Effectiveness of granulocyte colony-stimulating factor for patients with acute-on-chronic liver failure: a meta-analysis

BACKGROUND: The safety and efficacy of granulocyte colony-stimulating factor (G-CSF) for the treatment of acute-on-chronic liver failure (ACLF) remain uncertain. Therefore, we conducted a meta-analysis to draw a firmer conclusion. METHODS: We searched the Cochrane library, PubMed, Embase, and China Biology Medicine disc to identify relevant RCTs performed before January 2020. Risk ratios (RRs) and their 95% confidence intervals (95% CIs) were calculated using a random effects model. MAIN OUTCOME MEASURES: RRs (95% CI) for 1-, 2-, and 3-month survival rates. SAMPLE SIZE: Six RCTs, including three open-label studies. RESULTS: The six studies included 246 subjects (121 in a G-CSF group and 125 in a control group). G-CSF administration significantly improved the 1-, 2-, and 3-month survival rates in patients with ACLF. The pooled RRs (95% CI, P) were 0.43 (0.27–0.69, P =.0004), 0.44 (0.32–0.62, P <.00001), and 0.39 (0.22–0.68, P =.0009), respectively. CONCLUSION: G-CSF may be beneficial and effective in the treatment of ACLF, but further studies are needed to verify this conclusion. LIMITATIONS: The sample size was small, and studies were restricted to countries in Asia. PROSPERO REGISTRATION NUMBER: CRD42021225681 CONFLICT OF INTEREST: None.

Post-thyroidectomy complications in southwestern Saudi Arabia: a retrospective study of a 6-year period

BACKGROUND: Thyroidectomy is the surgical removal of all or part of the thyroid gland for non-neoplastic and neoplastic thyroid diseases. Major postoperative complications of thyroidectomy, including recurrent laryngeal nerve injury, hypocalcemia, and hypothyroidism, are not infrequent. OBJECTIVE: Summarize the frequency of surgical complications of thyroidectomy. DESIGN: Retrospective. SETTING: Secondary health facility in southwestern Saudi Arabia. PATIENTS AND METHODS: We collected data from the records of patients who were managed for thyroid diseases between December 2013 and December 2019. MAIN OUTCOME MEASURE: Complications following thyroidectomy. SAMPLE SIZE: 339 patients, 280 (82.6%) females and 59 (17.4%) males. RESULTS: We found 311 (91.7%) benign and 28 (8.3%) malignant thyroid disorders. Definitive management included 129 (38.1%) total thyroidectomies, 70 (20.6%) hemithyroidectomies, 10 (2.9%) subtotal thyroidectomies and 5 (1.5%) near-total thyroidectomies with 125 (36.9%) patients treated non-surgically. The overall complication rate was 11.3%. There were 4 (1.9%) patients with recurrent laryngeal nerve palsy, 16 (7.5%) patients with temporary hypoparathyroidism, 1 (0.5%) patient with paralysis of the external branch of the superior laryngeal nerve and 3 (1.4%) patients with wound hematoma. CONCLUSION: The rate of complications following thyroidectomy is still high. There is a need for emphasis on comprehensive measures to control the high rate of complications. LIMITATIONS: Retrospective design and no long-term follow up to monitor late complications. CONFLICT OF INTEREST: None.

Prognosis of patients hospitalized with a diagnosis of COVID-19 pneumonia in a tertiary hospital in Turkey

BACKGROUND: SARS-CoV2/COVID-19 emerged in China and caused a global pandemic in 2020. The mortality rate has been reported to be between 0% and 14.6% in all patients. In this study, we determined the clinical and laboratory parameters of COVID-19 related morbidity and mortality in our hospital. OBJECTIVES: Investigate the relationship between demographic, clinical, and laboratory parameters on COVID-19-related morbidity and mortality. DESIGN: Retrospective observational study. SETTINGS: Tertiary care hospital. PATIENTS AND METHODS: Patients diagnosed with COVID-19 pneumonia from March until the end of December were included in the study. MAIN OUTCOME MEASURES: The relationship between demographic, clinical, and laboratory parameters and the morbidity and mortality rates of patients diagnosed with COVID-19. SAMPLE SIZE: 124 patients RESULTS: The mortality rate was 9.6% (12/124). Coronary artery disease ( P <.0001) diabetes mellitus ( P =.04) fever (>38.3°C) at presentation ( P =.04) hypertension ( P <.0001), and positive smoking history ( P <.0001) were significantly associated with mortality. Patients who died were older, had a higher comorbid disease index, pneumonia severity index, fasting blood glucose, baseline serum creatinine, D-dimer, and had lower baseline haemoglobin, SaO 2 , percentage of lymphocyte counts and diastolic blood pressure. Patients admitted to the ICU were older, had a higher comorbidity disease index, pneumonia severity index, C-reactive protein, WBC, D-dimer, creatinine, number of antibiotics used, longer O 2 support duration, lower hemoglobin, lymphocyte (%), and baseline SaO 2 (%). CONCLUSIONS: Our results were consistent with much of the reported data. We suggest that the frequency, dosage, and duration of steroid treatment should be limited. LIMITATIONS: Low patient number, uncertain reason of mortality, no standard treatment regimen, limited treatment options, like ECMO. CONFLICT OF INTEREST: None.

Prognostic impact of human papillomavirus infection on cervical dysplasia, cancer, and patient survival in Saudi Arabia: A 10-year retrospective analysis

BACKGROUND: Data on human papillomavirus (HPV) prevalence and survival rates among HPV-infected women are scarce in Saudi Arabia. OBJECTIVE: Assess the prevalence of HPV genotypes in cervical biopsy specimens and its effect on survival over a 10-year timeframe. DESIGN: Retrospective, cross-sectional. SETTINGS: Saudi referral hospital. PATIENTS AND METHODS: Cervical biopsy specimens were collected from women aged 23-95 years old who underwent HPV detection, HPV genotyping, p16 INK4a expression measurement using immunohistochemistry. Kaplan-Meier plots were constructed to analyze overall survival rates. MAIN OUTCOME MEASURES: Survival rate of HPV-positive cervical cancer patients. SAMPLE SIZE: 315 cervical biopsy specimens. RESULTS: HPV was detected in 96 patients (30.4%): 37.3% had cervical cancer; 14.2% cervical intraepithelial neoplasia (CIN) III, 4.1% CIN II, and 17.0% CIN I. A significant association was found between HPV presence and cervical cancer (χ 2 =56.78; P <.001). The expression of p16 INK4a was a significant predictor of survival: women who had p16 INK4a overexpression had poorer survival rates (multivariate Cox regression, hazard ratio, 3.2; 95% CI, 1.1–8.8). In addition, multivariate models with HPV status and cervical cancer diagnosis showed that HPV status was a significant predictor of survival: HPV-positive women had better survival rates than HPV-negative women. CONCLUSION: These findings suggest that implementing cervical and HPV screening programs may decrease cervical cancer rates and improve survival rates of women in Saudi Arabia. LIMITATION: Single center and small sample size. CONFLICT OF INTEREST: None.

Abdominal aorta measurements by a handheld ultrasound device compared with a conventional cart-based ultrasound machine

BACKGROUND: Ultraportable or pocket handheld ultrasound devices (HUD) may be useful for large-scale abdominal aortic aneurysm screening. However, the reproducibility of measurements has not been compared with conventional cart-based ultrasound machines. OBJECTIVES: Investigate the intra- and inter-operator reproducibility of a HUD compared with a conventional ultrasound machine for aortic screening. DESIGN: Analytical, cross-sectional. SETTING: Ultrasound department at a large tertiary care hospital in Riyadh. PATIENTS AND METHODS: Eligible male participants aged ≥60 years were invited to participate upon arriving for a non-vascular ultrasound appointment. Three repeated anteroposterior measurements of the transverse aorta were made at the proximal and distal locations for each machine before repeating the measurements on a subset of participants by a second blinded operator. Intraclass correlation coefficients (ICC) and the Bland-Altman method were used to analyze reproducibility. MAIN OUTCOME MEASURE: Inter-system and intra- and inter-operator ICCs. SAMPLE SIZE: 114 males with repeated measurements by second operator on a subset of 35 participants. RESULTS: The median age (interquartile range) of participants was 68 years (62–74 years). The intra- and inter-operator ICCs were all >0.800 showing almost perfect agreement except for the inter-operator reproducibility at the proximal location using a conventional machine (ICC= 0.583, P =.007) and the Butterfly device (ICC=0.467, P =.037). The inter-system ICCs (95% CI) were 0.818 (0.736–0.874) and 0.879 (0.799–0.924) at the proximal and distal locations, respectively. The mean difference in aortic measurement between the ultrasound systems was 0.3 mm (1.7%) in the proximal location and 0.6 mm (3.6%) in the distal location. In total, >91% of the difference in measurements between the machines was <3 mm. The mean scanning time was 4:16 minutes for the conventional system and 3:53 minutes for the HUD ( P =.34). CONCLUSIONS: Abdominal aortic screening using a HUD was feasible and reliable compared with a conventional ultrasound machine. A pocket HUD should be considered for large-scale screening. LIMITATIONS: No cases of abdominal aortic aneurysm in the sample and lack of blinding. CONFLICT OF INTEREST: None.

Acute infrarenal abdominal aortic occlusion in a patient with COVID-19

A high rate of thrombotic complications have been observed in patients infected with COVID-19. These complications are related to increased blood hypercoagulabity, which can cause both venous and arterial thrombosis. We report a case of a 60-year-old man with COVID-19 pneumonia and thrombotic occlusion of the infrarenal abdominal aorta at the time of admission to the hospital. A CT scan showed a crazy-paving pattern in the lungs, consistent with COVID-19. A clinical suspicion of aortic thrombosis was confirmed by CT angiography. Embolectomy was undertaken a few hours later. At the end of the procedure, the patient was taken to the intensive care unit while intubated. The patient then worsened, developing severe renal failure, and died on day 1 after admission to the hospital. A CT scan, which is necessary for diagnosis of COVID-19, and a CT angiography, can be used to diagnose thrombotic events. It should be kept in mind that arterial thrombosis can be present not only in hospitalized COVID-19 patients but also at the time of admission. SIMILAR CASES PUBLSHED: 1

Early and late recurrences in lymph node-negative gastric cancer: a retrospective cohort study

BACKGROUND: Predictors of recurrence in patients with lymph node-negative gastric cancer (GC) who have undergone curative resection have been widely investigated, but not the effects of predictors on timing of recurrence. OBJECTIVE: Determine the factors associated with early and late recurrence in patients with node-negative GC. DESIGN: Retrospective cohort. SETTING: Academic tertiary care center. PATIENTS AND METHODS: The study included patients with node-negative GC after curative resection between 2008 and 2018 at two institutions. Early and late recurrences were determined using a minimum P value approach to evaluate the optimal cutoff for recurrence-free survival (RFS). A competing risk model and landmark analysis were used to analyze factors associated with early and late recurrences. MAIN OUTCOME MEASURES: Recurrence-free survival and factors associated with survival. SAMPLE SIZE: 606. RESULTS: After a median follow-up of 70 months, 50 (8.3%) patients experienced recurrent disease. The optimal length of RFS for distinguishing between early (n=26) and late recurrence (n=24) was 24 months ( P =.0013). The median RFS in the early and late recurrence groups was 11 and 32 months, respectively. Diffuse tumors (hazard ratio 3.358, P =.014), advanced T stage (HR 8.804, P =.003), perineural invasion (HR 10.955, P <.001), and anemia (HR 2.351, P =.018) were independent predictors of early recurrence. Mixed tumor location (HR 5.586, P =.002), advanced T stage (HR 5.066, P <.001), lymphovascular invasion (HR 5.902, P <.001), and elevated CA19-9 levels (HR 5.227, P <.001) were independent predictors of late recurrence. Similar results were obtained in the landmark analysis. CONCLUSIONS: Individualized therapeutic and follow-up strategies should be considered in future studies because of distinct patterns in predictors of early and late recurrence. LIMITATIONS: Retrospective design, small sample size. CONFLICT OF INTEREST: None.

Complications of intravascular intrauterine transfusion for Rh alloimmunization

BACKGROUND: Intravascular intrauterine transfusion (IUT) is considered a safe procedure, but complications still occur, including fatalities. OBJECTIVE: Review the outcomes of Rh alloimmunization, including indications and possible complications. DESIGN: Retrospective cohort (medical record review). SETTING: Tertiary care center. PATIENTS AND METHODS: We retrieved the records for all mothers who had an IUT for Rh alloimmunization between January 2009 and August 2019. We collected data on complications, post-transfusion hemoglobin and antibody combinations. MAIN OUTCOME MEASURE: Complications of IUT. SAMPLE SIZE: 119 mothers with 154 fetuses (154 different pregnancies). RESULTS: The 154 fetuses had 560 intrauterine transfusions. The median pre-IUT hemoglobin was a median of 8.0 g/dL while the median post-IUT hemoglobin 16 g/dL. Immediate procedure-related complications included fetal bradycardia in 2.7%, significant bleeding from the cord puncture site (for more than 2 minutes in 0.9%), and contractions in 0.9%. Eight (5.2%) were delivered by cesarean delivery due to IUT-specific complications such as post-procedure fetal bradycardia. Intrauterine fetal death complicated 8.4% of the pregnancies (13 fetuses). Phototherapy was required in 76 (49.4%), postnatal blood transfusions in 17 (11%), and exchange transfusion in 11 (7.1%). Neonatal death occurred 8 (5.2%). Data were insufficient to assess associations of complications with antibody combinations. CONCLUSIONS: Intrauterine transfusion is an effective treatment with high survival rates (around 90% for cases of Rh alloimmunization). LIMITATIONS: Case series. CONFLICT OF INTEREST: None.

Longitudinal effects of modified creatinine index on all-cause mortality in individuals receiving hemodialysis treatment

BACKGROUND: The modified creatinine index (mCI), as a surrogate marker of muscle mass, has been associated with poor outcomes in patients undergoing hemodialysis. However, a single assessment may not reflect the clinical significance before an adverse clinical endpoint. OBJECTIVE: Analyze mCI trajectories and their association with all-cause mortality in incident hemodialysis patients. DESIGN: Retrospective observational cohort. SETTING: Outpatient dialysis facility. PATIENTS AND METHODS: We followed a cohort of patients who underwent maintenance hemodialysis treatment at least three times weekly for at least three months from 19 June 2010 to 29 December 2017. Clinical and laboratory features were measured at baseline. Longitudinal changes in the mCI were modeled using a joint longitudinal and survival model adjusted for baseline covariates and body mass index trajectories. MAIN OUTCOME MEASURE: All-cause mortality. SAMPLE SIZE: 408 with 208 males (50.7%). RESULTS: The mean (SD) age was 62.2 (12.3) years. The mCI changes were evaluated for a median (interquartile range) follow-up of 2.16 (1.13, 3.73) years. Forty-six percent (n=188) of patients reached the endpoint. A steeper slope (per 0.1 unit increase in the decrease rate) in modified creatinine index was associated with increased risk of all-cause mortality (HR, 1.04; 95% CI, 1.02–1.07; P =.011). In addition, an annual 1 mg/kg/day decrease in modified creatinine index level increased the hazard of all-cause mortality by 4% (HR, 1.04; 95% CI, 1.02–1.07; P =.001). LIMITATIONS: Residual kidney function was not observed in the data. Setting was single center and thus results may not be generalizable to other populations. CONCLUSION: All-cause death was significantly associated with loss of muscle mass over time. Longitudinal trajectories of nutritional markers may predict the clinical outcomes in patients undergoing hemodialysis. This may also be valuable for individual risk stratification. Furthermore, early management may provide an opportunity to improve patient survival. CONFLICT OF INTEREST: None.

Characteristics and outcomes of 974 COVID-19 patients in intensive care units in Turkey

BACKGROUND: In our previous report on Turkish COVID-19 patients requiring intensive care, the 24 patients in a single ICU were elderly and mortality was high. We extended our analysis to include patients admitted to ten ICUs. OBJECTIVES: Report the demographics, clinical features, imaging findings, comorbidities, and outcomes in COVID-19 patients. DESIGN: Retrospective. SETTING: Intensive care unit. PATIENTS AND METHODS: The study includes patients with clinical and radiological confirmed or laboratory-confirmed COVID-19 infection who were admitted to ten ICUs between 15 March and 30 June 2020. MAIN OUTCOME MEASURES: Clinical outcomes, therapies, and death during hospitalization SAMPLE SIZE: 974, including 571 males (58%). RESULTS: The median age (range) was 72 (21–101) years for patients who died (n=632, 64.9%) and 70 (16–99) years for patients who lived (n=432, 35.2%) ( P <.001). APACHE scores, and SOFA scores were higher in patients who died than in those who survived ( P <.001, both comparisons). Respiratory failure was the most common cause of hospitalization (82.5%), and respiratory failure on admission was associated with death ( P =.013). Most (n=719, 73.8%) underwent invasive mechanical ventilation therapy. CONCLUSIONS: The majority of patients admitted to the ICU with a diagnosis of COVID-19 require respiratory support. LIMITATIONS: Although the Turkish Ministry of Health made recommendations for the treatment of COVID-19 patients, patient management may not have been identical in all ten units. CONFLICT OF INTEREST: None.