Acute Triple Coronary Artery Occlusion Leading to Cardiogenic Shock and Cardiac Arrest Emphasizing the Role of Mechanical Circulatory Support (Escalate before It's Too Late).

We report a case of cardiac arrest in a 38-year-old male with no past medical history who presented as a case of ST-segment elevation myocardial infarction, and coronary angiography showed triple coronary artery thrombosis complicated with cardiogenic shock (CS) that warrants starting on inotropic support and insertion of intra-aortic balloon pump. CS diagnosis with a high likelihood of deterioration was established based on hemodynamics assessment; hence, an early prompt decision for escalation of mechanical circulatory support to Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was made, which helped to prevent the patient's further deterioration and organ damage. The patient had uneventful VA-ECMO decannulation and was transferred to the ward and discharged after 28 days in stable condition on oral medical therapy and was following up regularly in the cardiology clinic. Therefore, early hemodynamics assessment in acute myocardial infarction CS cases will help predict rapid worsening, which may require prompt escalation of mechanical circulatory support and perhaps improve the outcome.

Connectivity-guided intermittent theta burst versus repetitive transcranial magnetic stimulation for treatment-resistant depression: a randomized controlled trial.

Disruption in reciprocal connectivity between the right anterior insula and the left dorsolateral prefrontal cortex is associated with depression and may be a target for neuromodulation. In a five-center, parallel, double-blind, randomized controlled trial we personalized resting-state functional magnetic resonance imaging neuronavigated connectivity-guided intermittent theta burst stimulation (cgiTBS) at a site based on effective connectivity from the right anterior insula to the left dorsolateral prefrontal cortex. We tested its efficacy in reducing the primary outcome depression symptoms measured by the GRID Hamilton Depression Rating Scale 17-item over 8, 16 and 26 weeks, compared with structural magnetic resonance imaging (MRI) neuronavigated repetitive transcranial magnetic stimulation (rTMS) delivered at the standard stimulation site (F3) in patients with 'treatment-resistant depression'. Participants were randomly assigned to 20 sessions over 4-6 weeks of either cgiTBS (n = 128) or rTMS (n = 127) with resting-state functional MRI at baseline and 16 weeks. Persistent decreases in depressive symptoms were seen over 26 weeks, with no differences between arms on the primary outcome GRID Hamilton Depression Rating Scale 17-item score (intention-to-treat adjusted mean, -0.31, 95% confidence interval (CI) -1.87, 1.24, P = 0.689). Two serious adverse events were possibly related to TMS (mania and psychosis). MRI-neuronavigated cgiTBS and rTMS were equally effective in patients with treatment-resistant depression over 26 weeks (trial registration no. ISRCTN19674644).

Percutaneous coronary intervention can be safely performed with left ventricular thrombus without increasing stroke risk: A 5-year retrospective review using real-world data.

INTRODUCTION: Left ventricular thrombus (LVT) increases the risk of ischemic stroke. However, it remains uncertain if the percutaneous coronary intervention (PCI) in the confirmed LVT setting further augments the stroke risk. Therefore, in this study, we evaluated the risk of stroke among patients with LVT undergoing CAG +/- PCI. METHODS: This retrospective observational cohort study included all the patients encountered with LVT from 1st of April 2015, to 31st of March 2020. The study population was divided into two groups: Longobardo et al. (2018) [1] patients with LVT who underwent CAG +/- PCI; Solheim et al. (2010) [2] patients with LVT who did not undergo CAG +/- PCI. The primary outcome evaluated was stroke during the index admission, and the secondary outcomes included in-hospital mortality, all-cause mortality, and stroke at 12 months post-discharge. Logistic regression was used to determine the risk of stroke associated with PCI among patients with LVT, and a p-value<0.05 indicated statistical significance. RESULTS: Of the 210 patients included, 119 underwent CAG +/- PCI, while 91 patients did not undergo CAG +/- PCI. Most of the patients were Asian (67%), male (96%), with a mean age of 56 years. Ischemic cardiomyopathy was the primary etiology of LVT in both groups (96% in the CAG +/- PCI group and 80% in non CAG +/- PCI group). During the index admission, stroke among patients with LVT did not differ between the CAG +/- PCI and non CAG +/- PCI groups (5% versus 3.3%; odds ratio (OR) 1.6, 95% confidence interval (CI) 0.34-6.4, p = 0.539; adjusted OR 0.9, 95% CI 0.09-10.6, p = 0.968). Similarly, in-hospital mortality, all-cause mortality, and stroke at 12 months did not differ between the study groups. CONCLUSION: Performing CAG +/- PCI among patients with LVT was not associated with an increased risk of stroke during admission or within 12 months in comparison to patients who did not undergo CAG +/- PCI, which may reassure cardiologists to perform CAG +/- PCI among patients with LVT safely.

Multidisciplinary Cognitive Function Assessment of Good versus Poor Performance in Children with Cochlear Implants: An Observational Cross-Sectional Study

Abstract Introduction Despite the developing technology of cochlear implants (CIs), implanted prelingual hearing-impaired children exhibit variable speech processing outcomes. When these children match in personal and implant-related criteria, the CI outcome variability could be related to higher-order cognitive impairment. Objectives To evaluate different domains of cognitive function in good versus poor CI performers using a multidisciplinary approach and to find the relationship between these functions and different levels of speech processing. Methods This observational, cross-sectional study used the word recognition score (WRS) test to categorize 40 children with CIs into 20 good (WRS/65%) and 20 poor performers (WRS < 65%). All participants were examined for speech processing at different levels (auditory processing and spoken language) and cognitive functioning using (1) verbal tests (verbal component of Stanford-Binet intelligence [SBIS], auditory memory, auditory vigilance, and P300); and (2) performance tasks (performance components of SBIS, and trail making test). Results The outcomes of speech processing at different functional levels and both domains of cognitive function were analyzed and correlated. Speech processing was impaired significantly in poor CI performers. This group also showed a significant cognitive function deficit, in which the verbal abilities were more affected (in 93.5%) than in the good performers (in 69.5%). Moreover, cognitive function revealed a significant correlation and predictive effect on the CI speech outcomes. Conclusion Cognitive function impairment represented an important factor that underlies the variable speech proficiency in cochlear-implanted children. A multidisciplinary evaluation of cognitive function would provide a comprehensive overview to improve training strategies.

Acute thrombotic occlusion involving three coronary arteries. A unique association with COVID-19 pneumonia.

Key Clinical Message: Respiratory viruses, particularly COVID-19, can be associated with severe cases of myocardial infarction (MI). Physicians should have a low threshold for MI in COVID-19 patients who present with persistent chest pain as MI in rapidly deteriorating cases can be missed. Prompt response includes both timely diagnosis and swift treatment. Abstract: The coronavirus disease 2019 (COVID-19) is associated with coronary artery thrombosis. Many cases of single-vessel and few cases of two-vessel thrombosis were reported. Herein, we report a unique association in a middle-aged man diagnosed with COVID-19 and presented later with acute myocardial infarction causing cardiogenic shock. The patient was found to have three-vessel thrombosis.

Multidisciplinary Cognitive Function Assessment of Good versus Poor Performance in Children with Cochlear Implants: An Observational Cross-Sectional Study.

Introduction Despite the developing technology of cochlear implants (CIs), implanted prelingual hearing-impaired children exhibit variable speech processing outcomes. When these children match in personal and implant-related criteria, the CI outcome variability could be related to higher-order cognitive impairment. Objectives To evaluate different domains of cognitive function in good versus poor CI performers using a multidisciplinary approach and to find the relationship between these functions and different levels of speech processing. Methods This observational, cross-sectional study used the word recognition score (WRS) test to categorize 40 children with CIs into 20 good (WRS/65%) and 20 poor performers (WRS < 65%). All participants were examined for speech processing at different levels (auditory processing and spoken language) and cognitive functioning using (1) verbal tests (verbal component of Stanford-Binet intelligence [SBIS], auditory memory, auditory vigilance, and P300); and (2) performance tasks (performance components of SBIS, and trail making test). Results The outcomes of speech processing at different functional levels and both domains of cognitive function were analyzed and correlated. Speech processing was impaired significantly in poor CI performers. This group also showed a significant cognitive function deficit, in which the verbal abilities were more affected (in 93.5%) than in the good performers (in 69.5%). Moreover, cognitive function revealed a significant correlation and predictive effect on the CI speech outcomes. Conclusion Cognitive function impairment represented an important factor that underlies the variable speech proficiency in cochlear-implanted children. A multidisciplinary evaluation of cognitive function would provide a comprehensive overview to improve training strategies.

Syncope following Pfizer BioNTech (bnt162b2) vaccination unmasking Brugada syndrome.

The Brugada syndrome is an uncommon inherited condition associated with increased risk of ventricular tachyarrhythmias and sudden cardiac death. Different triggers including fever are well known to precipitate the Brugada pattern on electrocardiogram. We report a patient who presents with syncope, two days after the first dose of the BNT162b2 vaccine due to fever-related unmasking of Brugada syndrome.

Acute Lymphoblastic Leukemia Presenting with Acute Decompensated Cardiac Failure.

We report the case of acute lymphoblastic leukemia (ALL) in a 29-year-old male with no past medical history who presented with symptoms and signs of heart failure due to possible infiltrative cardiomyopathy as suggested by echocardiography. Workup including different imaging modalities confirmed the diagnosis of ALL. The patient completed his treatment course with a resolution of heart failure symptoms and normalization of cardiac function which was confirmed by different imaging modalities.

Early Clinical Experiences of Esketamine Nasal Spray in the UK in Adults with Treatment-Resistant Major Depressive Disorder: Advisory Panel Recommendations.

Purpose: Treatment-resistant depression (TRD) is associated with profound morbidity for patients, placing a significant burden on those affected, the health service and wider society. Despite this, TRD remains chronically underserved in terms of viable treatment options. To address this gap, an advisory panel of psychiatrists and clinical researchers with experience in managing TRD convened to develop best practice statements on the use of esketamine nasal spray, one of the first TRD treatments to be licensed in 30 years. Methods: During a virtual meeting held on 12th November 2020, the advisory panel shared their experiences of using esketamine nasal spray in their clinical practice. The meeting focused on developing and refining recommendations for setting up and running an efficient esketamine nasal spray clinic for patients living with TRD. At the conclusion of the meeting, agreement was reached on all recommendation statements. Results: In setting up an esketamine nasal spray clinic, it is important to consider the logistical requirements involved and put measures in place to ensure it runs as efficiently as possible. Educating patients about the treatment and maintaining their well-being is paramount for preventing discontinuation. Putting in place checklists can be a useful strategy for ensuring treatment appointments run smoothly and safely. Conclusion: Providing additional treatment options for the management of TRD, such as esketamine nasal spray, is likely to be key to improving the long-term outcomes of this underserved patient population.

Effect of COVID-19 on gastrointestinal endoscopy practice: a systematic review.

BACKGROUND: Since the emergence of the novel corona virus (SARS-Cov-2) in the late 2019 and not only the endoscopy practice and training but also the health care systems around the globe suffers. This systematic review focused the impact of Corona Virus Disease (COVID-19) on the endoscopy practice. METHODS: A web search of different databases combining different search terms describing the endoscopy practice and the COVID-19 pandemic was done. Articles were screened for selection of relevant articles in two steps: title and abstract step and full-text screening step, by two independent reviewers and any debate was solved by a third reviewer. RESULTS: Final studies included in qualitative synthesis were 47. The data shown in the relevant articles were evident for marked reduction in the volume of endoscopy, marked affection of colorectal cancer screening, impairments in the workflow, deficiency in personal protective equipment (PPE) and increased likelihood of catching the infection among both the staff and the patients. CONCLUSION: The main outcomes from this review are rescheduling of endoscopy procedures to be suitable with the situation of COVID-19 pandemic in each Country. Also, the endorsement of the importance of PPE use for health care workers and screening of COVID-19 infection pre-procedure.Key messagesThe data focussing Gastrointestinal Endoscopy and COVID-19 emerged from different areas around the globe. The data presented on the published studies were heterogeneous. However, there were remarkable reductions in the volume of GI endoscopy worldwideStaff reallocation added a burden to endoscopy practiceThere was a real risk for COVID-19 spread among both the staff and the patients.

Quality indicators for colonoscopy in Egypt: A prospective multicenter study.

BACKGROUND AND STUDY AIMS: Despite its wide availability, we do not have sufficient data aboutthe quality of colonoscopy in Egypt. In this study, we proposed 13 indicators to assess the quality of colonoscopy procedures in the included study centers aiming to attain a representative image of the quality of CS in Egypt. PATIENTS AND METHODS: A multicenter prospective study was conducted between July and December 2020, which included all patients who underwent colonoscopy in the participating centers. The following were the proposed quality indicators: indications for colonoscopy, preprocedure clinical assessment, obtaining written informed consent, adequate colon preparation, sedation, cecal intubation rate (CIR), withdrawal time, adenoma detection rate (ADR), complication rate, photographic documentation, automated sterilization, regular infection control check, and well-equipped postprocedure recovery room. RESULT: A total of 1,006 colonoscopy procedures were performed during the study duration in the included centers. Our analysis showed the following four indicators that were fulfilled in all centers: appropriate indications for colonoscopy, preprocedure assessment, written informed consent, and automated sterilization. However, photographic documentation and postprocedure follow-up room were fulfilled only in 57 %. Furthermore, 71 % of the centers performed regular infection control checks. Adequate colon preparation was achieved in 61 % of the procedures, 81 % of the procedures were performed under sedation, 95.4 % CIR, 11-min mean withdrawal time, 15 % ADR, and 0.1 % overall complication rate. Statistically significant factors affecting CIR were age > 40 years, high-definition endoscope, previous colon intervention, and rectal bleeding, whereas those affecting ADR were age > 40 years, the use of image enhancement, previous colon intervention, rectal bleeding, the use of water pump, and a withdrawal time of > 9 min. CONCLUSION: Our study revealed the bright aspects of colonoscopy practice in Egypt, including high CIRs and low complication rates; conversely, ADR, bowel cleansing quality, and infection control measures should be improved.

Cognitive after-effects and associated correlates among post-illness COVID-19 survivors: a cross-sectional study, Egypt.

Background: COVID-19's after-effects among survivors are of increased concern. The cognitive aftermath of COVID-19 virus infection was underrated. This study aimed to identify and compare the cognitive impairment (CI) and its correlates among COVID-19 survivors and control subjects. A total of 85 adults who survived COVID-19 virus infection and an equal number of control subjects (matched for age, sex, education, and socioeconomic level) were included in this study. They were recruited from Zagazig University Hospitals, Sharkia Province, Egypt. All subjects were interviewed utilizing a semistructured demographic and clinical checklist, the Montreal Cognitive Assessment (MoCA) test, and the Hospital Anxiety Depression Scale (HADS). Results: More than half of COVID-19 survivors experienced CI (compared to only 8% of control subjects). Individuals who survived COVID-19 virus infection were more likely to have impairments in visuo-executive functions (OR: 0.3, 95% CI 0.2-0.5), attention (OR: 0.4, 95% CI 0.3-0.7), language (OR: 0.2, 95% CI 0.1-0.5), delayed recall (OR: 0.5, 95% CI 0.4-0.6), and total MoCA Scores (OR: 0.1, 95% CI 0.04-0.2). Among COVID-19 survivors, those who experienced CI were likely to be older (OR: 1.1, 95% CI 1.03-1.2), and of low-to-moderate education (OR: 4.9, 95% CI 1.6-15.1). Conclusions: CI was prevalent among COVID-19 survivors. The visuo-executive functions, attention, language, and delayed recall were the most affected domains. Older age and lower educational level predicted CI in COVID-19 survivors.

Asymptomatic Severe Aortic Stenosis: Contemporary Evaluation and Management.

Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries and most prevalent in the elderly. According to the current guidelines, intervention is recommended in symptomatic severe AS; however, in asymptomatic patients, aortic valve replacement (AVR) is considered when symptoms appear or the left ventricular dysfunction occurs, but the evidence supports these indications are poor. The optimal timing and modality of intervention in asymptomatic severe AS (ASAS) remain controversial. Earlier AVR in certain scenarios has been increasingly supported by some groups before subclinical irreversible myocardial damage occurs. In addition, the continuous advancement of percutaneous and surgical approaches where associated with a substantial decrease in mortality and perioperative complications which made many authors advocate for early intervention in those patients. Our review highlights the contemporary evaluation and management of ASAS and summarizes the current scientific evidence regarding optimal timing for intervention and indications for early AVR in such patients.

Prevalence and Predictors of Persistent Symptoms After Clearance of SARS-CoV-2 Infection: A Multicenter Study from Egypt.

Background and Aim: Little is known about the persistence of symptoms after clearance of SARS-CoV-2 infection. Our study aimed to assess persistent symptoms in COVID-19 patients after clearance of SARS-CoV-2 infection. Methodology: A multi-center survey was conducted on first wave COVID-19 patients with confirmed SARS-CoV-2 infection. Sociodemographic and clinical characteristics, including presenting symptoms and persistent symptoms after viral clearance and possible factors contributing to persistence of such symptoms, were collected using an online multicomponent questionnaire. Descriptive and inferential statistical analysis was performed to detect the most persisting symptoms and factors contributing to their persistence. Results: Overall, 538 patients were enrolled. Mean age was 41.17 (±SD 14.84), 54.1% were males, and 18.6% were smokers. Hypertension and diabetes were the most reported co-morbidities. Mild symptoms were reported in 61.3% of patients, 51.3% were admitted to hospital and 6.5% were admitted to the intensive care unit. Our study identified 49 types of persisting symptoms. Fatigue (59.1%), sense of fever (46.5%), anorexia (24.3%) and diarrhea (24.3%) were the most commonly reported persisting symptoms followed by loss of taste and smell (22.3%), headache (21.4%), cough (20.8) and dyspnea (21%). The use of hydroxychloroquine, azithromycin and multivitamins were significantly associated with persistence of symptoms (OR = 8.03, 8.89 and 10.12, respectively). Conclusion: Our study revealed that in COVID-19 recovered patients, many patients reported persistence of at least one symptom, particularly fatigue and sense of fever. Follow-up of patients after discharge from hospital is recommended until complete resolution of symptoms.

Clinical, Radiological, and Outcome Characteristics of Acute Pulmonary Embolism: A 5-year Experience from an Academic Tertiary Center.

BACKGROUND: Acute pulmonary embolism (PE) is a common and potentially life-threatening condition. This comprehensive study from a Gulf Cooperation Council (GCC) country aimed to evaluate the clinical, radiological, and outcome characteristics associated with acute PE. METHODS: This retrospective observational study analyzed data of patients with confirmed acute PE who were admitted to the largest academic tertiary center in the State of Qatar from January 1, 2014, to December 31, 2018. Data on the clinical presentation, radiologic, and echocardiographic findings, as well as outcomes were collected. RESULTS: A total of 436 patients were diagnosed with acute PE during the study period (male, 53%). Approximately 56% of the patients were < 50 years old at presentation, with a median age of 47 years. In approximately 69% of cases, the PE occurred outside the hospital. The main associated comorbidities were obesity (34.6%), hypertension (29.4%), and diabetes (25%). Immobilization (25.9%) and recent surgery (20.6%) were the most common risk factors. The most frequent presenting symptom was dyspnea (39.5%), and the most frequent signs were tachycardia (49.8%) and tachypnea (45%). Cardiac arrest was the initial presentation in 2.2% of cases. Chest X-ray findings were normal in 41%. On computed tomography pulmonary angiography (CTPA), 41.3% of the patients had segmental PE, 37.1% had central PE, and 64.1% had bilateral PE. The main electrocardiographic (ECG) abnormality was sinus tachycardia (98%). In patients who underwent echocardiography, right ventricular (RV) enlargement was the main echocardiographic finding (36.4%). Low-, intermediate-, and high-risk PE constituted 49.8%, 31.4%, and 18.8% of the cases, respectively. Thrombolysis was prescribed in 8.3% of the total and 24.4% of the high-risk PE cases. Complications of PE and its treatment (from admission up to 6 months post-discharge) included minor bleeding (14%), major bleeding (5%), PE recurrence (4.8%), and chronic thromboembolic pulmonary hypertension (CTEPH) (5%). A total of 15 (3.4%) patients died from PE. CONCLUSIONS: Acute PE can manifest with complex and variable clinical and radiological syndromes. Striking findings in this study are the younger age of acute PE occurrence and the low PE-related mortality rate.

Saddle versus non-saddle pulmonary embolism: differences in the clinical, echocardiographic, and outcome characteristics.

The central location, the size, and instability of saddle pulmonary embolism (PE) have raised considerable concerns regarding its hemodynamic consequences and the optimal management approach. Sparse and conflicting reports have addressed these concerns in the past. We aimed to evaluate the clinical presentation, hemodynamic and echocardiographic effects, as well as the outcomes of saddle PE, and compare the results with those of non-saddle type. This was a retrospective study of 432 adult patients with saddle and non-saddle PE. Overall, 432 patients were diagnosed with PE by computed tomography pulmonary angiography (CTPA). Seventy-three (16.9%) had saddle PE, and 359 had non-saddle PE. Compared to those with non-saddle PE, patients with saddle PE presented more frequently with tachycardia (68.5% vs. 46.2%, P= .001), and tachypnea (58.9% vs. 42.1%, P= .009) on admission, required more frequent intensive care unit (ICU) admissions (45.8% vs. 26.6%, P= .001) and thrombolysis/thrombectomy use (19.1% vs. 6.7%, P= .001), and were at more risk of developing decompensation and cardiac arrest after their initial admission (15.3% vs. 5.9%, P= .006). On echocardiography, right ventricular (RV) enlargement (60% vs. 31.1%, P= .000), RV dysfunction (45.8% vs. 22%, P= .000), and RV systolic pressure (RVSP) of greater than 40 mmHg (61.5% vs. 39.2%, P= .003) were significantly more observed with saddle PE. The two groups did not differ concerning the rates of hypotension (17.8% vs. 18.7%, P= .864) and hypoxemia (41.1% vs. 34.3%, P= .336) on admission and mortality rates. A logistic regression model indicated that the use of oral contraceptive pills (OCP), RVSP > 40 mmHg, and development of hypotension and decompensation following admission were associated with an increased likelihood of having saddle embolus. Saddle PE accounts for a higher proportion among all PE cases than previously reported. Patients with saddle PE tend to present more frequently with adverse hemodynamic and echocardiographic changes and decompensate after their initial presentation. OCP use, development of hypotension, and decompensation following admission and RVSP > 40 mmHg are significant predictors of saddle PE. These characteristics should not be overlooked when managing patients with saddle PE.

Sleep disturbances following recovery from COVID-19: a comparative cross-sectional study in Egypt.

BACKGROUND: Sequelae from COVID-19 are increasingly being reported, but sleep disturbances after recovery from the disease have had little attention. AIMS: This study aimed to identify and compare sleep disturbances and associated correlates among adults who have recovered from COVID-19 with those who have never been infected with the disease. METHODS: The sample included 85 adults who have recovered from COVID-19 and 85 adults who have never been infected (matched on age, sex, education and socioeconomic level). Individuals were recruited from Zagazig University Hospitals, Egypt from 1 September to 29 November 2020. Participants were interviewed using a sociodemographic and clinical checklist, the Pittsburgh Sleep Quality Index and the Hospital Anxiety Depression Scale. RESULTS: Most (77%) of the recovered cases had experienced sleep disturbances, compared with 46% of controls. Individuals who had recovered from COVID-19 were more likely to have poor subjective sleep quality (odds ratio (OR) 1.5, 95% confidence interval (CI): 1.1-2.1), prolonged sleep latency (OR 1.8, 95% CI: 1.3-2.6), shorter sleep duration (OR 1.6, 95% CI: 1.1-2.2), reduced sleep efficiency (OR 3.8, 95% CI: 2.0-7.1), frequent daytime dysfunction (OR 1.9, 95% CI: 1.2-3.1) and poor global Pittsburgh Sleep Quality Index score (OR 3.0, 95% CI: 1.5-6.0). Depressive (P = 0.002) and anxiety (P = 0.003) symptoms were associated with a poor global Pittsburgh Sleep Quality Index score among recovered female participants (P = 0,034) who had low-to-medium education level (P = 0.004). CONCLUSIONS: Further studies (e.g. population-based longitudinal studies) are needed on sleep disturbances as a potential sequelae of COVID-19, because it can impair mental and physical well-being.

Connectivity-Guided Theta Burst Transcranial Magnetic Stimulation Versus Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Moderate to Severe Depression: Magnetic Resonance Imaging Protocol and SARS-CoV-2-Induced Changes for a Randomized Double-blind Controlled Trial.

BACKGROUND: Depression is a substantial health and economic burden. In approximately one-third of patients, depression is resistant to first-line treatment; therefore, it is essential to find alternative treatments. Transcranial magnetic stimulation (TMS) is a neuromodulatory treatment involving the application of magnetic pulses to the brain that is approved in the United Kingdom and the United States in treatment-resistant depression. This trial aims to compare the clinical effectiveness, cost-effectiveness, and mechanism of action of standard treatment repetitive TMS (rTMS) targeted at the F3 electroencephalogram site with a newer treatment-a type of TMS called theta burst stimulation (TBS) targeted based on measures of functional brain connectivity. This protocol outlines brain imaging acquisition and analysis for the Brain Imaging Guided Transcranial Magnetic Stimulation in Depression (BRIGhTMIND) study trial that is used to create personalized TMS targets and answer the proposed mechanistic hypotheses. OBJECTIVE: The aims of the imaging arm of the BRIGhTMIND study are to identify functional and neurochemical brain signatures indexing the treatment mechanisms of rTMS and connectivity-guided intermittent theta burst TMS and to identify imaging-based markers predicting response to treatment. METHODS: The study is a randomized double-blind controlled trial with 1:1 allocation to either 20 sessions of TBS or standard rTMS. Multimodal magnetic resonance imaging (MRI) is acquired for each participant at baseline (before TMS treatment) with T1-weighted and task-free functional MRI during rest used to estimate TMS targets. For participants enrolled in the mechanistic substudy, additional diffusion-weighted sequences are acquired at baseline and at posttreatment follow-up 16 weeks after treatment randomization. Core data sets of T1-weighted and task-free functional MRI during rest are acquired for all participants and are used to estimate TMS targets. Additional sequences of arterial spin labeling, magnetic resonance spectroscopy, and diffusion-weighted images are acquired depending on the recruitment site for mechanistic evaluation. Standard rTMS treatment is targeted at the F3 electrode site over the left dorsolateral prefrontal cortex, whereas TBS treatment is guided using the coordinate of peak effective connectivity from the right anterior insula to the left dorsolateral prefrontal cortex. Both treatment targets benefit from the level of MRI guidance, but only TBS is provided with precision targeting based on functional brain connectivity. RESULTS: Recruitment began in January 2019 and is ongoing. Data collection is expected to continue until January 2023. CONCLUSIONS: This trial will determine the impact of precision MRI guidance on rTMS treatment and assess the neural mechanisms underlying this treatment in treatment-resistant depressed patients. TRIAL REGISTRATION: ISRCTN Registry ISRCTN19674644; https://www.isrctn.com/ISRCTN19674644. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31925.

Evaluation of perceived fears of COVID-19 virus infection and its relationship to health-related quality of life among patients with diabetes mellitus in Egypt during pandemic: a developing country single-center study.

AIMS/INTRODUCTION: COVID-19 pandemic and its associated circumstances had adversely affected patients with chronic diseases. This study aimed to assess the health-related quality of life (QoL), and identify its psychological and clinical correlates in patients with diabetes mellitus (DM) during pandemic in Egypt. MATERIALS AND METHODS: A cross-sectional study, using a convenience sampling technique, was conducted among patients with DM who were recruited from Zagazig University endocrinology outpatient clinics, Sharkia Province, Egypt from June 30 to September 29, 2020. A total of 200 consecutive patients were interviewed using a semistructured demographic and clinical checklist, the fear of COVID-19 scale (FCV-19S), the Hospital Anxiety and Depression Scale (HADS), and the short form 36 (SF-36) health survey. RESULTS: Poor physical and mental QoL was reported in 64% and 62% of patients with DM, respectively. Female gender, increased mean arterial pressure (MAP), associated physical comorbidities, and depressive symptoms were associated with lesser odds of physical QoL (OR 0.46, 0.96, 0.29, and 0.88, respectively). Besides, female gender, associated physical comorbidities, fear of COVID-19 virus infection (FCV), and depressive symptoms were associated with lesser odds of mental QoL (OR 0.41, 0.36, 0.91, and 0.84, respectively). The FCV was inversely correlated with all items of SF-36 among patients. CONCLUSION: QoL, either physical or mental, was adversely affected among patients with DM during pandemic. FCV was negatively correlated with all QOL domains. Longitudinal studies are warranted to explore the long-term effect of pandemic on the physical and mental well-being of patients with DM.

A Comparative Study of High-intensity Rosuvastatin Versus Atorvastatin Therapy Post-acute Coronary Syndrome Using Real-world Data.

A high-intensity statin is recommended for the secondary prevention of cardiovascular diseases (CVD). However, real-world evidence of the effectiveness of rosuvastatin following acute coronary syndrome (ACS) is scarce. This retrospective cohort study included patients diagnosed with ACS to compare between the 2 high-intensity statin therapies (rosuvastatin vs atorvastatin) in terms of a primary composite outcome of CVD-associated death, non-fatal ACS, and non-fatal stroke at 1 month and 12 months post discharge. The primary effectiveness outcome did not differ between the 2 groups at 1 month (1.3% vs 1%; aHR = 1.64, 95% CI 0.55-4.94, P= 0.379) and at 12 months (4.8% vs 3.5%; aHR = 1.48, 95% CI 0.82-2.67, P= 0.199). Similarly, the 2 groups had comparable safety outcomes. In conclusion, the use of high-intensity rosuvastatin compared to high-intensity atorvastatin therapy in patients with ACS had resulted in comparable cardiovascular effectiveness and safety outcomes.