bluuebunny/crossref_metadata_2025 huggingface dataset:
A Study of Correlation Between Tympanic Membrane Perforation Size With Hearing Loss in Patients With Inactive Mucosal Chronic Otitis Media
Authors: Kolluru Kartik , Kumar Sunil , Upadhyay Prabhakar
Published: October 2020

Purpose:

This study is directed towards establishing a correlation between the objective measurement of tympanic membrane (TM) perforation size with hearing loss in patients with inactive mucosal chronic otitis media (COM), and to compare the otoscopic findings of the TM perforation vis-a-vis the results obtained by image analysis of the endoscopic image of the perforation.

Materials and methods:

An observational, prospective and hospital based study was performed on 107 ears (78 patients) with inactive mucosal chronic otitis media. Objective measurement of the TM perforation size was done by capturing the images of the perforation on ImageJ analysis software. A correlation was established between the hearing loss and the perforation with respect to its size and location. The accuracy of the otoscopic finding of the perforation was established with respect to the endoscopic image of the perforation.

Results:

The extent of the hearing loss was seen to increase with increasing size of the TM perforation (r = 0.435, p < 0.0001). Posterior perforations had a 12% greater hearing loss than anterior perforations but this was significant only at the frequency of 500 Hz (p = 0.02). There was a positive correlation between the otoscopic estimation of the size of the perforation with the endoscopically obtained image.

Conclusion:

Hearing loss in chronic otitis media is directly proportional to the size of the TM perforation and posteriorly based perforations have worse audiometric thresholds at lower frequencies (500 Hz).
The role of endocrine-disrupting chemicals in uterine fibroid pathogenesis
Authors: Bariani Maria Victoria , Rangaswamy Roshni , Siblini Hiba , Yang Qiwei , Al-Hendy Ayman , Zota Ami R.
Published: October 2020

Purpose of review

Uterine leiomyoma (fibroids) is a gynecologic disorder impacting the majority of women in the United States. When symptomatic, these noncancerous tumors can cause severe morbidity including pelvic pain, menorrhagia, and infertility. Endocrine-disrupting chemicals (EDCs) may represent a modifiable risk factor. The aim of this review is to summarize recent human and experimental evidence on EDCs exposures and fibroids.

Recent findings

Multiple EDCs are associated with fibroid outcomes and/or processes including phthalates, parabens, environmental phenols, alternate plasticizers, Diethylstilbestrol, organophosphate esters, and tributyltin. Epidemiologic studies suggest exposure to certain EDCs, such as di-(2-ethylhxyl)-phthalate (DEHP), are associated with increased fibroid risk and severity. Both human and experimental studies indicate that epigenetic processes may play an important role in linking EDCs to fibroid pathogenesis. In-vitro and in-vivo studies show that DEHP, bisphenol A, and diethylstilbestrol can impact biological pathways critical to fibroid pathogenesis.

While research on EDCs and fibroids is still evolving, recent evidence suggests EDC exposures may contribute to fibroid risk and progression. Further research is needed to examine the impacts of EDC mixtures and to identify critical biological pathways and windows of exposure. These results could open the door to new prevention strategies for fibroids.
Testosterone therapy: where do the latest guidelines agree and differ?
Authors: Pelzman Daniel L. , Hwang Kathleen
Published: October 2020

Purpose of review

The incidence of testosterone deficiency and number of men on testosterone therapy (TTh) has increased significantly over the past 3 decades. This rise has been accompanied by controversies surrounding the indications and possible adverse effects of therapy. To better inform prescribing habits among providers, many major medical associations have devised guidelines regarding the diagnosis and management of testosterone deficiency. While these guidelines agree in many areas, there are some key differences that should be identified. This review will explore the similarities, differences, and rationale for these guidelines.

Recent findings

Over the past 7 years, much attention has been devoted to the implications of TTh on cardiac health. All reviewed guidelines include dedicated sections discussing these implications and the society's position on prescribing testosterone considering recent findings, however, differ on specific contraindications to TTh and when to initiate therapy after a cardiovascular event. In addition, the American College of Physicians released its first guideline earlier this year which may impact prescribing habits among primary care physicians.

The differences between testosterone deficiency guidelines may indicate gaps in our knowledge of testosterone deficiency and focuses of future research efforts. Prescribers should be aware of these differences and discuss all treatment options with their patients.
Hypogonadism and metabolic syndrome: review and update
Authors: Berg William T. , Miner Martin
Published: October 2020

Purpose of review

The prevalence of metabolic syndrome and hypogonadism continues to rise in the United States and around the world. These two conditions are inexorably linked, and understanding their relationship with each other is key to treating men with either of these conditions.

Recent findings

Testosterone has been shown to be a key regulator in the maintenance of metabolic homeostasis. A large volume of research has found that testosterone deficiency is closely linked to metabolic syndrome through complex physiologic mechanisms of endothelial dysfunction, inflammation, and glucose metabolism.

Interventions through lifestyle modification and testosterone replacement in hypogonadal men may reduce the morbidity and mortality risks associated with metabolic syndrome.
The value of 4D fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in the diagnosis of lung lesions
Authors: Zhang Lixia , Chen Jinyan , Xu Caiyun , Zhang Yin , Qi Lili , Zhang Xiyan
Published: October 2020

Objective

This study aimed to assess the clinical value of 4D fluorine-18-fluorodeoxyglucose PET/computed tomography (18F-FDG PET/CT) in the differential diagnosis for lung lesions.

Patients and methods

Fifty-eight patients with lung lesions including lung cancer, pneumonia nodules, and benign pulmonary nodules were enrolled. The PET/CT scan was performed immediately (15 min of dynamic scan), at 60 min (early scan), and at 120 min (delayed scan) after the injection of 18F-FDG. The time-activity curves (TACs) were generated from the dynamic PET. The maximum standardized uptake value (SUVmax) of each lesion at early and delayed scans was measured, and the retention index of SUVmax (RI-SUVmax) was calculated. The cutoff values for SUVmax were determined.

Results

Lung cancer lesions (27/31, 87.1%) exhibited a continuously rising slope of TAC, whereas pneumonia lesions (13/15, 86.66%) and benign pulmonary nodules (12/12, 100%) exhibited a continuously decreasing slope of TAC. The early-SUVmax and delayed-SUVmax in the pneumonia group were significantly lower than those in the lung cancer group, whereas notably higher than those in the benign pulmonary nodules group. The diagnostic accuracy was: delayed-SUVmax > early-SUVmax > RI-SUVmax.

Conclusion

The 4D 18F-FDG PET/CT exhibited excellent performance with high accuracy in the dynamic PET/CT.
Predictive value of sentinel lymph node imaging and biopsy in early cervical cancers: correlation with scintigraphic uptake patterns and histology
Authors: Subramanyam Padma , Palaniswamy Shanmuga Sundaram
Published: October 2020

Aim

This study was designed to 1) assess the feasibility, standardization of sentinel lymph node imaging (SLNI) and biopsy in early cervical cancers and also to determine the detection rates. 2) To analyze the SLN uptake pattern and correlate the findings with the histological grades of tumor.

Materials and methods

52 early cervical cancer patients underwent same-day 99mTc sulfur colloid (filtered) SLNI and biopsy with gamma probing. Patients underwent radical hysterectomy, para-aortic and pelvic lymphadenectomy irrespective of sentinel lymph node biopsy (SLNB) findings. We analyzed the colloid transit times, uptake pattern, lymphatic groups involved and histology.

Results

A total of 203 hot nodes (100% detection rate) were detected and harvested. Study showed 100% sensitivity, specificity, and negative predictive value. Internal iliac nodes were predominantly involved. Lymphatic uptake patterns were graded and correlated with tumor histology (Ki index). Transit time was relatively prolonged in patients with aggressive tumors.

Conclusion

SLNI and biopsy in early cervical malignancies are feasible with high detection rate. Scintigraphic patterns of nodal uptake were relevant and found to correlate with the tumor histological grades. We found that nonfocal nodal uptake patterns were mainly encountered in patients with tumors having higher Ki index. Immunohistochemistry further facilitated identification of lymph nodal metastases. The visual grading system, implemented in this study provides a good indication of the degree of impairment of lymphatic drainage. Higher visual scintigraphic grade denotes greater lymphatic tumor burden.
A review of pediatric neuroendocrine tumors, their detection, and treatment by radioisotopes
Authors: Haddad Tara , Fard-Esfahani Armaghan , Vali Reza
Published: October 2020

Neuroendocrine tumors (NETs) are rare in childhood. Neuroblastoma is the most common pediatric extracranial solid tumor, occurring >90% in children younger than 5 years of age. Pheochromocytoma and paraganglioma are rare NETs, causing hypertension in 0.5–2% of hypertensive children. Gastroenteropancreatic NETs can occur in children and are classified into carcinoids and pancreatic tumors. Nuclear medicine procedures have an essential role both in the diagnosis and treatment of NETs. Metaiodobenzylguanidine (MIBG) labeled with radioiodine has a well-established role in diagnosis as well as therapeutic management of the neuroblastoma group of diseases. During recent decades, establishing the abundant expression of somatostatin receptors by NETs first led to scintigraphy with somatostatin analogs (i.e. 99mTc/111In-octreotide) and, later, with the emergence of positron-emitting labeled agents (i.e. 68Ga-DOTATATE/DOTATOC/DOTANOC) PET scans with significantly higher detection efficiency became available. Therapy with somatostatin analogs labeled with beta emitters such as Lu-177 and Y-90, known as peptide receptor radionuclide therapy, is a promising new option in the management of patients with inoperable or metastasized NETs. In this article, pediatric NETs are briefly reviewed and the role of radioactive agents in the detection and treatment of these tumors is discussed.
The frequency and malignancy rate of incidental focal breast lesions identified by 18F-fluorodeoxyglucose positron emission tomography
Authors: Andersen Jeannette D. , Zacho Helle D. , Petersen Lars J.
Published: October 2020

Objective

To evaluate the frequency and malignancy rate of incidental focal uptake of 18F-fluorodeoxyglucose (FDG) in the breast on PET/computed tomography (CT).

Material and methods

All PET/CT scan reports from a single institution from 2010 to 2017 were electronically searched for words or phrases related to FDG uptake in the breast. Potentially eligible PET/CT scans were manually reviewed for the presence of focal incidental findings in the breast, and a final diagnosis was established based on pathology, clinical examinations, and clinical follow-up.

Results

A total of 19 551 PET/CT scans were reviewed, from which 66 patients (0.3%) presented with unexpected focal FDG-avid lesions of the breast. Fifty-three patients (80.3%) had follow-up evaluations. The final diagnosis showed malignancies in 38 patients. Thirty-four patients had biopsy-verified cancer (primary breast cancers, n = 30; metastasis, n = 4), and four patients with known lymphoma showed a tumour response in the breast after chemotherapy. The malignancy rate was 85.0% among patients who underwent biopsy (34 of 40 patients). The SUVmax was significantly higher in patients with a final malignant diagnosis (n = 38) than in those with a benign diagnosis (n = 15) (4.5 ± 2.9 vs. 2.7 ± 1.3, P = 0.03).

Conclusion

Incidental uptake of FDG in the breast was rare. However, the malignancy rate was high among these patients, particularly among patients who had a follow-up biopsy. We recommend biopsy or thorough follow-up in patients with incidental focal uptake of FDG in the breast.
The value of skeletal standardized uptake values obtained by quantitative single-photon emission computed tomography-computed tomography in differential diagnosis of bone metastases
Authors: Zhang Yiqiu , Li Beilei , Yu Haojun , Song Junyi , Zhou Yuhong , Shi Hongcheng
Published: October 2020

Purpose

The aim of this study was to explore the value of skeletal standardized uptake value (SUV) obtained by quantitative single-photon emission computed tomography-computed tomography (SPECT/CT) in differential diagnosis of bone metastases from benign lesions.

Materials and methods

Retrospective analysis has been conducted to 51 patients with extraskeletal malignant tumors who underwent whole-body bone scan with quantitative SPECT/CT imaging, and there are no more than three hotspots that were visually detected in the SPECT/CT imaging range. Fifty-one patients were enrolled, including 28 men and 23 women with an average age of 58.8 ± 9.5 (37–77) years. A total of 88 hotspots, including 40 benign lesions and 48 metastatic lesions, and corresponding normal sites were obtained. The region of interest (ROI) of the hotspots was sketched. The ROI of the normal bone of the spinal vertebral body adjacent to the lesions or normal bone of the symmetric side of the lesions of other locations was delineated to obtain the maximum SUV (SUVmax) and the average SUV (SUVave).

Results

The SUVmax value of all lesions was 20.73 ± 14.01 (3.90–92.61), and the SUVmax value of the corresponding normal parts was 5.88 ± 2.36 (2.08–12.52). The difference between the two groups was statistically significant (t = 10.343, P < 0.01). The SUVave of all lesions was 8.42 ± 4.81 (37–77), and the SUVave of the corresponding normal sites was 3.10 ± 1.51 (0.65–7.54). The difference between the two groups was statistically significant (t = 11.342, P < 0.01). The SUVmax of metastases was 24.77 ± 16.32 (3.90–92.61), and the SUVmax of benign lesions was 15.89 ± 8.51 (4.68–42.32). The difference between the two groups was statistically significant (t = 3.273, P = 0.002). The SUVave of metastases was 9.09 ± 5.59 (0.81–29.08), and the SUVave of benign lesions was 7.61 ± 3.57 (1.66–17.48). There was no significant difference between the two groups (t = 1.44, P = 0.154). The area under the curve (AUC) values of the SUVmax curves was greater than that of the SUVave curve. AUCs of the SUVmax and SUVave were 0.687 (P = 0.03) and 0.576 (P = 0.223), respectively. SUVmax had greater accuracy for discriminating bone metastasis from benign lesions. Hotspots of the patients with malignant neoplasms in bone SPECT/CT may be discriminated using SUVmax with certain accuracy, and the optimal cutoff value was 17.705.

Conclusion

The SUVmax of bone metastases was significantly larger than that of benign lesions, and there was no significant difference in SUVave between the two groups. Therefore, the SUVmax has a certain value for the differential diagnosis of metastases from benign lesions.
An Atypical Case of Thrombotic Microangiopathy Secondary to Acute Pancreatitis
Authors: Vissing Andrew , Wautlet Arnaud , Jain Shivi
Published: October 2020

Thrombotic microangiopathies (TMAs) are a group of disorders characterized by microangiopathic hemolytic anemia, thrombocytopenia, and end-organ damage. It can often be challenging to determine the underlying etiology. Our patient presented with acute pancreatitis and later developed thrombocytopenia and hemolytic anemia, along with acute renal failure. A working diagnosis of an atypical hemolytic uremic syndrome was made; however, he improved clinically and eculizumab was not started. Workup for the atypical hemolytic uremic syndrome was unrevealing. The authors propose that the pancreatitis triggered a secondary TMA, which although rare, has previously been described in the literature. This case illustrates the diagnostic and therapeutic challenges associated with TMAs.
Candidemia Diagnosis With T2 Nuclear Magnetic Resonance in a PICU: A New Approach
Authors: Cendejas-Bueno Emilio , Falces-Romero Iker , Laplaza-González María , Escosa-García Luis , Schuffelmann-Gutierrez Cristina , Romero-Gómez María P. , Verdú-Sánchez Cristina , Calderón-Llopis Belén , Amores-Hernández Irene , Pemán Javier , Gómez-Zamora Ana , Río-García Miguel , Menéndez-Suso Juan José , Rodríguez-Álvarez Diego , Durán-Lorenzo Iría , Pérez-Acosta Elena , Rubio Miguel Rodríguez , Álvarez-Rojas Elena , Martínez-Romillo Paloma Dorao , Goded-Rambaud Federico , de Lorenzo Abelardo García , Maseda Emilio , Mingorance Jesús , de la Oliva Pedro , García-Rodríguez Julio
Published: October 2020

OBJECTIVES:

Early diagnosis of invasive Candida infections is a challenge for pediatricians, intensivists, and microbiologists. To fill this gap, a new nanodiagnostic method has been developed using manual application of T2 nuclear magnetic resonance to detect Candida species. The aim of this study was to evaluate, prospectively, the usefulness as a tool diagnosis of the T2Candida panel in pediatric patients admitted at the PICU compared with blood culture.

DESIGN:

This is a prospective, observational, and unicentric study to compare T2Candida results with simultaneous blood cultures for candidemia diagnose.

SETTING:

This study was carried out in a 1,300-bed tertiary care hospital with a 16-bed medical-surgical PICU.

PATIENTS:

Sixty-three patients from 0 to 17 years old were enrolled in this study, including those undergoing solid organ transplantation (kidney, liver, pulmonary, multivisceral, intestinal, and heart) and hematopoietic stem cell transplantation.

MEASUREMENTS AND MAIN RESULTS:

Seven patients were positive by the T2Candida test. Only two of them had the simultaneous positive blood culture. T2Candida yielded more positive results than blood cultures.

CONCLUSIONS:

T2Candida might be useful for the diagnosis of candidemia in PICUs. The prevalence of candidemia might be underestimated in this pediatric population. The use of this diagnostic tool in these units may help clinicians to start adequate and timely antifungal treatments.
Outcome of Early Hemostatic Intervention in Children With Sepsis and Nonovert Disseminated Intravascular Coagulation Admitted to PICU: A Randomized Controlled Trial
Authors: El-Nawawy Ahmed A. , Elshinawy Mohamed I. , Khater Doaa M. , Moustafa Azza A. , Hassanein Nehad M. , Wali Yasser A. , Nazir Hanan F.
Published: October 2020

Objectives:

Evaluation of the outcome of early hemostatic management of disseminated intravascular coagulopathy in patients with severe sepsis/septic shock admitted to PICU, before the development of clinically overt disseminated intravascular coagulopathy.

Design:

Prospective interventional, open label randomized controlled clinical trial.

Setting:

PICU at Alexandria University Children’s Hospital.

Patients:

The study included 80 patients with proven severe sepsis/septic shock in nonovert disseminated intravascular coagulopathy stage. They were randomly assigned into two groups (group 1 and group 2).

Interventions:

Specific intervention was applied for group 1 (plasma transfusion, low-dose unfractionated heparin, and tranexamic acid).

Measurements:

All patients had assessment of Pediatric Index of Mortality 2 score, Pediatric Logistic Organ Dysfunction score, inotropic score, routine laboratory, and hemostatic tests including fibrin degradation products and d-dimers. Disseminated intravascular coagulopathy risk assessment scores were calculated on daily basis.

Results:

Mortality rate was significantly higher in group 2. Progression to overt disseminated intravascular coagulopathy was significantly more common among group 2 patients than group 1 (45% and 10%, respectively) (p < 0.0001). Disseminated intravascular coagulopathyRisk Assessment Scores were significantly higher on the second and fifth days among group 2 patients. The initial specific hemostatic intervention was the only significant predictor of survival and prevention of progression to overt disseminated intravascular coagulopathy.

Conclusions:

Our results suggest that early use of a combination of fresh frozen plasma transfusion, low-dose heparin, and tranexamic acid in children with severe sepsis/septic shock in the “window of opportunity” before the development of overt disseminated intravascular coagulopathy stage was associated with better outcome for survival and prevention of progression to overt disseminated intravascular coagulopathy, with no increase in bleeding risk. Larger multicenter studies are needed to further prove this practice.
Comparison of Prostate-Specific Membrane Antigen PET/CT and Contrast-Enhanced Magnetic Resonance Imaging in Follow-up Assessment of Juvenile Nasal Angiofibroma—A Novel Pilot Study
Authors: Thakar Alok , Sakthivel Pirabu , Arunraj Sreedharan Thankarajan , Bhalla Ashu Seith , Kakkar Aanchal , Kumar Rakesh , Kumar Rakesh
Published: October 2020

Purpose/Background

The specific identification of residual/recurrent juvenile nasal angiofibroma (JNA) following surgical treatment remains difficult. Contrast MRI and CT may not enable the differentiation of tumor from postsurgical reparative tissue. Functional imaging with prostate-specific membrane antigen (PSMA) PET/CT targeting tumor-associated neovasculature has recently demonstrated universal positive uptake in primary JNA and offers promise of greater accuracy in the detection or exclusion of recurrent/residual JNA.

Methods

In this prospective study, 18 postsurgical JNA patients with high suspicion for residual disease evinced by follow-up MR scan, or nasal endoscopy, or recent epistaxis during September 2018–November 2019 were included. All patients underwent head and neck spot PSMA PET/CT imaging. Postcontrast enhancement of a definite lesion was considered as a criterion for residual/recurrent tumor in contrast-enhanced MRI (CEMRI). In PSMA PET/CT, any abnormal uptake apart from physiological sites in the head and neck was considered as residual lesions. Radiological results were categorized as negative, suspicious, and residual/recurrent tumors. Any discrepancy between CEMRI and PSMA was resolved by surgical biopsies. The sensitivity, specificity, and positive and negative predictive values were separately calculated for CEMRI and PSMA PET/CT for diagnosing residual lesions. The interrater agreement κ value was also calculated.

Results

On CEMRI evaluation, 14 of 18 patients had residual tumors, 2 had suspicious residual lesions, and 2 had normal postoperative scans. On PSMA PET/CT, 12 of 18 patients had residual tumors, and 6 had normal negative scans. Surgical biopsy in all 4 discordant cases was negative for tumors and revealed only fibrosis. In 1 patient with residual tumor on both scans, discrepancy was noted with regard to tumor extent demonstrated by the 2 scans, and further surgical excision confirmed the imaging findings of PSMA PET/CT as accurate. The sensitivity, specificity, and positive and negative predictive values of CEMRI were 100%, 33.33%, and 75% and 100%, respectively. The sensitivity, specificity, and positive and negative predictive values of PSMA PET/CT were 100% for all parameters. The interrater agreement between the 2 tests (κ) is 0.5 (95% confidence interval, 0.19–0.81).

Conclusions

The68Ga-PSMA PET/CT is noted as more specific than the current standard of CEMRI in the identification of residual/recurrent JNA. It is the first radionuclide imaging scan that has found application in postoperative assessment of JNA.

Trial registration:Clinical Trials Registry of India (CTRI/2018/08/015479).
Ex Vivo Lung Perfusion: Current Achievements and Future Directions
Authors: Prasad Nikhil K. , Pasrija Chetan , Talaie Tara , Krupnick Alexander S. , Zhao Yunge , Lau Christine L.
Published: October 2020

There is a severe shortage in the availability of donor organs for lung transplantation. Novel strategies are needed to optimize usage of available organs to address the growing global needs. Ex vivo lung perfusion has emerged as a powerful tool for the assessment, rehabilitation, and optimization of donor lungs before transplantation. In this review, we discuss the history of ex vivo lung perfusion, current evidence on its use for standard and extended criteria donors, and consider the exciting future opportunities that this technology provides for lung transplantation.
The Impact of Performance Status on Length of Hospital Stay and Clinical Complications Following Liver Transplantation
Authors: Wallace David , Cowling Thomas E. , Walker Kate , Suddle Abid , Gimson Alex , Rowe Ian , Callaghan Chris , Heaton Nigel , van der Meulen Jan , Bernal William
Published: October 2020

Background.

Impaired pretransplant performance status (PS) is associated with chronic liver disease (CLD). We studied its impact on hospital length of stay (LOS), complications, and readmissions in the first year after liver transplantation.

Methods.

The Standard National Liver Transplant Registry was linked to a hospital administrative dataset, and all first-time liver transplant recipients with CLD aged ≥18 years in England were identified. A modified 3-level Eastern Cooperative Oncology Group score was used to assess PS. Linear- and logistic-fixed effect regression models were used to estimate the effect of specific posttransplant complications and readmissions in the first year after transplantation.

Results.

Six thousand nine hundred sixty-eight recipients were included. Impaired PS was associated with an increased LOS in the initial posttransplant period (comparing ECOG 1–3, adjusted difference 7.2 d; 95% confidence [CI], 4.8-9.6; P < 0.001) and in time spent on the ITU (adjusted difference 1.2 d; 95% CI, 0.4-2.0; P < 0.001). There was no significant association between ECOG status and total LOS of later admissions (adjusted difference, 2.5 d; 95% CI, –0.4-5.5; P = 0.23). Those with a poorer ECOG status had an increased incidence of renal failure (odds ratio, 1.5; 95% CI, 1.1-2.0; P = 0.004) and infection (odds ratio, 1.2; 95% CI, 1.1-1.4; P = 0.02) but not an increased incidence of readmission (odds ratio, 1.2; 95% CI, 0.9-1.5; P = 0.13).

Conclusions.

In liver transplant recipients with CLD, impaired pretransplant PS is associated with prolonged LOS in the immediate posttransplant period but not with LOS of later admissions in the first year after transplantation. Impaired PS increased the risk of renal failure and infection.
Kidney Transplantation in HIV-positive Patients: Current Practice and Management Strategies
Authors: Muller Elmi , Botha Francois C. J. , Barday Zunaid A. , Manning Kathryn , Chin-Hong Peter , Stock Peter
Published: October 2020

Background.

HIV-positive patients had been successfully transplanted for the last 15 y and the donor pool had successfully been expanded to also include HIV-positive donors.

Methods.

We aimed to evaluate the effectiveness of transplantation in HIV-positive patients and highlight some of the important issues reported in the literature. We pooled clinical data from different cohorts to show some of the common issues encountered in HIV-positive transplantation. Furthermore, we searched MEDLINE via PubMed, EMBASE, Cochrane CENTRAL to create a comprehensive table for current evidence for different issues currently encountered when transplanting HIV-positive patients.

Results.

We included data from 19 cohort studies and reported on outcomes of the current HIV-positive transplant programs. We made recommendations based on personal experience as well as the experience reported in the literature regarding rejection, opportunistic infection, and HIV-associated nephropathy. Opportunistic infections and malignancies are not a major problem for this population group.

Conclusions.

HIV-positive patients encounter very specific issues after transplantation, specifically related to drug interactions and higher rejection rates. When utilizing HIV-positive donors, the recurrence of HIV-associated nephropathy in the graft kidney is an issue which can be important. Despite some issues with high rejection rates, HIV-positive patients have similar results to HIV-negative patients posttransplantation.
Influenza Virus Infection and Transplantation
Authors: Marinelli Tina M. , Kumar Deepali
Published: October 2020

Influenza infection poses significant risk for solid organ transplant recipients who often experience more severe infection with increased rates of complications, including those relating to the allograft. Although symptoms of influenza experienced by transplant recipients are similar to that of the general population, fever is not a ubiquitous symptom and lymphopenia is common. Annual inactivated influenza vaccine is recommended for all transplant recipients. Newer strategies such as using a higher dose vaccine or multiple doses in the same season appear to provide greater immunogenicity. Neuraminidase inhibitors are the mainstay of treatment and chemoprophylaxis although resistance may occur in the transplant setting. Influenza therapeutics are advancing, including the recent licensure of baloxavir; however, many remain to be evaluated in transplant recipients and are not yet in routine clinical use. Further population-based studies spanning multiple influenza seasons are needed to enhance our understanding of influenza epidemiology in solid organ transplant recipients. Specific assessment of newer influenza therapeutics in transplant recipients and refinement of prevention strategies are vital to reducing morbidity and mortality.
The Potential Role of Efficacy and Safety Evaluation of N-Acetylcysteine Administration During Liver Procurement. The NAC-400 Single Center Randomized Controlled Trial
Authors: Gómez-Gavara Concepción , Moya-Herraiz Ángel , Hervás David , Pérez-Rojas Judith , LaHoz Agustín , López-Andújar Rafael
Published: October 2020

Background.

N-acetylcysteine infusions have been widely used to reduce ischemia/reperfusion damage to the liver; however, convincing evidence of their benefits is lacking.

Objective.

To perform the largest randomized controlled trial to compare the impact of N-acetylcysteine infusion during liver procurement on liver transplant outcomes.

Methods.

Single center, randomized trial with patients recruited from La Fe University Hospital, Spain, from February 2012 to January 2016. A total of 214 grafts were transplanted and randomized to the N-acetylcysteine group (n = 113) or to the standard protocol without N-acetylcysteine (n = 101). The primary endpoint was allograft dysfunction (Olthoff criteria). Secondary outcomes included metabolomic biomarkers of oxidative stress levels, interactions between cold ischemia time and alanine aminotransferase level and graft and patient survival (ID no. NCT01866644).

Results.

The incidence of primary dysfunction was 34% (31% in the N-acetylcysteine group and 37.4% in the control group [P = 0.38]). N-acetylcysteine administration reduced the alanine aminotransferase level when cold ischemia time was longer than 6 h (P = 0.0125). Oxidative metabolites (glutathione/oxidized glutathione and ophthalmic acid) were similar in both groups (P > 0.05). Graft and patient survival rates at 12 mo and 3 y were similar between groups (P = 0.54 and P = 0.69, respectively).

Conclusions.

N-acetylcysteine administration during liver procurement does not improve early allograft dysfunction according to the Olthoff classification. However, when cold ischemia time is longer than 6 h, N-acetylcysteine improves postoperative ALT levels.
MRI in disorders of consciousness
Authors: Snider Samuel B. , Edlow Brian L.
Published: October 2020

Purpose of review

In the study of brain-injured patients with disorders of consciousness (DoC), structural and functional MRI seek to provide insights into the neural correlates of consciousness, identify neurophysiologic signatures of covert consciousness, and identify biomarkers for recovery of consciousness.

Recent findings

Cortical volume, white matter volume and integrity, and structural connectivity across many grey and white matter regions have been shown to vary with level of awareness in brain-injured patients. Resting-state functional connectivity (rs-FC) within and between canonical cortical networks also correlates with DoC patients’ level of awareness. Stimulus-based and motor-imagery fMRI paradigms have identified some behaviorally unresponsive DoC patients with cortical processing and activation patterns that mirror healthy controls. Emerging techniques like dynamic rs-FC have begun to identify temporal trends in brain-wide connectivity that may represent novel neural correlates of consciousness.

Structural and functional MRI will continue to advance our understanding of brain regions supporting human consciousness. Measures of regional and global white matter integrity and rs-FC in particular networks have shown significant improvement over clinical features in identifying acute and chronic DoC patients likely to recover awareness. As they are refined, functional MRI paradigms may additionally provide opportunities for interacting with behaviorally unresponsive patients.
Relationship Between Brainstem Auditory Evoked Potentials and Clinical Function in Patients With Cerebral Infarction
Authors: Kim Yeong-Wook , Sohn Min Kyun , Jung Il-Young
Published: October 2020

Purpose:

The purpose of this study was to analyze the association between the brainstem auditory evoked potential (BAEP) and clinical outcomes at discharge in patients who have had subacute ischemic stroke.

Methods:

A total of 210 patients who have had ischemic stroke, confirmed by MRI within 3 months after onset, were enrolled. Demographics and stroke-related clinical assessment scales, such as the modified Barthel index and National Institute of Health Stroke Scale (NIHSS), were collected. Recorded latencies of waveforms I, III, and V of BAEP were bilaterally collected and analyzed. The results of the patients with supratentorial brain lesions were further analyzed.

Results:

The mean BAEP latencies of waveforms I, III, and V in the subjects were 1.84 ± 0.22, 4.07 ± 0.27, and 6.07 ± 0.33 ms, respectively. As the modified Barthel index and NIHSS scores at discharge functionally worsened, the latencies of all lesion-side BAEP waveforms were significantly delayed. In patients with supratentorial brain lesions only, there was a significant delay in the latency of waveform V at the lesion side as modified Barthel index severity increased (P = 0.048). As the NIHSS score functionally worsened, BAEP latencies III and V recorded at the lesion side significantly delayed (P = 0.023 and P = 0.003, respectively). In multivariate linear regression models, latency V was found to be a significant factor in predicting outcome at discharge, among other factors.

Conclusions:

In patients with ischemic stroke with the poor clinical outcome at discharge, there were delayed latencies of waveforms I, III, and V of BAEP performed in the early phase of stroke.
Extended laboratory panel testing in the Emergency Department for risk-stratification of patients with COVID-19: a single centre retrospective service evaluation
Authors: Ponsford Mark J , Burton Ross J , Smith Leitchan , Khan Palwasha , Andrews Robert , Cuff Simone , Tan Laura , Eberl Matthias , Humphreys Ian R , Babolhavaeji Farbod , Artemiou Andreas , Pandey Manish , Jolles Stephen , Underwood Jonathan
Published: October 2020

Background

The role of specific blood tests to predict poor prognosis in patients admitted with infection from SARS-CoV2 virus remains uncertain. During the first wave of the global pandemic, an extended laboratory testing panel was integrated into the local pathway to guide triage and healthcare resource utilisation for emergency admissions. We conducted a retrospective service evaluation to determine the utility of extended tests (D-dimer, ferritin, high-sensitivity troponin I, lactate dehydrogenase, procalcitonin) compared to the core panel (full blood count, urea & electrolytes, liver function tests, C-reactive protein).

Methods

Clinical outcomes for adult patients with laboratory-confirmed COVID-19 admitted between 17th March to 30st June 2020 were extracted, alongside costs estimates for individual tests. Prognostic performance was assessed using multivariable logistic regression analysis with 28-day mortality used as the primary endpoint, and a composite of 28-day intensive care escalation or mortality for secondary analysis.

Results

From 13,500 emergency attendances we identified 391 unique adults admitted with COVID-19. Of these, 113 died (29%) and 151 (39%) reached the composite endpoint. “Core” test variables adjusted for age, gender and index of deprivation had a prognostic AUC of 0.79 (95% Confidence Interval, CI: 0.67 to 0.91) for mortality and 0.70 (95% CI: 0.56 to 0.84) for the composite endpoint. Addition of “extended” test components did not improve upon this.

Conclusion

Our findings suggest use of the extended laboratory testing panel to risk stratify community-acquired COVID-19-positive patients on admission adds limited prognostic value. We suggest laboratory requesting should be targeted to patients with specific clinical indications.
DEVELOPING AND VALIDATING COVID-19 ADVERSE OUTCOME RISK PREDICTION MODELS FROM A BI-NATIONAL EUROPEAN COHORT OF 5594 PATIENTS
Authors: Jimenez-Solem Espen , Petersen Tonny S , Hansen Casper , Hansen Christian , Lioma Christina , Igel Christian , Boomsma Wouter , Krause Oswin , Lorenzen Stephan , Selvan Raghavendra , Petersen Janne , Nyeland Martin Erik , Zöllner Ankarfeldt Mikkel , Virenfeldt Gert Mehl , Winther-Jensen Matilde , Linneberg Allan , Ghazi Mostafa Mediphour , Detlefsen Nicki , Lauritzen Andreas , Smith Abraham George , de Bruijne Marleen , Ibragimov Bulat , Petersen Jens , Lillholm Martin , Middleton Jon , Mogensen Stine Hasling , Thorsen-Meyer Hans-Christian , Perner Anders , Helleberg Marie , Kaas-Hansen Benjamin Skov , Bonde Mikkel , Bonde Alexander , Pai Akshay , Nielsen Mads , Sillesen Martin
Published: October 2020

Background

Patients with severe COVID-19 have overwhelmed healthcare systems worldwide. We hypothesized that Machine Learning (ML) models could be used to predict risks at different stages of management (at diagnosis, hospital admission and ICU admission) and thereby provide insights into drivers and prognostic markers of disease progression and death.

Methods

From a cohort of approx. 2.6 million citizens in the two regions of Denmark, SARS-CoV-2 PCR tests were performed on subjects suspected for COVID-19 disease; 3944 cases had at least one positive test and were subjected to further analysis. A cohort of SARS- CoV-2 positive cases from the United Kingdom Biobank was used for external validation.

Findings

The ML models predicted the risk of death (Receiver Operation Characteristics – Area Under the Curve, ROC-AUC) of 0.904 at diagnosis, 0.818, at hospital admission and 0.723 at Intensive Care Unit (ICU) admission. Similar metrics were achieved for predicted risks of hospital and ICU admission and use of mechanical ventilation. We identified some common risk factors, including age, body mass index (BMI) and hypertension as driving factors, although the top risk features shifted towards markers of shock and organ dysfunction in ICU patients. The external validation indicated fair predictive performance for mortality prediction, but suboptimal performance for predicting ICU admission.

Interpretation

ML may be used to identify drivers of progression to more severe disease and for prognostication patients in patients with COVID-19. Prognostic features included age, BMI and hypertension, although markers of shock and organ dysfunction became more important in more severe cases.

We provide access to an online risk calculator based on these findings.

Funding

The study was funded by grants from the Novo Nordisk Foundation to MS (#NNF20SA0062879 and #NNF19OC0055183) and MN (#NNF20SA0062879). The foundation took no part in project design, data handling and manuscript preparation.
Enoxaparin is associated with lower rates of thrombosis, kidney injury, and mortality than Unfractionated Heparin in hospitalized COVID patients
Authors: Pawlowski Colin , Venkatakrishnan AJ , Kirkup Christian , Berner Gabriela , Puranik Arjun , O’Horo John C. , Badley Andrew D. , Soundararajan Venky
Published: October 2020

Although anticoagulants such as unfractionated heparin and low molecular weight heparin (LMWH, e.g. enoxaparin) are both being used for therapeutic mitigation of COVID associated coagulopathy (CAC), differences in their clinical outcomes remain to be investigated. Here, we employ automated neural networks supplemented with expert curation (‘augmented curation’) for retrospectively analyzing the complete electronic health records (EHRs) of 671 hospitalized COVID-19 patients administered either enoxaparin or unfractionated heparin, but not both. We find that COVID-19 patients administered unfractionated heparin but not enoxaparin have higher rates of mortality (risk ratio: 2.6; 95% C.I.: [1.2-5.4]; p-value: 0.02; BH adjusted p-value: 0.09), thrombotic events (risk ratio: 5.7, 95% C.I.: [2.1, 33.9], p-value: 0.024), acute kidney injury (risk ratio: 5.5; 95% C.I.: [1.2-17.7]; p-value: 0.02; BH adjusted p-value: 0.10), and bacterial pneumonia (risk ratio undefined; 95% C.I.: [1.0, 292]; p-value:0.02; BH adjusted p-value:0.10), compared to patients administered enoxaparin but not unfractionated heparin. Notably, even after controlling for potential confounding factors such as demographics, comorbidities, admission diagnosis, initial ICU status, and initial level of oxygen support, the above differences between the enoxaparin and unfractionated heparin patient cohorts remain statistically significant. This study emphasizes the need for mechanistically investigating differential modulation of the COVID-associated coagulation cascades by enoxaparin versus unfractionated heparin.
Lockdown impact on age-specific contact patterns and behaviours in France
Authors: Bosetti Paolo , Huynh Bich-Tram , Abdou Armiya Youssouf , Sanchez Marie , Eisenhauer Catherine , Courtejoie Noémie , Accardo Jérôme , Salje Henrik , Guillemot Didier , Moslonka-Lefebvre Mathieu , Boëlle Pierre-Yves , Béraud Guillaume , Cauchemez Simon , Opatowski Lulla
Published: October 2020

In the first trimester 2020, a significant number of countries implemented general lockdowns of their populations to contain the quickly expanding SARS-CoV-2 epidemic and avoid major saturation of health care capacity. Understanding how these unprecedented measures impacted population behaviour and contact patterns is key to predict more accurately the health, social and economic impacts of such extreme actions if they were to be applied to future outbreaks. We set up an online survey to measure how the lockdown affected social contact patterns in France, and collected information from 42,036 participants aged 18 years and over between April 10 and April 28, 2020. Among the participants who normally worked outside home prior to the lockdown (72% of the survey population), 68% reported that they had moved to working from home and 17% reported being unemployed during the lockdown.

Only 2% of participants used public transport during lockdown, as opposed to 37% before it. Participants reported increased frequency of washing hands, switch in greeting behaviour, but generally limited use of masks outside home. 138,934 contacts were reported, with an average 3.3 contacts per individual per day (1.7 for individuals aged >65 years old compared to 3.6 for younger age-groups). This represented a 70% reduction compared with previous surveys, consistent with reductions in transmission rates measured during the lockdown. Contacts in workplaces, shops, and transports on the previous day were respectively reported in only 11%, 31% and 0.5% of the participants. For those who maintained a professional activity outside home, the frequency of contacts at work dropped by 79%. This study shows that the lockdown dramatically affected population’s behavior, work, risk perception and contact patterns. Both frequency and heterogeneity of contacts were affected, impacting potential important features of virus dissemination. Such surveys are essential to evaluate more accurately the impact of past or future lockdowns and anticipate epidemic dynamics in these conditions.
A Comparative COVID 19 Characterizations and Clinical Course Analysis between ICU and Non ICU Settings
Authors: Patel Amit , Bhatt Parloop , Madan Surabhi , Shah Nitesh , Thakkar Vipul , Shah Bhagyesh , Chovatia Rashmi , Shah Hardik , Patel Minesh , Dabhi Pradip , Nanavati Aditi , Chag Milan , Parikh Keyur
Published: October 2020

Objective

With 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.

Design

A Clinical trial registry of India registered observational study (CTRI/2020/05/025247).

Setting

Certified COVID hospital located in Ahmedabad, Gujarat, India.

Participants

549 COVID positive patients hospitalized between 15 th May to 10 th August, 2020 and treated in ICU and non ICU settings.

Main Outcome Measure

Comparative analysis of demographic, clinical characteristics, investigations, treatment, complications and outcome of COVID patients in ICU and non ICU settings.

Results

Of 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).

Conclusion

About 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.