The role of heart rate variability in predicting delirium: A systematic review and meta-analysis.

Brain and heart interact through multiple ways. Heart rate variability, a non-invasive measurement is studied extensively as a predicting model for various health conditions including subarachnoid hemorrhage, cancer, and diabetes. There is limited evidence to predict delirium, an acute fluctuating disorder of brain dysfunction, as it poses a significant challenge in the intensive care unit (ICU) and post-operative setting. In this systematic review of 9 articles, heart rate variability indices were used to investigate the occurrence of post-operative and ICU delirium. This systematic review and meta-analysis reveal evidence of a strong predilection between postoperative and intensive care unit delirium and alterations in the heart rate variability, measured by mean differences for standard deviation of NN-intervals. Other heart rate variability indices [root mean squares of successive differences, low-frequency (LF), high-frequency (HF), and LF:HF ratio] showed lack of or very weak association. A non-invasive tool of brain and heart interaction may refine diagnostic predictions for acute brain dysfunctions like delirium in such population and would be an important step in delirium research.

Effect of COVID-19 during pregnancy: Studying the maternal and neonatal outcomes and assessing the placental changes related to SARS-CoV-2

BackgroundPregnant females affected with COVID-19 are reported to have poorer disease outcomes as compared to non-pregnant females of a similar age group. COVID-19 may lead to adverse changes in the placenta, which needs to be studied. MethodsThis is a case series of 63 pregnant women hospitalized with COVID-19 from May 2020 to February 2021.The primary outcomes were maternal death or complications. Results63 women were studied. 83.3% of women were in the age group of 26 to 35 years. 33% women had associated comorbidities. 68.3% of women tested positive in their third trimester, 15.9% and 11% tested positive in their second and first trimesters respectively. 73% women had mild disease and 27% women required oxygen support. 3/63 women died. One woman in the second and two women in the third trimester died respectively. Histopathological examination in 13 placentae (of 19 placentae examined) were suggestive of maternal and fetal malperfusion. ConclusionPregnant COVID-19 women may develop disease-related as well as obstetric complications.

Peri-implantitis and Practical Management: A Review

ABSTRACT@#At present, with an increasing number of implants placed, peri-implant diseases are also increasing. The inclusion of peri-implant disease in the latest classification of periodontal disease shows the global significance of the disease in addition to periodontal disease. Management for peri-implantitis is more complicated and similar to periodontitis, and bone loss is irreversible. Numerous studies throughout the decades were conducted using various techniques investigating the best method in treating peri-implantitis. Therefore, this article will explore the latest evidence for peri-implantitis and its management.

Remdesivir for the treatment of COVID-19 disease: A retrospective comparative study of patients treated with and without Remdesivir

BackgroundRemdesivir (RDV) in coronavirus disease 2019 (COVID-19) has been found to be beneficial in patients with severe disease; however, its role in mild-moderate disease and its optimal timing need to be identified. ObjectiveTo assess the course of illness and final outcome in patients who received RDV at various stages of illness, and compare it to the non-RDV group. MethodsThis is a retrospective data analysis of 1262 COVID-19 patients hospitalized from May5, 2020 to August 31, 2020. The primary outcomes were progression to mechanical ventilation (MV) or death. Kaplan Meier survival analysis and log rank test were used for evaluating primary outcomes. Results398 patients comprised the RDV group and 260 patients comprised the non-RDV group. 2/3rd of patients were above 50 years of age in both the groups and 3/4th patients were male. Mortality rate was 5.8% in RDV group (10.4% in non-RDV group). Mortality rate was 3.6%, 4% and 16.7% when RDV was started within 5 days, 5 to 10 days and after 10 days of symptom onset respectively. Fewer patients in RDV group progressed to MV (4.0% v/s 8.2%). Earlier discharge occurred in RDV group. Use of supplemental oxygen was observed in 44.7% patients in RDV group (54.2% in non-RDV group). No significant adverse events were observed with RDV. Survival analysis showed that probability of event (death) was significant for patients with hypertension (HT) and/or diabetes mellitus (DM) in RDV group. ConclusionEarly initiation of RDV is associated with shorter hospital stay, lower mortality as well as reduced need for supplemental oxygen and mechanical ventilation.

Developing a coordinate-based strategy to support cognitive targeted prostate biopsies and correlative spatial-histopathological outcome analysis / 亚洲男科学杂志(英文版)

Lack of investment for magnetic resonance (MR) fusion systems is an obstacle to deliver targeted prostate biopsies within the prostate cancer diagnostic pathway. We developed a coordinate-based method to support cognitive targeted prostate biopsies and then performed an audit on cancer detection and the location of lesions. In each patient, the prostate is considered as two separate hemiprostates, and each hemiprostate is divided into 4 × 4 × 4 units. Each unit is therefore defined by a three-dimensional coordinate. We prospectively applied our coordinates approach to target 106 prostatic lesions in 93 men. Among 45 (of 106; 42.5%) lesions positive for cancer, 27 lesions (60.0%) harbored clinically significant disease. PSA density was significantly higher in patients with proven cancer (median: 0.264 ng ml

Evaluating the Efficacy of Tocilizumab in Moderate to Severe COVID-19 with Progressive Illness despite Steroids: Identifying the Optimal Timing of its Administration in C3G study

BackgroundHigh mortality has been described in coronavirus disease 2019 (COVID-19) with cytokine release syndrome (CRS). Tocilizumab (TCZ), an interleukin-6 (IL-6) receptor antagonist may be associated with improved outcomes in such patients; however, the subgroups of patients who benefit the most need to be identified. ObjectiveTo analyze the efficacy and optimal timing of administration of TCZ in moderate to severe COVID-19 with features of CRS, where the response to steroids was poor. MethodsThis is a retrospective study of 125 patients admitted between May 5 to July 31, 2020, in a tertiary care hospital in western India, with moderate to severe COVID-19 who were treated with TCZ along with steroids. The primary outcomes were the need for mechanical ventilation (MV) or death, and secondary outcomes were a decrease in oxygen requirement and inflammatory markers; the incidence of secondary infections, and renal or hepatic dysfunction. Kaplan Meier survival analysis and log rank test were used for evaluating primary outcomes. Secondary outcomes were analyzed using the Wilcoxon Signed-Rank test. ResultsAmong 1081 patients admitted during the study period, 125 were administered TCZ (median age, 56 [95% CI 54 - 60] years; 100 [80%] male). The commonest symptoms were fever (96%), cough (64%), and dyspnea (48.8%). 78.4% patients had comorbidities (hypertension 51.2%, diabetes 43.2%, obesity 25.6% and chronic cardiac disease 13.6%). Of 117 patients who were treated with TCZ before requiring MV, 18.8% progressed to MV. Overall, 25% of the patients needed MV support. 65.3% of patients were discharged by day 14 after TCZ administration. Mortality was nil, 16.2%, 50%, and 62.5% in patients who received TCZ on room air, low flow oxygen, high flow nasal cannula (HFNC) and bilevel positive airway pressure (BiPAP), and MV respectively; overall 24.8% of patients died. Survival analysis showed no difference in outcome with respect to age and gender, while progression to MV showed a statistically significant reduction for the event death (90.9% of patients who progressed to MV died as compared to 6.3% who did not; log rank test with p < 0.0001). No adverse events were noticed. ConclusionMortality was least in patients of COVID-19 with CRS who received TCZ while on low flow oxygen. When administered in the early hypoxemic phase, TCZ is associated with reduced mortality and decreased need for mechanical ventilation.

A Comparative COVID 19 Characterizations and Clinical Course Analysis between ICU and Non ICU Settings

ObjectiveWith COVID-19 pandemic severely affecting India and Ahmedabad city being one accounting for half COVID cases, objective was to determine disease course and severity of in patients at a COVID care hospital. DesignA Clinical trial registry of India registered observational study (CTRI/2020/05/025247). SettingCertified COVID hospital located in Ahmedabad, Gujarat, India. Participants549 COVID positive patients hospitalized between 15 th May to 10 th August, 2020 and treated in ICU and non ICU settings. Main Outcome MeasureComparative analysis of demographic, clinical characteristics, investigations, treatment, complications and outcome of COVID patients in ICU and non ICU settings. ResultsOf the 549 hospitalized COVID positive patients, 159 were admitted in ICU during disease course while 390 had ward admissions. Overall median age was 52 (1-86) years. The ICU group was older (>65years), with associated comorbidities like hypertension and diabetes (p<0.001); higher proportion of males (79.25%); with dyspnea as a major clinical characteristic and consolidation in lungs as a major radiological finding as compared to ward patients. C - reactive protein, D-Dimer and Ferritin were higher in ICU patients. Overall 50% females depicted elevated Ferritin levels. Steriods(92.45%)and tocilizumab (69.18%) were more frequently used for ICU patients. Remdesivir was prescribed to both ICU and non ICU patients. Favirapir was also a line of treatment for 25% of ICU patients. Convalescent plasma therapy was given to 7 ICU patients. Complications like acute kidney injury (13.84%), shock (10.69 %), sepsis and encephalopathy were observed in ICU patients. Overall mortality rate was 5.47 % with higher mortality among males in comparison to females (p<0.0001). ConclusionAbout 29% of overall patients required ICU admission that was commonly elderly males. Chances of ICU admission were higher with baselines comorbidities (1.5 times) and dyspnea (3.4 times) respectively. A multi-specialty COVID care team and updated treatment protocols improves outcomes.

Esophageal Baseline Impedance From High-resolution Impedance Manometry Correlates With Mean Nocturnal Baseline Impedance From pH-impedance Monitoring

Background/Aims@#Esophageal baseline impedance (BI) can be extracted from pH-impedance tracings as mean nocturnal baseline impedance (MNBI), and from high-resolution impedance manometry (HRIM), but it is unknown if values are similar between acquisition methods across HRIM manufacturers. We aim to assess correlations between MNBI and BI from HRIM (BI-HRIM) from 2 HRIM manufacturers in the setting of physiologic acid exposure time (AET). @*Methods@#HRIM and pH-impedance monitoring demonstrating physiologic AET ( 0.5 were seen at MNBI at 7 cm for both systems, and at 9 cm for Medtronic. DBI-HRIM correlated with MNBI at 3 cm and 5 cm (P 0.1). @*Conclusions@#While numeric differences exist between manufacturers, BI-HRIM correlates with MNBI from corresponding channels in patients with physiologic AET. Comparison with AET elevation is needed to determine correlations between pathologic MNBI with BI-HRIM across manufacturers. The optimal HRIM channels from which BI values should be extracted also warrants further study.

Screening for Barrett's Esophagus: Balancing Clinical Value and Cost-effectiveness

In predisposed individuals with long standing gastroesophageal reflux disease (GERD), esophageal squamous mucosa can transform into columnar mucosa with intestinal metaplasia, commonly called Barrett's esophagus (BE). Barrett's mucosa can develop dysplasia, which can be a precursor for esophageal adenocarcinoma (EAC). However, most EAC cases are identified when esophageal symptoms develop, without prior BE or GERD diagnoses. While several gastrointestinal societies have published BE screening guidelines, these vary, and many recommendations are not based on high quality evidence. These guidelines are concordant in recommending targeted screening of predisposed individuals (eg, long standing GERD symptoms with age > 50 years, male sex, Caucasian race, obesity, and family history of BE or EAC), and against population based screening, or screening of GERD patients without risk factors. Targeted endoscopic screening programs provide earlier diagnosis of high grade dysplasia and EAC, and offer potential for endoscopic therapy, which can improve prognosis and outcome. On the other hand, endoscopic screening of the general population, unselected GERD patients, patients with significant comorbidities or patients with limited life expectancy is not cost-effective. New screening modalities, some of which do not require endoscopy, have the potential to reduce costs and expand access to screening for BE.

Simultaneous bilateral shoulder and bilateral central acetabular fracture dislocation: What to do? / 中华创伤杂志(英文版)

Musculoskeletal injuries following seizures have a high morbidity and mortality. These injuries are often missed and the diagnosis is delayed due to a lack of clinical suspicion and appropriate investigations.We report a case of 72 years old male with simultaneous bilateral central acetabular fracture dislocation and bilateral posterior shoulder fracture dislocation secondary to an epileptic seizure. Present study high- lights the significance of clinical suspicion and clinico-radiological evaluation for diagnosis of a rare injury following episode of seizures. Simultaneous fracture dislocation of all four limbs treated with a holistic approach can lead to a good functional recovery. Surgical management with open reduction and internal fixation is preferred and replacement arthroplasty should be reserved for cases with implant failure and elderly patients.