Pleural effusion in critically ill patients and intensive care setting

Pleural effusion usually causes a diagnostic dilemma with a long list of differential diagnoses.Many studies found a high prevalence of pleural effusions in critically ill and mechanically ventilated patients,with a wide range of variable prevalence rates of up to 50%-60%in some studies.This review emphasizes the importance of pleural effusion diagnosis and management in patients admitted to the intensive care unit(ICU).The original disease that caused pleural effusion can be the exact cause of ICU admission.There is an impairment in the pleural fluid turnover and cycling in critically ill and mechanically ventilated patients.There are also many difficulties in diagnosing pleural effusion in the ICU,including clinical,radiological,and even laboratory difficulties.These difficulties are due to unusual presentation,inability to undergo some diagnostic procedures,and heterogenous results of some of the performed tests.Pleural effusion can affect the patient’s outcome and prognosis due to the hemodynamics and lung mechanics changes in these patients,who usually have frequent comorbidities.Similarly,pleural effusion drainage can modify the ICUadmitted patient’s outcome.Finally,pleural effusion analysis can change the original diagnosis in some cases and redirect the management toward a different way.

Cardiac changes in infants of diabetic mothers

Diabetes mellitus(DM)is a systemic chronic metabolic disorder characterized by increased insulin resistance and/orβ-cell defects.It affects all ages from the foetal life,neonates,childhood to late adulthood.Gestational diabetes is a critical risk factor for congenital heart diseases(CHDs).Moreover,the risk increases with low maternal education,high body mass index at conception,undiagnosed pregestational diabetes,inadequate antenatal care,improper diabetes control,and maternal smoking during pregnancy.Maternal DM significantly affects the foetal heart and foetal-placental circulation in both structure and function.Cardiac defects,myocardial hypertrophy are three times more prevalent in infants of diabetic mothers(IDMs).Antenatal evaluation of the cardiac function and structures can be performed with foetal electrocardiography and echocardiography.Postnatal cardiac evaluation can be performed with natal and postnatal electrocardiography and echocardiography,detection of early atherosclerotic changes by measuring aortic intima-media thickness,and retinal vascular changes by retinal photography.Ameliorating the effects of diabetes during pregnancy on the offspring depends mainly on pregestational and gestational diabetes prevention.However,other measures to reduce the risk,such as using medications,nutritional supplements,or probiotics,still need more research.This review discusses the mechanism of foetal sequels and the risk factors that increase the prevalence of CHDs in gestational DM,the various cardiac outcomes of gestational DM on the foetus and offspring,cardiac evaluation of foetuses and IDMs,and how to alleviate the consequences of gestational DM on the offspring.

Cough as a neurological sign:What a clinician should know

Cough is a common respiratory complaint driving patients to seek medical advice.Besides being a fundamental respiratory sign,it is also a crucial neurological sign.There are three main types of coughs:Reflex cough(typeⅠ),voluntary cough(typeⅡ),and evoked cough(typeⅢ).Cough is a reflex predominantly mediated by control centers in the respiratory areas of the brainstem,modulated by the cerebral cortex.Cough reflex sensitivity could be increased in many neurological disorders such as brainstem space-occupying lesions,medullary lesions secondary to Chiari typeⅠmalformations,tics disorders such as Tourette's syndrome,somatic cough,cerebellar neurodegenerative diseases,and chronic vagal neuropathy due to allergic and non-allergic conditions.Meanwhile,cough sensitivity decreases in multiple sclerosis,brain hypoxia,cerebral hemispheric stroke with a brainstem shock,Parkinson's disease,dementia due to Lewy body disease,amyotrophic lateral sclerosis,and peripheral neuropathy as diabetic neuropathy,hereditary sensory and autonomic neuropathy typeⅣ,vitamin B12,and folate deficiency.Arnold's nerve ear-cough reflex,syncopal cough,cough headache,opioids-associated cough,and cough-anal reflex are signs that could help diagnose underlying neurological conditions.Cough reflex testing is a quick,easy,and cheap test performed during the cranial nerve examination.In this article,we reviewed the role of cough in various neurological disorders that increase or decrease cough sensitivity.

Plasma D-dimer level in early and late-onset neonatal sepsis

BACKGROUND Neonatal sepsis is a life-threatening disease.Early diagnosis is essential,but no single marker of infection has been identified.Sepsis activates a coagulation cascade with simultaneous production of the D-dimers due to lysis of fibrin.Ddimer test reflects the activation of the coagulation system.AIM To assess the D-dimer plasma level,elaborating its clinicopathological value in neonates with early-onset and late-onset neonatal sepsis.METHODS The study was a prospective cross-sectional study that included ninety neonates;divided into three groups:Group I:Early-onset sepsis(EOS);Group II:Late-onset sepsis(LOS);and GroupⅢ:Control group.We diagnosed neonatal sepsis according to our protocol.C-reactive protein(CRP)and D-dimer assays were compared between EOS and LOS and correlated to the causative microbiological agents.RESULTS D-dimer was significantly higher in septic groups with a considerably higher number of cases with positive D-dimer.Neonates with LOS had substantially higher levels of D-dimer than EOS,with no significant differences in CRP.Neonates with LOS had a significantly longer hospitalization duration and higher gram-negative bacteriemia and mortality rates than EOS(P<0.01).Gramnegative bacteria have the highest D-dimer levels(Acinetobacter,Klebsiella,and Pseudomonas)and CRP(Serratia,Klebsiella,and Pseudomonas);while gram-positive sepsis was associated with relatively lower levels.D-dimer had a significant negative correlation with hemoglobin level and platelet count;and a significant positive correlation with CRP,hospitalization duration,and mortality rates.The best-suggested cut-off point for D-dimer in neonatal sepsis was 0.75 mg/L,giving a sensitivity of 72.7%and specificity of 86.7%.The D-dimer assay has specificity and sensitivity comparable to CRP in the current study.CONCLUSION The current study revealed a significant diagnostic value for D-dimer in neonatal sepsis.D-dimer can be used as an adjunct to other sepsis markers to increase the sensitivity and specificity of diagnosing neonatal sepsis.

Bacterial co-infection in patients with SARS-CoV-2 in the Kingdom of Bahrain

BACKGROUND The coronavirus disease 2019(COVID-19)pandemic presents a significant challenge to the medical profession,increasing in the presence of microbial coinfection.Bacterial and Fungal co-infections increase the risk of morbidity and mortality in patients with COVID-19.AIM To study the bacterial profile in patients with COVID-19 who needed admission to receive treatment in the main centres concerned with managing COVID-19 disease in the Kingdom of Bahrain.METHODS The study was a retrospective observational analysis of the bacterial profile and the bacterial resistance in patients with confirmed COVID-19 disease who needed admission to receive treatment in the main centres assigned to manage patients with COVID-19 disease in the Kingdom of Bahrain from February to October 2020.We used the electronic patients’records and the microbiology laboratory data to identify patients’demographics,clinical data,microbial profile,hospital or community-acquired,and the outcomes.RESULTS The study included 1380 patients admitted with confirmed COVID-19 disease during the study period.51%were admitted from February to June,and 49%were admitted from July to October 2020,with a recurrence rate was 0.36%.There was a significant increase in bacterial and fungal co-infection in the second period compared to the first period.The most common isolated organisms were the gram-negative bacteria(mainly Klebsiella pneumoniae,Pseudomonas aeruginosa,multi-drug resistant Acinetobacter baumannii,and Escherichia coli),the grampositive bacteria(mainly coagulase negative Staphylococci,Enterococcus faecium,Enterococcus faecalis,Staphylococcus aureus)and fungaemia(Candida galabrata,Candida tropicalis,Candida albicans,Aspergillus fumigatus,Candida parapsilosis,Aspergillus niger).The hospital-acquired infection formed 73.8%,61.6%,100%gram-negative,gram-positive and fungaemia.Most of the hospital-acquired infection occurred in the second period with a higher death rate than communityacquired infections.CONCLUSION Bacterial and fungal co-infections in patients admitted with confirmed COVID-19 disease pose higher morbidity and mortality risks than those without coinfections.We should perform every effort to minimize these risks.

Gastrointestinal disorders in children with autism:Could artificial intelligence help?

Autism is one of the pervasive neurodevelopmental disorders usually associated with many medical comorbidities.Gastrointestinal(GI)disorders are pervasive in children,with a 46%-84%prevalence rate.Children with Autism have an increased frequency of diarrhea,nausea and/or vomiting,gastroesophageal reflux and/or disease,abdominal pain,chronic flatulence due to various factors as food allergies,gastrointestinal dysmotility,irritable bowel syndrome(IBS),and inflammatory bowel diseases(IBD).These GI disorders have a significant negative impact on both the child and his/her family.Artificial intelligence(AI)could help diagnose and manage Autism by improving children's communication,social,and emotional skills for a long time.AI is an effective method to enhance early detection of GI disorders,including GI bleeding,gastroesophageal reflux disease,Coeliac disease,food allergies,IBS,IBD,and rectal polyps.AI can also help personalize the diet for children with Autism by microbiome modification.It can help to provide modified gluten without initiating an immune response.However,AI has many obstacles in treating digestive diseases,especially in children with Autism.We need to do more studies and adopt specific algorithms for children with Autism.In this article,we will highlight the role of AI in helping children with gastrointestinal disorders,with particular emphasis on children with Autism.

Trends of central line-associated bloodstream infections in the intensive care unit in the Kingdom of Bahrain:Four years’experience

BACKGROUND The central venous line is an essential component in monitoring and managing critically ill patients.However,it poses patients with increased risks of severe infections with a higher probability of morbidity and mortality.AIM To define the trends of the rates of central line-associated bloodstream infections(CLABSI)over four years,its predicted risk factors,aetiology,and the antimicrobial susceptibility of the isolated pathogens.METHODS The study was a prospective case-control study,performed according to the guidelines of the Center for Disease Control surveillance methodology for CLABSI in patients admitted to the adult intensive care unit(ICU)and auditing the implementation of its prevention bundle.RESULTS Thirty-four CLABSI identified over the study period,giving an average CLABSI rate of 3.2/1000 central line days.The infection's time trend displayed significant reductions over time concomitantly with the CLABSI prevention bundle's reinforcement from 4.7/1000 central line days at the beginning of 2016 to 1.4/1000 central line days by 2018.The most frequently identified pathogens causing CLABSI in our ICU were gram-negative organisms(59%).The most common offending organisms were Acinetobacter,Enterococcus,and Staphylococcus epidermidis,each of them accounted for 5 cases(15%).Multidrug-resistant organisms contributed to 56%of CLABSI.Its rate was higher when using femoral access and longer hospitalisation duration,especially in the ICU.Insertion of the central line in the non-ICU setting was another identified risk factor.CONCLUSION Implementing the prevention bundles reduced CLABSI significantly in our ICU.Implementing the CLABSI prevention bundle is crucial to maintain a substantial reduction in the CLABSI rate in the ICU setting.

Tissue Doppler,speckling tracking and four-dimensional echocardiographic assessment of right ventricular function in children with dilated cardiomyopathy

BACKGROUND Right ventricular(RV)function is frequently overlooked during dilated cardiomyopathy(DCM)evaluation.AIM To evaluate RV function in children with idiopathic DCM using relatively recent echocardiographic modalities.METHODS We prospectively studied the cardiac function in 50 children with idiopathic DCM and 50 healthy children as a control group,using four-dimensional echocardiography(4-DE),Tissue Doppler Imaging(TDI),and two-dimensional-speckles tracking echocardiography(2-D-STE).RV EF was measured by 4-DE.RESULTS The auto left(LV)ejection fractions(EF)measured by 2-D-STE were significantly lower in the patients'group than in the control.The sphericity index was also significantly lower in children with DCM than in the control.RV EF measured by 4-DE was significantly lower in the patient's group than the control.RV S wave,e´/a'ratio,myocardial performance index(MPI),and tricuspid annular plane systolic excursion(TAPSE)were significantly impaired in children with DCM than in control.Both LV and RV global longitudinal strains(GLS)were significantly reduced in children with DCM than in control.RVGLS was significantly associated with the duration since diagnosis,tricuspid annulus S wave,RV MPI,and TAPSE,but not with the age of the patients,RV EF,or e´/a'ratio.CONCLUSION There was impairment of the RV LGS and other systolic and diastolic parameters in children with DCM.STE and TDI can help to detect the early decline of RV function.

Effects of adherence to the Mediterranean diet in children and adolescents with irritable bowel syndrome

BACKGROUND Irritable bowel syndrome(IBS)is a highly prevalent gastrointestinal disorder in children and adults,which increased over the past twenty years.The Mediterranean diet is a well-known diet full of antioxidants and anti-inflammatory ingredients.AIM To evaluate the safety,tolerability,and effects of adherence to the Mediterranean diet on disease patterns in children and adolescents with IBS.METHODS This prospective,cross-sectional case-controlled study included 100 consecutive IBS patients diagnosed according to Rome IV criteria,aged 12-18 years.Patients Group II on their regular diet for six months.Besides IBS scores(IBS-SSS,IBS-QoL,and total score),different clinical and laboratory parameters were evaluated at the start and end of the study.RESULTS The Mediterranean diet was safe and well-tolerated in IBS patients.IBS children and adolescents with good adherence to the Mediterranean diet(KIDMED Score≥8 points);group I showed significant improvement in IBS scores.IBS-SSS in the Mediterranean diet group was 237.2±65 at the beginning of the study and decreased to 163.2±33.8 at the end of the study(P<0.001).It did not show a significant improvement in the group with a regular diet(248.3±71.1 at the beginning of the study compared to 228.5±54.3 at the study end with P<0.05).The mean IBS-SSS in the Mediterranean diet group significantly improved compared with the group with a regular diet.Mean IBS-QoL in group I improved from 57.3±12.9 at the start of the study to 72.4±11.2 at the study end(P<0.001)and significantly improved when compared to its level in group II at the study end(59.2±12.7 with P<0.001),while group II showed no significant improvement in IBSQoL at the study end when compared to the beginning of the study(59.2±11.7 with P>0.05).The mean total IBS score in group I became 28.8±11.2 at the end of our study compared to 24.1±10.4 at the start(P<0.05)and significantly improved when compared to its level in group II at the end of the study(22.1±12.5 with P<0.05),while in group II,non-significant improvement in the total score at the end of our study compared to its mean level at the start of the study(22.8±13.5 with P>0.05).CONCLUSION The Mediterranean diet was safe and associated with significant improvement in IBS scores in children and adolescent patients with IBS.

Chest ultrasound in neonates:What neonatologists should know

For many years,ultrasound was thought to have no indications in pulmonary imaging because lungs are filled with air,creating no acoustic mismatch,as encountered by ultrasound wave beam.Lung ultrasound(LUS)was started in adult critical care settings to detect pleural effusion and acquired more indications over time.In the neonatal intensive care unit(NICU),the use of chest ultrasound has gained more attention during the last two decades.Being a radiation-free,bedside,rapid,and handy tool,LUS started to replace chest X-rays in NICU.Using LUS depends upon understanding the nature of normal lungs and the changes induced by different diseases.With the help of LUS,an experienced neonatologist can detect many of the respiratory problems so fast that interventional therapy can be introduced as early as possible.LUS can diagnose pleural effusion,pneumothorax,pneumonia,transient tachypnoea of the newborn,respiratory distress syndrome,pulmonary atelectasis,meconium aspiration syndrome,bronchopulmonary dysplasia,and some other disorders with very high accuracy.LUS will be helpful in initial diagnosis,follow-up,and predicting the need for further procedures such as mechanical ventilation,diuretic therapy,surfactant therapy,etc.There are some limitations to using LUS in some respiratory disorders such as bullae,interstitial emphysema,and other conditions.This review will highlight the importance of LUS,its uses,and limitations.