Colombia, en 2020 / Prevalence of Helicobacter pylori in patients undergoing upper digestive tract endoscopy at a referral hospital in Cali, Colombia, in 2020

Resumen Introducción: la infección por Helicobacter pylori tiene una alta prevalencia y distribución a nivel mundial. Por su asociación con el desarrollo de adenocarcinoma gástrico, las actualizaciones sobre su prevalencia son de interés para el médico internista o gastroenterólogo, así como para la generación de políticas públicas. Este estudio midió la prevalencia de H. pylori y evaluó su asociación con hallazgos endoscópicos e histopatológicos en adultos con indicación de endoscopia de vías digestivas altas (EVDA). Metodología: estudio de cohorte analítica para describir la prevalencia de H. pylori y evaluar factores de riesgo asociados a esta infección en pacientes adultos sometidos a EVDA ambulatoria por cualquier indicación médica en la unidad de endoscopia de un hospital universitario de cuarto nivel de complejidad entre junio y diciembre de 2020. Se describen hallazgos endoscópicos, histopatológicos y la prevalencia de H. pylori. Para explorar los factores de riesgo se usó la prueba chi cuadrado (χ2) para evaluar diferencias en las proporciones y las pruebas t de Student y U de Mann-Whitney para las variables continuas según su distribución. Resultados: 613 pacientes cumplieron los criterios de selección y fueron incluidos en el análisis. La indicación más frecuente de EVDA fue dispepsia. La prevalencia de H. pylori fue de 38,5% (intervalo de confianza [IC] 95%: 34,7%-42,4%). Conclusión: H. pylori es un tema de gran interés en las patologías gastrointestinales. La búsqueda endoscópica debe ser en el antro y cuerpo. Su presencia fue mayor en pacientes con esófago normal, gastritis nodular folicular, úlcera duodenal e inflamación aguda al estudio histológico. Se requieren más estudios que complementen el comportamiento epidemiológico local.

Abstract Introduction: Helicobacter pylori infection has a high prevalence and distribution worldwide. Due to its association with the development of gastric adenocarcinoma, updates on its prevalence are of interest to the internist or gastroenterologist and policymaking. This study measured the prevalence of H. pylori and evaluated its association with endoscopic and histopathological findings in adults with an indication for upper GI endoscopy (EGD). Materials and methods: This analytical cohort study describes the prevalence of H. pylori and assesses risk factors associated with this infection in adult patients undergoing outpatient EGD for any medical indication in the endoscopy unit of a quaternary care university hospital between June and December 2020. Endoscopic and histopathological findings and the prevalence of H. pylori are described. To explore the risk factors, the chi-square (χ2) test was used to evaluate differences in proportions and the Student's t and Mann-Whitney U tests for continuous variables according to their distribution. Results: 613 patients met the selection criteria and were included in the analysis. The most frequent indication for EGD was dyspepsia. The prevalence of H. pylori was 38.5% (95% confidence interval [CI]: 34.7-42.4%). Conclusion: H. pylori is a topic of great interest in gastrointestinal pathologies. The endoscopic search should take place in the antrum and body. Its presence was most common in patients with a normal esophagus, follicular nodular gastritis, duodenal ulcer, and acute inflammation upon the histological study. More studies are required to complement the local epidemiological behavior.

An Umbrella Review With Meta-Analysis of Chest Computed Tomography for Diagnosis of COVID-19: Considerations for Trauma Patient Management.

Background: RT-PCR testing is the standard for diagnosis of COVID-19, although it has its suboptimal sensitivity. Chest computed tomography (CT) has been proposed as an additional tool with diagnostic value, and several reports from primary and secondary studies that assessed its diagnostic accuracy are already available. To inform recommendations and practice regarding the use of chest CT in the in the trauma setting, we sought to identify, appraise, and summarize the available evidence on the diagnostic accuracy of chest CT for diagnosis of COVID-19, and its application in emergency trauma surgery patients; overcoming limitations of previous reports regarding chest CT accuracy and discussing important considerations regarding its role in this setting. Methods: We conducted an umbrella review using Living Overview of Evidence platform for COVID-19, which performs regular automated searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and more than 30 other sources. The review was conducted following the JBI methodology for systematic reviews. The Grading of Recommendations, Assessment, Development, and Evaluation approach for grading the certainty of the evidence is reported (registered in International Prospective Register of Systematic Reviews, CRD42020198267). Results: Thirty studies that fulfilled selection criteria were included; 19 primary studies provided estimates of sensitivity (0.91, 95%CI = [0.88-0.93]) and specificity (0.73, 95%CI = [0.61; 0.82]) of chest CT for COVID-19. No correlation was found between sensitivities and specificities (ρ = 0.22, IC95% [-0.33; 0.66]). Diagnostic odds ratio was estimated at: DOR = 27.5, 95%CI (14.7; 48.5). Evidence for sensitivity estimates was graded as MODERATE, and for specificity estimates it was graded as LOW. Conclusion: The value of chest CT appears to be that of an additional screening tool that can easily detect PCR false negatives, which are reportedly highly frequent. Upon the absence of PCR testing and impossibility to perform RT-PCR in trauma patients, chest CT can serve as a substitute with increased value and easy implementation. Systematic Review Registration: [www.crd.york.ac.uk/prospero], identifier [CRD42020198267].

Chest Computed Tomography for the Diagnosis of COVID-19 in Emergency Trauma Surgery Patients Who Require Urgent Care During the Pandemic: Protocol for an Umbrella Review.

BACKGROUND: Many health care facilities in low- and middle-income countries are inadequately resourced. COVID-19 has the potential to decimate surgical health care services unless health systems take stringent measures to protect health care workers from viral exposure and ensure the continuity of specialized care for patients. Among these measures, the timely diagnosis of COVID-19 is paramount to ensure the use of protective measures and isolation of patients to prevent transmission to health care personnel caring for patients with an unknown COVID-19 status or contact during the pandemic. Besides molecular and antibody tests, chest computed tomography (CT) has been assessed as a potential tool to aid in the screening or diagnosis of COVID-19 and could be valuable in the emergency care setting. OBJECTIVE: This paper presents the protocol for an umbrella review that aims to identify and summarize the available literature on the diagnostic accuracy of chest CT for COVID-19 in trauma surgery patients requiring urgent care. The objective is to inform future recommendations on emergency care for this category of patients. METHODS: We will conduct several searches in the L·OVE (Living Overview of Evidence) platform for COVID-19, a system that performs automated regular searches in PubMed, Embase, Cochrane Central Register of Controlled Trials, and over 30 other sources. The search results will be presented according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis). This review will preferentially consider systematic reviews of diagnostic test accuracy studies, as well as individual studies of such design, if not included in the systematic reviews, that assessed the sensitivity and specificity of chest CT in emergency trauma surgery patients. Critical appraisal of the included studies for risk of bias will be conducted. Data will be extracted using a standardized data extraction tool. Findings will be summarized narratively, and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach will be used to grade the certainty of evidence. RESULTS: Ethics approval is not required for this systematic review, as there will be no patient involvement. The search for this systematic review commenced in October 2020, and we expect to publish the findings in early 2021. The plan for dissemination is to publish the findings in a peer-reviewed journal and present our results at conferences that engage the most pertinent stakeholders. CONCLUSIONS: During the COVID-19 pandemic, protecting health care workers from infection is essential. Up-to-date information on the efficacy of diagnostic tests for detecting COVID-19 is essential. This review will serve an important role as a thorough summary to inform evidence-based recommendations on establishing effective policy and clinical guideline recommendations. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020198267; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=198267. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25207.

Personal protective equipment for reducing the risk of COVID-19 infection among healthcare workers involved in emergency trauma surgery during the pandemic: an umbrella review protocol.

INTRODUCTION: Many healthcare facilities in low-income and middle-income countries are inadequately resourced and may lack optimal organisation and governance, especially concerning surgical health systems. COVID-19 has the potential to decimate these already strained surgical healthcare services unless health systems take stringent measures to protect healthcare workers (HCWs) from viral exposure and ensure the continuity of specialised care for patients. The objective of this broad evidence synthesis is to identify and summarise the available literature regarding the efficacy of different personal protective equipment (PPE) in reducing the risk of COVID-19 infection in health personnel caring for patients undergoing trauma surgery in low-resource environments. METHODS: We will conduct several searches in the L·OVE (Living OVerview of Evidence) platform for COVID-19, a system that performs automated regular searches in PubMed, Embase, Cochrane Central Register of Controlled Trials and over 30 other sources. The search results will be presented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. This review will preferentially consider systematic reviews of experimental and quasi-experimental studies, as well as individual studies of such designs, evaluating the effect of different PPE on the risk of COVID-19 infection in HCWs involved in emergency trauma surgery. Critical appraisal of eligible studies for methodological quality will be conducted. Data will be extracted using the standardised data extraction tool in Covidence. Studies will, when possible, be pooled in a statistical meta-analysis using JBI SUMARI. The Grading of Recommendations, Assessment, Development and Evaluation approach for grading the certainty of evidence will be followed and a summary of findings will be created. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. The plan for dissemination is to publish review findings in a peer-reviewed journal and present findings at high-level conferences that engage the most pertinent stakeholders. PROSPERO REGISTRATION NUMBER: CRD42020198267.

Personal protective equipment for reducing the risk of COVID-19 infection among health care workers involved in emergency trauma surgery during the pandemic: An umbrella review.

BACKGROUND: Health care facilities in low- and middle-income countries are inadequately resourced to adhere to current COVID-19 prevention recommendations. Recommendations for surgical emergency trauma care measures need to be adequately informed by available evidence and adapt to particular settings. To inform future recommendations, we set to summarize the effects of different personal protective equipment (PPE) on the risk of COVID-19 infection in health personnel caring for trauma surgery patients. METHODS: We conducted an umbrella review using Living Overview of Evidence platform for COVID-19, which performs regular automated searches in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and more than 30 other sources. Systematic reviews of experimental and observational studies assessing the efficacy of PPE were included. Indirect evidence from other health care settings was also considered. Risk of bias was assessed with the AMSTAR II tool (Assessing the Methodological Quality of Systematic Reviews, Ottawa, ON, Canada), and the Grading of Recommendations, Assessment, Development, and Evaluation approach for grading the certainty of the evidence is reported (registered in International Prospective Register of Systematic Reviews, CRD42020198267). RESULTS: Eighteen studies that fulfilled the selection criteria were included. There is high certainty that the use of N95 respirators and surgical masks is associated with a reduced risk of COVID-19 when compared with no mask use. In moderate- to high-risk environments, N95 respirators are associated with a further reduction in risk of COVID-19 infection compared with surgical masks. Eye protection also reduces the risk of contagion in this setting. Decontamination of masks and respirators with ultraviolet germicidal irradiation, vaporous hydrogen peroxide, or dry heat is effective and does not affect PPE performance or fit. CONCLUSION: The use of PPE drastically reduces the risk of COVID-19 compared with no mask use in health care workers. N95 and equivalent respirators provide more protection than surgical masks. Decontamination and reuse appear feasible to overcome PPE shortages and enhance the allocation of limited resources. These effects are applicable to emergency trauma care and should inform future recommendations. LEVEL OF EVIDENCE: Review, level II.

Implementation and Usefulness of Telemedicine During the COVID-19 Pandemic: A Scoping Review.

OBJECTIVES: Identify and summarize the available literature on the acceleration in the use of telemedicine in the midst of the COVID-19 pandemic, with an aim to provide justification and guidance for its implementation to overcome the limitations associated with the pandemic worldwide. METHODS: We conducted a scoping review through different search strategies in MEDLINE and Google Scholar to identify the available literature reporting data on implementation and usefulness of various modalities of telemedicine during the current pandemic. We summarized the included studies according to field and mode of implementation in a narrative way. RESULTS: We included 45 studies that fulfilled selection criteria. About 38% of the studies were conducted in the United States of America (USA), followed by 15.5% in India and 15.5% in China. Most studies (73%) were cross-sectional studies based on historical records. All publications were written in English with the exception of 1 studied published in Spanish. The majority of reports focused on use of telemedicine for outpatient care, followed by in-hospital care. CONCLUSION: The COVID-19 pandemic has promoted the use of telemedicine, a tool that has transformed the provision of medical services. Several modes of implementation are useful to overcome difficulties for patient care during the pandemic. Its benefits are specific to different fields of medical practice. Such benefits, along with the guidance and reported experiences should invite health systems to work for an effective and comprehensive implementation of telemedicine in various fields.

Incidence and Effect of Diabetes Insipidus in the Acute Care of Patients with Severe Traumatic Brain Injury.

BACKGROUND: Literature on diabetes insipidus (DI) after severe traumatic brain injury (TBI) is scarce. Some studies have reported varying frequencies of DI and have showed its association with increased mortality, suggesting it as a marker of poor outcome. This knowledge gap in the acute care consequences of DI in severe TBI patients led us to conceive this study, aimed at identifying risk factors and quantifying the effect of DI on short-term functional outcomes and mortality. METHODS: We assembled a historic cohort of adult patients with severe TBI (Glasgow Coma Scale ≤ 8) admitted to the intensive care unit (ICU) of a tertiary-care university hospital over a 6-year period. Basic demographic characteristics, clinical information, imaging findings, and laboratory results were collected. We used logistic regression models to assess potential risk factors for the development of DI, and the association of this condition with death and unfavorable functional outcomes [modified Rankin scale (mRS)] at hospital discharge. RESULTS: A total of 317 patients were included in the study. The frequency of DI was 14.82%, and it presented at a median of 2 days (IQR 1-3) after ICU admission. Severity according to the Abbreviated Injury Scale (AIS) score of the head, intracerebral hemorrhage, subdural hematoma, and skull base fracture was suggested as risk factors for DI. Diagnosis of DI was independently associated death (OR 4.34, CI 95% 1.92-10.11, p = 0.0005) and unfavorable outcome (modified Rankin Scale = 4-6) at discharge (OR 7.38; CI 95% 2.15-37.21, p = 0.0047). CONCLUSIONS: Diabetes insipidus is a frequent and early complication in patients with severe TBI in the ICU and is strongly associated with increased mortality and poor short-term outcomes. We provide clinically useful risk factors that will help detect DI early to improve prognosis and therapy of patients with severe TBI.

A Scoping Review of Peer Support Writing Groups in Academic Medicine as a Valuable Tool for Physician-Scientists in the Publish or Perish Era.

In designing and implementing a peer support writing group for junior researchers at our home institution, we saw an opportunity to advance the understanding of this intervention as a valuable tool for future physician-scientists. We, therefore, performed a scoping literature review of the available literature on peer support writing groups in clinical disciplines to learn what has been described about this topic. We paid specific attention to the characteristics, implementation, and impact of these groups on the academic development of medical/healthcare scientists. We performed a scoping literature review following the conceptual framework proposed by Arksey and O'Malley. We included studies describing the characteristics, implementation, and impact/effects of peer support writing groups in clinical disciplines. All the information extracted was summarized descriptively to chart the available literature on peer support writing groups in clinical disciplines. We identified a total of 369 articles, of which six were finally included. The absolute number of papers published increased considerably after the participation in the peer support writing groups. The subjective comments of the participating individuals highlighted the positive effects of these groups on the academic productivity of attendees. Available information shows a significant increase in the absolute number of publications and a positive perception between individuals participating in peer support writing groups. Stakeholders should implement this strategy in their home academic institutions.