Lipoma of the gastrointestinal tract: a tertiary care centre experience

INTRODUCTION

Gastrointestinal (GI) lipomas are rare; however, they are frequent enough to be considered in the differential diagnosis of gut tumours. Here, we present our experience with GI lipomas managed at our institute over the last three years.

METHODS

This is a retrospective cohort study of patients with GI lipomas managed between January, 2020 and April, 2023 at a tertiary care centre. Clinical presentation, location, and details of surgical procedure were analysed.

RESULTS

Ten patients were included, six of whom had lipoma in the colon, one in the stomach, and one each in the duodenum, jejunum, and ileum. The mean age at the time of presentation was 48.8 years (range, 19-77 years), and strong male preponderance (4:1) was noted. Preoperative diagnosis of lipoma on cross-sectional imaging was possible in all patients. All patients were symptomatic and were managed surgically.

CONCLUSIONS

While GI lipomas are generally considered to be indolent and benign tumours, they can potentially lead to severe complications. The utilisation of computed tomography and magnetic resonance imaging has brought about a significant transformation in diagnosing this condition, enabling preoperative identification in most cases. The surgery offers a definitive treatment with minimal risk of postoperative complications.

Disseminated tuberculosis, CMV viraemia & haemophagocytic-lymphohistiocystosis syndrome in an adult patient with anti- IFNγ autoantibodies - case report and brief review

We report a case of an adult female with disseminated tuberculosis, cytomegalovirus viraemia and haemophagocytic-lymphohistiocystosis syndrome associated with neutralizing anti- interferon gamma (IFNγ) autoantibodies demonstrated by absent IFNγ stimulated STAT1 phosphorylation in the presence of patient sera. A brief review of immunodeficiency caused by anti-IFNγ autoantibodies is also described.

MEDITERRANEAN DIET AND ITS IMPACT ON THE ILLNESS CHARACTERISTIC OF YOUTH WITH IRRITABLE BOWEL CONDITION

Irritable Bowel Disorder (IBD) is a prevalent digestive illness that frequently affects young people and drastically decreases the Quality of Life (QoL). Adults with IBD indications may find relief from their symptoms through nutritional changes like the Mediterranean-style diet. Concerning the seriousness of symptoms, QoL, and additional pertinent results in young people with IBD, this investigation seeks to determine the impact of the Mediterranean-style diet. 200 individuals with IBD who met the Rome-IV criterion and were between the ages of 13 and 19 were enrolled in the present research. A Mediterranean-style diet was provided to the Study Group (SG), which consisted of 100 individuals, while the Control Group (CG), which consisted of 100 patients, followed the usual diet. Various laboratory and clinical characteristics were also assessed at the beginning and end of the study, in addition to IBD values. The Mediterranean-style diet has been demonstrated to be effective and tolerated well in kids and teenagers with IBD. The IBD -SSS (from 148±42.3 to 224±71) IBD -QoL (from 76.7±8.1 to 61.3±9.8), and cumulative IBD rating (from 29.3±11.7 to 32.6±12.1) all showed notable increases in individuals who followed well to this diet. The CG, in comparison, did not show any significant enhancements in these factors. This indicates that a Mediterranean-style diet might provide therapeutic advantages for IBD individuals, especially those who keep adherent to it, concerning symptom severity and QoL. The Mediterranean-style diet proved to be both secure and associated with notable improvements in IBD rates in young and adolescents with IBD.

INVESTIGATING THE EFFECT OF NICOTINE FROM CIGARETTES ON THE GROWTH OF ABDOMINAL AORTIC ANEURYSMS: REVIEW

Separating aneurysmal arterial disease from atherosclerosis and further occlusive artery conditions, it is a vascular degenerative disorder. Within the vascular tree, there is a regionalization of the propensity to produce aneurysms and the different locations result in different clinical processes. As the predominant risk factor for ubrenal abdominal aortic aneurysm (AAA), smoking is one of the most common manifestations of aneurysmal illness. For AAA compared to atherosclerosis, smoking is a far bigger risk factor. Along with contributing to the pathophysiology of AAA, smoking raises the likelihood that established AAA will rupture as well as its rate of expansion. The development of improved models for animals that are reliant on smoke or smoke constituents is helping to determine the mechanistic connection between AAA and smoking. According to the processes, there are long-lasting changes in the function of inflammatory and vascular smooth muscle cells. Focused on AAA, this review looks at the medical, epidemiology and mechanical evidence that links smoking to aneurysms.

ANXIETY SYNDROMES IN ADOLESCENTS WITH OPERATIONAL RESPIRATORY CONDITIONS: A PROSPECTIVE STUDY

Aim - determining the prevalence of anxiety disorders and their effect on disease progression and quality of life in adults with organic illnesses and functional disorders of the respiratory system treated in a pulmonology environment. A total of 135 young adults between the ages of 13 and 17 were analyzed. There were a total of 46 adolescents diagnosed with somatoform respiratory disorders (SRD), 45 adolescents diagnosed with bronchial asthma (BA), and 44 adolescents diagnosed with pneumonia. The Spielberger-Khanin anxiety questionnaire and the Nijmegen hyperventilation syndrome (HVS) scale were used for the research and diagnosis, respectively. The quality of life was measured using the asthma quality of life questionnaire (AQLQ). In comparison to adults with asthma (33.2%) and pneumonia (32.3%), adults with SRD (34.5%). There were mild immediate associations between the Spielberger scale and the Nijmegen HVS questionnaire for both trait and state anxiety, and mild inverse correlations between the Spielberger scale and the AQLQ for both state and trait anxiety. Adolescents with anxiety had a higher prevalence of trauma, pain, and social issues than their non-anxious counterparts who were referred to psychiatry. In adolescents, 5.1% had severe trait anxiety, and 19.3% had severe condition anxiety. Adolescents with SRD were twice as likely to suffer from extreme state and trait anxiety as the general population. It is hypothesized that anxiety problems are at the root of HVS and contribute to adults' dissatisfaction with their quality of life due to lung ailments. Although certain adolescents with anxiety disorders were referred for anxiety, this data nevertheless lends credence to the idea that using standardized and structured instruments regularly might help increase accuracy and detection rates in the clinic, regardless of the reason for referral. Complete evaluations are essential for this patient population due to the intricacy of their symptoms.

EFFECTS OF SOCIAL ESTRANGEMENT ON YOUNG PEOPLE'S MATURATION: A REVIEW OF THE RESEARCH

A major issue among adolescents in recent years has been social isolation, or the sensation cut off and alone from peers and society. The effects of social isolation on youngsters and adolescents are investigated with special attention paying to the possible negative effects on their physical and mental health. Multiple studies have shown a link between adversity in life domains and adolescent social isolation. Firstly, it can have a major effect on mental health, raising the probability of experiencing things like anxiety, sadness and even suicidal thoughts. Second, it prevents the development of vital social abilities, making it harder to make and keep close friends. In addition, social isolation is associated with worse academic performance, which in turn reduces the number of courses a student can take and the number of jobs they can have in the future. After looking over 520 papers, 15 were chosen for the systematic review. Four researches reported the implications on general health, while two investigations reported on ramifications affecting the Hypothalamic-pituitary-adrenal (HPA) axis area along with social and mental growth of children. In conclusion, social isolation affects youth development across a wide spectrum, including psychological well-being, interpersonal skills, and academic success. Children and adolescents who experience isolation are more likely to suffer from anxiety and sadness, according to the review's findings. Cortical levels rise and mental growth slows in socially isolated children. Children and adolescents should be monitored by health professionals during and after the COVID-19 pandemic to ensure that their mental and physical health needs are met.

APPLICATIONS OF THREE DIMENSIONAL FACIAL COMPUTED TOMOGRAPHY IN HEAD AND NECK REGION - A REVIEW

3D facial CT has evolved and revolutionized diagnosis leading to better management. The limitations of conventional 2D methods limit the therapeutic options related to leading to an erroneous treatment. Although 3D facial CT is expensive, its advantages outweigh the cons. They are used in surgery, prosthetic replacement, orthodontics and forensics.

IMPLICATION OF THREAT FACTORS AND PREEXISTING DISORDERS IN DIFFERENT ISCHEMIC STROKE SUBGROUPS IN ELDERLY PEOPLE: A SYSTEMATIC STUDY

Ischemic stroke is a major health issue, especially for the older population and it may have severe effects. Stroke diagnosis and treatment have advanced over the last 20 years, which has resulted in considerable reductions in death, long-term impairment, and the need for institutional care. Younger age groups have seen the majority of trials for acute, interventional, and preventive therapy. The purpose of this research was to identify distinct subgroups of older people who had suffered an ischemic stroke and examine the role that risk factors and previous illnesses played in their development. Ischemic stroke risk factors varied by age, gender and exhibited their own unique features. Smoking, cholesterol, and psychological/emotional stress were shown to have the greatest prevalence (p<0.06) among stroke patients aged 45-60. Smoking is associated with a significant (p<0.07) decline in health in elderly people. Our results imply that there are significant patterns of risk factors and preexisting illnesses among the various subgroups of older people who have had an ischemic stroke. Atherosclerotic (large-artery) and cardio embolic (small-artery) ischemic strokes were shown to be the most prevalent among the elderly. Strong associations were found between these subtypes and other risk factors, including higher cholesterol, diabetes, high blood pressure, and atrial fibrillation. This research emphasizes the need for individualized preventative methods and therapeutic therapy, as well as the need to recognize the variability of ischemic stroke in the elderly.

EARLY IMPLANT OUTCOMES IN ADULTS WITH DENTAL DECAY TREATED WITH PHOTODYNAMIC TREATMENT

A fast implant is a kind of implant to place in the cavity right away after dental extraction. These implants are shown to maintain cervical marrow and reduce the number of surgery operations required for patients. The Photodynamic treatment (PDT) uses antimicrobial processes to supplement nonsurgical periodontal therapy. Combined through the scaling and root planning (SRP), and PDT is more effective. This study aims to assess the effects of PDT on initial findings with dental implants (DI) placed in patients having gum disease with SRP against patients who do not at the 12-month follow-up point. An aggregate of 25 implants were inserted in 16 patients, 12 of whom were in the test group (TG) and 13 of whom were in the control group (CG). SRP is conducted toward rapid implant assignment in the control site, while PDT as an adjunct to SRP (SRP + PDT) is executed prior to instant implant insertion in test sites. At the beginning, 4 months, 8 months, and 12 months, gingival index, radiovisiographs, inquiring pocket intensity, clinical attachment level, and plaque index were obtained. Basic durability was assessed after implant insertion, and the recovery index was measured a week later. In this analysis, Analysis of Variance (ANOVA) technique is used to predict tooth decay earlier. The CG experienced 1.10 mm of mean marginal bone loss after the 12-month research period, compared to 0.97 mm for the (SRP + PDT) group. After reaching the CG and TG, the differences in plaque score and probe depth were noteworthy. Clinical indicators compared to the basis in a year revealed unquestionable improvement, including the probing depth gingival index, plaque index and clinical attachment level. Twelve months were spent monitoring the implants in both groups. The little bone loss improved, although it isn't clinically important. The endurance rate for rapid implants in the PDT grouping is the same as that of the group that underwent SRP. The impact of PTD is utilized as a supplement to SRP. Yet, the consequence is marginal. Because of the improved results with PDT, it is used successfully as an addition to SRP.

Radiation Therapy Sensitizes Head-and-Neck Cancer Cells to Killing by Chimeric Antigen Receptor (CAR)-NK Cells Targeting CD70

PURPOSE/OBJECTIVE(S)

CAR-T cell therapy is limited by toxicity, high cost, logistical manufacturing issues in the autologous setting and risk of GVHD in the allogeneic setting. Substitution of T cells with NK cells opens the possibility for an allogeneic off-the-shelf product with a better safety profile. However, the inadequate efficacy of CAR-NK cells against solid tumors can be extrapolated from experience with CAR-T cells. There is limited but promising preclinical evidence that radiation therapy (RT) enhances CAR-T cell tumoricidal activity against solid tumors. However, there is no data examining the potential synergy between RT and CAR-NK cell therapy.

MATERIALS/METHODS

We engineered CAR-NK cells with CD27 receptor as extracellular domain to target its natural ligand CD70, which is overexpressed in head-and-neck cancers (HNSCC). CAR-NK cell killing was assessed real-time through xCELLigence cytotoxicity assays. CD70+ OQ01 human HNSCCs were used for most experiments. FaDu is a CD70- HNSCC (negative ctrl). UMRC3 is a CD70+ kidney cancer cell line (positive ctrl). CD70 expression pre- and post-RT was assessed by flow cytometry and Western blot. Ionizing RT was compared at 5 doses: 0, 1.75, 3.5, 7, and 14 Gy. A single dose of 3.5 Gy was used for most experiments. Post-radiation effects were generally assessed at 3 days or 9 days post-RT. Intracellular staining was used to assess NK cell expression of IFN-γ, CD107a, and TNF-α by flow cytometry. CD27/CD70 interaction blockade was through α-CD27 pre-treatment of CAR-NK cells.

RESULTS

OQ01 HNSCCs heterogeneously express CD70 and are killed by CD70 CAR-NK cells in vitro. Pre-conditioning low-dose RT of 3.5 Gy applied to OQ01 HNSCCs 3 days prior to coculture with NK cells enhances CD70 CAR-NK cell killing, with ∼30% increased cytotoxicity against the tumor cells. Low-dose RT by itself did not induce acute cytolysis. As a possible mechanism for the increased sensitivity of irradiated OQ01 cells to CD70 CAR-NK cells, we found that RT enhances CD70 expression among HNSCCs in a dose-dependent manner. There was no increase in NK cell expression of IFN-γ, CD107a, and TNF-α with exposure to irradiated target cells. CD27/CD70 blockade does not solely abrogate RT-induced sensitization toward CAR-NK cell killing. Despite RT induction of transient increased expression of CD70, which normalizes by 9 days post-RT, there is persistent increase in RT-synergized target cell killing even at this later timepoint. Thus, altogether, RT sensitizes CD70-expressing HNSCC cells to CAR-NK cell killing in vitro.

CONCLUSION

This work represents the first preclinical study to identify the synergy of RT and CAR-NK cell therapy in solid tumors and is the first demonstration of CAR-NK cell activity against human HNSCCs. We show significantly enhanced potency of CAR-NK cells against irradiated tumor cells in vitro. Collectively, this research will be vital to guide efforts expanding into other target antigens and tumor types.

UNDERSTANDING THE VITAL DETERMINANTS SHAPING LEARNERS' PHYSICAL ACTIVITYAND PSYCHOEMOTIONAL WELLBEING IN THE COVID-19 PERIOD

The Corona Virus (COV-19) epidemic significantly affected the educational environment, requiring a quick transition to distance and blended learning methods. This extraordinary disruption had an incredible impact on pupil's levels of physical activity (PA), psycho-emotional health (PEH) and engagement with academic material. The research aims to examine the vital determinants that influenced various areas of learners' lives during CoV-19. The purpose of this 600-person study was to collect data on the subjects' overall health and PA levels for the CoV-19 pandemic. The SPSS application was used to process the questionnaire's collected data. The information given reveals the respondents' degree of PA throughout the quarantine. According to the breakdown, 15% indicated low levels of PA, 39% reported medium levels and 46% reported high levels. The data show that, despite the respondents' different levels of PA, little PA predominated for most of them. The limitations of distance learning throughout quarantine and the prevalent recommendation of leaving residence for necessary reasons were blamed for this tendency. There were fewer prospects for higher-intensity PA due to these circumstances.

AN INCREASED RISK OF HORMONAL DISORDERS, PRIMARILY DIABETES, IN INDIVIDUALS WITH Β -THALASSEMIA MAJOR: A RETROSPECTIVE ANALYSIS

β-Thalassemia major is an inherited blood condition marked by a serious anemia and a lifetime need for blood transfusions. The effects of β-thalassemia major on endocrine health, notably the risk of diabetes, remain largely unstudied, despite the fact that its haematological components are established. The purpose of this systematic analysis was to examine the incidence of reduced metabolism of glucose in β--thalassemia major. The articles were under the inclusion requirements, after which the data was retrieved. The main outcome was determined to be every prevalence (P) of DM (diabetes mellitus) in β-thalassemia major. In order to examine the percentage of aberrant glucose metabolism (GM) with individuals among β-thalassemia major, the P with the 95% CI (Confidence Interval) was utilized. In this retrospective investigation, we looked at a cohort of people with β-thalassemia major diagnoses to determine the incidence and risk of hormonal diseases, particularly diabetes. A specialist thalassemia facility treated 315 individuals with β-thalassemia major, and their medical records were examined. Age, gender, age at which a main diagnosis of β-thalassemia was made, the length of transfusion treatment, and concomitant diseases were gathered as part of the demographic and clinical data. Our research, which included 17 studies and 1500 cases altogether, showed that with β -thalassemia major had a considerably greater frequency of diabetes than people in general. With a mean beginning age of 30 years, diabetes was identified in 28% of the research cohort's participants. The combined meta-analysis showed that each year had a rather stable level of DM P in β-thalassemia major. In people with major β-thalassemia, the P of impaired fasting glucose (IFG), DM, and impaired glucose tolerance (IGT) was 17.22% (95% CI: 8.44%-26.02%), (6.57 (95% CI: 5.31%- 7.79%) and 12.47 % (95% CI: 5.97%-18.95%), respectively. Our research suggests that people with β-thalassemia major have a high chance of acquiring diabetes, particularly if they get extended transfusion treatment. For prompt diagnosis and care, early detection of diabetes and other hormonal problems in this group is crucial. In β-thalassemia major, there is a high frequency of endocrine problems, including improper GM. To stop growth and endocrine issues, treatment and preventative measures can be required.

EXPLORING CLINICAL VARIATIONS AND CO-MORBID TRENDS IN PD-MCI GROUPS

Parkinson's Disease in Mild Cognitive Impairment (PD-MCI) is a complex condition characterized by a variety of cognitive problems that coexist with the physical symptoms of Parkinson's disease (PD). This study aims to examine the different medical indicators and associated tendencies among different PD-MCI groups. We investigated 132 people who had been given PD-MCI diagnoses. Utilizing SPSS, statistical evaluations are carried out. In overall PD-MCI variants, this investigation found that visuospatial ability and attentional/executive performance are the most impaired cognitive areas. It was also noticed that distinct PD-MCI groups had variances in their neurological characteristics, in multi domain amnesia (Non-Memory) PD-MCI patients exhibiting especially severe issues with unstable posture and walking. The intricacy of PD- Mild Cognitive Impairment (MCI) is highlighted by those results, which also imply that the interplay between mental and physical signs may be controlled by a number of interrelated factors, such as particular cognitive areas, brain surfaces, and the general level of cognitive impairment.

Mortality in Two Waves of COVID-19: A Comparative Analysis of a Tertiary Care Hospital in India

Background COVID-19 has spread as two distinct surges of cases in many countries. Several countries have reported differences in disease severity and mortality in the two waves. Objective Compare the in-hospital mortality in the two COVID-19 waves at a tertiary care hospital in India. Methods We conducted a retrospective data collection. Distinct periods of surges in cases and admissions were defined as the first wave spanning from March 2020 to December 2020 and the second wave from April 2021 to June 21, 2021. The primary outcome of this study was to compare mortality rates in terms of total hospital mortality rate (TMR) and case fatality rate (CFR). Results Mortality rates of wave 2 were approximately 10 times that of wave 1 (TMR of 20.3% in wave 2 versus 2.4% in wave 1 and CFR of 1.5% versus 17.7% in wave 1 and 2, respectively). Mortalities in wave 2 had a larger proportion of severe disease at presentation, faster progression of symptoms to death, and more patients without any chronic comorbid condition dying due to the direct effect of COVID-19 acute respiratory distress syndrome (ARDS). Conclusion Our data matches the worldwide reported pooled hospital mortality figures and shows the comparative difference in disease severity between the two waves.

The Transportation of Maxwell Fluid in the Rotating and Stretching System: Rotor-Stator Spinning Disc Reactor Applications

We have developed a mathematical model and obtained a numerical solution for the motion of a non-Newtonian Maxwell fluid between two disks having rotation and stretching velocity with convective boundary constraints, porous medium and thermal radiation. The present Maxwell fluid flow model with specified boundary constraints is not discussed so far. The proposed model has a lot of applications in electrical power generation, nuclear energy plants, astrophysical flows, space vehicles, geothermal extractions, and spinning disc reactor. The Von Karman similarity approach is used for the solution and validation of the solution is also provided. The solution is obtained numerically with finite difference method (FDM) based ND-solve command in Mathematica software. The effects of magnetic field, porous medium, radiation parameter, Deborah number, Prandtl number, and Reynolds number on skin friction, heat transfer, flow and temperature fields are discussed in detail. Due to the significant void fraction in the medium, porosity parameter shows unique trend compared to other parameters for the radial velocity profile. It has tendency to enhance the radial velocity near both the disc but in the middle part of system, porosity parameter retards radial velocity significantly.

Marching Ahead through the Pandemic: Continuing Anesthesia Services in COVID Era—Our Experience from a Tertiary Care Cancer Centre

Introduction This paper aims to provide an overview of the administrative and clinical preparations done in a tertiary care cancer hospital in continuing operation theatre (OT) services through the COVID pandemic.

Methods Retrospective data collection, data for the past 1.5 years (COVID period) March 2020 to August 2021 were compared to surgical output for a similar duration of time before the COVID era (September 2018–February 2020).

Results A total of 1,022 surgeries were done under anesthesia in the COVID period as against 1,710 surgeries done in a similar time frame in the pre-COVID era. Overall, we saw a 40%drop in the total number of cases. Thorax, abdominal, and miscellaneous surgeries (soft tissue sarcomas, urology, and gyneconcology) saw a maximum fall in numbers; however, head and neck cases saw an increase in numbers during the pandemic. Surgical morbidity and mortality were similar in the COVID and pre-COVID era. No cases of severe COVID infection were reported among the healthcare staff working in OT.

Discussion We could successfully continue our anesthesia services with minimal risk to healthcare staff throughout the pandemic by adopting major guidelines in a pragmatic and practical approach with minor changes to suit our setup.

Evaluation of gingival displacement, bleeding and ease of application for polytetrafluoroethylene (PTFE) and conventional retraction cord - a clinical trial

OBJECTIVE

Conventional use of retraction cord in soft tissue management is effective only when the non-resilient nature of material does not jeopardize gingival health. Therefore this study aims to clinically evaluate the gingival displacement, ease of application and bleeding from polytetrafluoroethylene (PTFE) retraction cord.

PATIENTS AND METHODS

This study is a single-center, parallel-group, randomized controlled clinical trial (1:1). Sixty patients indicated for full coverage metal-ceramic restoration for first molars were enrolled and randomly allocated to experimental (PTFE Cord) and control (conventional plain retraction cord) groups. After crown preparation and isolation, a pre-displacement impression was made. Assigned gingival displacement material was applied for 5 minutes, followed by post-displacement impression. Casts were prepared and used for assessment of mean horizontal gingival displacement by measuring displacement using a stereomicroscope (20 x). Post-displacement gingival bleeding and ease of application were also assessed clinically. t-test and Chi-square tests were used for statistical assessment of gingival displacement, gingival bleeding and ease of application.

RESULTS

Gingival displacement, bleeding and ease of application were similar among study groups (p > 0.05). Mean gingival displacement in the experimental group was 197.1 µm, and 167.7 µm in the control group. Bleeding was observed in 30% and 20% of cases of experimental and control group, respectively. Ease of application was 'difficult' in 53.3% and 43.3% of cases of experimental and control group, respectively. Non-impregnated gingival retraction cord and PTFE cord displayed similar outcomes of gingival displacement, ease of placement and bleeding after cord removal.

CONCLUSIONS

Post-displacement bleeding and discomfort for PTFE cord placement suggest that this technique needs improvement. Therefore further studies are warranted to improve and investigate the physical and biological response to PTFE retraction cord.

How should we secure the cystic duct during laparoscopic cholecystectomy? A UK-wide survey of clinical practice and systematic review of the literature with meta-analysis

INTRODUCTION

It is currently unknown which method of cystic duct closure is most effective at reducing the risk of bile leak after laparoscopic cholecystectomy. The aims of this work were to determine the most common closure methods used in the UK and review available evidence on which method has the lowest risk of bile leak.

METHODS

We conducted an online survey through the Association of Upper Gastrointestinal Surgeons (AUGIS). We also undertook a systematic review using PubMed, EMBASE, MEDLINE and the Cochrane Library for studies that compared different methods for cystic duct occlusion and reported postoperative bile leak.

FINDINGS

There was significant variation in practice between consultant surgeons. For routine laparoscopic cholecystectomy metal clips were used most (64%) followed by locking polymer clips (33%) and suture ties (3%). In cases of a dilated cystic duct, preferences were locking polymer clips (60%), suture ties (30%) and metal clips (5%). We included six studies in our review with a total of 8,011 patients. Metal clips were associated with an increased odds of bile leak compared with locking polymer clips (OR 5.66, 95% CI 1.13-28.41, p=0.04) or suture ties (OR 4.17, 95% CI 0.72-24.31, p=0.12). Most studies were retrospective, unlikely to be adequately powered, and vulnerable to selection bias.

CONCLUSIONS

Limited available evidence suggests that metal clips have the highest risk of bile leak, but results are not strong enough to recommend a change in current clinical practice. A trial is now required to determine the best method of cystic duct closure.

Imaging Breast Microcalcifications Using Dark-Field Signal in Propagation-Based Phase-Contrast Tomography

Breast microcalcifications are an important primary radiological indicator of breast cancer. However, microcalcification classification and diagnosis may be still challenging for radiologists due to limitations of the standard 2D mammography technique, including spatial and contrast resolution. In this study, we propose an approach to improve the detection of microcalcifications in propagation-based phase-contrast X-ray computed tomography of breast tissues. Five fresh mastectomies containing microcalcifications were scanned at different X-ray energies and radiation doses using synchrotron radiation. Both bright-field (i.e. conventional phase-retrieved images) and dark-field images were extracted from the same data sets using different image processing methods. A quantitative analysis was performed in terms of visibility and contrast-to-noise ratio of microcalcifications. The results show that while the signal-to-noise and the contrast-to-noise ratios are lower, the visibility of the microcalcifications is more than two times higher in the dark-field images compared to the bright-field images. Dark-field images have also provided more accurate information about the size and shape of the microcalcifications.

The Effectiveness of SARS-CoV-2 Vaccination in Preventing Severe Illness and Death - Real-world Data from a Cohort of Patients Hospitalized with COVID-19

Background

While long-term studies on the correlates of protection, vaccine effectiveness, and enhanced surveillance are awaited for SARS-CoV-2 vaccine, studies on breakthrough infections help understand the nature and course of this illness among vaccinated individuals and guide in public health preparedness. This study aims to compare the differences in the hospitalization outcomes SARS-CoV-2 infection of fully vaccinated individuals with with those of unvaccinated and partially vaccinated individuals.

Materials and Methods

Single institution observational cohort study. This study compared the differences in clinical, biochemical parameters and the hospitalization outcomes of 53 fully vaccinated individuals with those of unvaccinated (1464) and partially vaccinated (231) individuals, among a cohort of 2,080 individuals hospitalized with SARS-CoV-2 infection. Descriptive statistics and propensity-score weighted multivariate logistic regression analysis adjusting for clinical and laboratory parameters were used to compare the differences and to identify factors associated with outcomes.

Results

Completing the course of vaccination protected individuals from developing severe COVID-19 as evidenced by lower proportions of those with hypoxia, abnormal levels of inflammatory markers, requiring ventilatory support, and death compared to unvaccinated and partially vaccinated individuals. There were no differences in these outcomes among patients who received either vaccine type approved in India.

Conclusions

Efforts should be made to improve the vaccination rates as a timely measure to prepare for the upcoming waves of this highly transmissible pandemic. Vaccination rates of the communities may also guide in the planning of the health needs and appropriate use of medical resources.

DFV890: a new oral NLRP3 inhibitor—tested in an early phase 2a randomised clinical trial in patients with COVID-19 pneumonia and impaired respiratory function

Background

Coronavirus-associated acute respiratory distress syndrome (CARDS) has limited effective therapy to date. NLRP3 inflammasome activation induced by SARS-CoV-2 in COVID-19 contributes to cytokine storm.

Methods

This randomised, multinational study enrolled hospitalised patients (18–80 years) with COVID-19-associated pneumonia and impaired respiratory function. Eligible patients were randomised (1:1) via Interactive Response Technology to DFV890 + standard-of-care (SoC) or SoC alone for 14 days. Primary endpoint was APACHE II score at Day 14 or on day-of-discharge (whichever-came-first) with worst-case imputation for death. Other key assessments included clinical status, CRP levels, SARS-CoV-2 detection, other inflammatory markers, in-hospital outcomes, and safety.

Findings

Between May 27, 2020 and December 24, 2020, 143 patients (31 clinical sites, 12 countries) were randomly assigned to DFV890 + SoC (n = 71) or SoC alone (n = 72). Primary endpoint to establish clinical efficacy of DFV890 vs. SoC, based on combined APACHE II score, was not met; LSM (SE), 8·7 (1.06) vs. 8·6 (1.05); p = 0.467. More patients treated with DFV890 vs. SoC showed ≥ 1-level improvement in clinical status (84.3% vs. 73.6% at Day 14), earlier clearance of SARS-CoV-2 (76.4% vs. 57.4% at Day 7), and mechanical ventilation-free survival (85.7% vs. 80.6% through Day 28), and there were fewer fatal events in DFV890 group (8.6% vs. 11.1% through Day 28). DFV890 was well tolerated with no unexpected safety signals.

Interpretation

DFV890 did not meet statistical significance for superiority vs. SoC in primary endpoint of combined APACHE II score at Day 14. However, early SARS-CoV-2 clearance, improved clinical status and in-hospital outcomes, and fewer fatal events occurred with DFV890 vs. SoC, and it may be considered as a protective therapy for CARDS.

Trial registration

ClinicalTrials.gov, NCT04382053.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01904-w.

Outcomes of COVID-19 in Cancer Patients who Developed Acute Kidney Injury During Hospitalization in a Tertiary Care Hospital in India

Background: The development of acute kidney injury (AKI) in patients infected with COVID-19 has been observed to be associated with poor outcomes. Our study aimed to measure the outcomes of COVID-19 in cancer patients who developed AKI during hospitalization and the predictive baseline clinical and laboratory factors associated with the development of AKI. Materials and Methods: This retrospective cohort study was conducted at a COVID hospital that included only cancer patients with COVID-19 infection. Acute kidney injury (AKI) was defined according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria. The demographic, clinical, laboratory and outcomes data were collected from the hospital electronic database and abstracted from the case files. Results: Thirteen (12.8%) of the total 102 cancer patients developed AKI during hospitalization. Out of 13, 11 (84.6%) patients presented with hypoxemia during admission and required oxygen support. Breathlessness [Odds Ratio (OR) (95% CI): 5.8 (1.1-31.3)] or hypoxemia [OR 22.6 (2.6-194.5)] at the time of presentation and requirement of oxygen support [OR 7.5 (1.4-40.5)] were significantly associated with AKI after adjusting for age, gender, vaccination status and comorbidities. Median baseline values of inflammatory markers were significantly higher among those who developed AKI. Out of 102, 27 (26.5%) patients had in-hospital mortality. Mortality was high among those who developed AKI compared to those who didn’t develop AKI (92.3% vs 16.1%, p-value: <0.001). Conclusions: The cancer patients infected by COVID-19 and who developed AKI were more vulnerable to poor outcomes in terms of in-hospital mortality. The patients with severe disease at presentation and higher levels of baseline inflammatory markers CRP, ferritin, and D-Dimer were more susceptible to the development of AKI and in turn, led to a higher risk of in-hospital mortality in these patients. 

Impact of COVID-19 Pandemic on Medical Practices

The COVID-19 pandemic has affected human life in all spheres. However, the medical and health practices seen changed a lot since the arrival of this pandemic. This article describes the positive and negative impact of covid in the medical field. The integration of telehealth needs to be emphasized and positive changes like hand hygiene, wearing a mask, and appropriate social distancing and online interactive learning may be useful in health care practices. Although, the negative effects of the pandemic like ignoring the patients with other comorbidity and deteriorating mental health of HCW must be kept in mind and should be properly addressed.  

Airway management, procedural data, and in-hospital mortality records of patients undergoing surgery for mucormycosis associated with coronavirus disease (COVID-19)

Purpose

Although unexpected airway difficulties are reported in patients with mucormycosis, the literature on airway management in patients with mucormycosis associated with Coronavirus disease is sparse.

Methods

In this retrospective case record review of 57 patients who underwent surgery for mucormycosis associated with coronavirus disease, we aimed to evaluate the demographics, airway management, procedural data, and in-hospital mortality records.

Results

Forty-one (71.9%) patients had a diagnosis of sino-nasal mucormycosis, fourteen (24.6%) patients had a diagnosis of rhino-orbital mucormycosis, and 2 (3.5%) patients had a diagnosis of palatal mucormycosis. A total of 44 (77.2%) patients had co-morbidities. The most common co-morbidities were diabetes mellitus in 42 (73.6%) patients, followed by hypertension in 21 (36.8%) patients, and acute kidney injury in 14 (28.1%) patients. We used the intubation difficulty scale score to assess intubating conditions. Intubation was easy to slightly difficult in 53 (92.9%) patients. In our study, mortality occurred in 7 (12.3%) patients. The median (range) mortality time was 60 (27–74) days. The median (range) time to hospital discharge was 53.5 (10–85) days. The median [interquartile range] age of discharged versus expired patients was 47.5 [41,57.5] versus 64 [47,70] years (P = 0.04), and median (interquartile range) D-dimer levels in discharged versus expired patients was 364 [213, 638] versus 2448 [408,3301] ng/mL (P = 0.03).

Conclusion

In patients undergoing surgery for mucormycosis associated with the coronavirus disease, airway management was easy to slightly difficult in most patients. Perioperative complications can be minimized by taking timely and precautionary measures.

Perioperative anaesthetic management in cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC): a retrospective analysis in a single tertiary care cancer centre

Objectives

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with increased morbidity and mortality. We retrospectively analysed the perioperative anesthetic management in patients undergoing HIPEC surgery.

Methods

After ethics approval, we reviewed the records of patients who underwent CRS/HIPEC from 2015 until 2020. We noted the peritoneal carcinomatosis index (PCI), blood loss, anastomoses done, total amount of fluid given, delta temperature and duration of surgery. These were correlated with the need for postoperative ventilation, length of ICU stay, Clavien–Dindo score and 30 day mortality.

Results

Of the 180 patients reviewed, the majority were women (85%) with a mean age of 48 years who had ovarian tumors (n=114). The total amount of fluid given was associated with an increased length of ICU stay (p=0.008). Prolonged surgery resulted in increased length of ICU stay (p<0.001), need for postoperative ventilation (p=0.006) and a poor Clavien–Dindo score (p=0.039). A high PCI score correlated with increased ICU stay, 30 day mortality (p<0.001), and the need for postoperative ventilation (0.005).

Conclusions

PCI, duration of surgery and blood loss were major predictors of postoperative morbidity. Additionally, the amount of fluid given and delta temperature affected patient outcome and should be individualized to the patient’s needs.

Coalescence of Anderson-localized modes at an exceptional point in 2D random media

In non-Hermitian settings, the particular position at which two eigenstates coalesce in the complex plane under a variation of a physical parameter is called an exceptional point. An open disordered system is a special class of non-Hermitian system, where the degree of scattering directly controls the confinement of the modes. Herein a non-perturbative theory is proposed which describes the evolution of modes when the permittivity distribution of a 2D open dielectric system is modified, thereby facilitating to steer individual eigenstates to such a non-Hermitian degeneracy. The method is used to predict the position of such an exceptional point between two Anderson-localized states in a disordered scattering medium. We observe that the accuracy of the prediction depends on the number of localized states accounted for. Such an exceptional point is experimentally accessible in practically relevant disordered photonic systems.

Silent Hypoxia in Coronavirus disease-2019: Is it more dangerous? -A retrospective cohort study

BACKGROUND

Hypoxia in patients with COVID-19 is one of the strongest predictors of mortality. Silent hypoxia is characterised by the presence of hypoxia without dyspnoea. Silent hypoxia has been shown to affect the outcome in previous studies.

METHODS

This was a retrospective study of a cohort of patients with SARS-CoV-2 infection who were hypoxic at presentation. Clinical, laboratory and treatment parameters in patients with silent hypoxia and dyspnoeic hypoxia were compared. Multivariate logistic regression models were fitted to identify the factors predicting mortality.

RESULTS

Among 2080 patients with COVID-19 admitted to our hospital, 811 patients were hypoxic with SpO₂ <94% at the time of presentation. Among them, 174 (21.45%) did not have dyspnoea since the onset of COVID-19 symptoms. Further, 5.2% of patients were completely asymptomatic for COVID-19 and were found to be hypoxic only on pulse oximetry. The case fatality rate in patients with silent hypoxia was 45.4% as compared to 40.03% in dyspnoeic hypoxic patients (P = 0.202). The odds ratio of death was 1.1 (95% CI: 0.41-2.97) in the patients with silent hypoxia after adjusting for baseline characteristics, laboratory parameters, treatment and in-hospital complications, which did not reach statistical significance (P = 0.851).

CONCLUSION

Silent hypoxia may be the only presenting feature of COVID-19. As the case fatality rate is comparable between silent and dyspnoeic hypoxia, it should be recognised early and treated as aggressively. Because home isolation is recommended in patients with COVID-19, it is essential to use pulse oximetry in the home setting to identify these patients.

COVID-19 Reinfection or Relapse: Case Series

One-time reinfection with SARS-Cov-2 does not warranty of immunity against reinfection due to various possible reasons for this like waning immunity or high viral load or an immunocompromised state. Cases of reinfection have been reported from many countries in the world, here in this case series we are sharing the experience of three cases of reinfection from India. Two of them were old with multiple comorbidities and one is a young patient with no comorbidity. All three-patient got reinfected less than two months.

A Correlation Analysis of Peripheral Oxygen Saturation and Arterial Oxygen Saturation Among COVID-19 Patients

Background and objective It has been observed that peripheral oxygen saturation (SpO2) measured by pulse oximeter is consistently lower than arterial oxygen saturation (SaO2) measured directly by blood gas analysis. In this study, we aimed to evaluate the correlation between SpO2 and SaO2, and SpO2 and partial pressure of oxygen (PaO2), and compare the SpO2/FiO2 (SF) and PaO2/FiO2 (PF) ratios in patients with coronavirus disease 2019 (COVID-19). Methods In this observational study, SpO2 was recorded and arterial blood gas analysis was performed among 70 COVID-19 patients presenting on room air (FiO2 = 0.21). SaO2 and PaO2 were recorded from arterial blood gas analysis. The SF and PF ratios were then calculated. Results The strength of correlations between SpO2 and SaO2, and SpO2 and PaO2, were significant (p<0.001) and moderately positive [Pearson coefficient (r) = 0.68, 0.53]. SpO2 value (85%), i.e., SF ratio (404.7 or below), was the best estimate for mild ARDS (acute respiratory distress syndrome) [PF ratio (300 or below)] with a sensitivity of 80.6% and specificity of 53%. Conclusion A pulse oximeter is a vital tool in the diagnosis and management of COVID-19. In our study, SpO2 was found to have a positive correlation with SaO2 and PaO2 with acceptable sensitivity but low specificity in estimating mild ARDS. Therefore, pulse oximetry can be used as a tool for the early diagnosis of mild COVID-19 ARDS as per the given considerations and clinical correlation.

Analysis of Unsteady Magnetohydrodynamic 3-D Rotating Flow and Transfer of Heat in Carbon Nanotube-Water Nanofluid: An Engineering Application

We have analysed unsteady Magnetohydrodynamic (MHD) 3-D rotating flow of Carbon Nanotube (CNT) water nanofluid past a stretching surface dealing with thermal radiation mechanism of heat transfer and heat source/sink. The mathematical model consists of a system of non-linear coupled Partial Differential Equations (PDEs). Numerical solution is obtained and discussed in detail. The influence of flow dominant parameters on the temperature profiles and flow-field are also discussed in detail using tables and graphs. Results are justified by previously published results in the limiting sense. Various crucial results are obtained, for example, unsteadiness parameter accelerates the fluid velocities in both directions near the sheet and reverse behaviour is noticed away from the sheet. However, fluid rotation causes reduction in primary velocity but it tends to accelerate secondary velocity near the sheet. Insertion of nanoparticle volume fraction intensifies fluid velocity and attenuates fluid temperature. We also found that multi-Walled Carbon Nanotubes (MWCNTs) offer more resistance for primary skin friction and less resistance for secondary skin friction when compared with Single-Walled Carbon Nanotubes (SWCNTs).

Glycated haemoglobin and the risk of postoperative complications in people without diabetes: a prospective population-based study in UK Biobank

Summary

The aim of our study was to clarify the association between glycated haemoglobin (HbA_1c) and postoperative outcomes in people without an existing diagnosis of diabetes. Half a million adults were recruited into the UK Biobank prospective cohort study between March 2006 and October 2010. We divided participants into three groups: no diagnosis of diabetes and HbA_1c < 42 mmol.mol⁻¹; no diagnosis of diabetes and elevated HbA_1c (≥ 42 mmol.mol⁻¹ with no upper limit); and prevalent diabetes (regardless of HbA_1c concentration) at recruitment. We followed up participants by linkage with routinely collected hospital data to determine any surgical procedures undertaken after recruitment and the associated postoperative outcomes. Our main outcome measure was a composite primary outcome of 30‐day major postoperative complications and 90‐day all‐cause mortality. We used logistic regression to estimate the odds of the primary outcome by group. We limited analyses to those who underwent surgery within one year of recruitment (n = 26,653). In a combined effects logistic regression model, participants not known to have diabetes with HbA_1c ≥ 42 mmol.mol⁻¹ had increased odds of the primary outcome (OR [95% CI] 1.43 [1.02–2.02]; p = 0.04), when compared with those without diabetes and HbA_1c < 42 mmol.mol⁻¹. This effect was attenuated and no longer statistically significant in a direct effects model with adjustment for hyperglycaemia‐related comorbidity (OR [95% CI] 1.37 [0.97–1.93]; p = 0.07). Elevated pre‐operative HbA_1c in people without diabetes may be associated with an increased risk of complications, but the association is likely confounded by end‐organ comorbidity. In contrast to previous evidence, our findings suggest that to prevent adverse postoperative outcomes, optimisation of pre‐existing morbidity should take precedence over reducing HbA_1c in people without diabetes.

Comparison between C-MAC and King Vision video laryngoscope (channelled blade) for tracheal intubation in aerosol-prevention intubation box for COVID-19 patients: A manikin-based study

BACKGROUND AND AIMS

The risk of contracting infection while intubating a coronavirus disease 2019 (COVID-19)-positive patient can be reduced by the use of personal protective equipment (PPE), video laryngoscope (VL) and aerosol-preventing intubation box. We compared two VLs (C-MAC and King Vision laryngoscope [KVL]) for ease of intubation and time taken to intubate the manikin using an intubation box.

METHODS

This randomised study involved healthcare workers having experience in using both C-MAC and KVL. After explaining the study and five practice sessions, a total of 63 volunteers were included; 61 participants gave consent and were enroled. The participants were allowed to intubate initially with one VL as per random sequence. Each participant performed three tracheal intubations with each device (C-MAC VL and KVL) on a manikin using an aerosol-prevention box over the head end at the time of intubation.

RESULTS

Time taken, percentage of glottic opening (POGO) score and the number of attempts taken for successful intubation with C-MAC and KVL were comparable in any of the three attempts (P > 0.05). The participants reported more difficulty in using KVL compared to C-MAC, and insertion of laryngoscope blade into the mouth of manikin for intubation was easy in group C-MAC compared to KVL in all three intubations (P < 0.01).

CONCLUSION

C-MAC and KVL take comparable time for successful intubation under COVID-19 simulation conditions. But C-MAC is more user-friendly.

60 Neoadjuvant Imatinib Mesylate – an Ace of Spaces for Surgical Management of an Oesophago-Gastric Junction Gastro-Intestinal Stromal Tumour

Introduction

Oesophageal gastro-intestinal stromal tumours (GISTs) are rare, accounting for less than five percent of all GIST, with the majority of these occurring at the oesophago-gastric junction (OGJ). Due to the anatomical location and size of these tumours at presentation, surgical resection is often a major undertaking.

Neoadjuvant treatment with tyrosine kinase inhibitors, such as Imatinib mesylate, have the potential to downstage such tumours, thereby limiting the extent of subsequent surgical resection. This may therefore reduce any potentially associated morbidity and mortality.

Case Description

We report the case of a 75-year-old gentleman who presented with a large OGJ GIST, which presented with dysphagia. The tumour was deemed too large for local excision due to the risk of compromising the lumen at the OGJ in attempting to obtain a clear resection margin. Given the patient’s co-morbidity, oesophagectomy or total gastrectomy was deemed too major an undertaking. Therefore, endoscopic biopsies were obtained with a view to possible neoadjuvant therapy. These confirmed DOG-1 and Exon-11 mutations, suggesting sensitivity to Imatinib mesylate. A standard dose regime of 400mg daily for a planned 36-month course was commenced. Subsequent imaging showed a substantial decrease in tumour bulk and the decision was made to perform a local excision. A local enucleation procedure was performed, and the patient made a sound recovery.

Post-operative histology of resected tumour showed almost complete tumour regression.

Discussion

This significant response to neoadjuvant Imatinib mesylate therapy demonstrates clear potential for its use in similar cases, where radical resection would cause significant morbidity and risk mortality.

43 The Value of Endoscopic Ultrasound (EUS) in the Investigative Pathway of Acute Idiopathic Pancreatitis (AIP)

Introduction

The British Society of Gastroenterology (BSG) guidelines on the management of acute idiopathic pancreatitis (AIP) state the incidence of idiopathic cases to be no more than 30%. However, before a firm diagnosis of AIP is made, Endoscopic Ultrasound (EUS) may be used to determine occult causes. This approach may help prevent recurrent attacks which may evolve into chronic pancreatitis.

Method

Retrospective analysis over a one-year period of cases of AIP in a tertiary referral centre was performed to see the incidence of AIP and the role of EUS. Patients with an identifiable cause for pancreatitis were excluded, leaving only those who had received a diagnosis of AIP and the diagnostic value of EUS was examined.

Results

Of the 101 patients diagnosed with AIP, 19% (n=19) underwent an EUS successfully. 79% (n=15) had no underlying cause of pancreatitis identified on EUS. In the remaining 21% of cases (n=4), microlithiasis, ductal stones, and pus requiring drainage were common findings. Of these patents, only 1 was referred for surgery. In the patient group with negative findings on EUS, 4% were unaffected, 2% were referred for surgery, 2% died and 7% had recurrent episodes of pancreatitis.

Conclusions

The results of this study show that EUS is a valuable modality in patients with suspected AIP, with a positive diagnostic rate of 21%. Therefore, we propose EUS needs to be included in the investigative pathway of all suspected AIP. Although EUS is a relatively scarce resource, further research is required to establish guidelines for the investigation of suspected AIP.

Clinical features, demography, and predictors of outcomes of SARS-CoV-2 infection at a tertiary care hospital in India: A cohort study

Background:

The “second wave” of the COVID-19 pandemic hit India from early April 2021 to June 2021. We describe the clinical features, treatment trends, and baseline laboratory parameters of a cohort of patients with SARS-CoV-2 infection and their association with the outcome.

Methods:

This was a retrospective cohort study. Multivariate logistic regression models were fitted to identify clinical and biochemical predictors of developing hypoxia, deterioration during the hospital stay, and death.

Results:

A total of 2080 patients were included. The case fatality rate was 19.5%. Among the survivors, the median duration of hospital stay was 8 (5–11) days. Out of 853 (42.3%%) of patients who had COVID-19 acute respiratory distress syndrome at presentation, 340 (39.9%) died. Patients aged >45 years had higher odds of death as compared to the 18–44 years age group. Vaccination reduced the odds of death by 40% (odds ratio [OR] [95% confidence interval [CI]]: 0.6 [0.4–0.9], P = 0.032). Patients with hyper inflammation at baseline as suggested by leukocytosis (OR [95% CI]: 2.1 [1.5–3.1], P < 0.001), raised d-dimer >500 mg/dL (OR [95% CI]: 3.2 [2.2–4.7], P < 0.001), and raised C-reactive peptide >0.5 mg/L (OR [95% CI]: 3.7 [2.2–13], P = 0.037) had higher odds of death. Patients who were admitted in the 2^nd week had lower odds and those admitted in the 3^rd week had higher odds of death.

Conclusion:

This study shows that vaccination status and early admission during the inflammatory phase can change the course of illness of these patients. Improving vaccination rates and early admission of patients with moderate and severe COVID-19 can improve the outcomes.

Country Experience with using the Country Assessment Tool (Lessons learned)

Findings from the CA show that research and data are largely available, but there are several knowledge gaps and we often lack a comprehensive overview. Gaps include longitudinal studies and knowledge of effects of implemented policy and practice. Lack of knowledge-based practice and policy development is a continuous challenge. Furthermore, we identified a lack of coordination of the migration health field, as well as cross-sectional collaboration.

Lessons learned: The CA and the JAHEE has provided a starting point for conversations with national partners, such as the directorate of health, about how we can strengthen the migration and health field in Norway. The CA has been presented and used in national conferences to highlight gaps and initiate collaboration to mitigate these gaps. The CA tool can become the comprehensive overview that we do not have today. While MIPEX covers integration policy, the CA covers broader topics touching on the work carried out in different sectors and levels in society that affect migrant health.

The Country Assessment Tool - process of development and use

The objective of the Country Assessment (CA) is to give an overview of the migration and health field in the partners' countries. Having an overview of the complex migration and health field enables partners to identify entry points for implementing actions to reduce inequities in migrant's health. The Country Assessment (CA) was based on findings from the projects first deliverable “Policy Framework for Action” (PFA). The PFA mapped key international policy documents between 2007 and 2018. We reviewed and extracted a coherent synthesis we called the ‘Road Map'. The synthesis identified six main areas that is covered in the CA tool: 1) Data and research 2) Governance and leadership 3) Intersectoral action 4) Health Service Responsiveness 5) Migrants access to health services 6) vulnerable groups. The Country Assessment template was piloted by two partner countries, Norway and Italy. The template was revised until all partners were satisfied with the range of questions. Partners then filled in readily available information and examples of available data and policy in their country.

Impact of COVID-19 on migrant populations in high-income countries: a systematic review

Background

Migrants in high-income countries (HICs) may have been disproportionately affected by the COVID-19 pandemic, yet the extent to which they are impacted, and their predisposing risk factors, are not clearly understood. We did a systematic review to assess clinical outcomes, indirect health and social impacts, and key risk factors in migrants.

Methods

Our systematic review following PRISMA guidelines (PROSPERO CRD42020222135) identified peer-reviewed and grey literature relating to migrants (foreign-born) and COVID-19 in 82 HICs. Primary outcomes were cases, hospitalisations and deaths from COVID-19 involving migrants; secondary outcomes were indirect health and social impacts and risk factors.

Results

3016 data sources were screened with 158 from 15 countries included in the analysis. We found migrants are at increased risk of SARS-CoV-2 infection and are over-represented among cases (e.g. constituting 42% of cases in Norway [to 27/4/2020], 26% in Denmark [to 7/9/2020], and 32% in Sweden [to 7/5/2020]); some datasets from Europe show migrants may be over-represented in deaths with increased all-cause mortality in migrants in some countries in 2020. Undocumented migrants, migrant health and care workers, and migrants housed in camps have been especially affected, with certain nationality groups disproportionately impacted. Migrants experience a range of risk factors for COVID-19, including high-risk occupations, overcrowded accommodation, and barriers to healthcare including inadequate information, language barriers, and reduced entitlement.

Conclusions

Migrants in HICs are at high risk of COVID-19, with a range of specific risk factors that have not been well-considered in the public health response to date. These data are of immediate relevance to the policy response to the pandemic, with strategies urgently needed to reduce transmission. Migrant populations must also be better considered in national plans for COVID-19 vaccination roll-out.

On behalf of ESGITM

Key messages

Migrants in high-income countries may be disproportionately represented in COVID-19 infections and deaths, with higher levels of many vulnerabilities and risk factors.

Migrants must be better included in all aspects of the pandemic response, including vaccination roll-out.

The Bergen Declaration 2018: Did it drive the Migration Health Agenda forward in Norway?

 

The growing body of migrant health research at all levels focuses around disease burden, risk factors/behaviours and on distal factors but research on policy issues remains limited. Internationally published declarations and recommendations to take the migrant health agenda forward address policy issues. However declarations at country are few and not systematically followed up.

The Bergen Declaration was endorsed at Norway's' First National Conference on Migration Health (2018) by the multi-disciplinary participants. The declaration reflects the ‘upstream' and ‘downstream' areas addressed and discussed at the conference and includes concrete recommendations for key areas. It was widely disseminated, including high-level policy makers. Prior to the second Migration Health Conference (2020), the progress of the recommendations were reviewed. Since 2018, Migrant Integration Policy Index (MIPEX) in Norway from 2015 was updated in 2019 and a Country Assessment as part of the WP7 of Joint Action on Health Equity Europe (JAHEE) was conducted providing the basis to review the recommendations of the Bergen Declaration. In addition, the 2020 Committee conducted a desk review and search to follow up the recommendations. The review revealed that among identified ‘upstream' areas most progress had been made with data collection and research and the least in policy and governance. Among the ‘downstream' areas some progress was observed regarding practise and access to health services. Education and Training had received some attention. The Bergen Declaration reflects the consensus regarding migrant health and recommendations to address these issues in Norway. Monitoring the progress made through data that included policy review revealed progress and gaps. Progress in research, education and practise was evident whereas policy change was not. Policy makers have not paid heed to the Bergen Declaration.

Key messages

The Bergen Declaration was a useful tool for initiating and monitoring progress in research, education and practice. Declarations do not support advancement of policies and other means are required to push the policies forward.

Cardiac output monitoring using transthoracic echocardiography in children after cardiac surgery-an observational study of feasibility and concordance with transpulmonary thermodilution

Background

Transthoracic echocardiography (TTE) is commonly used after pediatric cardiac surgery to monitor cardiac function and adequacy of surgery; however it depends on the availability of good echo window and operator skill [1]. Transpulmonary thermodilution (TPTD) is feasible along with calibrated continuous cardiac output measurement in children but seldom used due to cost and the need for a specialized catheter [2].

We hypothesized that TTE would be as good as TPTD, but limited in feasibility following pediatric cardiac surgery. Hence, the concordance, agreement as well as feasibility and trending of cardiac output monitoring by TTE was compared against a reference TPTD method in real-world usage in children after congenital heart surgery.

Methods

This was a secondary analysis of data from a previously registered and conducted study in our unit. TPTD monitoring was instituted in children undergoing congenital heart disease repair on cardiopulmonary bypass with a 3F femoral arterial cannula and a central venous injectate temperature sensor.

Cardiac output was also measured by transthoracic echocardiography by measurement of the left ventricular outflow tract (LVOT) diameter, LVOT velocity time integral (VTI) and the heart rate as previously described [3,4]. Measurements were taken after arrival in the ICU, and every 12 hours till after extubation. Correlation, Bland-Altman analysis and polar analysis was done for cardiac output measured by TPTD and TTE.

Results

TTE and TPTD measurements of cardiac output correlated well (Pearson's correlation coefficient 0.94; 95% CI 0.90–0.96) (Fig. 1A). Bland Altman analysis showed a mean bias of 0.15 l/min and upper and lower limits of agreement of 0.81 and −0.51 l/min respectively (Fig. 1B). Cardiac output measurement by TTE was possible in 72 instances while TPTD allowed measurement in all 113 instances. Hence, TTE was not feasible in 41 instances across 14 patients, including 19 instances in acyanotic and 22 instances in cyanotic patients. Polar analysis revealed acceptable trending.

Conclusions

TTE derived cardiac output demonstrated good correlation, minimal bias and narrow limits of agreement versus TPTD, and was feasible in most cases. This suggests TTE is an acceptable cardiac output measurement modality post pediatric cardiac surgery, as in adults [5]. TPTD-based continuous cardiac output monitoring might have a complementary role in pediatric cardiac critical care, particularly in high risk cases.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Institutional Special Research Grant from Postgraduate Institute of Medical Education and Research, Chandigarh, India. Figure 1

Clinical Profile and Risk Factors for Severe Disease in 402 Children Hospitalized with SARS-CoV-2 from India: Collaborative Indian Pediatric COVID Study Group

INTRODUCTION

There is a lack of large multicentric studies in children with COVID-19 from developing countries. We aimed to describe the clinical profile and risk factors for severe disease in children hospitalized with COVID-19 from India.

METHODS

In this multicentric retrospective study, we retrieved data related to demographic details, clinical features, including the severity of disease, laboratory investigations and outcome.

RESULTS

We included 402 children with a median (IQR) age of 7 (2-11) years. Fever was the most common symptom, present in 38.2% of children. About 44% had underlying comorbidity. The majority were asymptomatic (144, 35.8%) or mildly symptomatic (219, 54.5%). There were 39 (9.7%) moderate-severe cases and 13 (3.2%) deaths. The laboratory abnormalities included lymphopenia 25.4%, thrombocytopenia 22.1%, transaminitis 26.4%, low total serum protein 34.7%, low serum albumin 37.9% and low alkaline phosphatase 40%. Out of those who were tested, raised inflammatory markers were ferritin 58.9% (56/95), c-reactive protein 33.3% (41/123), procalcitonin 53.5% (46/86) and interleukin-6 (IL-6) 76%. The presence of fever, rash, vomiting, underlying comorbidity, increased total leucocyte count, thrombocytopenia, high urea, low total serum protein and raised c-reactive protein was factors associated with moderate to severe disease.

CONCLUSION

Fever was the commonest symptom. We identified additional laboratory abnormalities, namely lymphopenia, low total serum protein and albumin and low alkaline phosphatase. The majority of the children were asymptomatic or mildly symptomatic. We found high urea and low total serum protein as risk factors for moderate to severe disease for the first time.

COVID-19 Infection in a 13-year-old Heart Transplant Recipient in Immediate Post Transplant Period - A Case Report

Introduction

Experience regarding course and outcome of Covid-19 infection in heart transplant recipients is limited. Case fatality rate of 25% of covid-19 infection in adult recipients of heart transplant and mild and self-limited disease in young heart transplant patients have been reported in small case series. We describe a case where a 13 year old patient contracted covid-19 infection on 7^th post-operative day after undergoing heart transplant and was subsequently discharged from hospital uneventfully.

Case Report

A 13 year old boy, with dilated cardiomyopathy underwent orthotopic heart transplant surgery. In the immediate pre-operative period, the real-time polymerase chain reaction (RTPCR) of nasopharyngeal swabs of both the recipient and the brain-dead organ donor were negative for severe acute respiratory syndrome coronavirus type 2 (SARS CoV 2). The intraoperative and immediate postoperative periods were uneventful. The recipient got weaned off from mechanical ventilation on the 1^st postoperative day and O₂ support was weaned off on 4^th postoperative day. He was put on immunosuppressive regimen consisting of mycophenolate mofetil, tacrolimus and prednisone. On 7^th postoperative day, he complained of fever, sore throat and dry cough. Nasopharyngeal swab for RTPCR was sent. It reported positive for SARS CoV 2. He was shifted to isolation facility. He maintained more than 94% saturation on pulse oximetry in room air. Immunosuppressive regimen was continued. He was administered 5-day course of remdesivir. Inotropic support was weaned off on 10^th postoperative day. On serial bedside echocardiography, the allograft function was found to be normal throughout. He was kept on prophylactic antimicrobial, antifungal and anti-cytomegaloviral therapy and on prophylactic dose of low molecular weight heparin. There was initial rise in neutrophil lymphocyte ratio (17), C reactive protein (58 mg/l), ferritin (871 ng/ml), D-dimer (1904 ng/ml), Troponin T (227 pg/ml) levels, which gradually came down to within normal limits. He was discharged on 38^th postoperative day to a home isolation facility as his RTPCR for SARS CoV 2 was still positive, although he remained completely asymptomatic for the last 21 days.

Summary

The course of Covid-19 infection in the immediate post-transplant period of this young heart transplant recipient was largely uneventful.