The Importance of Referencing

<abstract><title style='display:none'>Abstract</title>Levodopa is a dopamine precursor and a mainstay treatment in the management of Parkinson’s disease. Its side effects induce dyskinesia, nausea, vomiting, and orthostatic hypotension. Acute levodopa acute poisoning is uncommon, with only a few reported cases in the medical literature. Treatment of poisoning by levodopa is mainly supportive. The case of a child admitted to a hospital for acute levodopa poisoning is presented in this report.</abstract>

Accidental Modopar© Poisoning in a Two-Year-Old Child: A Case Report

Knowledge Is Power

<abstract><title style='display:none'>Abstract</title><sec id="j_jccm-2019-0010_s_005_w2aab2b8b5b1b7b1aab1c16b1Aa"><title style='display:none'>Background</title>Lactic acidosis (LA) is a complication of diseases commonly seen in intensive care patients which carries an increased risk of mortality. It is classified by its pathophysiology; Type A results from tissue hypo-perfusion and hypoxia, and Type B results from abnormal metabolic activity in the absence of hypoxia. Reports of the co-occurrence of both types have been rarely reported in the literature relating to intensive care patients. This case report describes the challenging management of a patient diagnosed with both Type A and Type B LA.</sec><sec id="j_jccm-2019-0010_s_006_w2aab2b8b5b1b7b1aab1c16b2Aa"><title style='display:none'>Case presentation</title>A 55-year-old female with newly diagnosed diffuse large B-cell lymphoma (DLBCL) developed hospital-acquired pneumonia, respiratory failure, shock and intra-abdominal septicaemia from a bowel perforation. Blood gases revealed a mixed picture lactic acidosis. Correction of septic shock, respiratory failure and surgical repair caused initial improvement to the lactic acidosis, but this gradually worsened in the intensive care unit. Only upon starting chemotherapy and renal replacement therapy was full resolution of the lactic acidosis achieved. The patient was discharged but succumbed to her DLBCL several months later.</sec><sec id="j_jccm-2019-0010_s_007_w2aab2b8b5b1b7b1aab1c16b3Aa"><title style='display:none'>Conclusion</title>Type A and Type B LA can co-occur, making management difficult. A systematic approach can help diagnose any underlying pathology and aid in early management.</sec></abstract>

Refractory Lactic Acidosis and an Approach to Its Management - A Case Report

<abstract><title style='display:none'>Abstract</title> Anemia in patients admitted to an intensive care unit is common and affects almost all critically ill patients. The intensivist is faced with the challenge of treating multifactorial etiologies, mainly bleeding and blood loss due to phlebotomy and decreased erythropoiesis. Red cell transfusion, the most common treatment for anemia, comes with associated risks, which may further reduce the chance of survival of these patients. The best evidence suggests the practice of restrictive RBC transfusion (transfusion at Hb&lt;7 g/dl).In this article, the etiopathogenesis of the anemia in critically ill is reviewed, and current opinion on the pros and cons of various management strategies are discussed with emphasize on restrictive transfusion policy.</abstract>

Respiratory Intensive Care, Max Super Specialty Hospital, Saket, New Delhi, India

Flat No. 417, Dhruva Apartments, Plot no. 4, I P Extension, Patparganj, Delhi, India, Pin-110092.

Department of Medicine & TB, Chest Clinic Moti Nagar, North Delhi Municipal Corporation, New Delhi, India

Gen-X Diagnostics, Madhu Vihar, New Delhi, India

Anemia in Intensive Care: A review of Current Concepts

Hospital Resilience: A Recent Concept in Disaster Preparedness

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Introduction</title>
Traumatic brain injury (TBI) has become a significant cause of death and morbidity in childhood since the elucidation of infectious causes within the last century. Mortality rates in this population decreased over time due to developments in technology and effective treatment modalities.
</sec>
<sec><title style='display:none'>Aim of the study</title>
This retrospective cohort study aimed to describe the volume, severity and mechanism of all hospital-admitted pediatric TBI patients at a university hospital over a 5-year period.
</sec>
<sec><title style='display:none'>Material and Methods</title>
This was a single-center, retrospective cohort study including 90 pediatric patients with TBI admitted to a tertiary care PICU. The patients’ demographic data, injury mechanisms, disease and trauma severity scores, initiation of enteral nutrition and outcome measures such as hospital stay, PICU stay, duration of mechanical ventilation, mortality, and Glasgow Outcome Scale (GOS) were also recorded. Late enteral nutrition was defined as initiation of enteral feeding after 48 hours of hospitalization.
</sec>
<sec><title style='display:none'>Results</title>
Of the 90 patients included in the cohort, 60% had mild TBI, 21.1% had moderate TBI and 18.9% had severe TBI. Their mean age was 69 months (3–210 months). TBI was isolated in 34 (37.8%) patients and observed as a part of multisystemic trauma in 56 (62.2%). The most commonly involved site in multisystemic injury was the thorax (33.3%). The length of hospitalization in the late enteral nutrition group was significantly higher than that in the early nutrition group, while the PICU stay was not significantly different between the two groups. The multiple logistic regression analysis found a significant relationship between GOS-3rd month and PIM3 score, the presence of diffuse axonal injury and the need for CPR in the first 24 h of hospitalization.
</sec>
<sec><title style='display:none'>Conclusion</title>
Although our study showed that delayed enteral nutrition did not affect neurologic outcome, it may lead to prolonged hospitalization and increased hospital costs. High PIM3 scores and diffuse axonal injury are both associated with worse neurologic outcomes.
</sec>
</abstract>

A Retrospective Cohort Study of Traumatic Brain Injury in Children: A Single-Institution Experience and Determinants of Neurologic Outcome

The Human Microbiome in Intensive Care - A Journey Forward?

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Background</title>
Though laboratory tests have been shown to predict mortality in COVID-19, there is still a dearth of information regarding the role of biochemical parameters in predicting the type of ventilatory support that these patients may require.
</sec>
<sec><title style='display:none'>Methods</title>
The purpose of our retrospective observational study was to investigate the relationship between biochemical parameters and the type of ventilatory support needed for the intensive care of severely ill COVID-19 patients. We comprehensively recorded history, physical examination, vital signs from point-of-care testing (POCT) devices, clinical diagnosis, details of the ventilatory support required in intensive care and the results of the biochemical analysis at the time of admission. Appropriate statistical methods were used and P-values &lt; 0.05 were considered significant. Receiver operating characteristics (ROC) analysis was performed and Area Under the Curve (AUC) of 0.6 to 0.7, 0.7 to 0.8, 0.8 to 0.9, and &gt;0.9, respectively, were regarded as acceptable, fair, good, and exceptional for discrimination.
</sec>
<sec><title style='display:none'>Results</title>
Statistically significant differences (p&lt;0.05) in Urea (p = 0.0351), Sodium (p = 0.0142), Indirect Bilirubin (p = 0.0251), Albumin (p = 0.0272), Aspartate Transaminase (AST) (p = 0.0060) and Procalcitonin (PCT) (p = 0.0420) were observed between the patients who were maintained on non-invasive ventilations as compared to those who required invasive ventilation. In patients who required invasive ventilation, the levels of Urea, Sodium, Indirect bilirubin, AST and PCT were higher while Albumin was lower. On ROC analysis, higher levels of Albumin was found to be acceptable indicator of maintenance on non-invasive ventilation while higher levels of Sodium and PCT were found to be fair predictor of requirement of invasive ventilation.
</sec>
<sec><title style='display:none'>Conclusion</title>
Our study emphasizes the role of biochemical parameters in predicting the type of ventilatory support that is needed in order to properly manage severely ill COVID-19 patients.
</sec>
</abstract>

Study of Biochemical Parameters as Predictors for Need of Invasive Ventilation in Severely Ill COVID-19 Patients

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Background</title>
Since its debut, as reported by the first published studies, COVID-19 has been linked to life-threatening conditions that needed vital assistance and admission to the intensive care unit. Skeletal muscle is a core element in an organism’s health due to its ability to keep energy balance and homeostasis. Many patients with prolonged hospitalization are characterized by a greater probability prone to critical illness myopathy or intensive care unit-acquired weakness.
</sec>
<sec><title style='display:none'>Objective</title>
The main aim of this study was to assess the skeletal muscle in a COVID-19 cohort of critically ill patients by measuring the psoas area and density.
</sec>
<sec><title style='display:none'>Material and methods</title>
This is a retrospective study that included critically ill adult patients, COVID-19 positive, mechanically ventilated, with an ICU stay of over 24 hours, and who had 2 CT scans eligible for psoas muscle evaluation. In these patients, correlations between different severity scores and psoas CT scans were sought, along with correlations with the outcome of the patients.
</sec>
<sec><title style='display:none'>Results</title>
Twenty-two patients met the inclusion criteria. No statistically significant differences were noticed regarding the psoas analysis by two blinded radiologists. Significant correlations were found between LOS in the hospital and in ICU with psoas area and Hounsfield Units for the first CT scan performed. With reference to AUC-ROC and outcome, it is underlined that AUC-ROC is close to 0.5 values, for both the psoas area and HU, indicating that the model had no class separation capacity.
</sec>
<sec><title style='display:none'>Conclusion</title>
The study suggested that over a short period, the psoas muscle area, and the psoas HU decline, for both the left and the right sight, in adult COVID-19 patients in ICU conditions, yet not statistically significant. Although more than two-thirds of the patients had a negative outcome, it was not possible to demonstrate an association between the SARS-COV2 infection and psoas muscle impairment. These findings highlight the need for further larger investigations.
</sec>
</abstract>

Total Psoas Area and Psoas Density Assessment in COVID-19 Patients Using CT Imaging – Could Muscle Mass Alteration During Intensive Care Hospitalization be Determined?

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Introduction</title>
The severity of COVID-19 relies on several factors, but the overproduction of pro-inflammatory cytokines remains a central mechanism. The aim of this study was to investigate the predictive utility of interleukin (IL)-6, IL-8, IL-10, IL-12, tumor necrosis factor alpha (TNF-α), and interferon gamma (IFN-γ) measurement in patients with COVID-19.
</sec>
<sec><title style='display:none'>Material and Methods</title>
We prospectively enrolled 181 adult patients with COVID-19 admitted to the 1st Infectious Disease County Hospital Târgu Mureș from December 2020 to September 2021. Serum cytokine levels were measured and correlated with disease severity, need for oxygen therapy, intensive care unit (ICU) transfer, and outcome.
</sec>
<sec><title style='display:none'>Results</title>
We found significantly higher serum levels of IL-6, IL-8, and IL-10 in patients with severe COVID-19 and in those with a fatal outcome. The logistic regression analysis showed a significant predictive value for IL-8 regarding disease severity, and for IL6 and IL-10 regarding ICU transfer and fatal outcome.
</sec>
<sec><title style='display:none'>Conclusions</title>
Serum levels of IL-6, IL-8, and IL-10 were significantly increased in patients with COVID-19, but their predictive value regarding disease severity and the need for oxygen therapy was poor. We found IL-6 and IL-10 to have a good predictive performance regarding ICU transfer and fatal outcome.
</sec>
</abstract>

The Prognostic Utility of Cytokines in Hospitalized COVID-19 Patients

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Introduction</title>
Minitracheostomy involves the percutaneous insertion of a 4-mm-diameter cricothyroidotomy tube for tracheal suctioning to facilitate the clearance of airway secretions. The advantage of using the minitracheostomy is in the clearance of secretions, however data on their usefulness for respiratory failure after extubation is limited. Aim of the study: We aimed to assess the use of minitracheostomy for patients with challenging extubation caused by significant sputum.
</sec>
<sec><title style='display:none'>Material and Methods</title>
We conducted a retrospective analysis of consecutive case series. We analyzed the data of 31 patients with pneumonia. After minitracheostomy, the primary endpoints of reintubation within 72 hours and clinical effects, including mortality, length of intensive care unit (ICU), or hospital stay, were assessed. The successful extubation group included patients who did not require reintubation within 72 hours. Conversely, the reintubation group consisted of patients mandating reestablishment of intubation within 72 hours.
</sec>
<sec><title style='display:none'>Results</title>
Among those who underwent minitracheostomy after extubation, 22 (71%) underwent successful extubation and 9 underwent reintubation (reintubation rate: 29%). The in-hospital mortality rates after 30 days were 18.2% in the successful extubation group and 22.2% in the reintubation group. The ICU and hospital lengths of stay were 11 days (interquartile range: 8–14.3 days) and 23 days (interquartile range: 15.5–41 days), respectively, in the successful extubation group; they were 14 days (interquartile range: 11–18.5 days) and 30 days (interquartile range: 16–45.5 days), respectively, in the reintubation group.
</sec>
<sec><title style='display:none'>Conclusions</title>
The prophylactic use of minitracheostomy may be an option as a means of reducing reintubation in patients with pneumonia who are at very high risk of reintubation.
</sec>
</abstract>

Effectiveness of Minitracheostomy After Extubation in Patients with Pneumonia at High Risk of Reintubation: A Case Series

<abstract><title style='display:none'>Abstract</title>Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection in mechanically ventilated patients and results in high mortality, prolonged intensive care unit- (ICU) and hospital-length of stay and increased costs. In order to reduce its incidence, it is imperative to better understand the involved mechanisms and to identify the source of infection. The role of the endotracheal tube (ET) in VAP pathogenesis became more prominent over the last decades, along with extensive research dedicated to medical device-related infections and biofilms. ET biofilm formation is an early and constant process in intubated patients. New data regarding its temporal dynamics, composition, germ identification and consequences enhance knowledge about VAP occurrence, microbiology, treatment response and recurrence. This paper presents a structured analysis of the medical literature to date, in order to outline the role of ET biofilm in VAP pathogenesis and to review recommended methods to identify ET biofilm microorganisms and to prevent or decrease VAP incidence.</abstract>

Endotracheal Tube Biofilm and its Impact on the Pathogenesis of Ventilator-Associated Pneumonia

<abstract><title style='display:none'>Abstract</title>Despite the significant development and advancement in antibiotic therapy, life-threatening complication of infective diseases cause hundreds of thousands of deaths world. This paper updates some of the issues regarding the etiology and treatment of abdominal sepsis and summaries the latest guidelines as recommended by the Intra-abdominal Infection (IAI) Consensus (2017). Prognostic scores are currently used to assess the course of peritonitis. Irrespective of the initial cause, there are several measures universally accepted as contributing to an improved survival rate, with the early recognition of IAI being the critical matter in this respect. Immediate correction of fluid balance should be undertaken with the use of vasoactive agents being prescribed, if necessary, to augment and assist fluid resuscitation. The WISS study showed that mortality was significantly affected by sepsis irrespective of any medical and surgical measures. A significant issue is the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in the clinical setting, and the reported prevalence of ESBLs intra-abdominal infections has steadily increased in Asia. Europe, Latin America, Middle East, North America, and South Pacific. Abdominal cavity pathology is second only to sepsis occurring in a pulmonary site. Following IAI (2017) guidelines, antibiotic therapy should be initiated as soon as possible after a diagnosis has been verified.</abstract>

Abdominal Sepsis: An Update

<abstract><title style='display:none'>Abstract</title><sec id="j_jccm-2020-0038_s_004_w2aab3b7c34b1b6b1aab1c16b1Aa"><title style='display:none'>Objective</title>A rare variant Miller Fisher Syndrome overlap with Guillain Barre Syndrome is described in an adult patient with SARS-COV-2 infection.</sec><sec id="j_jccm-2020-0038_s_005_w2aab3b7c34b1b6b1aab1c16b2Aa"><title style='display:none'>Case Presentation</title>The clinical course of a 45-year-old immunosuppressed man is summarized as a patient who developed ataxia, ophthalmoplegia, and areflexia after upper respiratory infection symptoms began. A nasopharyngeal swab was positive for COVID-19 polymerase chain reaction. He progressed to acute hypoxemic and hypercapnic respiratory failure requiring intubation and rapidly developed tetraparesis. Magnetic resonance imaging of the spine was consistent with Guillain Barre Syndrome. However, the clinical symptoms, along with positive anti-GQ1B antibodies, were consistent with Miller Fisher Syndrome and Guillain Barre Syndrome overlap. The patient required tracheostomy and had limited improvement in his significant neurological symptoms after several months.</sec><sec id="j_jccm-2020-0038_s_006_w2aab3b7c34b1b6b1aab1c16b3Aa"><title style='display:none'>Conclusions</title>The case demonstrates the severe neurological implications, prolonged recovery and implications in the concomitant respiratory failure of COVID-19 patients with neurological symptoms on the spectrum of disorders of Guillain Barre Syndrome.</sec></abstract>

Atypical Variant of Guillain Barre Syndrome in a Patient with COVID-19

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