Colonoscopy screening for colorectal cancer in Egypt: a nationwide cross-sectional study.

BACKGROUND: Current guidelines advocate for colorectal cancer (CRC) screening in adults who are at risk by using direct visualization methods such as colonoscopy. However, in Egypt, there is a paucity of data regarding the current practice of colonoscopy screening. Moreover, more information is needed about the knowledge and attitudes of potential participants regarding the procedure and possible barriers that can limit their participation. METHODS: We conducted a nationwide cross-sectional study using an interview-based survey of patients aged 45 years or above who presented to outpatient clinics of nine university hospitals throughout Egypt. Participants were surveyed to assess their compliance with CRC colonoscopy screening guidelines, their knowledge of and attitude towards colonoscopy screening, and their perspective on potential barriers to colonoscopy screening. RESULTS: A total of 1,453 participants responded to our survey in the nine study centers. Only a minority of participants (2.3%) were referred for CRC screening. Referral rates were higher among those who knew someone with a history of CRC (5.3% vs 1.5%, p < 0.001) or had a discussion with their physician about CRC (25.8% vs 0.7%, p < 0.001). Few responders (3.2%) had good knowledge regarding CRC screening. After introducing the concept of CRC screening to all participants, most patients (66.7%) showed a positive attitude towards having the procedure. Financial burden and fear of results were the two most frequently cited barriers to undergoing CRC screening (81.1%; and 60.1%, respecteively). CONCLUSIONS: Despite the positive attitude, there is insufficient knowledge about CRC screening among eligible participants in Egypt. This has probably contributed to low compliance with current CRC screening guidelines and needs to be addressed at the national level.

Radial extracorporeal shock wave therapy as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients. A randomized controlled study.

PURPOSE: To evaluate the effectiveness of radial extracorporeal shock wave therapy (r ESWT) as an additional treatment modality for spastic equinus deformity in chronic hemiplegic patients. METHODS: 100 eligible stroke patients with calf muscles spasticity were randomized into 2 groups. Group I: 50 patients exposed to rESWT 1.500 pulses, 0.10 mJ to 0.3mJ/mm2, with a frequency 4 Hz once weekly for one month. Group II: 50 patients exposed to Sham rESWT once weekly for one month. Clinical, electrophysiological & musculoskeletal ultrasound assessments were done for all patients. RESULTS: After controlling baseline as covariate, the trend for modified Ashworth scale (MAS), Passive ankle dorsiflexion motion (PADFM), 10 meters walk test (10-MWT), and Ratio of maximum H reflex to maximum M response (H/M ratio) after one & two months was significantly different between the two groups, with improvement of all clinical and electrophysiological parameters in group I. CONCLUSION: ESWT represents a useful non-invasive, additional modality for the reduction of foot spasticity and equinus deformity in stroke patients.

Extracorporeal shock wave therapy represents a useful non-invasive, additional modality for reduction of foot spasticity and equinus deformity in chronic stroke patients.The application of such a modality improves limb posture, range of motion, and muscle extensibility.Early extracorporeal shock wave rehabilitative intervention in stroke patients reduces fat infiltration and fibrosis replacement of spastic muscle.

Network meta-analysis of randomized controlled trials comparing the effectiveness of different treatments in reducing amniocentesis-associated pain and anxiety.

OBJECTIVE: This network meta-analysis compared different methods to determine which is most efficient at lowering pain and anxiety in women undergoing amniocentesis. METHOD: We looked through all published randomized controlled trials in the databases PubMed, Scopus, Web of Science, Cochrane, and EM base. Anxiety and pain were the predominant results. We used the R software version 4.2.1 to analyze the data. RESULTS: We included a total of 20 studies, with sample sizes ranging from 60 to 570. Virtual reality was the most effective strategy for lowering pain during AC [MD = -1.30, 95% CI (-2.11, -0.49)]. In addition, paracetamol use was the most successful approach for lowering pain following AC [MD = -1.68, 95% CI (-1.99, -1.37)]. The use of H7 acupressure, however, was the strategy that significantly reduced anxiety following AC [SMD = -15.46, 95% CI (-17.77, -13.15)]. CONCLUSION: The most effective method for reducing pain is the combination of virtual reality with paracetamol. Whereas, the most effective way to reduce anxiety is to combine an ice gel pack with H7 acupressure before applying AC.

Current Approaches to Four Challenging Pain Syndromes.

During a conference of pain specialists, some of the experts addressed the potential management of four prevalent but difficult painful conditions, namely, chronic postsurgical pain (CPSP), knee osteoarthritis, chest trauma, and facet joint arthropathy. In all cases, the conditions posed challenges in accurate diagnoses as well as safe, effective treatments, especially using locoregional blocks. It is not clear why some surgical patients develop CPSP and others do not, although some risk factors have been identified. More importantly, the transitional phase of pain from acute to chronic deserves greater scrutiny. It appears as if more aggressive and more effective perioperative and postoperative analgesia could help mitigate or possibly prevent CPSP. Knee osteoarthritis is prevalent but is often managed pharmacologically and then with joint replacement; many patients simply live with the condition which can be viewed as a disease of the entire joint. New approaches with intra-articular injections of hyaluronic acid, platelet-rich plasma, and botulinum toxin may provide safe, effective, and durable pain control. Chest trauma can be extremely painful and a source of morbidity, but its management tends to rely on watchful waiting and drug therapy. New approaches to regional nerve blocks can be beneficial and may reduce troublesome symptoms such as the inability to cough or clear the lungs. Facet joint arthropathy is very prevalent among older people but is not completely clarified. It may be the source of intense pain with limited management strategies. The role of nerve blocks in facet joint arthropathy is an important new addition to the armamentarium of pain management, particularly for geriatric patients.

Efficacy and safety of baricitinib in treatment of systemic lupus erythematosus: a systematic review and meta-analysis.

BACKGROUND: SLE is an autoimmune disease marked by broad immunological dysregulation and multi-system inflammation. Baricitinib is one of the novel treatments for SLE. We conducted this meta-analysis to evaluate its safety and effectiveness in treating SLE. METHOD: We looked for all published randomized controlled trials in PubMed, Scopus, Web of Science, and Cochrane and included all RCTs comparing baricitinib and placebo in the treatment of SLE. Review Manager 5.4 program was used for data analysis. RESULTS: Three trials with a total of 1849 individuals were included. Participants in the baricitinib group were significantly more likely to attain SRI-4 response than those in the placebo group [RR = 1.11, 95% CI (1.02, 1.21), P = 0.01]. Additionally, baricitinib performed better than the placebo in terms of reduction of ≥ 4 points from baseline in SLEDAI-2 K score [RR = 1.13, 95% CI (1.04, 1.22), P = 0.004]. In terms of SLEDAI-2 K remission of arthritis or rash, baricitinib was also superior to placebo [RR = 1.08, 95% CI (1.00, 1.17), P = 0.04]. Treatment-emergent adverse events did not differ significantly [RR = 1.01, 95% CI (0.97, 1.05), P = 0.61]. CONCLUSION: Baricitinib is potentially safe and effective in the treatment of SLE. It has successfully met the study's primary endpoint and some secondary endpoints highlighting its potential to improve the outcomes of SLE. Despite achieving an SRI-4 response, glucocorticoids sparing and some other secondary outcomes weren't reached by baricitinib.

Post-traumatic radial nerve neuroma: A case report.

Introduction: Radial nerve neuromas (RNNs) are mostly post-traumatic conditions that occur after a complete or partial section of a nerve. Here we report a case of post-traumatic RNN with good functional progression after intense physical rehabilitation. Case presentation: A 49 years old patient with a post-complete section of the radial nerve underwent intensive physical rehabilitation with two sessions of ultrasound-guided injections of 10 % glucose saline around the neuroma. 12 months later, the patient improved his wrist and hand finger extension functions. Conclusion: Several surgical and non-surgical therapies have been proposed for the treatment of neuromas. However, no consensus currently exists, and management is frequently adapted to each patient.

Ultrasound-Guided Interventions for Carpal Tunnel Syndrome: A Systematic Review and Meta-Analyses.

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment, and recently, ultrasound-guided perineural injection (UPIT) and percutaneous flexor retinaculum release (UPCTR) have been utilized to treat CTS. However, no systematic review or meta-analysis has included both intervention types of ultrasound-guided interventions for CTS. Therefore, we performed this review using four databases (i.e., PubMed, EMBASE, Scopus, and Cochrane) to evaluate the quality of evidence, effectiveness, and safety of the published studies on ultrasound-guided interventions in CTS. Among sixty studies selected for systemic review, 20 randomized treatment comparison or controlled studies were included in six meta-analyses. Steroid UPIT with ultrasound guidance outperformed that with landmark guidance. UPIT with higher-dose steroids outperformed that with lower-dose steroids. UPIT with 5% dextrose in water (D5W) outperformed control injection and hydrodissection with high-volume D5W was superior to that with low-volume D5W. UPIT with platelet-rich plasma outperformed various control treatments. UPCTR outperformed open surgery in terms of symptom improvement but not functional improvement. No serious adverse events were reported in the studies reviewed. The findings suggest that both UPIT and UPCTR may provide clinically important benefits and appear safe. Further treatment comparison studies are required to determine comparative therapeutic efficacy.

Screw Impingement Causing Massive Swelling of the Sciatic Nerve: A Case Report.

Sciatic nerve (SN) injuries after hip fracture dislocation are described and are not uncommon. Several factors can lead to SN injury after hip surgery; among other factors, screw plates of synthesis materials can immigrate and lead to nerve impingement. We report a case of a 22-year-old male with a history of posterior wall fracture and hip dislocation after a motorway accident. Ultrasonography showed massive swelling of the SN with a cross-sectional area measured at 1.50 cm2 upstream to screw impingement. The reoperation option was judged too risky by the orthopedic surgeons; currently, the patient is undergoing platelet-rich plasma (PRP) injections around the nerve swelling and to the lifter muscles of the foot.

The Booster Effect of a Single Quarterly Dose of Hyaluronic Acid in Knee Osteoarthritis: Five-Year Results of a Registry-Based Study.

Objective Viscosupplementation by hyaluronic acid (HA) is well established non-surgical treatment of knee osteoarthritis (KOA). This registry-based study investigated the booster effect of a quarterly intra-articular single knee injection (30mg/2ml) for five years. Methods Sixty patients, including 29 males and 31 females, with a mean ± SD age 61.07 ± 9.15 with Kellgren-Lawrence grade I-III KOA, have been selected from a registry of interventional treatments for musculoskeletal pain conditions. To be eligible, patients had to be treated with a single quarterly intraarticular injection of HA with a follow-up of at least five years and assessed with Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Numeric Rating Scale (NRS) at baseline and after each HA injection in the first 24 months and at 36, 48, and 60 months. Results Sixty of 63 patients enrolled in this study completed the 60 months of follow-up. Patients had a marked improvement in knee function and pain, expressed by the significant reduction in WOMAC (T0 48.62±8.95 vs. T11 10.75±4.36; p<0.0001) and NRS scores (6.38±1.06 vs. T11 0.95±0.89 p<0.0001) from the baseline to the end of the follow-up period. Conclusion A quarterly injection of HA provides a rapid, safe, and stable long-term reduction of pain and improvement of function in elderly people with mild to moderate knee osteoarthritis along a five-year period of treatment and follow-up. Further investigations are necessary to confirm these findings.

Pulsed Radiofrequency for Postherpetic Trigeminal Neuralgia: A Case Report.

Trigeminal postherpetic neuralgia has been reported to cause chronic headaches and facial pain. There are various modalities of treatment ranging from pharmacological to surgical treatment. However, these are frequently accompanied by undesirable side effects and minimal efficacy. Pulsed radiofrequency has been used to treat chronic pain but it is often seen as an unconventional treatment for postherpetic neuralgia. Nonetheless, the literature supports its use for alleviating pain with minimal complications. This case demonstrates that pulsed radiofrequency can successfully treat intractable pain secondary to postherpetic neuralgia affecting all three trigeminal dermatomes.

Efficacy of Acupuncture, Intravenous Lidocaine, and Diet in the Management of Patients with Fibromyalgia: A Systematic Review and Network Meta-Analysis.

Introduction: This network meta-analysis aimed to assess the efficacy of acupuncture, intravenous lidocaine, and diet compared with other comparators such as physiotherapy and sham/placebo in fibromyalgia patients. Materials and Methods: We searched Embase, PubMed, Scopus, and Web of Science for relevant studies till September 2021. The included studies were randomized controlled clinical trials. For the network meta-analysis, we used the R software. Results: There were 23 included RCTs. The total sample size was 1409 patients. Compared with the sham/placebo group, the network analysis showed the highest improvement in the quality of life in the acupuncture group standardized mean difference (SMD) = -10.28, 95%-CI [-14.96; -5.59]), and then in the physiotherapy group (SMD = -7.48, 95%-CI [-14.72; -0.23]). For the pain, there was a significant reduction with acupuncture (SMD = -1.69, 95%-CI [-2.48; -0.89]), compared with sham/placebo. Regarding depression, it showed a significant reduction with acupuncture (SMD = -9.64, 95%-CI [-16.13; -3.14]) compared with sham/placebo. Finally, for stiffness, it showed no significant differences in the stiffness between acupuncture (SMD = -8.52, 95%-CI [-20.40; 3.36]), fluoxetine (SMD = -6.52, 95%-CI [-29.65; 16.61]), and physiotherapy (SMD = -4.64, 95%-CI [-22.83; 13.54]) compared with sham/placebo. Conclusions: The acupuncture showed a significant effect in the management of fibromyalgia patients. It reduced pain, depression, and enhanced the quality of life. While physiotherapy showed a significant improvement in the quality of life only. In contrast, intravenous lidocaine and diet showed no significant differences when compared with sham/placebo.

Efficacy of Botulinum Toxin, Local Anesthetics, and Corticosteroids in Patients With Piriformis Syndrome: A Systematic Review and Meta-analysis.

BACKGROUND: Piriformis syndrome (PS) is a painful condition caused by entrapment of the sciatic nerve within the piriformis muscle. PS is typically unilateral and mainly occurs related to entrapment of the sciatic nerve. Treatments include physiotherapy, analgesics, anti-inflammatory drugs, behavioral modifications, injection therapy with local anesthetics (LAs) and steroids, epidural injection, botulinum toxin (BT) injection, and surgery. OBJECTIVES: To investigate the efficacy of BT, LA, and corticosteroid (CS) injections in relieving pain in patients affected by PS. STUDY DESIGN: This systematic review and meta-analysis was conducted according to the "Cochrane Handbook for Systematic Reviews of Interventions" and the "Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA)" guidelines. METHODS: A systematic search was conducted through PubMed, Cochrane, Web of Science, and Scopus through April 2021 for studies investigating the efficacy of BT, LA, or CS injection in improving pain in patients with PS. After screening retrieved studies, data were extracted from included studies and pooled. Overall results were reported as standardized mean difference (SMD) and 95% confidence interval (CI). Analysis was performed using RevMan software version 5.4. RESULTS: Sixteen studies were included in this systematic review, and 12 of them were included in the quantitative synthesis. The pain scores decreased significantly after treatment with BT (SMD = -2.00; 95% CI [-2.84, -1.16], P < 0.001), LA and CS (SMD = -4.34; 95% CI [-5.77, 2.90], P < 0.001), LA (SMD = -3.73; 95% CI [-6.47, -0.99], P = 0.008), CS (SMD = -2.78; 95% CI [-3.56, -2.00], P < 0.001), and placebo injection (SMD = -0.04; 95% CI [-0.07, -0.01], P = 0.002). BT injection was less effective than LA and CS together (P = 0.006), more effective than placebo (P = 0.001), and similar to LA (P = 0.24) and CS (P = 0.18), when injected alone. LIMITATIONS: A wide variety of study designs were utilized to obtain the largest sample size available. Many of the included studies lack randomization, and some are retrospective in nature. These limitations may introduce bias into the analyzed data and affect the results. Many studies had a low sample size and are of moderate quality, limiting the generalizability of the results. Also, we could not conduct a direct meta-analysis due to the lack of sufficient double-arm studies comparing different types of injection therapies. CONCLUSIONS: In patients with PS, satisfactory pain improvement can be obtained by BT, LA plus CS, LA, or CS injection therapy. Injection of LA plus CS showed the best efficacy.

Motor-Sparing Neural Ablation with Modified Techniques for Knee Pain: Case Series on Knee Osteoarthritis and Updated Review of the Underlying Anatomy and Available Techniques.

Knee osteoarthritis (KOA) is ubiquitous. However, effective pain managements for patients with grades 3 or 4 KOA for whom conservative treatments are unsuccessful, but for whom surgery is not an option, remain lacking. This case series presented two motor-sparing interventional pain treatment modalities for five such patients. Three of the patients with a mean total WOMAC score of 41 underwent thermal radiofrequency (RF) ablation using a modified motor-sparing approach. One-week and four-week post-RF, the total score dropped to 27 (by 34%) and 19 (dropped 53.7%), respectively. Two other similar patients with a mean total WOMAC score 96 underwent chemical neurolysis using a motor-sparing approach with modified landmarks. The WOMAC score dropped to 58.5 (by 39.1%) and 49 (dropped by 49.0%), one-week and four-week postchemical neurolysis, respectively. A narrative review of the currently available approaches is also provided, with the conclusion that neural ablation using the modified landmarks approach may achieve better pain control and preserve the motor functions for patients with severe KOA for whom conservative treatment was unsuccessful and who are not candidates for surgery.

The Emerging Era of Interventional Imaging in Rheumatology: An Overview During the Coronavirus Disease-2019 (COVID-19) Pandemic.

Imaging has long been taking its place in the diagnosis, monitor, and prognosis of rheumatic diseases. It plays a vital role in the appraisal of treatment. Key progress in the clinical practice of rheumatology is the innovation of advanced imaging modalities; such as musculoskeletal ultrasound (MSUS), computerized tomography (CT) and magnetic resonance imaging (MRI). These modalities introduced a promising noninvasive method for visualizing bone and soft tissues to enable an improved diagnosis. The use of MSUS in rheumatology is considered a landmark in the evolution of the specialty and its ease of use and many applications in rheumatic diseases make it a forerunner instrument in the practice. The use of MSUS among rheumatologists must parallel the development rate of the excellence revealed in the specialty. Moreover, innovative interventional imaging in rheumatology (III-R) is gaining fame and key roles in the near future for a comprehensive management of rheumatic diseases with precision. This review article throws light on the emergence of these robust innovations that may reshape the guidelines and practice in rheumatology, in particular, efforts to enhance best practice during the coronavirus disease 2019 (COVID-19) pandemic are endorsed.

Efficacy of Ultrasound-Guided Injection of Botulinum Toxin, Ozone, and Lidocaine in Piriformis Syndrome.

Background: Piriformis syndrome (PS) is a painful musculoskeletal condition characterized by a deep gluteal pain that may radiate to the posterior thigh and leg. This study was designed to compare the effectiveness of ozone and BTX to lidocaine injection in treating piriformis syndrome that was resistant to medication and/or physical therapy. Study design: Between November 2018 and August 2019, we involved eighty-four subjects diagnosed with piriformis syndrome in a double-blinded, prospective, randomized comparative study to receive an ultrasound-guided injection of lidocaine (control group), botulinum toxin A, or local ozone (28 patients each group) in the belly of the piriformis muscle. Pain condition evaluated by the visual analog score (VAS) was used as a primary outcome, and the Oswestry Disability Index (ODI) as a secondary outcome, before, at one month, two months, three months, and six months following the injection. Results: The majority (58.3%) of patients were male, while (41.7%) were female. At one month, a highly significant decrease occurred in VAS and ODI in the lidocaine and ozone groups compared to the botulinum toxin group (p < 0.001). At six months, there was a highly significant decrease in VAS and ODI in the botulinum toxin group compared to the lidocaine and ozone groups (p < 0.001). Conclusion: Botulinum toxin may assist in the medium- and long-term management of piriformis syndrome, while lidocaine injection and ozone therapy may help short-term treatment in patients not responding to conservative treatment and physiotherapy.

Constraint-Induced Movement Therapy Combined With Botulinum Toxin for Post-stroke Spasticity: A Systematic Review and Meta-Analysis.

Stroke is considered one of the main causes of adult disability and the second most serious cause of death worldwide. The combination of botulinum toxin type A (BTX) with rehabilitation techniques such as modified constraint-induced movement therapy (mCIMT) has emerged as a highly efficient intervention for stroke patients to start synchronized motor function along with spasticity reduction. The current systematic review and meta-analysis were conducted in order to evaluate the available literature about the safety and efficacy of constraint-induced movement therapy (CIMT) combined with BTX in stroke patients with upper limb spasticity. Searches were conducted on WoS (Web of Science), Ovid, EBSCO-ASC&BSC, and PubMed for identifying relevant literature published from 2000-2020. Randomized Controlled Trials (RCTs) and Quasi-experimental studies were considered for inclusion. Rayyan (systematic review tool) QCRI (Qatar Computing Research Institute) was used for independent screening of the studies by two reviewers. For risk of bias and study quality assessment, Cochrane risk of bias tool (RoB 2) and Physiotherapy Evidence Database (PEDro) scales were used. Cochrane review manager was used to carry out the meta-analyses of the included studies. The search resulted in a total of 13065 references, of which 4967 were duplicates. After the title, abstract and full-text screening, two RCTs were deemed eligible for inclusion. Both the RCTs scored 8 on PEDro and were level evidence. The studies were heterogeneous. The findings of this meta-analysis in all the three joints post-stroke spasticity assessed on modified Ashworth scale (MAS) at four weeks post-injection aren't statistically significant (elbow P-value 0.74, wrist P-value 0.57, fingers P-value 0.42), however, according to one of the included studies the therapeutic efficacy of the combination of BTX-mCIMT injection assessed at four weeks post-injection in wrist and finger flexors was promising.  The effectiveness of BTX-CIMT combination over conventional therapy (CT) for improving post-stroke spasticity still needs to be explored with long-term, multicenter rigorously designed RCTs having a good sample size. However, the BTX-CIMT combination is promising for enhancing motor function recovery and improving activities of daily living (ADLs).

Peripheral neuropathy in systemic lupus erythematosus: what can neuromuscular ultrasonography (NMUS) tell us? A cross-sectional study.

OBJECTIVE: To evaluate peripheral nerve involvement in patients with SLE with neuromuscular ultrasonography (NMUS) and understand its role in investigating SLE-related peripheral neuropathy. METHODS: This is an observational cross-sectional study on patients with SLE and healthy controls. Five nerves in each patient were examined bilaterally with NMUS, and the cross-sectional area (CSA) of each nerve at certain sites was estimated. The mean CSA at each site, for each nerve, in each group was statistically analysed and compared between groups. RESULTS: 370 nerves were evaluated in 37 patients. By nerve conduction study (NCS), 36 patients had polyneuropathy (80.6% mixed type, 19.4% sensory). Significant mean CSA enlargement was present among the ulnar nerve at the Guyon's canal and mid-humerus (both p=0.001); tibial nerve at the distal leg and proximal to the tarsal tunnel (p=0.003 and p=0.001, respectively); and peroneal nerve at the popliteal fossa (p=0.042). The mean CSA showed high specificity compared with NCS. CONCLUSION: Our study shows that CSA could be a complementary tool to NCS for studying peripheral neuropathy in SLE. Furthermore, NMUS provides data on the different pathophysiological aspects of nerve involvement in SLE. Future studies using more than one sonographic parameter in combination with NCS and nerve histopathology are recommended to further investigate SLE-related neuropathy.Trial registration number NCT04527172.

Short-Term Outcomes and Predictors of Effectiveness of Tocilizumab in Systemic Juvenile Idiopathic Arthritis: A Prospective Cohort Study.

Background: Systemic Juvenile Idiopathic Arthritis (sJIA) is a unique category of juvenile arthritis in which interleukin 6 plays a major pathogenic role. This study aimed to describe the therapeutic short-term outcomes among patients with sJIA starting tocilizumab (TCZ) therapy and to identify possible predictors of treatment response. Methods: We conducted a prospective observational study including 65 patients with sJIA meeting ILAR classification criteria with active disease despite conventional therapy that were treated by TCZ between August 2019 and October 2020 as the first-line biological therapy. Clinical and serological parameters were recorded at baseline and after 1 year of TCZ therapy. Results: After 1 year, 25% of the patients achieved minimal disease activity and 35% achieved clinically inactive disease. A significant reduction of the 10-joint juvenile arthritis disease activity score and acute phase reactants was also observed. Patients with younger age (≤7 years), shorter disease duration (≤3 years), lower disease activity, and higher serum ferritin and systemic manifestations showed more favorable results. Conclusion: Patients with sJIA showed favorable disease outcomes with TCZ treatment for 1 year, especially if the drugs were administered earlier in the disease course and in younger patients with a more pronounced inflammatory status. Our results may help to define the profile of patients with sJIA who are more likely to benefit from IL-6 blockade.

Correction: Is the heart rate variability monitoring using the analgesia nociception index a predictor of illness severity and mortality in critically ill patients with COVID-19? A pilot study.

[This corrects the article DOI: 10.1371/journal.pone.0249128.].

Is the heart rate variability monitoring using the analgesia nociception index a predictor of illness severity and mortality in critically ill patients with COVID-19? A pilot study.

INTRODUCTION: The analysis of heart rate variability (HRV) has proven to be an important tool for the management of autonomous nerve system in both surgical and critically ill patients. We conducted this study to show the different spectral frequency and time domain parameters of HRV as a prospective predictor for critically ill patients, and in particular for COVID-19 patients who are on mechanical ventilation. The hypothesis is that most severely ill COVID-19 patients have a depletion of the sympathetic nervous system and a predominance of parasympathetic activity reflecting the remaining compensatory anti-inflammatory response. MATERIALS AND METHODS: A single-center, prospective, observational pilot study which included COVID-19 patients admitted to the Surgical Intensive Care Unit was conducted. The normalized high-frequency component (HFnu), i.e. ANIm, and the standard deviation of RR intervals (SDNN), i.e. Energy, were recorded using the analgesia nociception index monitor (ANI). To estimate the severity and mortality we used the SOFA score and the date of discharge or date of death. RESULTS: A total of fourteen patients were finally included in the study. ANIm were higher in the non-survivor group (p = 0.003) and were correlated with higher IL-6 levels (p = 0.020). Energy was inversely correlated with SOFA (p = 0.039) and fewer survival days (p = 0.046). A limit value at 80 of ANIm, predicted mortalities with a sensitivity of 100% and specificity of 85.7%. In the case of Energy, a limit value of 0.41 ms predicted mortality with all predictive values of 71.4%. CONCLUSION: A low autonomic nervous system activity, i.e. low SDNN or Energy, and a predominance of the parasympathetic system, i.e. low HFnu or ANIm, due to the sympathetic depletion in COVID-19 patients are associated with a worse prognosis, higher mortality, and higher IL-6 levels.