Aims: Accumulating evidence links COVID-19 incidence and outcomes with vitamin D status. We investigated if an interaction existed between vitamin D levels and social deprivation in those with and without COVID-19 infection. Methods: Upper- or lower-respiratory tract samples from 104 patients were tested for SARS-CoV-2 RNA in accordance with Public Health England criteria (January–May 2020) using RT-PCR. The latest serum total 25-hydroxyvitamin D(25-OHD) levels, quantified by LC-MS/MS, was obtained for each patient (September 2019–April 2020). Index of Multiple Deprivation (IMD) was generated for each patient. Univariate and logistic regression analyses examined associations between age, gender, 25-OHD, IMD score and SARS-CoV-2 result in the total cohort and subgroups. Results: In the total cohort, a positive SARS-CoV-2 test was significantly associated with lower 25-OHD levels and higher IMD. A positive test was associated with higher IMD in the male subgroup and with lower 25-OHD levels in those aged >72 years. Low 25-OHD and IMD quintile 5 were separately associated with positive COVID-19 outcome in the cohort. Patients in IMD quintile 5 with vitamin D levels ≤34.4 nmol/L were most likely to have a positive COVID-19 outcome, even more so if aged >72 years (OR: 19.07, 95%CI: 1.71–212.25; p=0.016). Conclusions: In this cohort, combined low vitamin D levels and higher social deprivation were most associated with COVID-19 infection. In older age, this combination was even more significant. Our data supports the recommendations for normalising vitamin D levels in those with deficient / insufficient levels and in groups at high-risk for deficiency.
The first suspect coronavirus in hydatidiform molar pregnancy accentuates the importance of taking into account the symptoms of Coronavirus in pregnancy, collaboration among physicians of various specialties, the role of convalescence home in continuing outpatient treatment with the aim to prevent the spread of the virus in the family environment.
Here we discuss a case of a middle-aged COVID-19 positive (on serology) female who presented with no symptoms pertaining to COVID-19 but with ITP related manifestations. The patient did not respond to platelet transfusion, but consecutive immunoglobulin infusion and steroid therapy resulted in a complete resolution.
Abstract: Aim: Coronavirus disease-2019 is an emerging disease that is threatening the world with a rapid increase in cases and deaths since it was first identified in December 2019. Our study aimed to assess the knowledge, practice, and attitude toward COVID-19 among physicians in Jordan and Palestine. Method: This is a cross-sectional study using an online survey conducted in April, 2020. A 36-items survey was developed and invitations were sent to physicians in different health sectors using social media. Results: A total of 454 physicians participated in this study with a mean age 36.2 10.8 years. The mean score of basic knowledge was 4.4 0.8, and there were significant statistical differences between basic knowledge mean scores among physicians in different professional degrees and physicians in different health sectors (P=0.0315, P=0.0137 respectively). Participants showed appropriate practical measures toward COVID-19, where the mean scores of indications for PCR test, indications for home quarantine, self-protection measures, and measures if physician self-suspected of COVID-19 were 5.4 1.4, 5.0 1.0, 6.1 1.1, 9.9 1.1 respectively. The mean score of attitudes toward COVID-19 were 41.5 3.3 and significantly related to the age and different experience years (P=0.0022, P=0.0077 respectively). Conclusion: As the global threat of COVID-19 continues to emerge, it is critical to improve the knowledge, practice, and attitudes of physicians worldwide.
Background: Arteriovenous access (AV) thrombosis is important and preventable problem among chronic hemodialysis (HD) patients. On the other hand, systolic blood pressure (SBP) alteration relates with higher cardiovascular mortality among these patients. In this study, we investigated the relation between SBP changes and arteriovenous access (AV) thrombosis. Methods: 50 HD patients with thrombosis and 50 HD patients without thrombosis were included in the study. Odds ratios and 95% confidence intervals were estimated with multivariate adjusted logistic regression models to determine the association between potential thrombosis-related risk factors and thrombosis risk. Results: Elder adults, women, and patients with arteriovenous grafts, lower intradialytic SBP and higher SBP variations during dialysis sessions had higher incidence of AV access thrombosis. Chronic inflammation and mineral metabolism related parameters were also found to be abnormal at the time of AV access thrombosis. Conclusions: Close monitoring and management of intra-dialytic hypotension, SBP variation in every dialysis session and correction of biochemical parameters are critical for earlier identification and prevention of AV access thrombosis in HD patients.
Introduction Although five-year survival rates for childhood cancer have surpassed 85%, childhood cancer survivors continue to suffer from long-term effects decades after treatment completion. The prevalence of pulmonary dysfunction is very common at 65.2% in adulthood. This study explores early changes in the trajectory of pulmonary function in pediatric cancer patients who received pulmonary toxic therapy. Methods In this single-center, retrospective cohort study, we included pediatric cancer patients diagnosed at <18 years old between January 1994 and December 2014. Patients were included if they received pulmonary toxic exposure: either chemotherapy (bleomycin, busulfan, lomustine carmustine or cyclophosphamide) or thoracic radiation. Outcomes included percent predicted values for spirometry, lung volumes, and diffusion capacity of the lungs post-treatment. Results Of 86 children who met inclusion criteria, 99% received pulmonary toxic chemotherapy, and 79% received thoracic radiotherapy. Patients showed an overall decrease in all three lung function parameters immediately post-treatment. Between one- and four-years post-treatment, there was a larger sustained decline in percent predicted lung function parameters for females (mean Forced Expiratory Volume in 1 Second, FEV1=81.0% ±15.7) than males (FEV1=93.2% ±10.2). Sensitivity analysis of 65 children who received radiation and bleomycin revealed pulmonary function trends similar to the overall population. Conclusions Our results reveal that male and female patients experience different lung function trajectories following pulmonary toxic cancer treatment, with females performing more poorly over time despite similar baseline function. Further research is needed to better understand the factors associated with poor lung function and impaired recovery post-treatment, particularly in females.
OBJECTIVES Surgery in COVID-19 patients carries a significant mortality and morbidity but the appropriate waiting period before a surgical intervention after recovering from COVID-19 is not known. We aim to determine the safety of deferring urgent surgery and to identify the earliest safe period for surgery by analysing our experience in patients who underwent cardiac surgery after recovering from COVID-19. METHODS Analysis of all patients undergoing cardiac surgery in our centre during March and April 2020, focusing in those who tested positive for COVID-19 in the pre-operative screening. RESULTS Four patients tested positive for COVID-19 during the preoperative screening. Two of them also showed radiological signs of COVID-19 lung disease. We delayed surgery until they tested negative and the radiological changes improved. None of the patients suffered a deterioration of their cardiac symptoms that mandated expediting the surgeries. As a result of waiting until COVID-19 resolution, all our patients survived the urgent cardiac surgery without developing any COVID-19-related complications. CONCLUSIONS From our experience, defering urgent cardiac surgery in patients with confirmed COVID-19 is safe. Operating as early as 4 days after a negative swab does not increase mortality and morbidity.
Background: The situation of the corona virus disease 2019(COVID-19) continues to evolve, our study explored the significance of serum levels of Matrix Metalloproteinase 3 (MMP3) as a marker for patients with COVID-19. Methods: Sixty-two COVID-19 patients in the First Hospital of Hunan University of Chinese Medicine and Loudi Center for Diseases Prevention and Control, from January to March 2020, were sampled as the novel coronavirus pneumonia infected group. One hundred and thirty-one cases from the First Hospital of Hunan University of Chinese Medicine, including 67 healthy individuals and 64 non- COVID-19 inpatients, served as the non-infected group. Approximately every 5 d, sera from 20 cases were collected and analyzed thrice, using an automatic biochemical analyzer, to detect serum MMP3 concentrations. Following normality tests, differences in serum MMP3 levels between the infected and non-infected group were analyzed via SPSS (version 25.0) software, using the Wilcoxon rank sum test. Results: The MMP3 concentration was 44.44（23.46~72.12）ng/ml in the infected group and 32.42 (28.16~41.21）ng/ml in the non-infected group. The difference between the two groups was statistically significant (Z=-2.799, P=0.005<0.05). Serum MMP3 concentration, measured over three separate time points, were 55.98 (30.80~75.97) ng/ml, 34.84 (0.00~51.84) ng/ml, and 5.71 (0.00~40.46) ng/ml, respectively. Conclusion: Detection of serum MMP3 levels may play an important role in the development of therapeutic approaches for COVID-19 and may indicate the severity of disease.
Mitotane is the only drug approved for treating adrenocortical carcinoma (ACC) by the FDA since 1959, despite the controversy regarding its efficacy in prolonging patient survival. This drug has cytotoxic effects on tumor tissue by inducing cell death and antisecretory effects on adrenal cells by inhibiting the synthesis of adrenocortical steroids involved in the pathogenesis of ACC. To reach the therapeutic plasma concentration, high doses of mitotane are usually necessary, which may result in several adverse effects. This suggests that important pharmacological features are involved in the mechanisms of action of this drug, such as first pass metabolism, tissue accumulation, and extensive time needed for drug elimination. However, few studies have reported the pharmacological aspects of mitotane, and they did not provide sufficient evidence regarding monitoring mitotane’s therapeutic effects. Therefore, this review summarized the chemistry, pharmacokinetics and pharmacodynamics, therapeutic effects, toxic effects, and new perspectives of mitotane treatment that are currently under investigation. Understanding the pharmacological profile of mitotane can improve the monitoring and efficacy of this drug in ACC treatment and can further provide useful information for the development of new drugs with specific action against ACC with fewer adverse effects.
Angiotensin-converting enzyme 2 (ACE 2) is the entry receptor for the novel coronavirus SARS-CoV-2, the aetiological agent of COVID-19. At the same time, ACE 2 expression decreases during COVID-19. Two seemingly contradictory relationships between the expression of ACE 2 and COVID-19 have been reported. Increased level of expression of ACE 2 may be a risk factor for the development of COVID-19 infection, while reduced ACE 2 expression during COVID-19 leads to acute respiratory distress syndrome. This article provides a comprehensive overview of available scientific knowledge about the role of ACE 2 in the pathogenesis of COVID-19, which is available up to current day. Also, it discusses unknown factors that we will have to reveal in order to understand the whole role of ACE 2 in the pathogenesis of COVID-19.
Background: The induction of labour has been increasing over the last decade. It is most often indicated when the safety of the baby or mother may be compromised. Objectives: This study aims to assess the quality of systematic reviews that examined the efficacy and/or safety of various methods of induction of labour. Search Strategy: An electronic database search of MEDLINE, Embase, and the Cochrane Library was conducted. The search strategy can be found in the online supplement. Selection Criteria: Systematic reviews that examined various methods of induction of labour. Inclusion and exclusion criteria can be found in the main text. Data Collection and Analysis: Study characteristics such as journal and impact factor, year of publication, source of funding, citation rate, etc. were retrieved. Quality assessment was conducted using A Measurement Tool to Assess Systematic Reviews (AMSTAR). Main Results: There were no significant relationships between mean AMSTAR score and number of citations (p=0.0875, r=0.25; 95% CI, -0.04 to 0.50), journal impact factor (p=0.2959, r=-0.15; 95% CI, -0.42 to 0.14), or publication year (p=0.5827, r=0.08; 95% CI, -0.20 to 0.36). Cochrane studies on average scored higher than non-Cochrane studies (p=0.01). No significant differences were detected between the AMSTAR scores of government and non-government funded studies (p=0.34). Conclusions: Better adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and for peer reviewers to appraise new systematic reviews with methodological assessment tools would enhance confidence in review conclusions.
Corona Virus Disease 2019 is an RNA virus that currently affecting more than 210 countries, more than 3,221,617 cases, and 228,263 deaths are reported till April 28, 2020. There is a knowledge gap regarding the incidence proportion of asymptomatic and symptomatic infection so that public health interventions can be reviewed. We searched the original articles in google Scholar for articles that were published from January 1 through May 5 2020, and country updated reports of coronavirus disease. Finally, reviewed to compile and make conclusions. Different epidemiologic studies support the possibility of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detected could able to transmit during the asymptomatic state. SARS-CoV-2 transmission in the absence of symptoms reinforces the value of measures that prevent the spread of SARS-CoV-2 by infected persons who may not exhibit illness despite being infectious. The existence of persons with asymptomatic SARS-CoV-2 infection who are capable of transmitting had many implications. The case-fatality rate for COVID-19 may be lower or inaccurate, reinforces the value of community interventions, and could enhance the need to increase the capacity for widespread testing and thorough contact tracing.
Objectives: The aim of this study is to evaluate the hematologic parameters and peripheral blood cell morphological changes in children with COVID-19 and compare them with those of children suspected but then confirmed to be negative for SARS-CoV-2. Methods: Thirty children were tested to be positive for SARS-CoV-2 and the remaining 40 were negative. Hemoglobin, leukocyte, neutrophil, lymphocyte, monocyte counts according to age-specific intervals, platelet, large unstained cell counts, and delta neutrophil index were recorded. Differential counts were formulated by manual counting and morphology of the blood cells were evaluated. Results: The mean leukocyte counts of the SARS-CoV-2 positive and negative groups were 7.0 ± 3.7x109/L and 10.4 ± 7.1x109/L, respectively (p<0.05). Nine (30%) children with COVID-19 had lymphopenia. Among children with COVID-19, absolute lymphocyte count was lower in those with pneumonia (p<0.05). Reactive lymphocytes were noted in 77.8% and 90% in the SARS-CoV-2 test positive and negative groups, respectively (p>0.05). Mean absolute neutrophil counts of the SARS-CoV-2 test positive and negative groups were 3.7±2.9 x109/L and 5.4±4.2 x109/L (p<0.05). Four patients (13.3%) with SARS-CoV-2 test positive had neutrophilia and seven (23.3%) had mild neutropenia. In the peripheral smear, vacuolated monocytes and dysplastic changes in neutrophils and platelets were noted in both groups. Conclusions: Leukocyte, neutrophil and monocyte counts were significantly lower in children with COVID-19 compared with symptomatic children without COVID-19. Lymphopenia, reactive lymphocytosis and dysplasia, could be noted in children with COVID-19. Further studies on hematological findings linked with the course of the disease in children are warranted.
The third ovary- Superfluous ovaryThis is a case of a 25-year-old female with normal female karyotype, who presented to us with primary infertility. Investigations revealed AMH level of 9ng/ml. On ultrasound imaging, two ovary-like structure with follicles on the left (in different planes) and one ovary on the right were visualized. With this ambiguity, patient consented for diagnostic laparoscopy.Intraoperative: there was one, phenotypically normal uterus, 2 fallopian tubes, all in anatomically normal position were noted. Two ovaries on the left side, placed at the normal anatomical position were visualized. Both ovaries had one ovarian ligament each. However, only the lateral one of the two on the left side was attached with the infundibulopelvic ligament. Right side had one normally placed ovary with normal attachments. Biopsy from the ovary without the infundibulopelvic ligament confirmed ovarian tissue on histopathology. Figure 1 and 2 are the labelled and unlabelled, respectively, laparoscopic images of our finding.The occurrence of more than 2 ovaries is a rare entity. Multiple theories have been proposed to explain the presence of the third ovary. Wharton1, in 1959, highlighted the association of supernumerary ovaries with congenital malformations involving urogenital system. In 1963, Pearl et al2, suggested that when the migration of some primitive germ cells is arrested at some point during the course of normal migration to the gonadal ridges, their inductive influence on the surrounding epithelium leads to the formation of ectopic ovarian tissue. In 1973, Printz et al3, suggested the possibility of gonadal ridge transplantation or migration. Lachman4, in 1991, hypothesized that supernumerary ovaries may be secondary to implantation of dislodged ovarian tissue due to previous pelvic surgery or pelvic inflammatory disease.With this literature, terminology and classification relevant to our finding, were suggested which are now commonly used. Those are as follows:1. Supernumerary ovaries: ovarian tissue entirely separated from the normally placed ovary. There is no ligamentous or direct connection with the ovaries, broad ligament, utero-ovarian ligament or infundibulo-pelvic ligament and it arises from a separate primordium1.2. Accessory ovary: the excess ovarian tissue is situated near the normally placed ovary, may be connected with, and seems to have developed from it, possibly from tissue that was split from the embryonic ovary during early development1.3. Ectopic ovary: the term was used by Lachman in 1991 to replace both terms, supernumerary and accessory ovary. It describes any ovarian tissue additional to normal ovaries with further sub-classification as post- surgical implant, post-inflammatory implant or true (embryogenic)4.The condition that we encountered, does not fit in the above-mentioned terminologies thereby making it unique. The presence of the third ovarian ligament excludes this condition to be termed as supernumerary or duplication or accessory ovary. Hence, the rarity of this observation or occurrence is worth reporting. We think the term “superfluous ovary” is a good descriptor of this condition. Embryologically, superfluous ovary may have developed due to the excessive mesenchymal proliferation on one side, due to which thicker gubernaculum was formed that subsequently duplicated. The excess of the mesenchymal cells could be the reason for double gonadal ridges on one side thereby forming superfluous ovary on one side only.The superfluous ovary, in our case, was functional. This could be explained with the fact that it responded to the ovarian stimulation. Though the literature suggests that ectopic tissue should be removed due to their possibility of malignant transformation, we could not justify removing this unusual presence of a fully functioning superfluous ovary. Subsequent follow-up will explain the fate of this unique occurrence.References:1. Wharton L.R. (1959) Two cases of supernumerary ovary and one of accessory ovary with an analysis of previously reported cases. American Journal of Obstetrics and Gynecology, 78, 1101–1109.2. Pearl M, Plotz EJ. Supernumerary ovary. Report of a case. Obstet Gynecol 1963;21:253‑6.3. Printz JL, Choate JW, Townes PL, Harper RC. The embryology of supernumerary ovaries. Obstet Gynecol 1973;41:246‑52.4. Lachman M.F. and Berman M.M. (1991) The ectopic ovary, a case report and review of the literature. Archives of Pathology Laboratory Medicine, 115, 233–235.
Primary bone composite sarcoma is a very rare entity that primarily affects adolescent and young adult patients. It usually combines areas of liposarcoma and osteosarcoma and up to 60% of cases have metastatic disease at diagnosis. It is a highly aggressive pathology with intrinsic resistance to conventional treatment schemes for bone sarcomas. The prognosis is poor, with long term survival rates that do not exceed 30%. We present the case of an adolescent female diagnosed with a primary agressive bone composite sarcoma with rhabdomyosarcoma foci and loco-regional lymph node involvement.
Our purpose is to assess epidemiological agent-based models– or ABMs - of the SARS-CoV-2 pandemic methodologically. The rapid spread of the outbreak requires fast-paced decision-making regarding mitigation measures. However, the evidence for the efficacy of non-pharmaceutical interventions such as imposed social distancing and school or workplace closures is scarce: few observational studies use quasi-experimental research designs, and conducting randomized controlled trials seems infeasible. Additionally, evidence from the previous coronavirus outbreaks of SARS and MERS lacks external validity, given the significant differences in contagiousness of those pathogens relative to SARS-CoV-2. To address the pressing policy questions that have emerged as a result of COVID-19, epidemiologists have produced numerous models that range from simple compartmental models to highly advanced agent-based models. These models have been criticized for involving simplifications and lacking empirical support for their assumptions. In order to address these voices and methodologically appraise epidemiological ABMs, we consider AceMod (the model of the COVID-19 epidemic in Australia) as an example of the modeling practice. Our case study shows that, although epidemiological ABMs involve simplifications of various sorts, the key characteristics of social interactions and the spread of SARS-CoV-2 are represented sufficiently accurately. This is the case because these modelers treat empirical results as inputs for constructing modeling assumptions and rules that the agents follow; and they use calibration to assert the adequacy to benchmark variables. Given this, we claim that the best epidemiological ABMs are models of actual mechanisms and deliver both mechanistic and difference-making evidence. Furthermore, the efficacy claims are not only internally valid but also adequately describe the effects of interventions in the targets of the models. We also discuss the limitations of ABMs and put forward policy recommendations.