Clinical characteristics and outcomes of immunosuppressed patients hospitalized with COVID-19: experience from London.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a global health emergency. Despite the widely hypothesized role of a cytokine storm in disease severity, no study thus far has explored the association between immunosuppression and disease severity in patients hospitalized with COVID-19. OBJECTIVE: This study aimed to examine the association between the use of immunosuppressant medication and outcomes of patients hospitalized with COVID-19. METHODS: Nine hundred and eighty-one consecutive patients hospitalized between 12 March 2020 and 15 April 2020, who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), were enrolled in this cohort study and subdivided by immunosuppression status. The patients were followed up for a minimum of 28 days (median 37 days) for the primary end-point of mortality. Secondary end-points included the composite of intubation or death, and the composite of mortality, intubation or continuous positive airway pressure (CPAP) requirement. RESULTS: During the follow-up period, 354 (36.1%) of study patients died. The immunosuppressed cohort (n = 31) had significantly higher mortality rates (aHR: 2.067, 95% CI: 1.20-3.57, P = 0.009). There was no association between immunosuppression and the composite end-point of mortality or intubation (aHR: 1.49 95% CI: 0.88-2.51, P = 0.14) and of the composite end-point of mortality, intubation or CPAP (aHR: 1.36 95% CI: 0.81-2.30 P = 0.245). CONCLUSION: In this cohort study of 981 confirmed COVID-19 patients consecutively hospitalized at a large North West London hospital, immunosuppressant use was associated with significantly higher mortality rates. These results support the current UK government's early isolation ('shielding') policy for these individuals and should be used to guide future research.

Risk factors for severe disease in patients admitted with COVID-19 to a hospital in London, England: a retrospective cohort study.

COVID-19 has caused a major global pandemic and necessitated unprecedented public health restrictions in almost every country. Understanding risk factors for severe disease in hospitalised patients is critical as the pandemic progresses. This observational cohort study aimed to characterise the independent associations between the clinical outcomes of hospitalised patients and their demographics, comorbidities, blood tests and bedside observations. All patients admitted to Northwick Park Hospital, London, UK between 12 March and 15 April 2020 with COVID-19 were retrospectively identified. The primary outcome was death. Associations were explored using Cox proportional hazards modelling. The study included 981 patients. The mortality rate was 36.0%. Age (adjusted hazard ratio (aHR) 1.53), respiratory disease (aHR 1.37), immunosuppression (aHR 2.23), respiratory rate (aHR 1.28), hypoxia (aHR 1.36), Glasgow Coma Scale <15 (aHR 1.92), urea (aHR 2.67), alkaline phosphatase (aHR 2.53), C-reactive protein (aHR 1.15), lactate (aHR 2.67), platelet count (aHR 0.77) and infiltrates on chest radiograph (aHR 1.89) were all associated with mortality. These important data will aid clinical risk stratification and provide direction for further research.

Differentiating recurrent tumours from post-treatment changes in head and neck cancers: does diffusion-weighted MRI solve the eternal dilemma?

AIM: To evaluate the utility of diffusion-weighted imaging (DWI) in differentiating post-treatment changes from tumour recurrence in head and neck cancers and to establish a threshold apparent diffusion coefficient (ADC) value to differentiate the two conditions. MATERIALS AND METHODS: This was a prospective study of 80 treated head and neck cancer patients. The patient cohort consisted of a wide spectrum of head and neck sites, including the oral cavity, oropharynx, larynx, hypopharynx, paranasal sinuses, orbits, salivary glands, and infra-temporal fossa. Qualitative analysis of the diffusion images and quantitative analysis of the corresponding ADC maps was performed and the data were correlated with histopathological findings and clinical examinations. RESULTS: The mean ADC value of recurrent tumours in the present cohort was 0. 932±0.19×10-3 mm2/s and the mean ADC value of lesions representing post-treatment changes was 1.394±0.32×10-3 mm2/s. A threshold ADC value of 1.2×10-3mm2/s used to differentiate post-treatment changes from recurrent head and neck cancers showed the highest combined sensitivity of 90.13%, specificity of 82.5%, accuracy of 86.4%, positive predictive value of 84.4%, negative predictive value of 88.9%, and mean kappa measurement of agreement of 72.8. CONCLUSION: Combined qualitative and quantitative analysis of DWI is a useful non-invasive technique to differentiate recurrent head and neck malignancies from post-treatment changes using a threshold ADC value.

Imaging for cochlear implantation: structuring a clinically relevant report.

Cochlear implantation is a proven treatment for bilateral severe to profound hearing loss. Imaging has an important role in deciding candidacy, providing realistic preoperative counselling, and predicting postoperative outcomes. Imaging also provides information about the potential difficulties a surgeon may encounter during the implantation. High-resolution computed tomography and high-resolution magnetic resonance imaging complement each other in assessing different aspects of the temporal bone and the auditory pathway in such patients. This review provides a structured format for reading pre-cochlear implant imaging studies with special focus on the surgeon's expectations in order to prepare a clinically relevant report. A constant communication between the imaging specialist and the cochlear implant surgeon improves image interpretation and ensures a successful implantation.

A Randomised Controlled Trial of Postoperative Sensitivity after Class II Restoration with Bulk-Fill vs Conventional Composites.

INTRODUCTION: Bulk-fill composites may simplify posterior restorations, saving time and reducing technical complexity. Post-operative sensitivity is a risk of posterior composites; bulk-fill composites could mitigate this. This single centre, double-blinded, parallel groups randomised controlled trial compared postoperative sensitivity following restoration of class II carious lesions with bulk-fill or conventional, layered composite. NULL HYPOTHESIS: there will be no difference in post-operative sensitivity between the two materials. METHODS: Participants requiring class II restoration of posterior teeth were randomised to bulk-fill (FU) (Coltene Fill-UpTM) or conventional, layered (BE) (Coltene Brilliant Everglow) composite. Allocation was concealed during cavity preparation. Only the operating dentist knew allocation. The outcome was 24 h post-operative sensitivity. RESULTS: 41 patients were randomised (20/group). Two patients from FU group were excluded from analysis (factors unrelated to intervention). There was no difference in postoperative sensitivity at 24 h nor any time point. Only participant age and baseline sensitivity scores significantly impacted post-operative sensitivity. One restoration debonded in FU group at 10 days, with no other adverse effects. No difference in time taken to place restorations was seen. CONCLUSIONS: Within the study's limitations, post-operative sensitivity after class II posterior restorations was no different in bulk-fill restorations compared with conventional, incrementally cured composite.

Salivary progesterone as a biochemical marker to predict early preterm birth in asymptomatic high-risk women.

OBJECTIVE: To evaluate salivary progesterone as a predictor of early preterm birth (PTB) and compare it with transvaginal sonographic (TVS) cervical length in asymptomatic high-risk women. DESIGN: Prospective study. SETTING: Departments of Obstetrics and Gynaecology and Biochemistry at UCMS & GTBH, Delhi, India. SAMPLE: Ninety pregnant women. METHODS: The progesterone concentration in saliva of asymptomatic pregnant women at high risk for preterm delivery was estimated by immunoassay, and cervical length was measured by TVS, at the first antenatal visit at 24-28 weeks of gestation, and then repeated 3-4 weeks later. MAIN OUTCOME MEASURES: Early PTB, mean and critical cut-off values of salivary progesterone, and a diagnostic value comparison of salivary progesterone with TVS cervical length. RESULTS: The mean value of salivary progesterone was significantly lower in all women who delivered at <37 weeks of gestation (n = 38), compared with the term group (n = 52; P < 0.001). Salivary progesterone decreased significantly from the first to the second visit, with the maximum decrease observed in women who delivered at <34 weeks of gestation (29.6%, 95% CI 17.8-41.4%, P < 0.002). The single predictive critical cut-off value for salivary progesterone was 2575 pg/ml, below which more than 80% of women delivered prematurely before 34 weeks of gestation, with sensitivity, specificity, and positive and negative predictive values of 83% (95% CI 58.6-96.4%), 86% (95% CI 75.9-93.1%), 60% (95% CI 38.6-78.8%) and 95% (95% CI 87.1-99.0%), respectively. The TVS cervical length decreased significantly (P < 0.001) in the women who delivered prematurely. CONCLUSIONS: Low salivary progesterone concentration can be used for predicting early PTB in asymptomatic high-risk women.

Common Medical Devices with Uncommon Complications.

Medical devices and materials commonly used in management of common gynecological conditions or during surgical procedures may present with acute or chronic complications due to incorrect application, improper use and lack of follow up. We present two interesting cases highlighting this problem. A strong index of suspicion is very crucial in early diagnosis and successful management.

An imaging checklist for pre-FESS CT: framing a surgically relevant report.

The reference standard for preoperative imaging in functional endoscopic sinus surgery (FESS) is multiplanar high-resolution computed tomography (HRCT). Surgeons require a precise preoperative anatomical road map, and hence it is essential for radiologists to be familiar with the normal three-dimensional sinonasal anatomy and the normal variants encountered in this region. Sagittal imaging has recently emerged as an important tool to visualize additional details in this critical anatomical region. Radiologists also need to report these examinations with special focus on the surgeon's expectations. Constant communication between the radiologist and the surgeon helps to resolve specific issues and improve the overall quality of reports. This results in better preoperative patient counselling and in predicting postoperative improvement in clinical status. This review provides a basic structured format for reporting pre-FESS CT, which can be tailored to meet individual requirements. The CT reporting format follows the order in which the sinonasal structures are approached during surgery.

Mature ovarian dermoid cyst invading the urinary bladder.

Mature ovarian dermoid cysts are common lesions, accounting for up to 10-25% of all ovarian neoplasms. Uncomplicated dermoid cysts are often asymptomatic and are relatively easy to diagnose on imaging and to treat. Symptoms develop once complications set in and these may cause diagnostic dilemmas. Torsion (16%) is the most common complication, while rupture, suppuration and malignant transformation are relatively uncommon. Of all these complications, spontaneous rupture into the urinary bladder is least common. The diagnosis of this condition has been through the use of cystoscopy or laparotomy in all cases reported so far. We report a case of a 30-year-old patient with pyuria and dysuria, where ultrasound examination clearly demonstrated an ovarian dermoid cyst invading the urinary bladder. A clear-cut imaging diagnosis helped to allow planning of surgery in advance and a mucosa-sparing partial bladder resection could be performed.

Comparative analysis of conventional cold curettage versus endoscopic assisted coblation adenoidectomy.

OBJECTIVE: To compare conventional cold curettage adenoidectomy with endoscopic assisted coblation adenoidectomy in terms of operative time, primary blood loss, post-operative residual tissue and post-operative pain. METHODS: This prospective non-randomised study was carried out on 60 patients aged 5-12 years. One group underwent conventional cold curettage adenoidectomy and the other underwent endoscopic assisted coblation adenoidectomy, with 30 patients per group. RESULTS: Mean operation duration was significantly higher for endoscopic assisted coblation adenoidectomy. Mean blood loss was 44.33 ml in conventional cold curettage adenoidectomy and 32.47 ml in endoscopic assisted coblation adenoidectomy. The pain grade was significantly lower in endoscopic assisted coblation adenoidectomy. Forty per cent of patients who underwent conventional cold curettage adenoidectomy had adenoid tissue post-surgery, while it was completely absent in endoscopic assisted coblation adenoidectomy patients. CONCLUSION: Coblation adenoidectomy has significant advantages over conventional adenoidectomy in terms of reduced blood loss, no post-operative residual tissue and lower pain grade on day 1 after surgery.

Protein isolation by solution-controlled gel sorption.

Illustrated are the principles for isolating proteins from solution by sorption into a polymer gel phase, driven by the addition of a water-soluble polymer to the protein solution. The separation is shown to be analogous to conventional two-phase aqueous extraction. However, the use of a gel phase rather than a solution for absorbing the protein makes separation of the protein from the polymer and the recycling of the gel phase much simpler. The model system used was linear poly(ethylene glycol) (PEG) and dextran gel. Increasing the molecular weight and concentration of the PEG favored sorption by the gel of ovalbumin, bovine serum albumin, cytochrome c, and hemoglobin. The proteins could be quantitatively recovered by immersing the gel in PEG-free solution.

A case control study of gene environmental interaction in fetal growth restriction with special reference to organochlorine pesticides.

OBJECTIVES: Organochlorine pesticides (OCPs) and oxidative stress are reported to be associated with adverse reproductive outcomes. Glutathione S-transferase (GST) is a polymorphic supergene family involved in the detoxification of numerous toxins including OCPs. OCPs are endocrine disrupter and prenatal exposure to them may be associated with fetal growth restriction (FGR). The objectives of the present study were (i) to determine the frequencies of polymorphic alleles of GSTM1 and GSTT1 genes in women with idiopathic FGR, (ii) to analyze the maternal and cord blood levels of the OCPs, and (iii) to identify the gene environment interaction that increases the risk of FGR. STUDY DESIGN: Maternal and cord blood samples of 50 FGR cases (birth weight <10 percentile for gestational age as per Lubchenco's growth chart) and equal number of normal pregnancies who were occupationally non exposed to OCPs and excluding all the known high risk factors such as anemia, hypertension, antiphospholipid antibody syndrome, medical disease, dietary habit, living style, parity, and BMI. The collected samples at the time of delivery/after delivery were analyzed for OCPs levels by gas chromatography and polymorphic analysis for GSTM1/GSTT1 gene using multiplex PCR. RESULTS: Significantly higher levels of α,ß,γ-HCH and p,p'-DDT were found in maternal blood and significantly higher levels of ß and γ-HCH and p,p'-DDT were found in cord blood of FGR cases as compared to controls. The genotypic distribution of GSTM1/GSTT1 was almost similar in both the groups, but the frequency of GSTM1-/GSTT1- (null) genotype was significantly higher in FGR cases as compared to controls (p<0.05, OR=6.42). When interaction between GSTM1/GSTT1 genes polymorphism-OCPs levels and birth weight (gene-environment interaction) was ascertained, a significant association was seen between ß-HCH and GSTM1- genotype with reduction in birth weight of 213g. CONCLUSION: Higher levels of OCPs in pregnant women may be considered as an important aetiological factor in 'idiopathic' FGR. GST polymorphism can influence the relationship between prenatal exposure to pesticides and FGR. The present study provides evidence that polymorphism in xenobiotic metabolising genes may modify the effect of environmental health hazards and increase the risk of FGR.

Occurrence of dual infection of peste-des-petits-ruminants and goatpox in indigenous goats of central India.

Peste-des-petits-ruminants (PPR), bluetongue (BT) and goatpox (GP) have been well recognized as causes of significant economic losses in the small ruminant population of Asia and Africa. We describe here the occurrence of these three in an outbreak noticed in non-descript goats from a subtropical region of central India. An investigation was carried out to confirm the aetiology of the heavy mortality in goats (74.6%, 112/150), with testing of samples from 12 surviving animals exhibiting mixed clinical signs indicative of PPR, BT and GP. Sandwich ELISA was used to detect PPR virus antigen and competition ELISA to detect PPR virus and BT virus antibodies. GP was confirmed on the basis of nodular lesions and an immunodiffusion assay. Eight of the 12 affected animals (66.7%) were positive for PPR virus and BT virus antibodies, and two goats (16.7%, 2/12) exhibiting clinical lesions of pox were also found positive for PPR virus/antibodies and BT virus antibodies, respectively. Although BT virus could not be identified in any sample, detection of BT virus antibodies indicated previous or possibly concurrent infection with BT virus in these goats. The N-gene-based RT-PCR was used to confirm the PPR infection in these goats, and one of the amplicons was sequenced. The sequence and phylogenetic analysis revealed close proximity to PPR virus isolates from Tibet and China, with sequence homology of up to 96.9%. The sequence homology was relatively low with the majority of other Indian isolates (72.7-93.5%). The detection of this new PPR virus sequence indicates the circulation of cross-border strains in this region of India. It is presumed that the heavy mortality observed in goats is possibly attributable to the occurrence of mixed infection of PPR and GP, or PPR, BT and GP.

Detection of Rotavirus Infection in Bovine Calves by RNA-PAGE and RT-PCR.

A total of 128 diarrhoeic faecal samples were collected from cattle and buffalo calves from Pantnagar and Dehradun during winter months. Of the 110 cattle calves screened by RNA-PAGE, rotavirus was detected in 13 samples (11.81%) while no sample from buffalo calves was found positive. All samples were found to have long electropherotype and two distinct electropherotypes having segment variation were observed. The overall prevalence of rotavirus was 10.15% (13/128). RT-PCR targeting group specific VP6 gene confirmed Group A rotavirus in 10 out of 13 samples, while three samples remained un-groupable.