Assessment of Sarcopenia Using Muscle Ultrasound in Patients With Cirrhosis and Sarcopenic Obesity (AMUSE STUDY).

BACKGROUND AND AIMS: Sarcopenic obesity (SO) marks a confluence of 2 complex entities involving the muscle-liver-adipose tissue axis. Computed tomographic (CT) scan-derived skeletal muscle index (SMI) remains the gold standard for sarcopenia assessment in SO. However, it has intrinsic limitations of cost, radiation, and point of care applicability. We assessed the role of muscle ultrasound (US) in SO. METHODS: A total of 52 patients with cirrhosis and obesity were assessed for sarcopenia using SMI. US assessment of thigh and forearm muscles was done to record quadriceps muscle thickness (QMT), quadriceps feather index (QMFI), forearm muscle thickness (FMT), and forearm feather index (FFI), respectively. Evaluated US parameters were correlated with SMI and assessed for diagnostic accuracy using the area under the curve. RESULTS: A total of 40 (76.9%) males and 12 (23.1%) females [mean age: 50.9 y (43.8 to 53.5 y)] were included. QMT [0.45 cm/m 2 (0.42 to 0.48 cm/m 2 ) vs. 0.67 cm/m 2 (0.63 to 0.70 cm/m 2 )], QMFI [0.82 cm/m 2 (0.77 to 0.87 cm/m 2 ) vs. 1.12 cm/m 2 (1.06 to 1.19 cm/m 2 )], FMT [0.19 cm/m 2 (0.17 to 0.20 cm/m 2 ) vs. 0.25 cm/m 2 (0.23 to 0.27 cm/m 2 )], and FFI [0.38 cm/m 2 (0.35 to 0.412 cm/m 2 ) vs. 0.47 cm/m 2 (0.44 to 0.50 cm/m 2 )] were significantly lower in patients with SO ( P <0.01). A positive correlation with SMI was seen for all parameters in the entire cohort. The strongest correlation was exhibited by QMT ( r =0.70) and QMFI ( r =0.70) in males. The area under the curve of QMT, QMFI, FMT, and FFI were 0.98 (95% confidence interval: 0.96-1), 0.95 (0.89-1), 0.85 (0.75-0.96), and 0.80 (0.68-0.93), respectively. CONCLUSIONS: US-based assessment of sarcopenia has excellent diagnostic accuracy and correlates well with computed tomography-SMI in patients with SO. US may serve as an easy-to-use, point of care tool for assessing sarcopenia in SO with the advantage of repeated sequential assessment.

A Pilot Study on COVID-19 Positive Subjects: An Excerpt of Post-Infection-Pro-Diabetic Disposition & Related Consequences in Correlation to Hepato-Pancreatic Bio-Markers, Pro-Inflammatory Cytokines and Other Risk Factors.

COVID-19, a global pandemic that led to increased morbidity and mortality worldwide since its outcome at the end of the year 2019. A newly discovered variant of severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2) was the arbitrator for spreading the syndrome by droplet transmission causing multi-organ failure in many occasions. A post-infection-pro-diabetic disposition was found evident in this study with the persistence of hepato-pancreatic aberrations in respect of reference range of tissue specific bio-markers in hospital admitted COVID-19 cases. The results of this study show that hyperglycemia is a risk factor in precipitating disease oriented complications to the patients with COVID-19 disease. A post-infection follow- up on glycemic-index and related complexities is a vital need to the COVID-19 infected convalescent subjects. Implementation of guidelines on social measure and awareness of anti-viral interventions may be the only way to prevent COVID-19 transmission.

A Pilot Study on Blood Components in COVID-19 Affected Subjects: A Correlation to UPR Signalling and ER-Stress.

Abstract: The endoplasmic reticulum (ER) is the site for protein synthesis, its folding and secretion. An intricate set of signalling pathways, called UPR pathways, have been evolved by ER in mammalian cells, to allow the cell to respond the presence of misfolded proteins within the ER. Breaching of these signalling systems by disease oriented accumulation of unfolded proteins may develop cellular stress. The aim of this study is to explore whether COVID-19 infection is responsible for developing this kind of endoplasmic reticulum related stress (ER-stress). ER-stress was evaluated by checking the expression of ER-stress markers e.g. PERK (adapting) and TRAF2 (alarming). ER-stress was correlated to several blood parameters viz. IgG, pro- and anti-inflammatory cytokines, leukocytes, lymphocytes, RBC, haemoglobin and PaO2/FiO2 ratio (ratio of arterial oxygen partial pressure to fractional inspired oxygen) in COVID-19 affected subjects. COVID-19 infection was found to be a state of protein homeostasis (proteostasis) collapse. Changes in IgG levels showed very poor immune response by the infected subjects. At the initial phase of the disease, pro-inflammatory cytokine levels were high and anti-inflammatory cytokines levels were low; though they were partly compromised at later phase of the disease. Total leukocyte concentration increased over the period of time; while percentage of lymphocytes were dropped. No significant changes were observed in cases of RBC counts and haemoglobin (Hb) levels. Both RBC and Hb were maintained at their normal range. In mildly stressed group, PaO2/FiO2 ratio (oxygenation status) was in the higher side of normal range; whereas in other two groups the ratio was in respiratory distress syndrome mode. Virus could induce mild to severe ER-stress, which could be the cause of cellular death and systemic dysfunction introducing fatal consequences. Graphical Abstract: Schematic representation of SARS-CoV-2 infection and related consequences.

POEMS Syndrome: Clinical and Laboratory Approach Towards Diagnosis.

Polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes (POEMS) syndrome is a rare multisystem paraneoplastic disorder. Here we describe a case of a 50 year old post-menopausal female who presented with chief complaints of difficulty in walking, getting up from squatting position and tingling sensation of bilateral lower limbs since 1 month. Additional unusual features in the patient included hepatosplenomegaly, endocrinal involvement in the form of hypothyroidism and elevated estradiol levels for her age. There were skin changes in the form of hyperpigmentation. M protein was not noted on serum electrophoresis but was visible on serum protein immunofixation (IgA lambda). She was investigated as a case of polyneuropathy and later a provisional clinical diagnosis of POEMS was made based on the presence of major and minor criteria. The patient was managed with methyl prednisolone, calcium carbonate and vit D3 and topical antibiotics for local infections.

Percutaneous transthoracic embolisation for massive haemoptysis secondary to peripheral pulmonary artery pseudoaneurysms.

OBJECTIVE: Pulmonary artery pseudoaneurysms (PAPs) are rare, but important and treatable cause of massive haemoptysis. Minimal data exists on their interventional radiology management due to their rarity, especially direct percutaneous injection. Here, we report our experience of direct percutaneous management of such pseudoaneurysms. METHODS: Data of patients presenting to our department from January 2014 to November 2019 was retrospectively analysed, who presented with massive haemoptysis, and CT angiography positive for pulmonary artery pseudoaneurysms. Only patients treated with direct percutaneous intervention were included. Twelve patients who were managed endovascularly were excluded from the study. Observations were tabulated under age, sex, underlying pathology, lobe involved, number and size of the pseudoaneurysm, imaging guidance and embolising agent. Technical and clinical success and complications were then analysed. RESULTS: Twenty-nine pseudoaneurysms were treated in 27 patients with a mean age of 41.4 years. The most common underlying aetiology was tuberculosis (85.1%), with the most common location being bilateral upper lobes (31% each). CT guidance was the most frequently used imaging guidance (26/29). N-butyl cyanoacrylate (NBCA) glue mixture was used in 79.3% and reconstituted thrombin in the remaining 20.7% pseudoaneurysms. Complete technical and clinical success rates were 93.1% and 88.9% respectively. No major complications were seen except for development of significant pneumothorax in one patient. CONCLUSION: Pulmonary pseudoaneurysms are rare but fatal cause for massive haemoptysis. Interventional radiology management via direct percutaneous embolisation is a safe and minimally invasive treatment measure in selective patients, with successful outcomes and minimal complication and recurrence rates. KEY POINTS: • Pulmonary artery pseudoaneurysms are rare but important and treatable cause of massive haemoptysis. • This study shows the advantages of percutaneous management of these pseudoaneurysms as an alternate to endovascular embolisation, in case endovascular embolisation is not feasible or practical. • It is a safe and minimally invasive treatment, with technical success of 93.1% and clinical success of 88.9% in this study.

Diagnostic accuracy of Liver Imaging Reporting and Data System locoregional treatment response criteria: a systematic review and meta-analysis.

OBJECTIVE: There is increasing adoption of Liver Imaging Reporting and Data System (LI-RADS) treatment response (LR-TR) criteria. However, there is still a relative lack of evidence evaluating the performance of these criteria. We performed this study to assess the diagnostic accuracy of LI-RADS LR-TR criteria. METHODS: A thorough search of PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials for studies reporting diagnostic accuracy of LI-RADS LR-TR criteria was conducted through 30 June 2020. The meta-analytic summary of sensitivity, specificity, and diagnostic odds ratio of LI-RADS LR-TR criteria was computed using explant histopathology as the reference standard. The quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. RESULTS: Four studies were found eligible for meta-analysis. The total number of LR-TR observations was 462 (240 patients, 82.5% males). Different locoregional therapies (LRTs), including bland embolization, chemoembolization, radiofrequency ablation, and microwave ablation, had been used. The mean time interval between LRT and liver transplantation ranged from 181 to 219 days. There was a moderate to good inter-reader agreement for LR-TR criteria. The pooled sensitivity and specificity of LR-TR criteria for viable disease were 62% (95% CI, 49-74%; I2 = 69%) and 87% (95% CI, 76-93%; I2 = 57%), respectively. The pooled diagnostic odds ratio and area under the curve were 9.83 (95% CI, 5.34-18.08; I2 = 19%) and 0.80. CONCLUSIONS: LI-RADS LR-TR criteria have acceptable diagnostic performance for the diagnosis of viable tumor after LRT. Well-designed prospective studies evaluating criteria of equivocal lesions and effect of different LRTs should be performed. KEY POINTS: • The pooled sensitivity and specificity of LI-RADS LR-TR criteria for the diagnosis of viable tumor were 62% and 87%, respectively. • The pooled diagnostic odds ratio and area under the curve were 9.83 and 0.80. • LR-TR criteria had a moderate to good inter-reader agreement.

Larger bore percutaneous catheter in necrotic pancreatic fluid collection is associated with better outcomes.

OBJECTIVE: To evaluate the impact of initial catheter size on the clinical outcomes in acute pancreatitis (AP). METHODS: This retrospective study comprised consecutive patients with AP who underwent percutaneous catheter drainage (PCD) between January 2018 and May 2019. Three hundred fifteen consecutive patients underwent PCD during the study period. Based on the initial catheter size, patients were divided into group I (≤ 12 F) and group II (> 12 F). The differences in the clinical outcomes between the two groups, as well as multiple subgroups (based on the severity, timing of drainage, and presence of organ failure (OF)), were evaluated. RESULTS: One hundred forty-six patients (mean age, 41.2 years, 114 males) fulfilled the inclusion criteria. Ninety-nine (67.8%) patients had severe AP based on revised Atlanta classification. The mean pain to PCD was 22 days (range, 3-267 days). Mean length of hospitalization (LOH) was 27.9 ± 15.8 days. Necrosectomy was performed in 20.5% of patients, and mortality was 16.4%. Group I and II comprised 74 and 72 patients, respectively. There was no significant difference in baseline characteristics, except for a greater number of patients with OF in group II (p = 0.048). The intensive care unit stay was significantly shorter, and multiple readmissions were less frequent in group II (p = 0.037 and 0.013, respectively). Patients with severe AP and moderately severe AP in group II had significantly reduced rates of readmissions (p = 0.035) and significantly shorter LOH (p = 0.041), respectively. CONCLUSION: Large-sized catheters were associated with better clinical outcomes regardless of disease severity and other baseline disease characteristics. KEY POINTS: • Larger catheter size for initial PCD was associated with better clinical outcomes in AP. • The benefits were independent of the severity of AP, timing of PCD (ANC vs. WON) and presence of organ failure.

Interventional radiology management of extremity pseudoaneurysms: a pictorial essay.

Pseudoaneurysms are vascular abnormalities caused by a damaging force on an arterial wall, resulting in a persistent extravasation of blood into the surrounding tissue, which can be the result of infection, inflammation, trauma or any iatrogenic procedure. The incidence of extremity artery pseudoaneurysms is rising because of increased number of endovascular procedures. As a number of complications are associated with these false aneurysms, it is important to know the treatment modalities available. Ultrasound is the most common method of diagnosing extremity pseudoaneurysm because of their superficial location. Computed tomographic angiography is the next investigation of choice as it has three-dimensional capability and can help evaluate the vascular bed. Digital subtraction angiography is rarely used for diagnosis alone, and is used only when a therapeutic procedure is planned. Treatment of these pseudoaneurysms has shifted from open surgical procedures to minimally invasive treatment in recent years. The different techniques for tackling these lesions include ultrasound-guided compression, percutaneous thrombin or glue embolisation and endovascular coil or stent graft placement. In this pictorial essay, we review the different treatment modalities so that an interventional radiologist is aware of all the treatments he can offer when confronted with these lesions.

Screening of the Leaf Extracts of Culinary Herbs (Apium graveolens, Petroselinum crispum, Cichorium endivia, and Anethum graveolens) for Their Antibacterial Activity Against Escherichia coli.

INTRODUCTION: In the current era, infectious diseases pose a significant global challenge, primarily attributed to the widespread and prolonged use of antibiotics, which develop antimicrobial resistance. A significant proportion of pharmaceutical agents utilized globally can be traced back to plant origins, constituting approximately 25%. Medicinal applications harness a wide spectrum of plant-derived components, including flowers, leaves, stems, fruits, roots, waxes, oils, bioactive compounds, phytochemicals, and various other constituents. MATERIALS AND METHODS: Our experiment evaluated the antibacterial activity of four different culinary plant leaf extracts. These extracts were prepared using four different solvents and were investigated against the gram-negative bacteria Escherichia coli DH5α using agar well diffusion and agar disc diffusion methods by measuring the zone of inhibition. RESULTS: The aqueous extract of all leaves did not show any antibacterial activity, likely due to poor diffusion due to the formation of a precipitate. Conversely, Cichorium endivia has shown the highest antibacterial activity in isopropanol as compared to other herbs. Among the herbs examined, organic extracts from endives and soybeans have demonstrated notably strong antibacterial activity compared to the other herbs. CONCLUSION: Conducting a systematic screening of leaf extracts from various culinary herbs to assess their antibacterial effectiveness against E. coli has produced encouraging and noteworthy results. In the investigation of various herbs, organic extracts derived from endives and soybeans have exhibited particularly robust antibacterial efficacy when compared to other herbal extracts.

Lipoprotein Ratios: Correlation With Glycated Hemoglobin (HbA1c) Among Thyroid Disorders' Patients.

INTRODUCTION: Thyroid disorders and diabetes mellitus are prevalent conditions in the modern era. Moreover, glycated hemoglobin (HbA1c) is the established (prognostic as well as diagnostic) marker for long-term glycemic control, whereas the lipid profile is the marker for cardiovascular risks. The association of hypothyroidism with dyslipidemia is also a well-established fact. The current study explores a correlation between thyroid profile, glycemic status, and various lipoprotein indices. OBJECTIVE: To look for an association between thyroid profile, glycemic status, and various lipoprotein indices. METHODOLOGY: The cross-sectional study conducted at AIIMS Gorakhpur included a total of 108 subjects, with 37 normal subjects (Group I) and 71 patients) with T2DM (Type-2 diabetes mellitus) (Group II). Baseline characteristics of the two groups were compared for age, sex, presence of hypertension, fasting blood glucose, and body mass index (BMI). Blood samples were collected from the patients. The sera were analyzed for HbA1c and lipid profile, which included total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C). Serum samples were also used to estimate the thyroid stimulating hormone (TSH) and triiodothyronine (fT3). The association between thyroid profile, glycemic status, and various lipoprotein indices was calculated. STATISTICAL ANALYSIS:  Kolmogorov-Smirnov test for normality of the data. Spearmann correlation was used for nonparametric data. RESULTS: There were significantly higher levels of total cholesterol, triglycerides, and LDL-C levels in T2DM subjects than in non-diabetic subjects. There was also a significant positive correlation observed between TSH and TC among the normal control group (ρ =0.348, P=0.04). Similarly, significant positive correlations were found for TG (ρ =0.354, P=0.04) and LDL-C (ρ =0.431, P=0.03) among non-diabetic subjects. Among patients with T2DM, TSH was significantly correlated positively with TG (ρ =0.530, P=0.006) and LDL-C (ρ =0.443, P=0.03). Similarly, in the same group, among lipid ratios, TG/HDL-C (ρ =0.311, P=0.04) and LDL-C/HDL-C (ρ =0.227, P=0.05) were significantly correlated to TSH. Furthermore, there were significant positive correlations between TSH and HbA1c (ρ =0.301, P=0.04). fT3 was found to have a strong negative correlation with HbA1c among patients with T2DM (ρ =-0.454, P=0.02). CONCLUSION: Thyroid disorders exert significant effects on glycemic control and lipid metabolism, which may impact HbA1c levels and lipid profile parameters.

Correction: Lipoprotein Ratios: Correlation With Thyroid Profile and Glycated Hemoglobin (HbA1c) Among Diabetes Mellitus Patients.

[This corrects the article DOI: 10.7759/cureus.54191.].

Lipoprotein Ratios: Correlations With Glycated Hemoglobin Among Type 2 Diabetes Mellitus Patients.

Introduction Diabetes mellitus (DM) has become a common disorder in India, and can be even considered as an epidemic in most developing countries. It usually adds a big burden on the economy through its macro and microvascular complications which often require hospitalisation. Glycated hemoglobin (HbA1c) is considered a well-established test to track long-term glycemic control, and hence can be used for both diagnosis and prognosis of disease. On the other hand, lipid profile is a significant marker of cardiovascular risks. Objective To investigate the clinical relevance of lipid profile and correlate with glycemic control in type 2 DM patients. Methodology This observational study used laboratory results (HbA1c and lipid profile) of 140 patients who attended various out-patient departments (OPD) of All India Institute of Medical Sciences (AIIMS), Gorakhpur. On the advice of clinicians, for routine follow-up, blood samples were collected from the patients (aged 20-50 years, 84 males, and 56 females, with a history of more than three years of type 2 DM). The sera were analyzed for HbA1c and lipid profile [which included triglycerides (TG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C)]. Based on HbA1c levels the study subjects were divided into three groups, namely group I (HbA1c <7%, n=14), group II (HbA1c7%-8.5%, n=91), and group III (HbA1c >8.5%, n=35). Correlation studies between HbA1c and parameters of lipid profile were explored in the study. Data generated were checked for normality and correlation studies were accordingly done. Results Elevated levels of HbA1c were associated with a notable parallel increase in LDL-C levels (P<0.05), TG, and TC. There was no notable correlation observed between HbA1c and HDL-C levels. However, as HbA1c levels increased, the TG/HDL-C and LDL-C/HDL-C ratios displayed a gradual rise (P<0.05). Conclusion LDL-C and the LDL-C/HDL-C ratio serve as valuable tools for evaluating and mitigating cardiovascular disease risk and are correlated to glycemic control among individuals with type 2 DM.

Antinuclear antibody (ANA) positivity pattern by line immunoassay in a hospital from eastern India: Update from a laboratory perspective.

Context: The existence of more than one antibody in systemic autoimmune rheumatic diseases (SARDs) or connective tissue disease (CTD) along with features of more than one autoimmune disease (AD) in an individual is suggestive of overlap syndrome (OS). Line immunoassay (LIA) can target many autoantibodies in a single approach, thus making the identification of OS feasible. Aims and Objectives: This study aimed to identify the pattern of distribution of antinuclear antibodies by LIA prevalent in a hospital population in eastern India and identify common forms of SARD in this belt based on laboratory findings. Material and Methods: A total of 1660 samples received for ANA profile testing by LIA were analysed. Statistical Analysis: Factor analysis was performed with factor loading scores used in the k-means algorithm to identify clustering of various autoantibodies. Results: U1-snRNP positivity was the highest at 16.69%, and the least frequent autoantibody noted was anti-Jo-1 at 0.71% positivity. Based on the outcome of factor analysis, three clusters were determined. Cluster 1 showed a predominance of anti-PM/Scl antibodies, cluster 2 showed a predominance of anti-dsDNA, anti-histone, anti-SmD1, anti-nucleosomes, anti-PCNA, anti-Po, anti-SSA/Ro52, anti-SSA-Ro60, anti-SSB/La, anti-Scl-70, anti-Mi-2, anti-Ku and anti-AMA-M2, and cluster 3 showed a predominance of anti-U1-snRNP. Conclusions: Mixed connective tissue disease (MCTD) and overlap syndrome (OS) are prevalent more than pure form of an AD in our study population. OS may be missed out by monospecific immunoassays and hence adds to diagnostic challenges. LIA may be more useful in identifying specific autoantibodies by a single approach rather than monospecific immunoassays in populations after a positive screen by indirect immunofluorescence (IIF).

The Prognostic Value of De Ritis Ratio on the Survival Rate of ICU-Admitted COVID-19 Patients During the Second Wave: A Retrospective Study in a Tertiary Care Hospital in India.

Background Prognostic markers are essential for optimizing COVID-19 patient care. This retrospective study examines the prognostic value of the De Ritis ratio (DRR) in intensive care unit (ICU)-admitted patients during the second wave of the pandemic. Methods A retrospective study of four-month duration (March to June 2021) was conducted on 161 ICU-admitted COVID-19 patients in a tertiary care hospital in India. The data included demographics, comorbidities, laboratory results, ICU admission dates, and survival outcomes. The De Ritis ratio was calculated on day 0, day 2, and day 5. The analyses included descriptive statistics, diagnostic accuracy, and logistic regression. Results Survival rates decreased with ICU stay: day 0 (survival, 58.4%; mortality, 41.6%), day 2 (survival, 54.5%; mortality, 45.5%), and day 5 (survival, 49.5%; mortality, 50.5%). De Ritis ratio's diagnostic accuracy varied, with increasing specificity and negative predictive value (NPV). Logistic regression showed higher day 5 De Ritis ratios, and male gender was associated with reduced survival odds. Conclusion The De Ritis ratio demonstrates promise as an early prognostic marker for COVID-19 patients, with an increase in predictive accuracy over time. The results emphasize the De Ritis ratio's potential as an early indicator of disease severity, offering clinicians a tool to recognize patients at higher risk and enhance the effectiveness of critical care interventions.

Development of Predictive Models Based on Biochemical Parameters to Triage COVID-19 Patients: A Study Conducted in a Tertiary Care Hospital.

Background The COVID-19 disease continues to cause severe mortality and morbidity. Biochemical parameters are being used to predict the severity of the infection. This study aims to predict disease severity and mortality to help reduce mortality through timely intervention in a cost-effective way. Methods A total of 324 COVID-19 cases admitted at our hospital (All India Institute of Medical Sciences, Patna, BR, India) between June 2020 to December 2020 (phase 1: 190 patients) and April 2021 to May 2021 (phase 2: 134 patients) were recruited for this study. Statistical analysis was done using SPSS Statistics version 23 (IBM Corp., Armonk, NY, USA) and model prediction using Python (The Python Software Foundation, Wilmington, DE, USA). Results There were significant differences in biochemical parameters at the time of admission among COVID-19 patients between phases 1 and 2, ICU and non-ICU admissions, and expired and discharged patients. The receiver operating characteristic (ROC) curves predicted mortality solely based on biochemical parameters. Using multiple logistic regression in Python, a total of four models (two each) were developed to predict ICU admission and mortality. A total of 92 out of 96 patients were placed into the correct management category by our model. This model would have allowed us to preserve 17 of the 21 patients we lost. Conclusions We developed predictive models for admission (ICU or non-ICU) and mortality based on biochemical parameters at the time of admission. A predictive model with a significant predictive capability for IL-6 and procalcitonin values using normal biochemical parameters was proposed. Both can be used as machine learning tools to prognosticate the severity of COVID-19 infections. This study is probably the first of its kind to propose triage for admission in the ICU or non-ICU at the medical emergency department during the first presentation for the necessary optimal treatment of COVID-19 based on a predictive model.

Delineation of Lingual Artery as an Additional Organ-At-Risk for Stereotactic Body Radiation Therapy of Head and Neck Cancers.

Lingual artery (LA) stenosis or bleeding can be a potentially fatal consequence of stereotactic body radiation therapy of recurrent head and neck cancer. We aim to provide delineation guidelines for LA contouring during head and neck radiation. Three experienced radiation oncologists and 1 radiologist studied the course of LA and its anatomic relationships. A step-by-step guideline was formulated for its delineation on contrast-enhanced axial computed tomography scans. We recommend that LA should be considered an important organ at risk for stereotactic body radiation therapy of head and neck cancer. Its delineation and dose constraints should be considered on a case-to-case basis.

The second wave of COVID-19 wreaked havoc: A look at clinical and laboratory parameters of survivors and non-survivors admitted to Intensive Care Unit, a single-centered retrospective study.

Background: The second wave of COVID-19 was disastrous and claimed many lives in India and abroad. The most challenging task was to provide the required treatment as per the patient's condition, within a limited span of time. The lack of prognostic predictors at the time of admission led to failure in prioritizing the patient's need for intensive care. Aim: This study was conducted to find out the clinical and laboratory parameters at the time of admission to ICU as predictors of outcomes in COVID-19 patients, which can help in judicious utilization of the available resources for better patient care. Subjects and Methods: Study comprises of 161 ICU admitted patients. Study of clinical traits, comorbidities, test results, and demographic variables were carried out among survivors and non-survivor. Result: Maximum death were patients of age group 21-30 years and male gender. Mortality in hypertensives, diabetics, and patients with sepsis were found to be statistically significant. Patients who developed ARDS and pneumonia or needed ventilation died invariably. High levels of laboratory parameters like IL-6, LDH, PT, INR, aPTT, ferritin, WBC count, and D-dimer were significantly associated with poor outcomes and at a particular cutoff had optimum sensitivity and specificity to predict mortality in ICU admitted COVID-19 patients. At the same time, low lymphocyte count and PaO2/FiO2 ratio was significantly associated with bad prognosis (P < 0.05). Conclusion: This paper will help in prioritizing patients in ICU who need special attention especially at the time of meager supply of resources.

A Knowledge, Attitude, and Practice (KAP) Study on Phlebotomy Among Nurses in a Tertiary Hospital in Patna, India.

INTRODUCTION: For most clinicians and nursing officers, laboratory testing is an unfamiliar part of medical caregiving, and ignorance may lead to serious avoidable errors. Phlebotomy, the first basic step towards laboratory testing, is to be taken seriously otherwise unnecessary repeat testing becomes mandatory. We hypothesized that there are some gaps in knowledge, attitude, and practice (KAP) among these nursing officers regarding practices of phlebotomy, which may influence the quality of blood samples. This study aims to assess the overall nurses' knowledge, attitude, and practice of phlebotomy to provide a remarkable improvement in blood sampling practice in our hospital. MATERIAL AND METHODS: A prospective study was conducted involving nurses posted in different wards in All India Institute of Medical Sciences (AIIMS) Patna, India. A phlebotomy questionnaire was designed based on KAP on the clinical and laboratory standards of the WHO guidelines. A total of 30 questions were distributed among the nursing staff, 10 each from knowledge, attitude, and practice. Descriptive and logistic regression analyses were used to analyze the KAP levels and their influencing factors. All continuous variables were tested for normality conditions using the Shapiro-Wilk test and P>0.05 were considered for normality. RESULTS AND CONCLUSION: The total average score of knowledge among the nurses was 7.62 (95%CI: 15.77-16.56). It was found that the nurses, on average, had a very strong positive attitude (93.36%). Regarding the distribution of practices of nurses, it was found that 87% had good practice as most of the positive practice items had high responses. The knowledge of phlebotomy among nurses was found to be satisfactory, except in a few areas. An education program on phlebotomy should be developed for nurses to improve and enhance their knowledge of phlebotomy.

Variation in biochemical parameters in COVID-19 patients admitted at a tertiary care dedicated COVID hospital: A prospective study.

Introduction: COVID-19 infection has a myriad of presentation. Rural India and other developing nations are relatively resource poor, not having access to modern specialized investigations. In this study, we tried to evaluate only biochemical parameters in predicting the severity of the infection. The aim of this study was to find a cost-effective means to predict the clinical course at the time of admission and thereby to reduce mortality and, if possible, morbidity by timely intervention. Materials and Methods: All COVID-19-positive cases admitted at our hospital from March 21 to December 31, 2020, were recruited in this study. The same acted as sham control at recovery. Results: We observed a significant difference in biochemical parameters at the time of admission and discharge, between mild/moderate disease and severe disease. We found slightly deranged liver function tests at admission, which becomes normal at the time of discharge. Urea, C-reactive protein (CRP), procalcitonin, lactate dehydrogenase, and ferritin concentrations in severe/critical patients were significantly higher than that in the mild/moderate group. Receiver operating characteristic curves were plotted to predict the severity on the basis of biochemical parameters independently, of the patients based on these values. Conclusion: We proposed cutoff values of certain biochemical parameters, which will help in judging the severity of the infection at admission. We developed a predictive model with a significant predictive capability for CRP and ferritin values, using normal available biochemical parameters, routinely done in resource-poor centers. Clinicians working in resource-poor situations will be benefitted by having an idea of the severity of the disease. Timely intervention will reduce mortality and severe morbidity.

Résumé Introduction: L'infection au COVID19 a une myriade de présentations. L'Inde rurale et d'autres pays en développement sont relativement pauvres en ressources, non avoir accès aux enquêtes spécialisées modernes. Dans cette étude, nous avons essayé d'évaluer uniquement les paramètres biochimiques pour prédire la gravité de l'infection. Le but de cette étude était de trouver un moyen rentable de prédire l'évolution clinique au moment de l'admission et ainsi de réduire la mortalité et, si possible, la morbidité par une intervention rapide. Matériels et méthodes: Tous les cas positifs au COVID19 admis à notre hospitalisés du 21 mars au 31 décembre 2020, ont été recrutés dans cette étude. La même chose a agi comme un contrôle factice lors de la récupération. Résultats: Nous avons observé une différence significative dans les paramètres biochimiques au moment de l'admission et de la sortie, entre une maladie légère/modérée et une maladie grave. Nous avons trouvé des tests de la fonction hépatique légèrement dérangés à l'admission, qui deviennent normaux au moment de la sortie. Urée, protéine Créactive (CRP, les concentrations de procalcitonine, de lactate déshydrogénase et de ferritine chez les patients sévères/critiques étaient significativement plus élevées que chez les patients légers/modérés groupe. Les courbes caractéristiques de fonctionnement du récepteur ont été tracées pour prédire la gravité sur la base de paramètres biochimiques indépendamment, deles patients en fonction de ces valeurs. Conclusion: Nous avons proposé des valeurs seuils de certains paramètres biochimiques, qui permettront de juger de la gravité de l'infection à l'admission. Nous avons développé un modèle prédictif avec une capacité prédictive significative pour les valeurs de CRP et de ferritine, en utilisant les paramètres biochimiques normaux disponibles, systématiquement effectués dans les centres pauvres en ressources. Les cliniciens travaillant dans des situations où les ressources sont limitées bénéficier d'avoir une idée de la gravité de la maladie. Une intervention rapide réduira la mortalité et la morbidité grave. Mots-clés: COVID19, ferritine, lactate déshydrogénase, urée.

Unraveling the Role of Tumor Necrosis Factor-Alpha in Diabetic Peripheral Neuropathy: A Systematic Review and Meta-Analysis.

Diabetic peripheral neuropathy (DPN) is a prevalent and debilitating complication of diabetes mellitus, leading to sensory abnormalities, decreased balance, and increased risk of foot problems. Although tumor necrosis factor-alpha (TNF-α) has emerged as a potential factor in the pathogenesis of DPN, its role remains contested. This study intends to thoroughly analyze the association between TNF-α and DPN by combining data from various global studies. This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and included 23 articles investigating TNF-α levels in DPN patients for systematic review and 11 articles for meta-analysis. Data were extracted, and heterogeneity was examined. A random-effect model was chosen due to high heterogeneity. The major outcome measure across studies was serum TNF-α levels. The meta-analysis found a significant mean difference of 15.2464 (95% confidence interval = 4.4963; 25.9965) under the random-effect model due to the substantial heterogeneity (I2 = 98.1%) among included studies. The meta-analysis indicates a consistent elevation in TNF-α levels in individuals with DPN compared to those without neuropathy. This underlines the potential of TNF-α as a biomarker and contributor to diabetic neuropathy. Despite heterogeneity, the study's extensive scope and systematic approach enhance the trustworthiness and generalizability of the findings.