Subcutaneous emphysema and pneumomediastinum in patients with COVID-19 disease; case series from a tertiary care hospital in Pakistan.

Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23-75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. Eight out of ten patients had spontaneous pneumomediastinum on their initial chest x-ray in the emergency department. The median duration of assisted ventilation before the development of SE was 5.5 days (interquartile range, 5-10 days). The highest positive end-expiratory pressure (PEEP) was 10 cmH2O for patients recieving invasive mechanical ventilation, while 8 cmH2O was the average PEEP in patients who had developed subcutaneous emphysema on non-invasive ventilation. All patients received corticosteroids while six also received tocilizumab, and seven received convalescent plasma therapy, respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8-25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to COVID-19 triggered by the use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and SE whenever present, is associated with poor outcome in critically ill COVID-19 ARDS patients.

Asthma knowledge and approach among Pakistani family physicians and the impact of an educational programme.

OBJECTIVES: To assess asthma knowledge and approach among Pakistani family physicians and the impact of an educational programme. DESIGN: A total of 89 family physicians attending a continuing medical education programme were evaluated using a 17-item questionnaire before and after a lecture and seminar-based educational programme. Three scores -- total score (TSc), knowledge subscore (KSc) and approach subscore (ASc) -- were calculated before and after the course. RESULTS: A total of 82 (92%) family physicians completed the questionnaire. A minimum TSc of > or =9 was achieved by 57% physicians before the course; this increased to 78% after the course. Physicians with < or =10 years since graduation achieved a higher baseline TSc than those who had graduated > or =20 years previously. The latter group showed a larger post-course improvement. Analysis of individual questions disclosed that 79% of family physicians were unable to assess the empirical risk of asthma in an unborn child, 61% were unable to correctly classify/treat Stage 2 asthma and a similar number peak expiratory flow rate (PEFR) (l/min) based acute asthma exacerbation. Reassuringly, 97% correctly identified clinical signs and 87% life-threatening features of asthma. CONCLUSION: Of all family physicians who responded to the questionnaire, 57% achieved acceptable baseline standards. Deficiencies regarding areas such as genetic counselling and disease severity assessment were observed. Strengths in identifying clinical signs and life-threatening features were evident. Continuing medical education resulted in a significant improvement in the post-course assessment, regardless of the years since graduation.

Smoking habits and beliefs of future physicians of Pakistan.

OBJECTIVE: To assess the habits, knowledge and attitudes towards smoking among Pakistani medical students. METHODS: A cross-sectional study was conducted from March 2004 to July 2005 at three medical colleges using a World Health Organization (WHO) questionnaire. A total of 1,029 medical students participated in the study. RESULTS: The prevalence of smoking was found to be 11.2%. Smoking was more prevalent among males, hostel residents and first year medical students. Almost half of the smokers had tried to quit smoking. A family member or a friend was considered to be the most likely person to help quit smoking. The majority believed that passive smoking was harmful to health and were generally supportive of legislative measures to reduce tobacco use, such as the restriction of smoking in public places and the prohibition of sale of tobacco to children. Lesser but significant numbers thought that there should be a complete ban on smoking advertisements and that the price of tobacco products should be increased. CONCLUSION: The study shows a high prevalence of tobacco use in future physicians in spite of adequate knowledge about and a satisfactory attitude towards smoking.

Trends in hospital-based management of acute asthma from a teaching hospital in South Asia.

The aim of this study is to evaluate the hospital-based management of acute asthma in south Asia and to compare practices over a 10-year period. Adult patients (n = 102) admitted at a teaching hospital with acute asthma were studied. Documentation of precipitating factors, family history and physical signs were inadequate in more than half of patients. Pulse oximetry was documented in 95 (93%) patients, but peak flow monitoring was performed only in 50 (49%) patients. Ten-year trend showed deterioration in history and physical examination skills, under use of peak flow readings, and poor pre-discharge instructions. Some aspects of improved care included frequent use of pulse oximeter, preference of inhaled over systemic bronchodilators and increased use of systemic steroids. Significant deficiencies were identified in hospital-based management of acute asthma. Most aspects of asthma care continued to fall short of asthma guidelines.