High Post-Infection Protection after COVID-19 among Healthcare Workers: A Population-Level Observational Study.

Background: Even though a few years have passed since the coronavirus disease 2019 (COVID-19) outbreak, information regarding certain aspects of the disease, such as post-infection immunity, is still quite limited. This study aimed to evaluate post-infection protection and COVID-19 features among healthcare workers (HCWs), during three successive surges, as well as the rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reinfection, reactivation, re-positivity, and severity. Methods: This cross-sectional population-level observational study was conducted from 20 April 2020 to 18 February 2021. The study population included all HCWs in public or private hospitals in Fars Province, Southern Iran. The infection rate was computed as the number of individuals with positive polymerase chain reaction (PCR) tests divided by the total number of person-days at risk. The re-infection was evaluated after 90 days. Results: A total of 30,546 PCR tests were performed among HCWs, of which 13,749 (61.94% of total HCWs) were positive. Considering the applied 90-day threshold, there were 44 (31.2%) cases of reactivation and relapse, and 97 (68.8% of infected and 1.81% of total HCWs) cases of reinfection among 141 (2.64%) diagnosed cases who experienced a second episode of COVID-19. There was no significant difference in symptoms (P=0.65) or the necessity for ICU admission (P=0.25). The estimated protection against repeated infection after a previous SARS-CoV-2 infection was 94.8% (95% CI=93.6-95.7). Conclusion: SARS-CoV-2 re-positivity, relapse, and reinfection were rare in the HCW population. After the first episode of infection, an estimated 94.8% protection against recurring infections was achieved. A preprint version of this manuscript is available at DOI:10.21203/rs.3.rs-772662/v1 (https://www.researchsquare.com/article/rs-772662/v1).

Does red blood cell transfusion affect clinical outcomes in critically ill patients? A report from a large teaching hospital in south Iran.

BACKGROUND: Despite the beneficial effects, RBC transfusion can be associated with infectious and non-infectious complications in critically ill patients. OBJECTIVES: Investigate current RBC transfusion practices and their effect on the clinical outcomes of patients in intensive care units (ICUs). DESIGN: Retrospective observational study. SETTING: Three mixed medical-surgical adult ICUs of a large academic tertiary hospital. PATIENTS AND METHODS: From March 2018 to February 2020, all adult patients admitted to medical or surgical ICU. Patients who received one or more RBC transfusions during the first month of ICU admission were included in the "transfusion" group, while the remaining patients were assigned to the "non-transfusion" group. MAIN OUTCOME MEASURES: Mortality and length of ICU and hospital stay. SAMPLE SIZE: 2159 patients. RESULTS: Of 594 patients who recieved transfusions, 27% of patients received red blood cell (RBC) products. The mean pre-transfusion hemoglobin (Hb) level was 8.05 (1.46) g/dL. There was a significant relationship between higher APACHE II scores and ICU mortality in patients with Hb levels of 7-9 g/dL (OR adjusted=1.05). Also, ICU mortality was associated with age (OR adjusted=1.03), APACHE II score (OR adjusted=1.08), and RBC transfusion (OR adjusted=2.01) in those whose Hb levels were >9 (g/dl). CONCLUSION: RBC transfusion was associated with an approximately doubled risk of ICU mortality in patients with Hb>9 g/dL. High APACHE II score and age increase the chance of death in the ICU by 8% and 3%, respectively. Hence, ICU physicians should consider a lower Hb threshold for RBC transfusion, and efforts must be made to optimize RBC transfusion practices. LIMITATIONS: Single-center and retrospective study.

Ultrasonographic evaluation of diaphragm thickness and excursion: correlation with weaning success in trauma patients: prospective cohort study.

PURPOSE: Prolonged mechanical ventilation (MV) subjects multiple trauma patients to ventilator-induced diaphragmatic dysfunction. There is limited evidence on the predictive role of diaphragm ultrasound (DUS) for weaning success in multiple trauma patients. Therefore, we evaluated Ultrasound of the diaphragm as a valuable indicator of weaning outcomes, in trauma patients. MATERIAL AND METHODS: This prospective cohort study included 50 trauma patients from September 2018 to February 2019. DUS was performed twice: upon ICU admission and the first weaning attempt. The diagnostic accuracy of indexes was evaluated by ROC curves. RESULTS: The study included patients with a mean age of 35.4 ± 17.37, and 78% being male. The median injury severity score was 75 (42-75). The failure group exhibited significantly lower right diaphragmatic excursion (DE) compared to the success group (P = 0.006). In addition, the failure group experienced a significant decrease in both right and left DE from admission to the first attempt of weaning from MV (P < 0.001). Both groups showed a significant decrease in inspiratory and expiratory thickness on both sides during weaning from MV compared to the admission time (P < 0.001). The findings from the ROC analysis indicated that the Rapid shallow breathing index (RSBI) (Sensitivity = 91.67, Specificity = 100), respiratory rate (RR)/DE (Right: Sensitivity = 87.5, Specificity = 92.31), and RR/TF (Thickening Fraction) (Right: Sensitivity = 83.33, Specificity = 80.77) demonstrated high sensitivity and specificity in predicting weaning outcome. CONCLUSION: In the context of patients with multiple trauma, employing DUC and assessing diaphragmatic excursion, thickness, RR/DE index, RR/TF index, and RSBI can aid in determining successful ventilator weaning.

Association Between Neutrophil Density and Survival in Trauma Patients Admitted to the Intensive Care Unit; a Retrospective Cohort Study.

Introduction: Altered immune responses, in particular neutrophil changes, are perceived to play a key role in immune responses to trauma. This study aimed to evaluate the association of neutrophil changes with patients' survival in severe multiple trauma cases. Methods: The current retrospective cohort study was conducted using data from patients admitted in the intensive care unit (ICU) of a trauma center in Shiraz, Iran, between 2016 and 2021. Patients were divided into three groups (i.e., normal, neutropenia, and neutrophilia) based on neutrophil count at the time of ICU admission, and the association of neutrophil count with in-hospital mortality was analyzed. Results: 2176 patients with the mean age of 37.90 ± 18.57 years were evaluated (84.04% male). The median trauma severity based on injury severity score (ISS) in this series was 9 (4 -17). Patients were divided in to three groups of neutrophilia (n = 1805), normal (n = 357), and neutropenia (n = 14). There were not any significant differences between groups regarding age distribution (p = 0.634), gender (p = 0.544), and trauma severity (p = 0.197). The median survival times for the normal, neutropenia, and neutrophilia groups were 49 (IQR: 33 -47) days, 51 (IQR: 8- 51) days, and 38 (IQR: 26 - 52) days, respectively (p = 0.346). The log-rank test showed a statistically significant difference between the three groups adjustment for ISS (p ≤ 0.001). For each unit increase in ISS, the hazard ratio increased by 2%. In ISS 9-17, the hazard ratio increased by 11% compared to ISS<4. Also, in ISS>17, the hazard ratio increased by 76% compared to ISS<4 in ICU-hospitalized patients. Conclusions: In general, the findings of the present study showed that the survival rate of patients in the normal group after ISS adjustment was higher than the other two groups. Also, the Cox model showed that the mortality risk ratio in the neutropenia group was 15 times higher than the normal group.

Prediction prolonged mechanical ventilation in trauma patients of the intensive care unit according to initial medical factors: a machine learning approach.

The goal of this study was to develop a predictive machine learning model to predict the risk of prolonged mechanical ventilation (PMV) in patients admitted to the intensive care unit (ICU), with a focus on laboratory and Arterial Blood Gas (ABG) data. This retrospective cohort study included ICU patients admitted to Rajaei Hospital in Shiraz between 2016 and March 20, 2022. All adult patients requiring mechanical ventilation and seeking ICU admission had their data analyzed. Six models were created in this study using five machine learning models (PMV more than 3, 5, 7, 10, 14, and 23 days). Patients' demographic characteristics, Apache II, laboratory information, ABG, and comorbidity were predictors. This study used Logistic regression (LR), artificial neural networks (ANN), support vector machines (SVM), random forest (RF), and C.5 decision tree (C.5 DT) to predict PMV. The study enrolled 1138 eligible patients, excluding brain-dead patients and those without mechanical ventilation or a tracheostomy. The model PMV > 14 days showed the best performance (Accuracy: 83.63-98.54). The essential ABG variables in our two optimal models (artificial neural network and decision tree) in the PMV > 14 models include FiO2, paCO2, and paO2. This study provides evidence that machine learning methods outperform traditional methods and offer a perspective for achieving a consensus definition of PMV. It also introduces ABG and laboratory information as the two most important variables for predicting PMV. Therefore, there is significant value in deploying such models in clinical practice and making them accessible to clinicians to support their decision-making.

Unintended impact of COVID-19 pandemic on the rate of catheter related nosocomial infections and incidence of multiple drug resistance pathogens in three intensive care units not allocated to COVID-19 patients in a large teaching hospital.

BACKGROUND: The prevalence of resistant hospital infections in the intensive care unit (ICU) increases mortality and antibiotic resistance. COVID-19 pandemic may have unintended impact on nosocomial infections (NI) and the prevalence of resistant microorganism. METHODOLOGY: The present non-interventional study was performed by a pre and a post survey each lasting 8 months before (March-October 2019) and after (March-October 2020) the onset of COVID-19 pandemic in three ICU's, not allocated to COVID-19 patients, in Nemazee Hospital, Shiraz, Iran. The rates of the following nosocomial infections were compared at pre- and post-pandemic period: ventilator associated pneumonia (VAP), central line associated blood stream infection (CLABSI), catheter-associated urinary tract infections (CAUTI) and incidence of multiple drug resistance (MDR) pathogens. RESULTS: Pre-pandemic and pandemic incidence of VAP was 23.5 and 17.2 cases per 1000 device-days, respectively; an absolute decrease of 27%. The main reason for the decrease in the rate of VAP during the pandemic was a significant decrease in the rate of VAP caused by Acinetobacter baumannii; from 39 to 17% in total VAP episodes. The rate of VAP associated with other microorganisms remained relatively unchanged from 14.2 cases in pre-pandemic period to 14.3 cases per 1000 MV-days during the pandemic (P = 0.801). Pre-pandemic incidence of CLABSI was 7.3 cases and, in pandemic period, was 6.5 cases per 1000 device-days (IRR = 0.88, 95% CI 0.43-1.73, P = 0.703). Pre-pandemic incidence of CAUTI was 2 and in pandemic period, was 1.4 cases per 1000 device-days (IRR = 0.70, 95% CI 0.22-1.98, P = 0.469). CONCLUSION: The results of the present study showed a decrease in the incidence of VAP in critically ill non-COVID-19 patients during the pandemic compared to before the pandemic, especially regarding Acinetobacter baumannii.

The Effectiveness of the Intermediate and Therapeutic Doses of Enoxaparin in COVID-19 Patients: A Comparative Study of Factor Xa Inhibition.

BACKGROUND: Management of anticoagulant therapy in COVID-19 patients is critical. Low-molecular-weight heparin (LMWH) thromboprophylaxis is already recommended, and anti-Factor Xa (anti-FXa) monitoring has been used to titrate LMWH doses. METHODS: Through a cross-sectional study, we evaluated anti-FXa activity in patients admitted to the ICU, receiving intermediate dose (30, 40, 50 mg, subcutaneously [SC], twice daily) or therapeutic dose (1 mg/kg, SC, Q12h) of enoxaparin to find whether the patients in these two groups achieved anti-FXa levels in the accepted thromboprophylaxis range. RESULTS: The occurrence of deep vein thrombosis was 26% in the therapeutic-dose group and 17% in the intermediate-dose group. D-dimer values were nearly 3.5-fold higher in those who received a therapeutic dose of anticoagulants than in those who received intermediate-dose thromboprophylaxis. Patients in the therapeutic-dose group had significantly higher IL-6 levels (p ≤ 0.001). More than one-third of the patients in the therapeutic-dose group (n = 8; 42.18%) and approximately half of the patients in the intermediate-dose group (n = 12; 52.2%) achieved the target range level of anti-FXa. Patients who received therapeutic doses were more likely to have anti-FXa levels above the expected range (47.4 vs 13% in the intermediate-dose group; p < 0.05). CONCLUSION: Therapeutic dose of enoxaparin in critically ill COVID-19-infected patients did not reduce the incidence of thromboembolic events and, on the other hand, may predispose these patients to increased risk of bleeding by increasing anti-FXa activity above the desired level. Administration of intermediate-dose thromboprophylaxis is suggested to achieve anti-FXa levels in the accepted thromboprophylaxis range.

The clinical and paraclinical effectiveness of four-hour infusion vs. half-hour infusion of high-dose ampicillin-sulbactam in treatment of critically ill patients with sepsis or septic shock: An assessor-blinded randomized clinical trial.

PURPOSE: This study was conducted to determine whether critically ill patients admitted to the intensive care unit (ICU) with sepsis and septic shock may benefit from extended infusion of ampicillin/sulbactam compared with those receiving intermittent infusion. MATERIAL AND METHODS: This randomized assessor-blinded clinical trial was conducted in the ICUs of Nemazee and Shahid Rajaee hospital, Shiraz, Iran, from August 2019 to August 2021. The participants randomly received 9 g Ampicillin/Sulbactam every 8 h by either extended (infused over 4 h) or intermittent (infused over 30 min) intravenous infusion if their estimated glomerular filtration rate based on Cockrorft-Gault formula was higher than 60 ml/min. RESULTS: Totally, 136 patients were enrolled and allocated to the intervention and control groups, each with 68 patients. Clinical cure was significantly higher in the extended group (P = 0.039), but ICU and hospital length of stay did not differ between the groups (P = 0.87 and 0.83, respectively). The ICU (P = 0.031) and hospital (P = 0.037) mortality rates in the extended infusion group were significantly lower than those in the intermittent infusion group. CONCLUSION: These data should be replicated in larger clinical trials before providing any recommendation in favor of this method of administration in clinical practice.

Trauma and COVID-19: Clinical and Paraclinical similarities between Trauma Patients with Positive and Negative PCR Tests.

Objective: To compare clinical and paraclinical similarities between trauma patients with positive RT-PCR tests (PCR+ve) and the RT-PCR negative ones (PCR -ve). Methods: This a case-control study, where cases had a PCR+ve and controls had a negative result. Two groups were compared regarding (para) clinical values. Multivariable binary logistic regression analysis investigated the variables predicting COVID-19 and the mortality rate. Results: Both groups were similar regarding the clinical findings and comorbidities (p>0.05). PCR+ve group had lower lymphocyte count (1.41 [1.45] vs. 1.66 [1.61], p=0.030), CPK level (411 [928.75] vs. 778 [1946.5]. p=0.006) and CRP level (17 [42.5] vs. 24 [50.75], p=0.004). However, none of these findings were significant in the multivariable analysis. Finally, PCR+ve group had increased odds of death (OR=2.88; 95% CI=1.22-7.41). Conclusion: Unlike our primary hypothesis, the study failed to mark any significant (para) clinical features guiding us to detect COVID-19 earlier in trauma patients. Moreover, the PCR+ve group is at increased mortality risk. A larger, multicentric prospective study should be designed to address this issue.

Pharmacokinetic assessment of vancomycin in critically ill patients and nephrotoxicity prediction using individualized pharmacokinetic parameters.

Introduction: Therapeutic drug monitoring (TDM) and pharmacokinetic assessments of vancomycin would be essential to avoid vancomycin-associated nephrotoxicity and obtain optimal therapeutic and clinical responses. Different pharmacokinetic parameters, including trough concentration and area under the curve (AUC), have been proposed to assess the safety and efficacy of vancomycin administration. Methods: Critically ill patients receiving vancomycin at Nemazee Hospital were included in this prospective study. Four blood samples at various time intervals were taken from each participated patient. Vancomycin was extracted from plasma samples and analyzed using a validated HPLC method. Results: Fifty-three critically ill patients with a total of 212 blood samples from June 2019 to June 2021 were included in this study. There was a significant correlation between baseline GFR, baseline serum creatinine, trough and peak concentrations, AUCτ, AUC24h, Cl, and Vd values with vancomycin-induced AKI. Based on trough concentration values, 66% of patients were under-dosed (trough concentration <15 µg/ml) and 18.9% were over-dosed (trough concentration ≥20 µg/ml). Also, based on AUC24h values, about 52.2% were under-dosed (AUC24h < 400 µg h/ml), and 21.7% were over-dosed (AUC24h > 600 µg h/ml) that emphasizes on the superiority of AUC-based monitoring approach for TDM purposes to avoid nephrotoxicity occurrence. Conclusion: The AUC-based monitoring approach would be superior in terms of nephrotoxicity prediction. Also, to avoid vancomycin-induced AKI, trough concentration and AUCτ values should be maintained below the cut-off points.

Predictors of Intensive Care Unit Admission in Patients with Confirmed Coronavirus Disease 2019: A Cross-Sectional Study.

Background: The coronavirus disease 2019 (COVID-19) has become the leading source of pneumonia outbreaks in the world. The present study aimed to compare the condition of intensive care unit (ICU) and non-ICU COVID-19 patients in terms of epidemiological and clinical features, laboratory findings, and outcomes in three cities across Iran. Methods: In a cross-sectional study, 195 COVID-19 patients admitted to five hospitals across Iran during March-April 2020 were recruited. Collected information included demographic data, laboratory findings, symptoms, medical history, and outcomes. Data were analyzed using SPSS software with t test or Mann-Whitney U test (continuous data) and Chi square test or Fisher's exact test (categorical variables). P<0.05 was considered statistically significant. Results: Of the 195 patients, 57.4% were men, and 67.7% had at least one comorbidity. The prevalence of stroke, chronic obstructive pulmonary disease, and autoimmune diseases was higher in ICU than in non-ICU patients (P=0.042, P=0.020, and P=0.002, respectively). Compared with non-ICU, ICU patients had significantly higher white blood cell (WBC) count (P=0.008), cardiac troponin concentrations (P=0.040), lactate dehydrogenase levels (P=0.027), erythrocyte sedimentation rates (P=0.008), and blood urea nitrogen (BUN) (P=0.029), but lower hematocrit levels (P=0.001). The mortality rate in ICU and non-ICU patients was 48.1% and 6.1%, respectively. The risk factors for mortality included age>40 years, body mass index<18 Kg/m2, hypertension, coronary artery disease, fever, cough, dyspnea, ST-segment changes, pericardial effusion, and a surge in WBC and C-reactive protein, aspartate aminotransferase, and BUN. Conclusion: A high index of suspicion for ICU admission should be maintained in patients with positive clinical and laboratory predictive factors.

Prediction of Patients with COVID-19 Requiring Intensive Care: A Cross-sectional Study Based on Machine-learning Approach from Iran.

Background: Prioritizing the patients requiring intensive care may decrease the fatality of coronavirus disease-2019 (COVID-19). Aims and objectives: To develop, validate, and compare two models based on machine-learning methods for predicting patients with COVID-19 requiring intensive care. Materials and methods: In 2021, 506 suspected COVID-19 patients, with clinical presentations along with radiographic findings, were laboratory confirmed and included in the study. The primary end-point was patients with COVID-19 requiring intensive care, defined as actual admission to the intensive care unit (ICU). The data were randomly partitioned into training and testing sets (70% and 30%, respectively) without overlapping. A decision-tree algorithm and multivariate logistic regression were performed to develop the models for predicting the cases based on their first 24 hours data. The predictive performance of the models was compared based on the area under the receiver operating characteristic curve (AUC), sensitivity, and accuracy of the models. Results: A 10-fold cross-validation decision-tree model predicted cases requiring intensive care with the AUC, accuracy, and sensitivity of 97%, 98%, and 94.74%, respectively. The same values in the machine-learning logistic regression model were 75%, 85.62%, and 55.26%, respectively. Creatinine, smoking, neutrophil/lymphocyte ratio, temperature, respiratory rate, partial thromboplastin time, white blood cell, Glasgow Coma Scale (GCS), dizziness, international normalized ratio, O2 saturation, C-reactive protein, diastolic blood pressure (DBP), and dry cough were the most important predictors. Conclusion: In an Iranian population, our decision-based machine-learning method offered an advantage over logistic regression for predicting patients requiring intensive care. This method can support clinicians in decision-making, using patients' early data, particularly in low- and middle-income countries where their resources are as limited as Iran. How to cite this article: Sabetian G, Azimi A, Kazemi A, Hoseini B, Asmarian N, Khaloo V, et al. Prediction of Patients with COVID-19 Requiring Intensive Care: A Cross-sectional Study based on Machine-learning Approach from Iran. Indian J Crit Care Med 2022;26(6):688-695. Ethics approval: This study was approved by the Ethical Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1399.018).

Comparison of chest CT scan findings between COVID-19 and pulmonary contusion in trauma patients based on RSNA criteria: Established novel criteria for trauma victims.

PROPOSE: In this study, we re-assessed the criteria defined by the radiological society of North America (RSNA) to determine novel radiological findings helping the physicians differentiating COVID-19 from pulmonary contusion. METHODS: All trauma patients with blunt chest wall trauma and subsequent pulmonary contusion, COVID-19-related signs and symptoms before the trauma were enrolled in this retrospective study from February to May 2020. Included patients (Group P) were then classified into two groups based on polymerase chain reaction tests (Group Pa for positive patients and Pb for negative ones). Moreover, 44 patients from the pre-pandemic period (Group PP) were enrolled. They were matched to Group P regarding age, sex, and trauma-related scores. Two radiologists blindly reviewed the CT images of all enrolled patients according to criteria defined by the RSNA criteria. The radiological findings were compared between Group P and Group PP; statistically significant ones were re-evaluated between Group Pa and Group Pb thereafter. Finally, the sensitivity and specificity of each significant findings were calculated. The Chi-square test was used to compare the radiological findings between Group P and Group PP. RESULTS: In the Group PP, 73.7% of all ground-glass opacities (GGOs) and 80% of all multiple bilateral GGOs were detected (p < 0.001 and p = 0.25, respectively). Single bilateral GGOs were only seen among the Group PP. The Chi-square tests showed that the prevalence of diffused GGOs, multiple unilateral GGOs, multiple consolidations, and multiple bilateral consolidations were significantly higher in the Group P (p = 0.001, 0.01, 0.003, and 0.003, respectively). However, GGOs with irregular borders and single consolidations were more significant among the Group PP (p = 0.01 and 0.003, respectively). Of note, reticular distortions and subpleural spares were exclusively detected in the Group PP. CONCLUSION: We concluded that the criteria set by RSNA for the diagnosis of COVID-19 are not appropriate in trauma patients. The clinical signs and symptoms are not always useful either. The presence of multiple unilateral GGOs, diffused GGOs, and multiple bilateral consolidations favor COVID-19 with 88%, 97.62%, and 77.7% diagnostic accuracy.

Which criteria is a better predictor of ICU admission in trauma patients? An artificial neural network approach.

PURPOSE: One of the most critical concerns in the intensive care unit (ICU) section is identifying the best criteria for entering patients to this part. This study aimed to predict the best compatible criteria for entering trauma patients in the ICU section. METHOD: The present study was a historical cohort study. The data were collected from 2448 trauma patients referring to Shahid Rajaee Hospital between January 2015 and January 2017 in Shiraz, Iran. The artificial neural network (ANN) models with cross-validation and logistic regression (LR) with a backward method was used for data analysis. The final analysis was performed on a total of 958 patients who were transferred to the ICU section. RESULTS: Based on the present results, the motor component of the GCS score at each cutoff point had the highest importance. The results also showed better performance for the AUC and accuracy rate for ANN compared with LR. CONCLUSION: The most critical indicators in predicting the optimal use of ICU services in this study were the Motor component of the GCS. Results revealed that the ANN had a better performance than the LR in predicting the main outcomes of the traumatic patients in both the accuracy and AUC index. Trauma section surgeons and ICU specialists will benefit from this study's results and can assist them in making decisions to predict the patient outcomes before entering the ICU.

Adequacy of maternal anesthesia depth with two sodium thiopental doses in elective caesarean section: a randomized clinical trial.

BACKGROUND: Administration of an optimal dose of anesthetic agent to ensure adequate depth of hypnosis with the lowest risk of adverse effects to the fetus is highly important in cesarean section. Sodium thiopental (STP) is still the first choice for induction of anesthesia in some countries for this obstetric surgery. We aimed to compare two doses of STP with regarding the depth of anesthesia and the condition of newborn infants. METHODS: In this clinical trial, parturient undergoing elective Caesarian section were randomized into two groups receiving either low-dose (5 mg/kg) or high-dose (7 mg/kg) STP. Muscle relaxation was provided with succinylcholine 2 mg/kg and anesthesia was maintained with O2/N2O and sevoflurane. The depth of anesthesia was evaluated using isolated forearm technique (IFT) and bispectral index (BIS) in various phases. Additionally, infants were assessed using Apgar score and neurobehavioral test. RESULTS: Forty parturient were evaluated in each group. BIS was significantly lower in high-dose group at skin incision to delivery and subcutaneous and skin closure. Also, significant differences were noticed in IFT over induction to incision and incision to delivery. Apgar score was significantly lower in high-dose group at 1 min after delivery. Newborn infants in low-dose group had significantly better outcomes in all three domains of the neurobehavioral test. CONCLUSION: 7 mg/kg STP is superior to 5 mg/kg in creating deeper hypnosis for mothers. However, it negatively impacts Apgar score and neurobehavioral test of neonates. STP seems to has dropped behind as an acceptable anesthetic in Cesarean section. TRIAL REGISTRATION: IRCT No: 2016082819470 N45 , 13/03/2019.

Establishment of a novel triage system for SARS-CoV-2 among trauma victims in trauma centers with limited facilities.

OBJECTIVES: The triage of trauma patients with potential COVID-19 remains a major challenge given that a significant number of patients may be asymptomatic or pre-symptomatic. This study aimed to compare the specificity and sensitivity of available triage systems for COVID-19 among trauma patients. Furthermore, it aimed to develop a novel triage system for SARS-CoV-2 detection among trauma patients in centers with limited resources. METHODS: All patients referred to our center from February to May 2020 were enrolled in this prospective study. We evaluated the SARS-CoV-2 triage protocols from the WHO, the Iranian Ministry of Health and Medical Education (MOHME), and the European Centre for Disease Control and Prevention (ECDC) for their effectiveness in finding COVID-19 infected individuals among trauma patients. We then used these data to design a stepwise triage protocol to detect COVID-19 positive patients among trauma patients. RESULTS: According to our findings, the WHO protocol showed 100% specificity and 13.3% sensitivity. The MOHME protocol had 99% specificity and 23.3% sensitivity. While the ECDC protocol showed 93.3% sensitivity and 89.5% specificity, it did not prioritize patients based on traumatic injuries and unstable conditions. Our stepwise triage protocol, which prioritizes traumatic injuries, had 93.3% sensitivity and 90.3% specificity. CONCLUSION: Our study shows that the triage protocols from the WHO, MOHME and ECDC are not best equipped to diagnose SARS-CoV-2 infected individuals among trauma patients. In our proposed stepwise triage system, patients are triaged according to their hemodynamic conditions, COVID-19 related clinical states, and COVID-19 related laboratory findings. Our triage model can lead to more accurate and resource-effective management of trauma patients with potential COVID-19 infection. LEVEL OF EVIDENCE: Level Ⅲ.

The effect of silymarin on liver enzymes and antioxidant status in trauma patients in the intensive care unit: a randomized double blinded placebo-controlled clinical trial.

AIM OF THE STUDY: This study was conducted to investigate the positive effect of silymarin on liver enzymes and antioxidant status in trauma patients with elevated liver enzymes due to trauma-induced liver injury, admitted to the intensive care unit. MATERIAL AND METHODS: This one-year, randomized, double-blinded, placebo-controlled clinical trial was conducted on 90 trauma patients. The participants were assigned to either receiving Livergol tablets containing 140 mg of silymarin or 140 mg of placebo three times daily for 14 days. Liver enzymes, including aspartate transaminase (AST), alanine transaminase (ALT) and alkaline phosphatase (ALP), were measured at baseline and days 3, 7, 9 and 14 after intervention. Also, antioxidant markers were measured at baseline and day 14 after treatment. RESULTS: Receiving silymarin supplement significantly lowered the liver enzymes, compared to placebo (p < 0.05). The mean serum level of malondialdehyde (MDA) was significantly decreased and the mean serum levels of total antioxidant capacity (TAC) and thiol groups were significantly increased in the silymarin group from baseline to day 14. In the placebo group, mean serum levels of MDA and thiol groups were significantly increased, while serum level of TAC was not significantly changed at day 14, compared to baseline. Also, the mean serum level of MDA was significantly lower, while the serum levels of thiol groups and TAC were significantly higher in the silymarin group. CONCLUSIONS: Silymarin supplementation significantly improved some antioxidant markers (TAC and thiol) and decreased liver enzymes in patients with trauma-induced liver injury.

Evaluation of Chest CT Scan as a Screening and Diagnostic Tool in Trauma Patients with Coronavirus Disease 2019 (COVID-19): A Cross-Sectional Study.

BACKGROUND: The lack of enough medical evidence about COVID-19 regarding optimal prevention, diagnosis, and treatment contributes negatively to the rapid increase in the number of cases globally. A chest computerized tomography (CT) scan has been introduced as the most sensitive diagnostic method. Therefore, this research aimed to examine and evaluate the chest CT scan as a screening measure of COVID-19 in trauma patients. METHODS: This cross-sectional study was conducted in Rajaee Hospital in Shiraz from February to May 2020. All patients underwent unenhanced CT with a 16-slice CT scanner. The CT scans were evaluated in a blinded manner, and the main CT scan features were described and classified into four groups according to RSNA recommendation. Subsequently, the first two Radiological Society of North America (RSNA) categories with the highest probability of COVID-19 pneumonia (i.e., typical and indeterminate) were merged into the "positive CT scan group" and those with radiologic features with the least probability of COVID-19 pneumonia into "negative CT scan group." RESULTS: Chest CT scan had a sensitivity of 68%, specificity of 56%, positive predictive value of 34.8%, negative predictive value of 83.7%, and accuracy of 59.3% in detecting COVID-19 among trauma patients. Moreover, for the diagnosis of COVID-19 by CT scan in asymptomatic individuals, a sensitivity of 100%, specificity of 66.7%, and negative predictive value of 100% were obtained (p value: 0.05). CONCLUSION: Findings of the study indicated that the CT scan's sensitivity and specificity is less effective in diagnosing trauma patients with COVID-19 compared with nontraumatic people.