Journal of Emergency Medicine, Trauma and Acute Care - 2 - International Conference in Emergency Medicine and Public Health-Qatar Proceedings, October 2016

Background: Vomiting is a symptom commonly encountered in emergency settings, with many differential diagnoses. In the following case, the diagnosis was nearly missed and the outcome could have been critical.

Methods: A case study was performed, supported by literature review. A 32 year-old lady presented to the Emergency Department with repeated vomiting for one day. She has had epigastric discomfort for several days. Her blood pressure was 119/74 mmHg, heart rate 118/minute, and she was afebrile. She had been under the in-vitro fertilisation program and received human chorionic gonadotrophin, oocyte retrieval and embryo transfer 8, 6, and 3 days respectively prior to presentation. On examination, her abdomen was soft, non-tender. Urinary pregnancy test was negative. Her sodium level was 131 mmol/l, Hb 17.0 g/dL, white cell count 20.5 ×  10*9/L, and platelet 485 ×  10*9/L. The rest of the renal and liver functions and amylase, were normal. She was admitted to the Emergency Ward with a working diagnosis of gastritis. On reassessment, her abdomen was noted to be slightly distended although no tenderness or guarding was elicited. Ovarian hyperstimulation syndrome was suspected, and gynaecology was consulted for further evaluation.

Results: Transvaginal ultrasound scan showed a normal-sized uterus with thickened endometrium and no intrauterine sac. Both ovaries were enlarged, left ovary 6.1 ×  4.3 cm and right ovary 5.0 ×  5.3 cm. Significant pelvic free fluid was present. The diagnosis was confirmed to be early ovarian hyperstimulation syndrome. Ovarian hyperstimulation syndrome is an iatrogenic complication from assisted reproduction technology. Following gonadotropin therapy, this condition usually develops several days after oocyte retrieval or assisted ovulation, with ovarian enlargement due to multiple ovarian cysts. Complications include ascites, haemoconcentration, hypovolaemia, and electrolyte imbalances.

Conclusion: Emergency physicians should consider ovarian hyperstimulation syndrome in patients who had received assisted reproduction presenting with repeated vomiting.

Background: Trauma is a major cause of death worldwide that can result death or permanent disability. Globally, 6–10% of all deaths are attributed to traumatic injuries. In Saudi Arabia, trauma is a public burden as a result of its socioeconomic impact. Our aim is to describe the pattern of traumatic injuries and predictors of in-hospital mortality among patients admitted through the ED of King Abdulaziz Medical City.

Methods: A retrospective cohort study was conducted on 3786 trauma-injured patients admitted from 2012 to 2014. Data on: patient characteristics, trauma characteristics and outcome characteristics, were extracted from a prospectively collected database. Logistic regression analysis and ROC curve were applied.

Results: Of 3786, (77.5%) of victims were males, (29.8%) injuries occurred in the age group (15–25 years). Blunt injuries constituted (87.1%), followed by burns (7%), intentional injuries (5%) and drowning & foreign body (1%). Data showed seasonal variation with two main peaks in March and August (p < 0.001). In-hospital mortality rate was (4.7%. Significant predictors of in-hospital mortality were age (p < 0.001), intubation need (p = 0.009), ISS (p < 0.001), RTS (p = 0.007), GCS (p = .004) and road traffic accidents (p = 0.001). The cut-off points for prediction of in-hospital mortality: were as follows: ISS = 22, AUC = 93%, ATS = 9, AUC = 78% and GCS = 8, AUC = 83%.

Conclusions: Our recommendation is targeted to ED policy makers to recognize the patterns of injury and the seasonal variation to structure and distribute the facilities and staff in a cost-effective manner. Also, enforcing trauma preventative measures should be encouraged. Secondly, for ED physicians to enhance the use of in-hospital predictors of mortality. Finally, educational programs targeting the general population are essential to cover all aspects.

Background: Patients experiencing psychiatric emergencies often require resources not available at the hospital to which they present and frequently require transfer to an appropriate psychiatric facility as it is the case at the Emergency Department of HGH. This typically involves being held in the Emergency Department (ED) until a psychiatric bed is available. Boarding of psychiatric patients, (defined as a length of stay greater than four hours after medical clearance), is ubiquitous throughout emergency departments nationwide (USA) and in Qatar.

Methods: The Emergency Department at HMC established in May 2014 an innovative and pioneering psychiatric liaison service based in ED, it is the first in the Gulf Area. In this study we are set to look at the difference in response time, boarding time, and disposition during the last six month compared to a similar period of a previous year.

Results: When initiated treatment in ED and mobilized the community based services available in Qatar, the preliminary results indicate a substantial decrease of total admissions, a similar decrease in overnight boarding and a shorter turnaround time to disposition. A 18% decrease of total admissions, and a 300% decrease in overnight boarding.

Conclusion: Having a dedicated psychiatric team embedded in a busy emergency department is conducive to providing a higher quality of mental health care, decrease the adverse occurrences associated with boarding the severely mentally ill. We established a training program (C&L Fellowship with one year ER psychiatry and educational modules for the medical ED Staff).

Background: Although Retropharyngeal Hematoma (RPH) has unknown frequency but considered a rare condition which can cause a life threatening airway obstruction. Various precipitating factors have been mentioned as causes of RPH as blunt head or neck trauma, whiplash injury, coagulopathy, central line insertion, stellate ganglion block, sneezing, severe coughing as well as spontaneous RPH.

Methods: We report a case of severe life threatening retropharyngeal hematoma secondary to a closed stable C5-C6 fracture that caused severe upper airway obstruction.

Results: As the RPH can develop hours or days, even after an apparently minor precipitating injury, in our patient it took almost 3 hours from time of accident till the development of severe upper airway obstruction (picture to be added in main poster). It was such a large collection hematoma that caused severe upper airway obstruction with cannot intubate cannot intubate situation.

Conclusion: RPH can cause a mechanical displacement of the pharynx & larynx making securing airway with ETT almost impossible with conventional laryngoscopy or even video-assisted techniques. On the other hand, the time taken for RPH to develop and to cause mechanical obstruction can be limited enough to allow proper preparations as well as availability of fiberoptic technique. We should keep a high index of suspicion of retropharyngeal hematoma and airway involvement in cases of cervical spine fracture, in order to help other physician to increase their awareness and anticipation of such life threatening & meantime avoidable condition.

Keywords: retropharyngeal hematoma, airway obstruction

Urticaria is a common presentation in Emergency Department. Most of the time its idiopathic or immune mediated. In a small proportion of cases it may be a symptom of serious medical illness. We report two case of urticaria with underlying medical causes.

Case 1: A 33-year-old female presented to emergency with recurrent urticaria, which started 5 months back. Even though it responded to antihistamines, symptoms recurred on discontinuing medicines. No other symptom and no other past medical illness. Clinical examination was unremarkable, except for extensive urticaria. Her laboratory evaluation showed hyperthyroidism, and deranged liver function test (LFT). She was started on carbimazole and symptoms improved after a few weeks. Symptom recurred after 3 months when dose was reduced and promptly relieved on restarting old dose. After few weeks she discontinued her medication and symptom recurred. On restarting the medicine she improved again. Her LFT also improved on follow up.

Case 2: One young female was seen in emergency with episodic urticaria for 6 months. She responded to antihistamines but recurred on discontinuing medicine. No significant illness in past. Clinical examination showed anaemia and generalised urticaria. Her laboratory test showed microcytic hypo chromic anaemia and her iron profile was suggestive iron deficiency. Urticaria symptoms improved after she was initiated on iron replacement.

Discussion: The above two cases represents two systemic causes of urticaria. Exact mechanism of how these disorder produce urticaria is unknown. In case of iron deficiency, iron therapy even in the absence of anaemia, is found to improve urticaria. The prevalence of thyroid autoimmunity is high in patients with chronic idiopathic urticaria. Mast cell over stimulation by thyroid hormone is thought to be the mechanism behind the urticaria in hyperthyroidism. Physicians should look for systemic causes when patients present with recurrent symptoms.

Introduction: Omental infarction is a rare cause of acute abdomen resulting from vascular compromise of the greater omentum. Vague symptoms and non-specific signs at presentation make the clinical presentation diagnostically challenging. Evidence to guide the management of omental infarct is still controversial and limited. However, general approach is to manage it conservatively and to consider surgery only if there is a deterioration in the clinical condition. We report a case of omental infraction presented to the ED with acute abdomen that showed fruitful recovery by conservative management without requiring surgery or prolonged hospitalization.

Case Report: A 23-year-old Ethiopian male patient, presented to the ED with colicky abdominal pain of few hours duration, which was sudden in onset and was increasing in the severity. The pain started in the right side of the abdomen just lateral to the umbilicus associated with anorexia. On the physical examination; he appeared to be in pain and on the palpation of the abdomen, there was tenderness and minimal rebound tenderness over the right iliac fossa and to a lesser degree over the right lumbar region. CT scan with contrast revealed an ill-defined focal area of increased fat stranding in the omental fat in the right lumbar region, anterior to the mid ascending colon, typical to that of focal area of omental infraction.

Conclusion: Omental infarction is a rare benign cause of acute abdomen. The widespread availability of CT allows us to recognize the cases while they are in the Emergency Department.

Background: The American Heart Association (AHA) recommends to treat cardiac arrest due to Torsade de Pointes (TdP) with 1–2 grams of intravenous (IV) magnesium over 5 minutes. A second dose can be repeated within 5–15 minutes, and a continuous infusion may be considered. In cases of TdP due to severe hypokalemia, the doses and rate of administration of IV potassium chloride (KCL) are not described explicitly in the guidelines.

Methods: In this case report, we describe a peritoneal dialysis (PD) patient who had a prolonged history of hospital stay with infected diabetic foot. He was on the medical ward, but recently admitted to the Intensive Care Unit with septic shock needing inotropic support. He developed a TdP cardiac arrest with a serum potassium of 2.4 millimol/litre. We managed the cardiac arrest according to AHA guidelines and also administered a total of 120 milliEquivalent (mEq) of KCL over 2 hours. The severe refractory hypokalemia improved, and the recurrent TdP subsequently stopped only after we urgently drained the PD fluid during the resuscitation as a last resort. We also avoided administration of sodium bicarbonate even though he was severely acidotic during and after the resuscitation.

Results: To compliment this case report, we reviewed the literature available on hypokalemia in PD patient, and also on the established treatment of TdP.

Conclusion: In cardiac arrest situation secondary to hypokalemia, repeated high doses of IV KCL, up to a total of 120 mEq may be required, provided point of care testing is available. Draining the PD fluid during resuscitation, might expedite the correction of the refractory hypokalemia and malignant arrhythmias.

Background: Abdominal pain is one of the most common presenting symptoms in Emergency Department. During a recent audit, it was found that Patients presenting to HGH emergency room with a chief complaint of abdominal pain are the most common patient's category to be delayed to disposition. Currently 62% of patients with abdominal pain admitted to Male Urgent Area in Emergency Department HGH were delayed to Disposition for more than 6 hrs.

Aim: To decrease the percentage of patients with abdominal pain delayed in Male Urgent Area ED, HGH for more than 6 hrs from 62% to 50% by May 2015 Project Scope; Project period: February 10th to 24th May 2015; Place: Male Urgent Area, Emergency HGH; Population: Male patients Expected Benefits of the project; Improve Patient Flow; Improve Patient safety; Improve patient Satisfaction.

Intervention: All abdominal pain patients must first be reviewed by the consultant of the See & Treat before transfer to male urgent area. Dedicated bed for reassessment of abdominal pain in Male Urgent Area. Flagging of patients when ready for reassessment.

Results: Post-intervention length of Stay Male Urgent Area has reduced by 2.28 hrs.

Conclusions: Early senior involvement has an impact on decreasing the Length of Stay in abdominal pain patients. Flagging patients for reassessment had an impact on the Length of Stay. It was very challenging to implement the changes and reach out to every staff being a big department.

Next steps: Quarterly Audit _ Publication of the Audit _ Continuous Education & Implementing to other Areas of the ED.

The present paper was designed to reflect the impact of conflict on the health situation in Yemen. A total of 2,305,048 people are displeased from their residences. The consequences of conflict permeate countless aspects of society, and are not limited to the mass causality (death and injured), inaccessibility to the health services and disturbance of health system. The most vulnerable group is the children who are highly affected by the current conflict, data shows that Acute malnutrition is dramatically increased in 2015 survey from 2014 survey, in Hodeida and Aden governorates GAM rates is 31% and 23 in 2015 respectively while in 2014 it was 18% in Hodeida and 10% in Aden. This analysis shows that the negative effect of war on health is particularly intense in the short term following the onset of a conflict, and children are the most affected group.

Background: Reports on burden of hepatitis C and hepatitis B virus (HCV/HBV) are a big challenge for district to minimize the transmission of associated risk factors. Study was conducted to know the prevalence of HCV/HBV infection in pregnant women and their blood donors attended a surgical referral clinic for cesarean delivery.

Objective: To determine the prevalence of HCV/HBV infection among pregnant women and their blood donors.

Methods: A cross-sectional analytical study (record review) of all pregnant women and their blood donors (family members) was conducted from 10th to 15th February 2015 at a private surgical clinic in district Naushahro Feroze. Data from 1st January to 31st December 2014 gathered on results of blood screening used by ELISA test.

Results: Of 175 women aged 15–52 years, 13% (n = 22) tested positive (13 HCV; 9 HBV) besides these a total of 656 blood donors aged 16–40 years reported for blood donations and were 22% (n = 145) tested positive (80 HCV; 65 HBV). The highest positivity rate was seen in women aged 25 years or less (26%) compared with those aged above 25 years (9%) OR = 3.02 (95% CI 1.03 to 9.98). Statistically significant difference was identified between ages of donors who were aged below 25 years were high positivity rate (30%) compared to above 25 years positive for hepatitis infection (24%) OR = 1.15. 02 (95% CI 1.01 to 2.34).

Conclusions: One in eight pregnant women attending surgical clinic for cesarean delivery and one in five blood donors who came to attend for bleed has evidence of HCV/HBV infection. These HCV/HBV positive mothers may be at increased risk of transmitting HCV/HBV infection to their unborn babies. We suggest that all pregnant women attending 1st antenatal care be tested for HCV/HBV infection; exposed babies need to receive HBV vaccines at birth. Further molecular studies on risk factors needed in these settings.

Background: Previous reports suggest prevalence of high stress levels and psychological morbidity among medical students. This study aimed to elucidate factors for Perceived Stress (PS), role of Emotional Intelligence (EI) in the experience of PS and its association with academic background and satisfaction with career choice among medical students.

Methods: A cross-sectional survey was conducted in Riyadh-Medical-College-Saudi-Arabia on First (n = 40) and Final year (n = 35) Female medical undergraduates during year 2015. Students were administered Schutte's Emotional Intelligence Inventory and Cohen's Perceived Stress Scale. Additional information was collected on participant demographics, previous qualification in higher education and career satisfaction level. Basic descriptive statistics –correlation & regression were used for data analysis.

Results: The survey had a 99% response rate. Seniors were more stressed than Juniors. Although there was no significant difference for EI scores between the two groups, still, there existed a ‘definite trend’ of ‘Low EI Scores’ being associated with ‘High Perceived Stress Levels’. ‘Low scorers’ on the EI were more likely to be (i) younger age group, (ii) without a previous higher education qualification (iii) not satisfied with their decision to study medicine (p < 0.01).

Conclusions: There is an inverse correlation between EI and PS. Significant predictors of PS are age, previous higher education qualification, satisfaction with the decision to study medicine and EI level. It would be interesting to explore by further research, if any possible difference exists between genders. The ‘t’ statistic indicates EI as a pivotal predictor of PS in medical profession. We suggest that health profession institutions could organize regular programs to enhance students' EI. Considering substantial previous research evidence on Stress and Professionalism being an interrelated phenomenon in Health professions, it would be logical to consider EI as a possible qualitative selection criterion for medical students to improve eventual outcomes.

Background: Utilization of primary health care services is an important determinant of health. Individuals who receive primary health care are generally healthier than those who do not. Despite the importance of primary health care use, there are many barriers to health care access that are experienced by populations in Arab countries. This study examined primary health-care use and accessibility among adolescents living in the United Arab Emirates.

Methods: In a cross-sectional study, we collected primary health-care use, sociodemographic and residential data for 6363 local and expatriate adolescents. Analysis consisted of descriptive statistics, and bivariate and multivariate analyses. Logistic regression modelling was employed to examine predictors of health-care use, specifically ‘not receiving care when needed’, ‘having a routine physical check-up without having a specific problem’, and ‘travelling for medication or treatment to other countries’.

Results: The most-consulted health professionals were dentists or orthodontists, family doctors and eye specialists. Local adolescents were more likely to attend public clinics or hospitals than private clinics or hospitals, while the opposite was true for expatriate adolescents. In the last 12 months 22.6% of participants had not obtained needed health care, and 19.5% had not had a routine physical health check-up. Common reasons for not obtaining care were busy schedules, dislike/fear of doctors and long waiting times. Predictors of not obtaining needed care included nationality and income, while those for having a routine check-up were mother's education and car ownership.

Conclusions: Improvements to the health-care sector are needed in order to increase health-care accessibility among adolescents.

Background: Urinary retention is a common presenting complaint in Emergency Department. Meningitis can be an unusual cause for this. This combination is referred to as Meningitis Retention Syndrome (MRS). We present 2 cases of MRS diagnosed in A&E, Alkhor.

Case 1: A 43-year-old male presented to ED with low grade fever, head ache of 10 days and dysuria of 2 days duration. Examination was unremarkable except for palpable bladder. Examination of CNS was normal. He was discharge on antibiotic after catheterisation of urinary bladder. He was readmitted to ED after few days with worsening of symptoms. Physical examination was unremarkable. CT head (contrast) showed meningeal enhancements and CSF study showed lymphocytic pleocytosis. He was initiated on anti-tubercular treatment (ATT). Patient improved and was discharged.

Case 2: A 42-year-old male presented to ED with fever and dysuria. He was managed as a case of urinary tract infection. He was readmitted to ED with fever and urinary retention. Physical examination was unremarkable except for temperature 38.5°C. Blood test and urinalysis were normal. He was discharged on medication. 2 days later he was admitted with altered sensorium high grade fever and clinical features of meningitis. CSF study showed lymphocytic pleocytosis. Patient was initiated on ATT. Patient had a prolonged and stormy hospital stay and later improved.

Discussion: Meningitis Retention syndrome is thought to be a very minute form of acute disseminated encephalomyelopathy. Urinary retention might reflect acute shock phase of this disorder. Most of the previously reported cases were due to aseptic meningitis but here we report two cases of MRS due to tuberculous meningitis Acute urinary retention can provide a critical clue to the diagnosis of meningitis as a cause of fever of unknown origin.

Background: Fibrous dysplasia affecting the spine is considered an uncommon entity in polyostotic fibrous dysplasia and aneurysmal bone cysts occurring in this setting is rare. Although, these are benign conditions, they may present with acute cord compression and fractures which necessitate emergency treatment.

Clinical course: Our patient is a 38-year-old Egyptian male who presented to the Emergency Department with a 2-week history of increasing pain over the thoracolumbar spine with acute bilateral lower limb weakness and difficulty walking. There was no history of trauma or fever. Physical examination revealed significant sensory loss below the level of the umbilicus with paraparesis of bilateral lower limbs. X-rays revealed large expansile lesion over the mid thoracic vertebrae and multiple expansile lesions involving the ribs. Subsequent CT and MRI showed features of multiple areas of polyostotic fibrous dysplasia with secondary cystic degeneration and aneurysmal bone cysts formation, worst at T6-7 complicated with severe central spinal canal stenosis, cord compression. The patient underwent urgent spinal cord decompression with laminectomy at T6 and T7 and hemilaminectomy at T4 and T5 with aneurysmal cyst curettage and fat graft placement and subsequent physiotherapy and rehabilitation with complete resolution of motor and sensory deficits.

Discussion: This case highlights the presentation of benign, non-malignant, non-infectious, and non-traumatic acute spinal cord compression in the Emergency Department. This case also showcases classical radiological images of a rare combination of polyostotic fibrous dysplasia of the spine with subsequent cystic degeneration and aneurysmal bone cyst formation causing acute spinal cord compression.

Background: While there are benefits for over-the-counter medication (OTC) use, there are serious risks associated with OTC usage. These include self-misdiagnosis, possible delay in receiving needed therapy, use of suboptimal therapy, and increased resistance to antimicrobial agents. The patterns of (OTC) usage among adolescents remains largely understudied. The objectives of this study are: (1) to determine the profile of OTC use among adolescents from the United Arab Emirates (UAE); and (2) to determine the biological or physical, psychological or behavioral, and social predictors of OTC use among the UAE adolescent population.

Methods: In a cross-sectional study, we collected data on the prevalence of OTC use for a sample of 6,363 adolescents aged 13 to 20 years. We also collected demographic, socioeconomic, residential, and behavioral data. Analysis consisted of descriptive statistics, and bivariate and multivariate analyses. Logistic regression modelling was employed to examine predictors of over-the-counter medication use.

Results: Overall, 51% of participants in this study reported OTC use. The most common form of OTC used was acetaminophen. Significant predictors of OTC use include nationality (UAE, GCC, Arab/Middle East, Arab/Africa, Western, Other), needed health care but did not receive it, sex (female), age (15–18 years), any medical diagnosis, unconventional drug use, spending more than 5 hours using TV and computer daily, and using prescription medicine.

Conclusions: Considering the high prevalence of OTC use among adolescents from the UAE, public health policies and strategies that promote appropriate use of OTC in this population are needed.

Background: Tobacco consumption among youth is a growing public health concern worldwide. This paper examines the prevalence, profile, and predictors of tobacco-use among expatriate and national adolescents attending secondary schools in the United Arab Emirates (UAE).

Methods: Using a cross-sectional study design, we collected data on the prevalence of tobacco-use for a sample of 6,363 adolescents aged 13 to 20 years, including current smoking of cigarettes, midwakh, shisha, and any other form of tobacco. We also collected demographic, socioeconomic, residential, and behavioural data.

Results: Results suggest that 8.9% of participants smoked cigarettes, 6.3% smoked midwakh, 7.4% smoked shisha, and 6.4% smoked any other form of tobacco in the past 30 days. Overall, 14.0% of adolescents were current smokers, defined as participants who reported occasional or daily use of at least one form of tobacco in the past 30 days. Results consistently indicate that the prevalence of tobacco use is higher among males than females, regardless of age and tobacco form. Among males, cigarette usage is the most popular whereas shisha is the most smoked tobacco form among females. Consistent predictors of tobacco smoking include being male, age, parents' marital status, ever using illegal drugs, exposure to smoking at home or with friends, ethnicity, and location of residence.

Conclusions: Findings of this study emphasize the need for continued public health strategies and education campaigns to discourage adolescents from using tobacco. Knowledge of predictors of tobacco-use can be used to target at-risk adolescents through various anti-tobacco use initiatives and tobacco control measures.

Background: Globally, almost half of all adolescent deaths occur due to injury. Injuries related to accidental fall, being struck by an object or person, and road traffic injury (RTI) are particularly relevant among adolescents. Accidental falls and RTI are the most common causes of injury among children and adolescents. This study examines the profile of injuries among adolescents in the United Arab Emirates (UAE), including motor vehicle injuries (MVI), and identifies related factors associated with injury.

Methods: A cross-sectional study design determined incidence of injury for a sample of 6,363 adolescents aged 13 to 19 years. Data collected information on injury in the past 12 months, socio-demographic, behavioral, sensory data, and traffic-related behaviors. Logistic regression modeling was used to examine predictors of physical injury for the past 12 months, including injuries from motor vehicle collisions.

Results: Among participants, 18% experienced injury; the three top causes include accidental falls (38%), being struck by an object or person (18%), and MVI (13%). Identified risk factors that are amenable for prevention include smoking behavior, exposure to smoking, physical activity profile, family income, and speeding behavior. In relation to MVI, significant predictors are attending private schools (OR = 2.58), physical activity (OR = 1.11), family income (OR = 16.25), and speeding (OR = 2.34). Additionally, expatriates were less likely to experience MVI than locals.

Conclusion: Our findings highlight the need for public health policies and education programs that reduce injury among the UAE adolescent population. Future studies should build upon these findings to plan and implement tailored injury prevention strategies for this sub-population.

Background: Tobacco consumption adversely affects cardiovascular (CV) disease (CVD) and risk profile, including hypertension. The long-term effect of cigarette smoking on blood pressure (BP) in adolescents is still, however, equivocal. Thus, the current study examined the CV hemodynamics in male adolescent cigarette smokers versus non-smokers.

Methods: Resting heart rate, systolic (SBP) and diastolic (DBP) BP, mean arterial pressure (MAP), pulse pressure (PP), and rate pressure products (RPP) were examined using automatic oscillatory method, while smoking status was determined with Youth Risk Behavior Survey (YRBS).

Results: After covariating for cofactors, the ANCOVA showed that CV hemodynamics were lower (p <  0.05), in the male adolescent smokers versus non-smokers. Additionally, regression showed that smoking predicted the reduction in SBP (20.6%), DBP (5.0%), MAP (13.4%), PP (7.5%), and RPP (13.4%).

Conclusion: The results suggest that cigarette smoking lowers CV hemodynamics in adolescent. However, more studies are needed to describe the mechanism(s) for lowering CV hemodynamics and explain the relationship of adolescent smoking with adulthood CVDs.

Background: Pulmonary infections caused by Pneumocystis in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraces. In such cases, it can be challenging to maintain adequate gas exchange by mechanical ventilation and at the same time prevent further barotrauma or ventilator-induced lung injury (VILI). We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis jirovecii infection, rescued with veno-venous extracorporeal membrane oxygenation (V-V ECMO).

Case: A 26-year-old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation to reduce work of breathing. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients’ pulmonary parameters worsened and he developed severe type 2 respiratory failure necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-lung protective ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus (HIV) infection. Patient was successfully treated with appropriate antibiotics and de-cannulated after six days of ECMO support.

Conclusion: ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia.

Introduction: Tobacco consumption contributes substantially to cardiovascular (CV) diseases (CVD), including hypertension. However, the effect of waterpipe (WP) smoking on CV hemodynamics in adolescents is unknown. Thus, the current study investigated the relationship of WP smoking with CV indices.

Methods: Indices including heart rate (HR), systolic (SBP), and diastolic (DBP) blood pressures, mean arterial blood pressure (MAP), pulse pressure (PP) and rate pressure product (RPP) were obtained from 7th–10th grade male students.

Results: After controlling for confounding factors, SBP, DBP, MAP, and RPP were significantly lower (p < 0.05) in WP smokers versus non-smokers.

Conclusion: The results indicate that WP smoking lowers CV hemodynamics, which is perplexing given that tobacco smoking is associated with an immediate increase in CV hemodynamics and CVDs in adulthood. Therefore, future studies are needed to determine the mechanism(s) for lowered CV hemodynamics and the pathway between WP smoking and heightened risk of developing CV diseases adulthood, namely hypertension.