Category Archives: Original Research

A Randomised Control Study Comparing Ultrasonography with Standard Clinical Methods in Assessing Endotracheal Tube Tip Positioning

Jayalekshmi Sreedevi1, George Neethu2, George Anjali2, Paul Cherish2

1 Travancore Medical College, Kollam, Kerala, India
2 Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India

DOI: 10.2478jccm-2024-0019

Introduction: Airway ultrasound has been increasingly used in correct positioning of endotracheal tube. We hypothesize that a safe distance between endotracheal tube tip and carina can be achieved with the aid of ultrasound.
Aim of the study: Our primary objective was to determine whether ultrasound guided visualisation of proximal end of endotracheal tube cuff is better when compared to conventional method in optimal positioning of tube tip. The secondary objective was to find the optimal endotracheal tube position at the level of incisors in adult Indian population.
Materials and Methods: There were 25 patients each in the conventional group and the ultrasound group. Conventional method includes auscultation and end tidal capnography. In the ultrasound group the upper end of the endotracheal tube cuff was positioned with an intent to provide 4 cm distance from the tube tip to the carina. X ray was used in both groups for confirmation of tip position and comparison between the two groups. Further repositioning of the tube was done if indicated and the mean length of the tube at incisors was then measured.
Results: After x ray confirmation, endotracheal tube repositioning was required in 24% of patients in the USG group and 40 % of patients in the conventional group. However, this result was not found to be statistically significant (p = 0.364). The endotracheal tube length at the level of teeth was 19.4 ± 1.35 cm among females and 20.95 ± 1.37 cm among males. 
Conclusions: Ultrasonography is a reliable method to determine ETT position in the trachea. There was no statistically significant difference when compared to the conventional method. The average length of ETT at the level of incisors was 19.5 cm for females and 21 cm for males.

Keywords: , , , , ,
Full text: PDF

Ventilator-Associated Events Cost in ICU Patients Receiving Mechanical Ventilation: A Multi-State Model

Alkmena Kafazi1, Eleni Apostolopoulou1, Vasiliki Benetou2, Georgia Kourlaba3, Christos Stylianou4, Ioanna D Pavlopoulou1

1 Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
2 Medical School, National and Kapodistrian University of Athens, Athens, Greece
3 Department of Nursing, University of Peloponnese, Tripoli, Greece
4 The 417 Army Equity Fund Hospital, Athens, Greece

DOI: 10.2478jccm-2024-0016

Introduction: Cost analysis is complicated by the fact that patients acquire infections during their hospital stay, having already spent time at risk without having an infection. Multi-state models (MSM) accounts for this time at risk treating infections as time-dependent exposures from ICU admission.
Aim of the study: To estimate ventilator-associated events (VAEs) direct additional cost in ICU patients.
Material and Methods: This was a prospective, observational study carried out for a two-year period in four medical-surgical ICUs of Athens, Greece. The sample consisted of adult patients who received mechanical ventilation for ≥4 days and were followed until discharge from the ICU or until death. CDC standard definitions were used to diagnose VAEs. To estimate VAEs additional length of stay (LOS), we used a four-state model that accounted for the time of VAEs. The direct hospital cost was calculated, consisting of the fixed and variable cost. The direct additional cost per VAEs episode was calculated by multiplying VAEs extra LOS by cost per day of ICU hospitalization.
Results: In the final analysis were included 378 patients with 9,369 patient-days. The majority of patients were male (58.7%) with a median age of 60 years. Of 378 patients 143 (37.8%) developed 143 episodes of VAEs. VAEs crude additional LOS was 17 days, while VAE mean additional LOS after applying MSM was 6.55±1.78 days. The direct cost per day of ICU hospitalization was € 492.80. The direct additional cost per VAEs episode was € 3,227.84, € 885.56 the fixed and € 2,342.28 the variable cost. Antibiotic cost was € 1,570.95 per VAEs episode. The total direct additional cost for the two-year period was € 461,581.12.
Conclusions: These results confirm the importance of estimating VAEs real cost using micro-costing for analytical cost allocation, and MSM to avoid additional LOS and cost overestimation.

Keywords: , , , ,
Full text: PDF

The Utility of Serial Lipid Measurements as a Potential Predictor of Sepsis Outcome: A Prospective Observational Study in a Tertiary Care Hospital

Afrah Abdul Malick1, Jeyakumar Manavalan2, Viveka Murugiah1, Manikandan Bose1, Hariharan Alexander1, Suganthy Kanakasekaran1

1 Velammal Medical College Hospitals and Research Institute, Madurai, Tamil Nadu, India
2 Sri Manakula Vinayagar medical college and Hospital, Puducherry, India

DOI: 10.2478jccm-2024-0015

Background and aim: Sepsis is the major cause of morbidity and mortality for patients admitted to an intensive care unit worldwide. Currently, Procalcitonin (PCT) is a widely used prognostic marker for sepsis. The high cost of estimating Procalcitonin limits its utility in all health facilities. Lipid Profile, being a frequently done routine investigation, is studied in sepsis patients to predict the prognosis of sepsis. This study was aimed to assess the association between lipid profile parameters, procalcitonin and clinical outcomes in patients with sepsis.
Materials and methods: It is a prospective observational study conducted in a tertiary care hospital in the Department of Biochemistry in collaboration with the Intensive Care Unit (ICU). We included 80 sepsis patients from medical and surgical ICUs. Among them, 59 (74%) survived and 21 (26%) expired. Serum lipid profile, procalcitonin and variables required for APACHE II score are measured at two intervals, one during admission and on day 5. All the parameters were compared between the survivors and the non-survivors.
Results: Serum PCT levels were reduced on Day 5 [3.32 (1.27-11.86)] compared to Day 0 [13.42 (5.77-33.18)] in survivors. In survivors, Total Cholesterol, LDL-C and Non-HDL-C were significantly elevated on Day 5 compared to Day 0. In non-survivors, HDL-C significantly decreased on Day 5. Between survivors and non-survivors, HDL-C significantly decreased on Day 5 (23.88 ± 10.19 vs 16.67 ± 8.27 mg/dl). A Negative correlation was observed between HDL-C & PCT.
Conclusion: Serum Lipid profile levels, namely Total cholesterol, HDL-C and LDL-C, have possible associations with the severity of sepsis. HDL-C have a negative association with the clinical scoring system in sepsis patients. Overall, the findings from our study suggest that lipid profile parameters have possible implications in predicting the outcome of patients with sepsis.

Keywords: , , , ,
Full text: PDF

Weekend Effect and Mortality Outcomes in Aortic Dissection: A Prospective Analysis

Cosmin Marian Banceu1, Marius Harpa2, Klara Brinzaniuc2, Nicolae Neagu2, Dan Alexandru Szabo2, Diana Mariana Banceu3, Hussam Al Hussein2, Daiana Cristutiu3, Alexandra Puscas2, Alexandru Stan2, Marvin Oprean4, Adrian Popentiu5, Marius Neamtu Halic6, Horatiu Suciu2

1 Doctoral School, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania.
3 Emergency Institute for Cardiovascular Diseases and Transplantation Targu Mures, Romania; Targu Mures Institute for Cardiovascular Diseases and Heart Transplantation, Targu Mures, Romania
4 Amherst College, Amherst, Massachusetts, USA
5 Faculty of Medicine, Lucian Blaga University of Sibiu, Sibiu, Romania
6 Swiss Federal Institute of Forest, Snow and Landscape Research WSL, Birmensdorf, Switzerland; Institute of Environmental Engineering, ETH Zurich, Switzerland; Swiss Federal Institute for Environmental Science and Technology – Eawag, Switzerland

DOI: 10.2478jccm-2024-0014

Background: Aortic dissection (AD) is a critical heart condition with potentially severe outcomes. Our study aimed to investigate the existence of a “weekend effect” in AD by examining the correlation between patient outcomes and whether their treatment occurred on weekdays versus weekends.
Methods: Specifically, we prospectively analysed the effect of weekday and weekend treatment on acute AD patient outcomes, both before surgical intervention and during hospitalization, for 124 patients treated from 2019–2021, as well as during 6 months of follow-up.
Results: The mean age of the study population was 62.5 years, and patient age exhibited a high degree of variability. We recorded a mortality rate before surgery of 8.65% for the weekend group and 15% for the weekday group, but this difference was not statistically significant. During hospitalization, mortality was 50% in the weekend group and 25% in the weekday group, but this difference was not statistically significant. Discharge mortality was 9.61% in the weekend group and 5% in the weekday group.
Conclusions: Our findings suggest that there was no significant difference in mortality rates between patients admitted to the hospital on weekends versus weekdays. Therefore, the period of the week when a patient presents to the hospital with AD appears not to affect their mortality.

Keywords: , , ,
Full text: PDF

Longitudinal Assessment of ROX and HACOR Scores to Predict Non-Invasive Ventilation Failure in Patients with SARS-CoV-2 Pneumonia

Abhijeet Anand1, Sai Teja Kodamanchili1, Ankur Joshi2, Rajnish Joshi1, Jai Prakash Sharma3, Goyal Abhishek4, Abhijit P Pakhare2, Yogesh Niwariya5, Rajesh Panda6, Sunaina T Karna3, Alkesh K Khurana4, Saurabh Saigal1

1 All India Institute of Medical Science, Bhopal, Madhya Pradesh, India
2 Community and Family Medicine, All India Institute of Medical Science , Bhopal, Madhya Pradesh, India
3 Department of Anaesthesia and Critical Care, All India Institute of Medical Science , Bhopal, Madhya Pradesh, India
4 Department of Pulmonary Medicine, All India Institute of Medical Science , Bhopal, Madhya Pradesh, India
5 Department of Cardiothoracic Vascular Surgery, All India Institute of Medical Science , Bhopal, Madhya Pradesh, India
6 Kalinga Institute of Medical Sciences, Bhubneshwar, India

DOI: 10.2478jccm-2024-0013

Introduction: NIV (Non-invasive ventilation) and HFNC  (High Flow nasal cannula) are being used in patients with acute respiratory failure.  HACOR score has been  exclusively calculated for patients on NIV, on other hand ROX index is being used for  patients on HFNC. This is  first study where ROX index has been used in patients on NIV to predict failure.
Aim of the study: This study investigates the comparative diagnostic performance of HACOR score and ROX index to predict NIV failure.
Methods: We performed a retrospective cohort study of non-invasively ventilated Covid 19 patients admitted between 1st April 2020 to 15th June 2021 to ICU of a tertiary care teaching hospital located in Central India. We assessed factors responsible for NIV failure, and whether these scores HACOR/ ROX index have discriminative capacity to predict risk of invasive mechanical ventilation.
Results: Of the 441 patients included in the current study, 179 (40.5%) recovered, while remaining 262 (59.4%) had NIV failure. On multivariable analysis, ROX index > 4.47 was  found  protective for NIV-failure (OR 0.15 (95%CI 0.03-0.23; p<0.001). Age > 60 years and  SOFA score were other significant independent predictors of NIV-failure. The AUC for prediction of failure rises from 0.84 to 0.94 from day 1 to day 3 for ROX index and from 0.79 to 0.92 for HACOR score in the same period, hence ROX score was non-inferior to HACOR score in current study. DeLong’s test for two correlated ROC curves had  insignificant difference expect day-1 (D1: 0.03 to 0.08; p=3.191e-05 ,D2: -0.002 to 0.02; p = 0.2671, D3: -0.003 to 0.04; p= 0.1065).
Conclusion: ROX score of 4.47 at day-3 consists of good discriminatory capacity to predict NIV failure. Considering its non-inferiority to HACOR score, the ROX score can be used in patients with acute respiratory failure who are on NIV.

Keywords: , , , ,
Full text: PDF

User’s Search for Information: A Multi-Language Cross-Sectional Assessment of Websites about Healthcare-Associated Infections

Valentin Nădășan1, Dalma Kasza2, Konrád-Ottó Kiss3, David Maior4, Marius Mărușteri5

1 Hygiene Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Neurology Clinic II, County Emergency Clinical Hospital of Targu Mures, Romania
3 Anesthesiology and Intensive Care Clinic, County Emergency Clinical Hospital of Targu Mures, Romania
4 Trauma and Ortopedics Clinic, County Emergency Clinical Hospital of Targu Mures, Romania
5 Medical Informatics and Biostatistics Department, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania

DOI: 10.2478jccm-2024-0011

Introduction: Healthcare-associated infections have a significant impact on public health, and many patients and their next-of-kin are seeking information on the internet. The study aimed to assess the quality of online written content about healthcare-associated infections available in English, Romanian, and Hungarian languages.
Materials and methods: The study sample included 75 websites, 25 for each language subgroup. The assessment involved examining the general characteristics, adherence to established credibility criteria, and the completeness and accuracy of informational content. The evaluation was conducted using a topic-specific, evidence-based benchmark. Two evaluators independently graded completeness and accuracy; scores were recorded on a scale from 0 to 10. A comparative analysis of websites was performed, considering pertinent characteristics, and potential factors influencing information quality were subjected to testing. The statistical significance was set at 0.05.
Results: For the overall study sample, the average credibility, completeness, and accuracy scores were 5.1 (SD 1.7), 2.4 (SD 1.5), and 5.9 (SD 1.0), respectively. Pairwise comparison tests revealed that English websites rated significantly higher than Romanian and Hungarian websites on all three quality measures (P<0.05). Website specialization, ownership, and main goal were not associated with credibility or content ratings. However, conventional medicine websites consistently scored higher than alternative medicine and other websites across all three information quality measures (P<0.05). Credibility scores were positively but weakly correlated with completeness (rho=0.273; P=0.0176) and accuracy scores (rho=0.365; P=0.0016).
Conclusions: The overall quality ratings of information about healthcare-associated infections on English, Romanian, and Hungarian websites ranged from intermediate to low. The description of information regarding the symptoms and prevention of healthcare-associated infections was notably unsatisfactory. The study identified website characteristics possibly associated with higher-quality online sources about healthcare-associated infections, but additional research is needed to establish robust evidence.

Keywords: , , , , , ,
Full text: PDF

Neonatal Resuscitation Practices in Romania: A Survey of the Romanian Association of Neonatology (ANR) and the Union of European Neonatal and Perinatal Societies (UENPS)

Manuela Cucerea1, Marta Simon1, Silvia Maria Stoicescu2, Ligia Daniela Blaga3, Radu Galiș4, Maria Stamatin5, Gabriela Olariu6, Maria Livia Ognean7

1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
2 Carol Davila University of Medicine and Pharmacy: Universitatea de Medicina si Farmacie Carol Davila din Bucuresti
3 Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
4 Oradea County Emergency Hospital: Spitalul Clinic Judetean De Urgenta Oradea
5 Grigore T Popa University of Medicine and Pharmacy Iasi Faculty of Medicine: Universitatea de Medicina si Farmacie Grigore T Popa lasi Facultatea de MedicinaRinggold ID 162290
6 Emergency County Hospital Timisoara: Spitalul Clinic Judetean de Urgenta Timisoara
7 Lucian Blaga University of Sibiu Faculty of Medicine: Universitatea Lucian Blaga din Sibiu Facultatea de Medicina

DOI: 10.2478jccm-2024-0010

Introduction: This study is part of a European survey on delivery room practices endorsed by the Union of European Neonatal and Perinatal Societies (UENPS) and the Romanian Association of Neonatology (ANR). The aim of our study was to evaluate the current neonatal resuscitation practices in Romanian maternity hospitals and to compare the results between level III and level II centers.
Material and Methods: The questionnaire was distributed through ANR by email link to heads of neonatal departments of 53 Romanian maternity hospitals with more than one thousand of births per year between October 2019 and September 2020, having 2018 as the reference year for data collection.
Results: The overall response rate to the questionnaire was 62.26% (33/53), 83.33% (15/18) for level-III centers and 51.43% (18/35) for level-II centers. Of the responding centers, 18 (54,54%) were academic hospitals, 15 (83,33%) were level III and 3 (16,67%) level II hospitals. In 2018, responding centers reported 81.139 births representing 42.66% of all Romanian births (190.170). There were significant differences between level-III and level-II maternity hospitals regarding the number of births in 2018 (3028.73±1258.38 vs 1983.78±769.99; P=0.006), lowest GA of routinely assisted infants in delivery room (25.07±3.03 weeks vs 30.44±3.28, P<0.001), inborn infants with BW<1500 admitted to neonatal intensive care unit (NICU) in 2018 (66.86±39.14 g vs 22.87±31.50 g; P=0.002), and antenatal counseling of parents before the delivery of a very preterm infant or an infant with expected problems (60% vs 22.2%; P=0.027). There were no significant differences of thermal and umbilical cord management, positive pressure delivery, heart rate assessment between responding centers.
Conclusion: The adherence to new guidelines was high among responding centers regarding thermal and umbilical cord management, initial FiO2, but aspects like antenatal counseling, EKG monitoring, laryngeal mask, and heated/humidified gases availability and administration, and simulation-based training require further implementation.

Keywords: , , ,
Full text: PDF

Retrospective Study of the Use of Heparins in Pregnant Women and in vitro Testing on the HCT 116 Colorectal Carcinoma Cell Line

Felicia Fiat1,2, Diana-Aurora Arnautu3, Brenda Cristina Bernad2,4, Alina Anton5, Iasmina Marcovici5,6, Alexandra-Denisa Semenescu5,6, Elena Silvia Bernad1

1 Department of Obstetrics-Gynecology II, Faculty of Medicine, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
2 Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
3 Department of Cardiology, Victor Babeș University of Medicine and Pharmacy, Timisoara, Romania
4 Center for Neuropsychology and Behavioral Medicine, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
5 Department of Toxicology, Drug Industry, Management and Legislation, Faculty of Pharmacy, “Victor Babes” University of Medicine and Pharmacy Timisoara, Romania
6 Research Center for Pharmaco-Toxicological Evaluations, University of Medicine and Pharmacy Victor Babes Timisoara, Romania

DOI: 10.2478jccm-2024-0009

Introduction: Pregnant women manifest an increased risk of developing coagulation disorders. Unfractionated heparin (HEP) and low-molecular-weight heparin (LMWHep) are considered as selective medication in the case of pregnancy which needs anticoagulant treatment. In addition to anticoagulant properties, HEP and its derivatives manifest other properties including anti-cancer potential. According to Globocan’s latest data, colorectal cancer (CRC) is the second most encountered form of malignancy in the case of women, manifesting some special particularities, as confusion of symptoms from cancer with symptoms encountered normally in pregnant women (such as constipation or rectal bleeding), delayed diagnosis because of limitations imposed both for the fetus and for the mother, and the need for special treatment.
Aim: The aim of the present work is to follow the incidence and safety of consumption of HEP and LMWHep in the case of pregnant women and to analyze their potential on the HCT 116 colorectal carcinoma cells.
Results: Analyzing the consumption of heparins in case of pregnant women hospitalized from 01.01.2022 to 31.12.2022 at the Pius Brînzeu” Emergency Clinical Hospital from Timisoara, Obstetrics and Gynecology Clinic I, it was observed that 44,6% of the patients were administered the following medication and no administration risks were observed. When tested on HCT 116 cells, heparins manifested a significant anti-migratory effect (with wound healing rates of 2,6%, when tested with HEP 100 UI concentration and 14.52% wound healing rates in case of fraxiparine 100 UI). In addition, different signs of apoptosis were observed, suggesting the pro-apoptotic potential of the tested substances.
Conclusions: Heparins remain the preferred medication to be administered to pregnant women with the potential for coagulation disorders, showing a high safety profile. Testing on the cancerous line of colorectal carcinoma highlights important properties that stimulate future studies, to establish the anti-tumor potential and the exact mechanism of action.

Keywords: , , , , ,
Full text: PDF

Weaning Outcome is Associated with ELWI and Impaired Diastolic Function

Dimitra Bagka1, George Zakynthynos2, Vasiliki Tsolaki1, Jonh Papanikolaou3, Vasilis Vazgiourakis1, Maria Baka1, Konstantinos Pratsas1, Demosthenes Makris1

1 General University Hospital of Larissa, Larisa, Greece
2 University of Athens, Athens, Greece
3 General Hospital of Trikala, Greece

DOI: 10.2478jccm-2024-0008

Objectives: To evaluate hemodynamic profiles of critical care patients undergoing spontaneous t-piece trial (SBT) and present weaning failure.
Methods: Prospective observational study conducted in ready-to-wean non-cardiac ICU patients. Clinical, echocardiographic and thermodilution-derived variables were recorded before and after a 2-hour SBT. Weaning from mechanical ventilation was defined as preservation of spontaneous breathing for 48 hours following successful SBT.
Results: Fourteen patients succeeded weaning, five manifested T-trial-failure and six late-failure. Weaning outcome was significantly associated with ELWI(Extravascular lung-water index), global-end-diastolic index and impaired diastolic function, as indicated by pre-T Doppler early wave velocities (E/Em); Fifty-six percent of participants presented ELWI≥7mL/kg when fulfilling predetermined criteria for weaning. ELWI, impaired pulmonary permeability and left ventricular diastolic dysfunction were independent determinants of ELWI.
Conclusions: ELWI before SBT and impaired diastolic function (as indicated by pre-T E/Em) might be weaning outcome determinants and their assessment may allow better risk stratification in weaning decision making.

Keywords: , , , ,
Full text: PDF

Pediatric Critical Care Illness Severity Toolkit: Stata Commands for Calculation of Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction Scores

Razvan Azamfirei1,2, Colleen Mennie1, James C. Fackler1,3, Sapna R. Kudchadkar1,3,4

1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
2 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Romania
3 Department of Pediatrics, Charlotte R. Bloomberg Children’s Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
4 Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA

DOI: 10.2478/jccm-2023-0033

Introduction: Illness severity scoring tools, such as PRISM III/IV, PIM-3, and PELOD-2, are widely used in pediatric critical care research. However, their application is hindered by complex calculation processes, privacy concerns with third-party online calculators, and challenges in accurate implementation within statistical packages.
Methods: We have developed a comprehensive, open-source toolkit for implementing the PIM-3, Simplified PIM-3, and PELOD-2 scores. The toolkit includes the pim3 and pelod2 commands and is compatible with Stata versions 12 and above. It features robust data validation, error messaging, a graphical interface, and support for SI and Imperial units. The toolkit’s accuracy was validated through unit testing and synthetic data, comparing results with existing implementations.
Results: In performance tests, the toolkit exhibited a median processing time of 21.82 seconds for PELOD-2, 14.06 seconds for PIM-3, and 9.74 seconds for Simplified PIM-3, when applied to datasets of 10,000,000 records. It consistently achieved 100% accuracy in both synthetic data tests and manual spot checks.
Conclusion: The toolkit decreases processing time and improves accuracy in calculating pediatric critical care severity scores such as PELOD-2, PIM-3, and Simplified PIM-3. Its application in large datasets and validation highlights its utility as a tool for streamlining pediatric critical care research.

Keywords: , , ,
Full text: PDF