Clinical and laboratory features of COVID-19: Predictors of severe prognosis

BACKGROUND

Coronavirus disease 2019 (COVID-19) emerged first in December 2019 in Wuhan, China and quickly spread throughout the world. Clinical and laboratory data are of importance to increase the success in the management of COVID-19 patients.

METHODS

Data were obtained retrospectively from medical records of 191 hospitalized patients diagnosed with COVID-19 from a tertiary single-center hospital between March and April 2020. Prognostic effects of variables on admission among patients who received intensive care unit (ICU) support and those who didn't require ICU care were compared.

RESULTS

Patients required ICU care (n = 46) were older (median, 71 vs. 43 years), with more underlying comorbidities (76.1% vs. 33.1%). ICU patients had lower lymphocytes, percentage of large unstained cell (%LUC), hemoglobin, total protein, and albumin, but higher leucocytes, neutrophils, neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocytes ratio (PLR), urea, creatinine, aspartate amino transferase (AST), lactate dehydrogenase (LDH), and D-dimer when compared with non-critically ill patients (p < 0.001). A logistic regression model was created to include ferritin, %LUC, NLR, and D-dimer. %LUC decrease and D-dimer increase had the highest odds ratios (0.093 vs 5.597, respectively) to predict severe prognosis. D-dimer, CRP, and NLR had the highest AUC in the ROC analysis (0.896, 0.874, 0.861, respectively).

CONCLUSIONS

The comprehensive analysis of clinical and admission laboratory parameters to identify patients with severe prognosis is important not only for the follow-up of the patients but also to identify the pathophysiology of the disease. %LUC decrease and D-dimer, NLR, and CRP increases seem to be the most powerful laboratory predictors of severe prognosis.

Awareness and Knowledge of Patients' Bill of Right among Physicians and Patients in a Tertiary Hospital in Southwest Nigeria

BACKGROUND

Patients' Bill of Right (PBoR) was launched in Nigeria in 2018 with the aim of improving health service delivery to Nigerians. However, knowledge of PBoR among physicians and patients is pivotal to achieving its laudable objective.

AIM

This study assessed the awareness and knowledge of PBoR and associated factors among physicians and their patients at the University of Medical Sciences Teaching Hospital in Ondo State, Southwest Nigeria.

METHODS

This was a cross-sectional study that assessed awareness and knowledge of PBoR among physicians and patients using questionnaire. Maximum score obtainable was 16 and those with less than 8 were considered as having poor knowledge, 8-12 as good knowledge and 13-16 as excellent knowledge. P value of <0.05 was taken as significant.

RESULTS

Four hundred and fifty-three respondents made up 199 physicians and 254 patients participated in the study. There were 227(50.1%) males and 226(49.9%) females. Amongst the participants, 212(46.8%) were aware of existence of PBoR and 108(23.8%) claimed to be aware of its contents. Physicians and patients with good to excellent knowledge were 60.6% and 21.3 % respectively. The physicians had significantly better knowledge of PBoR compared to patients (p= <0.001). Factors associated with good to excellent knowledge of PBoR were male gender (p= 0.004), higher educational level (p= <0.001), being physician (p= <0.001) and younger age (p= <0.001).

CONCLUSION

Overall level of knowledge of PBoR was unsatisfactory especially among the patients. There is an urgent need for government to adequately educate and sensitize the public on PBoR in order to ensure qualitative health services delivery.

Cytomorphological spectrum of hand, wrist, and foot lesions at tertiary care center in central India

BACKGROUND

Fine-needle aspiration cytology (FNAC) being a fast technique is used as a primary investigation to diagnose wide spectrum of hand, wrist, and foot lesions. These sites are prone to trauma, reparative, and infectious process, which forms mass lesions mimicking neoplasia. Our study highlighted the importance of FNAC with the chance of reduction in biopsy or excision.

AIMS AND OBJECTIVES

To report the prevalence and cytomorphological spectrum of hand and foot lesions with the aim of consolidating the diagnostic potential and also correlate the cytological evaluation with histopathology.

MATERIALS AND METHODS

This retrospective observational study was done in central India for the period of 5.5 years. The archive cytology slides of patients with palpable lesions at these sites are reviewed and analyzed.

RESULTS

Of the total 6512 FNAC cases, 115 cases presented as swelling in the hand, wrist, and foot are reviewed. Age ranged from 4 months to 80 years with M:F = 1.25:1. Of the 111 satisfactory smears (96.7%), 21 cases (18.9%) diagnosed as inflammatory lesion, including synovitis, tuberculosis, gout, and fat necrosis. Sixty cases as benign non-neoplastic (tumor-like) lesions with the most common being ganglion (29). Of the 30 neoplastic lesions, 26 were benign tumor with the most common being mesenchymal neoplasms (19), followed by giant cell tumor of tendon sheath. Malignant tumors included malignant melanoma, small round cell tumor, and squamous-cell carcinoma.

CONCLUSION

FNAC is useful investigation for early diagnosis of hand and foot lesions. These lesions are benign mostly with less malignancy occurrence (<2%), compared with other soft tissue lesions.

Demographic and Clinical Profile of Dengue Fever in a Tertiary Care Hospital of South India

BACKGROUND

Dengue fever is the most common viral communicable disease caused by the bite of Aedes aegypti mosquito. Worldwide about 3.9 billion people are at the risk of this infection.

MATERIALS AND METHODS

This prospective study was done in patients of dengue fever admitted in a service hospital in the coastal area of southern India from 01 Jan 2018 to 31 Dec 2018.

RESULTS

751 patients of confirmed dengue patients were admitted with 555 (73.9%) males and 196 (26.1%) females. The mean age was 30.6 (SD± 10.48) years, mean day of admission after the onset of illness was 3.4 days (SD±2.76). The most common presentation was fever (99.33%) followed by myalgia (77.62%), headache (67.24%), vomiting (35.41%), nausea (26.76%) and fatigue (9.05%). Bleeding diathesis was evident in 97patients (12.91%). 306 (40.75%) patients presented with warning signs. The mean duration of hospitalization was 5.73 (SD± 2.75) days. Four patients died due to severe dengue (mortality rate-0.53%).

CONCLUSION

Intense monitoring, early detection, and management of complications can prevent mortality in dengue.

A Prospective Audit of Airway Code Activations and Adverse Events in Two Tertiary Hospitals

INTRODUCTION

Airway management outside the operating room can be challenging, with an increased risk of difficult intubation, failed intubation and complications. We aim to examine airway practices, incidence of difficult airway and complications associated with airway code (AC) activation.

METHODS

We conducted a prospective audit of AC activations and adverse events in two tertiary hospitals in Singapore. We included all adult patients outside the operating room who underwent emergency intubation by the AC team after AC activation. Adult patients who underwent emergency intubation without AC activation or before the arrival of the AC team were excluded. Data were collected and documented by the attending anaesthetists in a standardised survey form shortly after their responsibilities were completed.

RESULTS

The audit was conducted over a 20-month period from July 2016 to March 2018, during which a total of 224 airway activations occurred. Intubation was successful in 218 of 224 AC activations, giving a success rate of 97.3%. Overall, 48 patients (21.4%) suffered an adverse event. Thirteen patients (5.8%) had complications when intubation was carried out by the AC team compared with 35 (21.5%) by the non-AC team.

CONCLUSION

Dedicated AC team offers better success rate for emergency tracheal intubation. Non-AC team attempted intubation in the majority of the cases before the arrival of the AC team. Increased intubation attempts are associated with increased incidence of adverse events. Equipment and patient factors also contributed to the adverse events. A multidisciplinary programme including the use of supraglottic devices may be helpful to improve the rate of success and minimise complications.

Age- and sex-related characteristics of the increasing trend of nontuberculous mycobacteria pulmonary disease in a tertiary hospital in South Korea from 2006 to 2016

BACKGROUND/AIMS

The incidence rate of nontuberculous mycobacterial pulmonary disease (NTM-PD) is increasing worldwide. However, data regarding the age- and sex-specific epidemiology of NTM-PD are limited. This study aimed to investigate the long-term epidemiologic trends of NTM-PD within the recent 11- year period in a tertiary referral hospital in Korea.

METHODS

We retrospectively reviewed the medical records of the patients diagnosed with NTM-PD between January 2006 and December 2016 at Severance Hospital, South Korea.

RESULTS

There were 1,017 incident cases with NTM-PD during the study period. The mean age was 62.7 years, and 41.2% were men. Women were younger than men (59.9 years vs. 66.7 years, p < 0.001) and a higher proportion of women had bronchiectasis (88.6% vs. 77.1%, p < 0.001). The incidence rates of NTM-PD annually increased by 14% (95% confidence interval, 10% to 19%) from 1.2 in 2006 to 4.8 in 2016 (per 100,000 patients-year). The peak incidence rate was in the 50s for women and in the 70s for men, except for those aged ≥ 80 years. Mycobacterium avium complex was the most common causative species of NTM-PD (63.6%).

CONCLUSION

The incidence rate of NTM-PD in a tertiary referral hospital in South Korea continued to increase from 2006 to 2016. Furthermore, there were age- and sex-related differences in the clinical characteristics, which might contribute to understanding the nature of the disease and inherited and acquired host factors.

Establishment of a high-dependency unit in Malawi

Adults admitted to hospital with critical illness are vulnerable and at high risk of morbidity and mortality, especially in sub-Saharan African settings where resources are severely limited. As life expectancy increases, patient demographics and healthcare needs are increasingly complex and require integrated approaches. Patient outcomes could be improved by increased critical care provision that standardises healthcare delivery, provides specialist staff and enhanced patient monitoring and facilitates some treatment modalities for organ support. In Malawi, we established a new high-dependency unit within Queen Elizabeth Central Hospital, a tertiary referral centre serving the country's Southern region. This unit was designed in partnership with managers, clinicians, nurses and patients to address their needs. In this practice piece, we describe a participatory approach to design and implement a sustainable high-dependency unit for a low-income sub-Saharan African setting. This included: prospective agreement on remit, alignment with existing services, refurbishment of a dedicated physical space, recruitment and training of specialist nurses, development of context-sensitive clinical standard operating procedures, purchase of appropriate and durable equipment and creation of digital clinical information systems. As the global COVID-19 pandemic unfolded, we accelerated unit opening in anticipation of increased clinical requirement and describe how the high-dependency unit responded to this demand.

Assessment knowledge and practices of central line insertion and maintenance in adult intensive care units at a tertiary care hospital in Saudi Arabia

BACKGROUND

Awareness of central line bundle by healthcare workers (HCWs) is essential for preventing catheter-associated bloodstream infections (CLABSI). The objective was to assess the knowledge and practice of insertion and maintenance central line bundles among HCWs in intensive care units (ICUs).

METHODS

A cross-sectional study was conducted at King Abdul-Aziz medical city in Riyadh between November 2017 and April 2018. The target was nurses and physicians working in three ICUs. The knowledge and practice were assessed using a structured study questionnaire that included also demographic characteristics.

RESULTS

A total 171 nurses and 41 physicians were included in the current analysis. More than 90% of HCWs correctly answered 9 out of 12 knowledge questions, specially questions related hand hygiene, maximal barrier, daily assessment, and dressing change. The overall knowledge score was 82% and was significantly higher among those who received central line bundle training. Self-reported compliance (all or most of the time) with 10 different bundle recommendations ranged between 50% and 97%, being highest with hand hygiene, maximal barrier, and using chlorhexidine (97% each) and lowest with using the subclavian site (50%). The overall self-reported compliance score was 87% and was significantly higher among nurses. There was weak positive correlation between knowledge and practice (correlation coefficient 0.266, p=0.001).

CONCLUSION

Knowledge and compliance of central line bundle were generally high in our HCWs. Training is important in improving knowledge of central line bundle. Future educational activities should focus on specific compliance deficiencies such as using the subclavian site and dressing change.

Pediatric recurrent fever and autoinflammation from the perspective of an allergist/immunologist

Autoinflammatory diseases are monogenic and polygenic disorders due to dysregulation of the innate immune system. The inherited conditions have been clustered with primary immunodeficiencies in the latest practice parameters; however, these diseases have unique clinical presentations, genetics, and available therapies. Given the presentation of fevers, rashes, and mucosal symptoms observed in many of these syndromes, patients are likely to present to an allergist/immunologist. Although there has been attention in the literature to diagnosis and treatment of rare, genetically defined autoinflammatory disorders, physicians are challenged by increasing numbers of patients with intermittent or periodic fevers who face unnecessary morbidities due to a lack of a diagnosis. The broad differential of diseases presenting with fever includes autoinflammatory syndromes, infections associated with immunodeficiency and/or allergies complicated by infection, and less commonly, autoimmune disorders or malignancy. To address this challenge, we review the history of the medical approach to fever, current diagnostic paradigms, and controversies in management. We describe the spectrum of disorders referred to a recurrent fever disorders clinic established in an Allergy/Immunology division at a tertiary pediatric care center. Finally, we provide practical recommendations including historical features and initial laboratory investigations that can help clinicians appropriately manage these patients.

Red reflex test at the maternity hospital: results from a tertiary hospital and variables associated with inconclusive test results

OBJECTIVES

Describe the results of the red reflex test in full-term newborns, as well as identify factors associated with red reflex test outcome and compare hospital length of stay between patients with inconclusive and normal red reflex test results.

METHODS

Descriptive cross-sectional study of the results of the red reflex test performed in a tertiary hospital maternity unit between 2014 and 2018. A nested case-control study was also performed to search for anthropometric, gestational, and neonatal variables associated with the outcome of the red reflex test.

RESULTS

There were121 identified cases of inconclusive red reflex test in 11,833 newborns. Sixteen alterations were confirmed, four considered severe: two cases of congenital glaucoma, one of cataract, and one of coloboma. Mean birth weight (p=0.04), length (p=0.03), and head circumference (p=0.02) were lower in patients with inconclusive red reflex test; however without a relevant effect size (d=-0.21, -0.22, and -0.25, respectively).The proportion of white, mixed-race, and black patients was significantly different between the groups (p<0.001), with a higher chance of inconclusive results in mixed-race (OR=2.22) and black (OR=3.37) patients when compared to whites. An inconclusive red reflex test led to an increase in hospital length of stay from 62 to 82hours (p<0.001).

CONCLUSIONS

The red reflex test was able to identify four severe alterations in 11,833 newborns (0.03%). In the 121 newborns in which the red reflex test was classified as inconclusive, there was a 20-hour increase in the hospital length of stay, but a severe alteration was confirmed in only 3.3% of them. Differences in red reflex between white, mixed-race, and black patients should be considered.

Coronavirus disease 2019: Knowledge, attitude, and practice of pregnant women in a tertiary hospital in Abakaliki, southeast Nigeria

OBJECTIVE

To determine the knowledge, attitude, and practice of antenatal attendees towards COVID-19 in Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria.

METHODS

A cross-sectional survey was carried out among 430 consenting pregnant women attending antenatal clinics between March 1 and May 30, 2020, using pretested questionnaires.

RESULTS

The mean age and mean gestational age of the respondents were 30.04 years (95% confidence interval [CI] 28.9-31.1) and 26.3 weeks (95% CI 23.3-29.3), respectively. More than four-fifths (82%) of the women believed that COVID-19 is real and their main source of information was mass media. The majority had adequate knowledge of COVID-19. More than half of the respondents said COVID-19 is a curable disease and that chloroquine can be used. The majority showed a good attitude and preventive practice of COVID-19 disease; however, one-fourth (24%) thought that infected individuals should be killed to prevent the spread of the virus.

CONCLUSION

The study population has good knowledge, attitude, and practice of COVID-19 disease. However, it is worrisome that some respondents thought that infected individuals should be killed. Proper education must be given to the populace to avert these negative attitudes while promoting a positive preventive attitude. The study population has adequate knowledge, good attitude, and preventive practice of COVID-19; however, community education is needed to reduce anxiety among the populace.

Seroprevalence of COVID-19 Amongst Health Care Workers in a Tertiary Care Hospital of a Metropolitan City from India

BACKGROUND

Seroprevalence studies for COVID-19 evaluate the extent of undetected transmission in a defined community, with special significance among health care workers (HCW) owing to their greater exposure and potential to transmit.

METHODS

A total of 1122 HCW (approximately 25% of the employees) of a large tertiary care hospital in India were recruited for this cross-sectional study. COVID PCR-positive HCW were excluded. Based on their risk-assessment, participants were grouped into three categories. A questionnaire was administered and they were tested for SARS-CoV-2-IgG antibodies using the chemiluminescence.

RESULTS

The overall seroprevalence among workers was 11.94%, which included 19.85% in COVID units, 11.09% in non-COVID units, and 8% in administrative workers (p=0.007). Antibody prevalence was highest in the department of gastroenterology (11.94%), followed by oncology (10.53%), pathology (10.26%), emergency medicine (7.84%) and critical care medicine (7%). Housekeeping staff, food and beverage staff, lab assistants and technicians had higher seroprevalence rate than doctors and nurses (p < 0.0001). HCW with a history of BCG vaccination in childhood and those who received an adequate prophylactic dose of hydroxychloroquine (HCQ) had a lower seroprevalence as compared to those who did not (7.31% vs. 16.8% and 1.30% vs. 11.25% respectively).

CONCLUSION

BCG vaccination, HCQ prophylaxis, and the job profile influence the seroprevalence rate in HCW. Seroprevalence rate and follow-up evaluation of its durability may help hospitals to triage their staff at risk, rationalize their placement, prioritize the use of PPE, thereby potentially reducing the risk.

Effect of Antenatal Couple Counselling on Postpartum Uptake of Contraception among Antenatal Clients and their Spouses attending Antenatal Clinic of a Northern Nigeria Tertiary Hospital: A Randomized Controlled Trial

BACKGROUND

Contraceptive non-use has great influence on maternal health and mortality in Northern Nigeria. Contraception counselling improves utilization, compliance to and efficiency of contraceptive methods. This study aimed at determining the effect of antenatal couple counselling on postpartum uptake of contraception among antenatal clients and their spouses.

MATERIALS AND METHODS

This was a randomized controlled trial of 150 antenatal clients with their spouses at a tertiary hospital in Northern Nigeria. Participants were randomly assigned to intervention and control groups. A well-designed questionnaire was used to assess participants' contraception awareness, contraceptive uptake pre- and post-intervention and husband participation. A validated counselling tool GATHER was used for the counselling.

RESULTS

Baseline knowledge of contraception was high (92%) among participants however, contraceptive uptake was low (28.3%); there was no significant difference between intervention and control groups (P= 0.94) at baseline. Post-intervention, there was significant difference in postpartum contraceptive uptake between intervention and control groups (48.5% versus 31.0%, respectively; McNemar's chi-square P=0.0001). The determinants of postpartum contraceptive uptake were participants' educational status [Odds ratio (OR)= 10.26, 95% CI =1.31-80.48,P= 0.03], occupation (OR= 10.25, 95% CI=1.06-87.38,P=0.03) and husbands' participation (OR = 0.03, 95% CI = 0.005-0.21,P=0.0001).

CONCLUSION

Antenatal couple counselling impacted positively on postpartum contraceptive uptake. Inclusion of antenatal couple contraception counselling services should be promoted.

Modulation of hearing function following the downgrading or upgrading of endolymphatic hydrops in Meniere's disease patients with endolymphatic duct blockage

The present study was to investigate the dynamics of endolymphatic hydrops (EH) and hearing function, and explore whether the hearing loss is caused by EH alone and whether the hearing function can be modulated by changes in the EH. The extent of EH visualized by gadolinium (Gd)-enhanced inner ear magnetic resonance imaging, hearing thresholds and the summating potential/action potential ratio (-SP/AP ratio) of electrocochleography (ECochG) were recorded prior to and following surgery in 22 patients with intractable Meniere's disease (MD) who underwent endolymphatic duct blockage (EDB). The difference value of the hearing threshold and -SP/AP ratio was significantly positively correlated with the difference value of the endolymph to vestibule-volume ratio (EVVR) and grading of cochlear hydrops between prior to and following surgery. Among patients with a decreased EVVR, the average hearing threshold and -SP/AP ratio was significantly decreased following surgery, as compared to that prior to surgery. Six out of seven patients with a hearing improvement (≥10-dB decline) and 4/5 patients with a negative conversion of EcochG showed downgrading of their hydrops in the cochlea and/or vestibule. By contrast, among patients with an increased EVVR, the average hearing threshold and -SP/AP ratio tended to increase following EDB, as compared with that prior to surgery. One out of two patients with a hearing deterioration (≥10-dB elevation) showed upgrading of her hydrops in both cochlea and vestibule. The present results showed the downgrading of cochlear and/or vestibular hydrops accompanied by the downregulation of the hearing threshold and -SP/AP ratio of EcochG, as well as the upgrading of cochlear and/or vestibular hydrops that tended to upregulate the hearing threshold and -SP/AP ratio of EcochG; this suggested that hearing loss is likely to be caused by hydrops and that the impaired hearing function be modulated by changes in the hydrops.

Treatment outcomes of Nigerian patients with tuberculosis: A retrospective 25-year review in a regional medical center

Introduction

Tuberculosis (TB) remains a global health challenge and leading infectious killer worldwide. The need for continuous evaluation of TB treatment outcomes becomes more imperative in the midst of a global economic meltdown substantially impacting resource-limited-settings.

Methods

This study retrospectively reviewed 25-years of treatment outcomes in 3,384 patients who were managed for TB at a tertiary hospital in Nigeria. Confirmed TB cases were given directly observed therapy of a short-course treatment regimen and monitored for clinical response.

Results

Out of 1,146,560 patients screened, there were 24,330 (2.1%) presumptive and 3,384 (13.9%) confirmed TB cases. The patients’ mean age was 35.8 years (0.33–101 years). There were 1,902 (56.2%) male, 332(9.8%) pediatric, and 2,878 (85%) pulmonary TB cases.

The annual mean measured treatment outcomes were as follows: adherence, 91.4(±5.8) %; successful outcome, 75.3(±8.8) % potentially unsatisfactory outcome, 14.8(±7.2) %; and mortality 10.0(±3.6) %.

Female, extra-pulmonary TB (EPTB), newly diagnosed, and relapsed patients compliant with treatment had successful outcomes. Adulthood and HIV infection were mortality risk factors.

Conclusion

The mean annual successful treatment outcome is 75.3(±8.8) %. Female, pediatric, EPTB, new, and relapsed patients were predisposed to successful treatment outcomes. Lessons learned will guide future program modifications.

Identifying critically ill children at high risk of acute kidney injury and renal replacement therapy

Acute kidney injury (AKI), a common complication in paediatric intensive care units (PICU), is associated with increased morbidity and mortality. In this single centre, prospective, observational cohort study, neutrophil gelatinase-associated lipocalin in urine (uNGAL) and plasma (pNGAL) and renal angina index (RAI), and combinations of these markers, were assessed for their ability to predict severe (stage 2 or 3) AKI in children and young people admitted to PICU. In PICU children and young people had initial and serial uNGAL and pNGAL measurements, RAI calculation on day 1, and collection of clinical data, including serum creatinine measurements. Primary outcomes were severe AKI and renal replacement therapy (RRT). Secondary outcomes were length of stay, hospital acquired infection and mortality. The area under the Receiver Operating Characteristic (ROC) curves and Youden index was used to determine biomarker performance and identify optimum cut-off values. Of 657 children recruited, 104 met criteria for severe AKI (15∙8%) and 47 (7∙2%) required RRT. Severe AKI was associated with increased length of stay, hospital acquired infection, and mortality. The area under the curve (AUC) for severe AKI prediction for Day 1 uNGAL, Day 1 pNGAL and RAI were 0.75 (95% Confidence Interval [CI] 0∙69, 0∙81), 0∙64 (95% CI 0∙56, 0∙72), and 0.73 (95% CI 0∙65, 0∙80) respectively. The optimal combination of measures was RAI and day 1 uNGAL, giving an AUC of 0∙80 for severe AKI prediction (95% CI 0∙71, 0∙88). In this heterogenous PICU cohort, urine or plasma NGAL in isolation had poorer prediction accuracy for severe AKI than in previously reported homogeneous populations. However, when combined together with RAI, they produced good prediction for severe AKI.

A mathematical model of COVID-19 transmission in a tertiary hospital and assessment of the effects of different intervention strategies

Novel coronavirus (named SARS-CoV-2) can spread widely in confined settings including hospitals, cruise ships, prisons, and places of worship. In particular, a healthcare-associated outbreak could become the epicenter of coronavirus disease (COVID-19). This study aimed to evaluate the effects of different intervention strategies on the hospital outbreak within a tertiary hospital. A mathematical model was developed for the COVID-19 transmission within a 2500-bed tertiary hospital of South Korea. The SEIR (susceptible-exposed-infectious-recovered) model with a compartment of doctor, nurse, patient, and caregiver was constructed. The effects of different intervention strategies such as front door screening, quarantine unit for newly admitted patients, early testing of suspected infected people, and personal protective equipment for both medical staff and visitors were evaluated. The model suggested that the early testing (within eight hours) of infected cases and monitoring the quarantine ward for newly hospitalized patients are effective measures for decreasing the incidence of COVID-19 within a hospital (81.3% and 70% decrease of number of incident cases, respectively, during 60 days). Front door screening for detecting suspected cases had only 42% effectiveness. Screening for prohibiting the admission of COVID-19 patients was more effective than the measures for patients before emergency room or outpatient clinic. This model suggests that under the assumed conditions, some effective measures have a great influence on the incidence of COVID-19 within a hospital. The implementation of the preventive measures could reduce the size of a hospital outbreak.

Predictor for supraphysiologic serum estradiol elevation on hCG triggering day of controlled ovarian stimulation using letrozole and gonadotropins in women with estrogen-dependent cancers

The objective of this study was to evaluate predicting factors for supraphysiologic serum estradiol elevation during controlled ovarian stimulation (COS) with administration of letrozole and gonadotropins in patients with estrogen-dependent cancer. Use of aromatase inhibitors is recommended to prevent the potential effects of elevated serum estradiol levels and recurrence of tumor in patients with estrogen-dependent cancers during COS. Although previous studies reported that letrozole have shown an effective lowering of peak estrogen levels, a part of patients shows supraphysiologic levels of estrogen associated with ovarian stimulation despite the administration of letrozole. From January 2009 to December 2019, patients with estrogen-dependent cancer who underwent COS with antagonist protocol using a letrozole (5 mg/ day) to keep estrogen levels low were included in this study. Early monitoring serum estradiol was measured in all patients on the 4-6th day of stimulation. Subjects were classified into two groups according to the serum estradiol level on hCG triggering day, physiologic estradiol group (≤400 pg/mL) and supraphysiologic estradiol group (>400 pg/mL). A total of 96 COS cycles were retrospectively analyzed. Supraphysiologic level of serum estradiol was found in 21.9% of the patients. Mean age, AMH, duration of stimulation, total dose of gonadotropins administered were not different between the two groups. However, early monitoring serum estradiol level was significantly higher in the supraphysiologic estradiol group (67.1±47.9 vs. 115.6±78.1, p = 0.001) and was associated with the occurrence of supraphysiologic elevation of serum estradiol on hCG triggering day. Patients with early monitoring serum estradiol ≥84.5 pg/mL had an odds ratio of 5.376 [95% CI, 1.613–17.913] for supraphysiologic elevation of serum estradiol compared to those with early monitoring serum estradiol below 84.5 pg/mL. In conclusion, early monitoring serum estradiol is an independent predicting factor for supraphysiologic level of serum estradiol on hCG triggering day in the COS cycles using letrozole and gonadotropins.

Cancer obscures extrapulmonary tuberculosis (EPTB) at a tertiary hospital in Northern Malawi

Data on the prevalence of extrapulmonary tuberculosis (EPTB) patients are limited in many African countries including Malawi. We conducted a retrospective review of all histology reports for cancer suspected patients at Mzuzu Central Hospital (MZCH) between 2013 and 2018 to determine the proportion of EPTB cases among cancer suspected patients and characterised them epidemiologically. All reports with inconclusive findings were excluded. In total, 2214 reports were included in the review, 47 of which reported EPTB, representing 2.1% (95% CI 1.6-2.8). The incidence of EPTB was significantly associated with sex, age and HIV status. Men were more than twice (OR 2.1; 95% CI 1.2-3.9) as likely to have EPTB as women while those with HIV were more than six times (OR 6.4; 95% CI 1.7-24.8) as likely to have EPTB compared to those who were HIV-negative. EPTB demonstrated an inverse relationship with age. The highest proportion of EPTB was found from neck lymph nodes (10.3% (5.4-17.2)). A reasonable number of EPTB cases are diagnosed late or missed in Malawi's hospitals. There is a need for concerted efforts to increase EPTB awareness and likely come up with a policy to consider EPTB as a differential diagnosis in cancer suspected patients.

SARS-CoV-2 Testing in Patients With Cancer Treated at a Tertiary Care Hospital During the COVID-19 Pandemic

PURPOSE

To analyze the prevalence of SARS-CoV-2 infection in patients with cancer in hospital care after implementation of institutional and governmental safety measurements.

METHODS

Patients with cancer routinely tested for SARS-CoV-2 RNA by nasal swab and real-time polymerase chain reaction between March 21 and May 4, 2020, were included. The results of this cancer cohort were statistically compared with the SARS-CoV-2 prevalence in the Austrian population as determined by a representative nationwide random sample study (control cohort 1) and a cohort of patients without cancer presenting to our hospital (control cohort 2).

RESULTS

A total of 1,688 SARS-CoV-2 tests in 1,016 consecutive patients with cancer were performed. A total of 270 of 1,016 (26.6%) of the patients were undergoing active anticancer treatment in a neoadjuvant/adjuvant and 560 of 1,016 (55.1%) in a palliative setting. A total of 53 of 1,016 (5.2%) patients self-reported symptoms potentially associated with COVID-19. In 4 of 1,016 (0.4%) patients, SARS-CoV-2 was detected. At the time of testing at our department, all four SARS-CoV-2-positive patients were asymptomatic, and two of them had recovered from symptomatic COVID-19. Viral clearance was achieved in three of the four patients 14-56 days after testing positive. The estimated odds ratio of SARS-CoV-2 prevalence between the cancer cohort and control cohort 1 was 1.013 (95% CI, 0.209 to 4.272; P = 1), and between control cohort 2 and the cancer cohort it was 18.333 (95% CI, 6.056 to 74.157).

CONCLUSION

Our data indicate that continuation of active anticancer therapy and follow-up visits in a large tertiary care hospital are feasible and safe after implementation of strict population-wide and institutional safety measures during the current COVID-19 pandemic. Routine SARS-CoV-2 testing of patients with cancer seems advisable to detect asymptomatic virus carriers and avoid uncontrolled viral spread.

Assessment of cooperation and compliance in adult patients at three stages of orthodontic treatment at a tertiary care hospital: A cross-sectional study

OBJECTIVE

The study was conducted to assess cooperation and compliance in adult orthodontic patients during the leveling and alignment, space closure/molar correction and finishing stages of orthodontic treatment.

MATERIALS AND METHODS

This cross-sectional study was conducted on adult patients undergoing fixed orthodontic mechanotherapy in a tertiary care hospital. Patient cooperation was assessed during orthodontic treatment stages using Orthodontic Patient Cooperation Scale (OPCS) and compliance by Clinical Compliance Evaluation (CCE) form. A sample size of 38 subjects was included for each stage of treatment; therefore, a total of 114 subjects were recruited for the study. Shapiro-Wilk test identified that the data were normally distributed. One way ANOVA was used to evaluate the percentage cooperation and compliance among three stages. Pair-wise comparisons among the three stages were performed using Post hoc Tukey test. Simple and multiple linear regression analysis were carried out to see the factors associated with cooperation and compliance.

RESULTS

A statistically significant difference was seen for scores of patient cooperation and compliance using CCE (P=0.01); however, the results of the OPCS were non-significant among the three stages of treatment (P=0.16). There was a significant difference in patient cooperation and compliance between space closure/molar correction and finishing stage (P=0.01). A highly significant decline in oral hygiene was found with the progression of orthodontic treatment, from space closure/molar correction to the finishing stage of treatment (P<0.001).

CONCLUSIONS

Improvement in the cooperation and compliance levels for adult orthodontic patients was observed during the space closure/molar correction stage, which then showed a decline as the treatment progressed. Maintenance of oral hygiene was gradually reduced with the progression of orthodontic treatment.

Maternal placental growth factor and soluble fms-like tyrosine kinase-1 reference ranges in post-term pregnancies: A prospective observational study

Background

Post-term pregnancies have increased risks for adverse fetal and maternal outcomes. Maternal concentrations of the placenta-associated proteins placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) have been identified as predictors for preeclampsia and fetal growth restriction, both syndromes of placental dysfunction. We have proposed that low maternal circulating PlGF and increased sFlt-1 are general markers for syncytiotrophoblast stress, which increases at and beyond term, even in apparently uncomplicated pregnancies. Our aim was to establish circulating PlGF, sFlt-1, and sFlt-1/PlGF reference ranges in healthy post-term pregnancies (gestational week ≥40⁺²), comparing with healthy term pregnancies and evaluating associations between time to delivery and biomarker percentiles.

Methods

Of 501 healthy, singleton post-term pregnancies prospectively recruited between September 2016 and December 2017 at our tertiary obstetric department, 426 with an uncomplicated delivery outcome contributed PlGF and sFlt-1 serum concentrations for reference range construction. A retrospective, cross-sectional, term group with an uncomplicated delivery outcome (n = 146) served as comparison. Differences in percentile values between groups and confidence intervals were calculated by quantile regression.

Results

In post-term pregnancies the 5^th, 50^th, and 95^th percentiles for PlGF were: 70, 172, and 496 pg/mL; for sFlt-1: 2074, 4268, and 9141 pg/mL; and for sFlt-1/PlGF 5.3, 25.5, and 85.2. Quantile regression analyses comparing the post-term to the term group showed for PlGF a trend towards higher 10^th through 30^th percentiles, for sFlt-1 significantly higher 10^th through 80^th percentiles, and for sFlt-1/PlGF ratio significantly higher 30^th percentile and significantly lower 95^th percentile.

PlGF below the 5^th percentile and sFlt-1/PlGF ratio above the 95^th percentile was associated with shorter time to delivery (p = 0.031 and p = 0.025, respectively).

Conclusions

Our findings support the concept of increasing syncytiotrophoblast stress post-term in clinically healthy pregnancies. Whether post-term dysregulated angiogenic markers reflect a biological placental clock merits further investigation.

The Impact of COVID-19 on the Use of Radiology Resources in a Tertiary Hospital

BACKGROUND

The coronavirus disease 2019 (COVID-19) has escalated to be a global threat to public health. Analysis of the use of radiology resources may render us insight regarding the public health behavior during pandemic. We measured the influence COVID-19 had on the use of radiology resources in terms of the number of examinations performed, and turnaround time for portable radiography.

METHODS

This study was conducted at a tertiary hospital located in area where the prevalence of COVID-19 infection was low (0.01%). We compared the number of radiology examinations 1) before pandemic (in 2019) vs. during peak of pandemic (January to March 2020), and 2) before pandemic vs. after the peak of pandemic (April to June 2020) via t-tests. We repeated similar analyses for subgroups as follows: gender, age, department (outpatient, inpatient, emergency, screening), body parts, and modality. We also performed a survey of radiologic technologists regarding the turnaround time and rate-limiting step of portable radiography for patients with and without suspicion or confirmation of COVID-19.

RESULTS

Although not statistically significant, the daily number of examinations during the peak of pandemic decreased by 9 percentage points (2,638 vs. 2,413; difference [95% CI], -225 [-489, 38]; P = 0.094). The percentage change was especially notable for children, emergency, and screening department (25, 19, and 44 percentage points, respectively). After the peak of the pandemic, the number of examinations increased back to near the pre-pandemic level (2,638 vs. 2,588; -50 [-317, 218]; P = 0.71). The turnaround time for portable radiography tended to be longer for patients with suspicion or confirmation of COVID-19, with donning personal protective equipment being the major rate-limiting step.

CONCLUSION

The number of examinations decreased during the pandemic, reflecting the tendency of the public to refrain from seeking medical care even in a community of low infection risk. Nevertheless, burden of healthcare providers may not have decreased as much, considering longer turnaround time required for COVID-19 related examinations.