Steroids use in non-oxygen requiring COVID-19 patients: a systematic review and meta-analysis

BACKGROUND

Corticosteroids have become the mainstay treatment in severe COVID-19. However, its role is mild disease is controversial due to lack of robust scientific evidence. This systematic review and meta-analysis were conducted to assess effect of steroids in mild COVID-19 patients.

METHODS

PubMed, EMBASE, Web of Science and medRxiv were searched from 31 December 2019 to 14 May 2021 for studies that reported effectiveness of steroids in non-oxygen requiring COVID-19 patients in terms of progressing to severe disease, mortality, duration of fever, duration of viral clearance and length of hospital stay (LOHS). Studies on inhalational steroids, case reports and reviews were excluded. Risk of bias (ROB) was assessed by the Cochrane's ROB tool and ROBANS tool. Quantitative data synthesis was done using the generic inverse variance method.

RESULTS

A total of 6411 studies were identified, 2990 articles were screened after exclusion. Seven studies which fit the criteria (involving 2214 non-oxygen requiring COVID-19 patients) were included and analysed. Overall odds of progression to severe disease among the non-oxygen requiring COVID-19 patients receiving steroids was 5.97 [95% confidence interval (CI): 1.27-27.99, I2 = 0%] and odds of death (OR: 1.35, 95% CI: 1.01-1.79; I2 = 0%) as compared to the patients not receiving steroids. Mean duration of fever (7.4 days), duration to viral clearance (18.9 days) and LOHS (20.8 days) were significantly higher in the steroid arm, as compared to that in no-steroid arm (6.7, 16.5 and 15.2 days, respectively).

CONCLUSION

Steroids in non-oxygen requiring COVID-19 patients can be more detrimental than beneficial.

PROTOCOL REGISTRATION

The study was prospectively registered in PROSPERO (CRD 42021254951).

COVID-19-associated mucormycosis presenting to the Emergency Department-an observational study of 70 patients

BACKGROUND

Mucormycosis (MM) is a deadly opportunistic fungal infection and a large surge in COVID-19-associated mucormycosis (CAM) is occurring in India.

AIM

Our aim was to delineate the clinico-epidemiological profile and identify risk factors of CAM patients presenting to the Emergency Department (ED).

DESIGN

This was a retrospective, single-centre, observational study.

METHODS

We included patients who presented with clinical features or diagnosed MM and who were previously treated for COVID-19 in last 3 months of presentation (recent COVID-19) or currently being treated for COVID-19 (active COVID-19). Information regarding clinical features of CAM, possible risk factors, examination findings, diagnostic workup including imaging and treatment details were collected.

RESULTS

Seventy CAM patients (median age: 44.5 years, 60% males) with active (75.7%) or recent COVID-19 (24.3%) who presented to the ED in between 6 May 2021 and 1 June 2021, were included. A median duration of 20 days (interquartile range: 13.5-25) was present between the onset of COVID-19 symptoms and the onset of CAM symptoms. Ninety-three percent patients had at least one risk factor. Most common risk factors were diabetes mellitus (70%) and steroid use for COVID-19 disease (70%). After clinical, microbiological and radiological workup, final diagnosis of rhino-orbital CAM was made in most patients (68.6%). Systemic antifungals were started in the ED and urgent surgical debridement was planned.

CONCLUSION

COVID-19 infection along with its medical management have increased patient susceptibility to MM.

Deceleration and Trapping of SrF Molecules

We report on the electrostatic trapping of neutral SrF molecules. The molecules are captured from a cryogenic buffer-gas beam source into the moving traps of a 4.5-m-long traveling-wave Stark decelerator. The SrF molecules in X^{2}Σ^{+}(v=0,N=1) state are brought to rest as the velocity of the moving traps is gradually reduced from 190  m/s to zero. The molecules are held for up to 50 ms in multiple electric traps of the decelerator. The trapped packets have a volume (FWHM) of 1  mm^{3} and a velocity spread of 5(1)  m/s, which corresponds to a temperature of 60(20) mK. Our result demonstrates a factor 3 increase in the molecular mass that has been Stark decelerated and trapped. Heavy molecules (mass>100  amu) offer a highly increased sensitivity to probe physics beyond the standard model. This work significantly extends the species of neutral molecules of which slow beams can be created for collision studies, precision measurement, and trapping experiments.

P–460 Impact of various cancers on semen parameters in a tertiary onco-fertility unit in India

Study question

This study evaluated differences in semen parameters in male cancer patients in our ethnic population who banked their sperms prior to cancer treatment

Summary answer

We found significant differences in semen concentration, motility and morphology between different types of cancers, especially testicular cancers

What is known already

Impaired spermatogenesis and abnormal semen parameters in cancer patients has been noted, however certain cancer types are more damaging than others. In testicular cancer, spermatogenesis impairment is more quantitative than qualitative with sperm morphology being the most affected parameter. Among non testicular cancers, lymphoma cases usually show the most significantly impaired semen parameters

Study design, size, duration

We conducted a retrospective study analyzing semen parameters in 49 cancer patients between October 2014 to January 2020 who presented to the onco-fertility unit, Max Multispeciality Hospitals, New Delhi.

Furthermore, we did our analysis based on total of 101 samples and were broadly divided into testicular (37 samples) and non testicular cancers (64 samples). Patients who had previously received any form of cancer treatment including chemotherapy or radiotherapy were not included in this study

Participants/materials, setting, methods

Testicular Cancer(TC) group was further subcategorized into Seminoma and Non Seminoma groups whereas Non Testicular Cancer (NTC) group was subcategorized into Lymphoma and Non Lymphoma groups. Semen was collected by masturbation and analysis was performed in keeping with the WHO criteria. Statistical analyses was performed using SPSS software. p values <0.05 were considered to indicate statistical significance.

Main results and the role of chance

In Testicular cancer (TC), 92% samples (34/37) had abnormal semen parameters whereas only 24.4% samples (22/64) were abnormal in Non Testicular cancer (NTC). Additionally, there were significant differences in sperm concentration, motility and morphology between TC and NTC groups.

Individually,

TC: Oligozoospermia was seen in 73% (27/37) with subdivision between Seminoma and Non Seminoma groups being 81.3% (13/16) and 61.9% (13/21).

Asthenozoospermia was seen in 86.5% (32/37) samples with subdivision between Seminoma and Non Seminoma groups being 87.5% (14/16) and 81% (17/21).

Teratozoospermia was seen in 59.5% (22/37) samples with subdivision between Seminoma and Non Seminoma groups being 75% (12/16) and 42.86% (9/21).

Combined OATS observed in 59.5% (22/37) samples with subdivision between Seminoma and Non Seminoma groups being 75% (12/16) and 42.86% (9/21)

NTC: Oligozoospermia was seen in 18.8% (12/64) samples with subdivision between Lymphoma and Non Lymphoma groups being 26.92% (7/26) and 26.32% (10/38).

Asthenozoospermia was seen in 32.8% (21/64) samples with subdivision between Lymphoma and Non Lymphoma groups being 34.62% (9/26) and 34.21% (13/38).

Teratozoospermia was seen in 17.2% (11/64) samples with subdivision between Lymphoma and Non Lymphoma groups being 26.9% (7/26) and 23.68% (9/38).

Combined OATS observed in 17.2% (11/64) samples with subdivision between Lymphoma and Non Lymphoma groups being 26.9% (7/26) and 23.68% (9/38).

Limitations, reasons for caution

Study was conducted in a single institution with lesser overall number of patients. Duration, staging and grading of cancers were also not individually assessed, which could be a further limiting factor.

Wider implications of the findings: Testicular cancers, especially seminomas, have the most severe effect upon semen parameters. Among NTC patients, lymphomas have the worst impact. Knowing the varying effect of different cancers on semen parameters in our ethnic population helps ART specialists and oncologists to appropriately modify patient counseling and improve fertility outcomes.

Trial registration number

RMO13019

Clinical characteristics and disease burden in prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intense pruritus, but information on patient experience and impact on quality of life (QoL) remains understudied.

AIM

To characterize disease characteristics and QoL in a global sample of patients with PN.

METHODS

An anonymous survey was distributed via patient support groups for PN.

RESULTS

In total, 231 members responded to the survey. The majority of respondents reported itch localized both to nodules and to intervening skin (67.0%). Associated symptoms included prickling, pain, stinging and burning. The extensor lower legs (69% right, 67.3% left) and flexor forearms (66.1% right, 62% left) were the most common sites of itch. Participants reported frequent healthcare utilization, with 36.3% visiting a doctor ≥ 10 times in the past year. Physician-diagnosed anxiety (45.4%), depression (16.4%) and the atopic triad (18.7%) were commonly reported. Patients with PN had mean scores of 16.4, 11.6 and 16.8 on the Dermatology Life Quality Index, Pittsburgh Sleep Quality Index and 5-Dimensions Itch, respectively.

CONCLUSIONS

Severe pruritus with accompanying pain, stinging and burning is characteristic of PN, with the majority of patients experiencing itch in both nodular and interlesional skin. Patients further report decreased QoL scores and impaired sleep. Patient experiences should guide future management of PN.

Predictors of no-reflow phenomenon following percutaneous coronary intervention for ST-segment elevation myocardial infarction

OBJECTIVES

No reflow during percutaneous coronary intervention (PCI) is a complex issue with serious outcomes. Multiple studies have studied predictors of no-reflow during primary PCI, but data on patients with the late presentation is sparse, which constitutes the majority of patients in peripheral centers. This study aimed to determine predictors of no-reflow during PCI in patients with ST-segment elevation myocardial infarction (STEMI) in 7 days.

METHODS

It was a single-center prospective case-control study performed at a tertiary care center and included 958 patients with STEMI who underwent PCI within 7 days of symptom onset. Baseline and angiographic data of patients undergoing PCI were recorded and patients divided into reflow and no-reflow group.

RESULTS

Of 958 who underwent PCI, 182 (18.9%) showed no-reflow by myocardial blush grade (MBG)<2. No-reflow group had a higher mean age (66.46±10.71 vs. 61.36±9.94 years), lower systolic blood pressure (SBP) on admission (100.61±26.66 vs. 112.23±24.35, P<0.0001), a higher level of peak Troponin I level (9.37±2.81 vs. 7.66±3.11ng/dL, P<0.0001), low left ventricular ejection fraction (36.71±3.89 vs. 39.58±4.28% respectively P<0.0001). Among angiographic data and procedural features, multivariable logistic regression analysis identified that advanced age, reperfusion time>6hours, SBP<100mmHg on admission, functional status of Killip class for heart failure≥3, lower EF (≤35%), low initial myocardial blush grade (≤1) before PCI, long target lesion length, larger reference diameter of vessel (>3.5mm) and high thrombus burden on angiography were found to be independent predictors of no-reflow (P<0.05).

CONCLUSION

No-reflow phenomenon after PCI for STEMI is complex and multifactorial and can be identified by simple clinical, angiographic, and procedural features. Preprocedural characters of the lesion and early perfusion decides the fate of the outcome.

A supersonic laser ablation beam source with narrow velocity spreads

A supersonic beam source for SrF and BaF molecules is constructed by combining the expansion of carrier gas (a mixture of 2% SF₆ and 98% argon) from an Even-Lavie valve with laser ablation of a barium/strontium metal target at a repetition rate of 10 Hz. Molecular beams with a narrow translational velocity spread are produced at relative values of Δv/v = 0.053(11) and 0.054(9) for SrF and BaF, respectively. The relative velocity spread of the beams produced in our source is lower in comparison with the results from other metal fluoride beams produced in supersonic laser ablation sources. The rotational temperature of BaF is measured to be 3.5 K. The source produces 6 × 10⁸ and 10⁷ molecules per steradian per pulse in the X²Σ⁺ (ν = 0, N = 1) state of BaF and SrF molecules, respectively, a state amenable to Stark deceleration and laser cooling.

Is higher power shorter duration radiofrequency energy is better than lower power longer duration strategy in catheter ablation of atrial fibrillation A meta-analysis

Background

An ideal strategy for radiofrequency ablation (RFA) of atrial fibrillation (AF) in the left atrium should be efficient enough to achieve transmural lesions in left atrium with no or minimal collateral tissue damage. Resistive heating of high power short duration (HPSD) RFA has been found to result in lesions larger in width but lesser in depth compared to lower power longer duration (LPLD) RFA in some experimental studies.

Purpose

This meta-analysis was performed to compare procedural, short-term and long-term outcomes of HPSD versus LPLD RFA of AF.

Methods

PubMed, Embase and Cochrane databases were systematically reviewed. Five observational studies meeting criteria were included in the meta-analysis. All the studies scored six or more points in the New-castle Ottawa scale. There were considerable variations in the ablation strategies across the studies. However, radiofrequency power more than 40W was considered as high power. Hypergeometric model with exact likelihood function was utilized for statistical analysis.

Results

Baseline parameters and ablation details have been depicted in Table 1. 740 patients with HPSD and 287 patients with LPLD ablation strategies, were followed up from 6 to 30 months. Total procedural time (P value &lt;0.0001) and ablation time (P value &lt;0.0001) were significantly lower in the HPSD group than LPLD group. However, the fluoroscopy time was similar (P value = 0.09) in both the groups (Table 2). There were no occurrences of atrio-esophageal fistula or pulmonary venous stenosis in any of the studies. Cardiac tamponade (P value = 0.56), stroke (P value = 0.70) and AF recurrences (P value = 0.81), were similar in both groups (Table 2).

Conclusion

Newer HPSD and conventional LPLD RFA, both the strategies are very safe procedure for treatment of RFA with low to no procedural complications. AF recurrence rates were reasonably high irrespective of ablation strategies, however, no strategy scored statistically better over the other one. Large randomized multi-centric studies with long-term follow up are needed to test the theoretical advantage of HPSD ablation over the traditional ablation strategy of AF.

Funding Acknowledgement

Type of funding source: None

A narrative review of gaps in the provision of integrated care for noncommunicable diseases in India

BACKGROUND

Low- and middle-income countries (LMICs) account for a higher burden of noncommunicable diseases (NCD) and home to a higher number of premature deaths (before age 70) from NCDs. NCDs have become an integral part of the global development agenda; hence, the scope of action on NCDs extends beyond just the health-related sustainable development goal (SDG 3). However, the organization and integration of NCD-related health services have faced several gaps in the LMIC regions such as India. Although the national NCD programme of India has been in operation for a decade, challenges remain in the integration of NCD services at primary care. In this paper, we have analysed existing gaps in the organization and integration of NCD services at primary care and suggested plausible solutions that exist.

METHOD

The identification of gaps is based out of a review of peer-reviewed articles, reports on national and global guidelines/protocols. The gaps are organized and narrated at four levels such as community, facility, health system, health policy and research, as per the WHO Innovative Care for Chronic Conditions framework (WHO ICCC).

RESULT

The review found that challenges in the identification of eligible beneficiaries, shortage and poor capacity of frontline health workers, poor functioning of community groups and poor community knowledge on NCD risk factors were key gaps at the community level. Challenges at facility level such as poor facility infrastructure, lack of provider knowledge on standards of NCD care and below par quality of care led to poor management of NCDs. At the health system level, we found, organization of care, programme management and monitoring systems were not geared up to address NCDs. Multi-sectoral collaboration and coordination were proposed at the policy level to tackle NCDs; however, gaps remained in implementation of such policies. Limited research on the effect of health promotion, prevention and, in particular, non-medical interventions on NCDs was found as a key gap at the research level.

CONCLUSION

This paper reinforces the need for an integrated comprehensive model of NCD care especially at primary health care level to address the growing burden of these diseases. This overarching review is quite relevant and useful in organizing NCD care in Indian and similar LMIC settings.

Designing a comprehensive Non-Communicable Diseases (NCD) programme for hypertension and diabetes at primary health care level: evidence and experience from urban Karnataka, South India

BACKGROUND

India accounts for more than two-third of mortality due to non-communicable diseases (NCDs) in south-east Asia. The burden is high in Karnataka, one of the largest states in southern India. There is a need for integration of disease prevention, health promotion, treatment and care within the national program at primary level. A public-private partnership initiative explored evidence gaps to inform a health system based, integrated NCD programme across care continuum with a focus on hypertension and diabetes.

METHODS

The study was conducted during 2017-18 in urban parts of Mysore city, covering a population of 58,000. Mixed methods were used in the study; a population-based screening to estimate denominators for those with disease and at risk; cross-sectional surveys to understand distribution of risk factors, treatment adherence and out of pocket expenses; facility audits to assess readiness of public and private facilities; in-depth interviews and focus group discussions to understand practices, myths and perceptions in the community. Chi-square tests were used to test differences between the groups. Framework analysis approach was used for qualitative analysis.

RESULTS

Twelve and 19% of the adult population had raised blood sugar and blood pressure, respectively, which increased with age, to 32 and 44% for over 50 years. 11% reported tobacco consumption; 5.5%, high alcohol consumption; 40%, inadequate physical activity and 81%, inappropriate diet consumption. These correlated strongly with elderly age and poor education. The public facilities lacked diagnostics and specialist services; care in the private sector was expensive. Qualitative data revealed fears and cultural myths that affected treatment adherence. The results informed intervention design across the NCD care continuum.

CONCLUSIONS

The study provides tools and methodology to gather evidence in designing comprehensive NCD programmes in low and middle income settings. The study also provides important insights into public-private partnership driving effective NCD care at primary care level.

The 2017 International Joint Working Group White Paper by INDUSEM, the Emergency Medicine Association and the Academic College of Emergency Experts on Establishing Standardized Regulations, Operational Mechanisms, and Accreditation Pathways for Education and Care Provided by the Prehospital Emergency Medical Service Systems in India

The government of India has done remarkable work on commissioning a government funded prehospital emergency ambulance service in India. This has both public health implications and an economic impact on the nation. With the establishment of these services, there is an acute need for standardization of education and quality assurance regarding prehospital care provided. The International Joint Working Group has been actively involved in designing guidelines and establishing a comprehensive framework for ensuring high-quality education and clinical standards of care for prehospital services in India. This paper provides an independent expert opinion and a proposed framework for general operations and administration of a standardized, national prehospital emergency medical systems program. Program implementation, operational details, and regulations will require close collaboration between key stakeholders, including local, regional, and national governmental agencies of India.

The case of self-resolving type III achalasia after bilateral lung transplant

BACKGROUND

Post-surgical achalasia has been previously described in large case series but there are limited data on the natural progression of the disease process. In general, achalasia is considered an "incurable" disease as per published guidelines. We present here, the first report of a patient with post-surgical achalasia which resolved spontaneously.

METHODS

This is a retrospective chart review.

KEY RESULTS

A 60-year-old male presented for dysphagia 3 months status post-bilateral lung transplant and was diagnosed with achalasia following positive manometry. Absent any treatment, his repeat manometry showed complete, spontaneous resolution of the achalasia 2 years following lung transplant.

CONCLUSIONS & INFERENCES

To our knowledge, this is the first such case of spontaneously resolving achalasia following bilateral lung transplant. This case warrants further study in to the natural progression of post-surgical achalasia.