Idiopathic recurrent serositis-Off the beaten track.

A 63-year-old female presented with chest pain and fever, and was found to have recurrent pleuropericardial effusions. Extensive investigations including infection screen and serologies, autoimmune screen and pleural and pericardial biopsy revealed no secondary aetiologies. She was diagnosed with idiopathic recurrent serositis (IRS). Our patient developed rash to naproxen, so she was started on colchicine monotherapy and responded well clinically. A review of the literature demonstrated that pleuropericardial effusions are rare occurrences, with patients occasionally being perceived as a medical enigma. This case study recommends an approach to guide physicians in their diagnosis and management of patients with pleuropericardial syndrome. Our case had an inflammatory phenotype, either autoimmune or seronegative serositis of unclear aetiology, which was recurrent and required pharmacological treatment. While the treatment for IRS lies in combined therapy with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and colchicine, monotherapy with colchicine was effective in the treatment and preventing recurrence in our unique case.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Setting-specific Transmission Rates: A Systematic Review and Meta-analysis.

BACKGROUND: Understanding the drivers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission is crucial for control policies, but evidence of transmission rates in different settings remains limited. METHODS: We conducted a systematic review to estimate secondary attack rates (SARs) and observed reproduction numbers (Robs) in different settings exploring differences by age, symptom status, and duration of exposure. To account for additional study heterogeneity, we employed a beta-binomial model to pool SARs across studies and a negative-binomial model to estimate Robs. RESULTS: Households showed the highest transmission rates, with a pooled SAR of 21.1% (95% confidence interval [CI]:17.4-24.8). SARs were significantly higher where the duration of household exposure exceeded 5 days compared with exposure of ≤5 days. SARs related to contacts at social events with family and friends were higher than those for low-risk casual contacts (5.9% vs 1.2%). Estimates of SARs and Robs for asymptomatic index cases were approximately one-seventh, and for presymptomatic two-thirds of those for symptomatic index cases. We found some evidence for reduced transmission potential both from and to individuals younger than 20 years of age in the household context, which is more limited when examining all settings. CONCLUSIONS: Our results suggest that exposure in settings with familiar contacts increases SARS-CoV-2 transmission potential. Additionally, the differences observed in transmissibility by index case symptom status and duration of exposure have important implications for control strategies, such as contact tracing, testing, and rapid isolation of cases. There were limited data to explore transmission patterns in workplaces, schools, and care homes, highlighting the need for further research in such settings.

Ministry of Health Clinical Practice Guidelines: Prevention, Diagnosis and Management of Tuberculosis

The Ministry of Health (MOH) has developed the clinical practice guidelines on Prevention, Diagnosis and Management of Tuberculosis to provide doctors and patients in Singapore with evidence-based treatment for tuberculosis. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Prevention, Diagnosis and Management of Tuberculosis, for the information of SMJ readers. The chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Achieving optimal clinical outcomes in ultrasound-guided central venous catheterizations of the internal jugular vein after a simulation-based training program for novice learners.

INTRODUCTION: The aim of this study was to determine the number of ultrasound-guided (USG) central venous catheterization (CVC) of the internal jugular vein (IJV) residents had to perform, after a simulation-based training program, to achieve optimal clinical outcomes. METHODS: We conducted a single-center, prospective, observational study in the medical intensive care unit of a university-affiliated teaching hospital. Residents participated in a formal training program, consisting of a simulation-based workshop and 5 supervised USG CVC insertions on patients. Subsequent USG CVC of the IJV performed by residents during their rotation were assessed. Data on the overall success (OS), first pass success (FP) and mechanical complication (MC) rates were serially collected over 2 years, spanning 4 cohorts of residents. RESULTS: Thirty-two residents performed a total of 337 USG CVC of the IJV. Residents had previously performed an average of 9 CVC via the landmark technique. None had performed USG CVC before. Results showed that residents improved in their OS, FP, and MC rates as they performed more USG CVC. Residents needed to perform 7 USG CVCs to achieve optimal clinical outcomes of high OS and FP as well as low MC rates. There was a significant improvement in OS, FP, and MC rates for the eighth and subsequent USG CVCs compared with the first 7 USG CVCs (82% vs. 99% [P < 0.001], 70% vs. 92% [P < 0.001] and 11% vs. 0%, respectively). CONCLUSIONS: After a formal training program consisting of a simulation-based workshop and 5 supervised USG CVCs on critically ill adults, residents were able to achieve optimal clinical outcomes after performing 7 procedures.

Clinical characteristics and outcome of severe melioidosis requiring intensive care.

STUDY OBJECTIVE: To describe the clinical characteristics and outcome of patients with severe melioidosis requiring intensive care. DESIGN: Retrospective chart review. SETTING: Two ICUs from a tertiary-care teaching hospital. PATIENTS: Twenty-seven adult ICU patients with microbiologically documented melioidosis. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The median age was 59 years with a male preponderance (26:1). Twenty patients (74%) had medical comorbidities, with diabetes mellitus being the most common (59.3%). Almost all patients (96.3%) were bacteremic. Twenty patients (74.1%) presented with pneumonia. Twenty patients (74.1%) were in septic shock, and 16 patients (59.3%) had ARDS. Twelve patients (44.4%) required hemodialysis. The patients had a median of three organ dysfunctions, and the median APACHE (acute physiology and chronic health evaluation) II score was 27. The overall mortality was 48.1%. Mortality among patients with septic shock was 60%. The median ICU length of stay for survivors and nonsurvivors was 11 days and 2 days, respectively. Multivariate analysis revealed that the number of organ dysfunctions is an independent predictor of mortality (odds ratio, 8.2; 95% confidence interval, 1.3 to 51.4). CONCLUSIONS: The outcome of severe melioidosis requiring intensive care is poor, with death being predicted by the number of organ dysfunctions.