Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

In December 2019, a novel coronavirus was isolated from the respiratory epithelium of patients with unexplained pneumonia in Wuhan, China. This pathogen, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes a pathogenic condition that has been termed coronavirus disease 2019 (COVID-19) and has reached pandemic proportions. As of 17 September 2020, more than 30 million confirmed SARS-CoV-2 infections have been reported in 204 different countries, claiming more than 1 million lives worldwide. Accumulating evidence suggests that SARS-CoV-2 infection can lead to a variety of clinical conditions, ranging from asymptomatic to life-threatening cases. In the early stages of the disease, most patients experience mild clinical symptoms, including a high fever and dry cough. However, 20% of patients rapidly progress to severe illness characterized by atypical interstitial bilateral pneumonia, acute respiratory distress syndrome and multiorgan dysfunction. Almost 10% of these critically ill patients subsequently die. Insights into the pathogenic mechanisms underlying SARS-CoV-2 infection and COVID-19 progression are emerging and highlight the critical role of the immunological hyper-response - characterized by widespread endothelial damage, complement-induced blood clotting and systemic microangiopathy - in disease exacerbation. These insights may aid the identification of new or existing therapeutic interventions to limit the progression of early disease and treat severe cases.

/pdf/immunity-endothelial-injury-and-complement-induced-32uniklkq5.pdf

Immunity, endothelial injury and complement-induced coagulopathy in COVID-19.

Background Convalescent plasma and hyperimmune immunoglobulin may reduce mortality in patients with viral respiratory diseases, and are currently being investigated in trials as potential therapy for coronavirus disease 2019 (COVID-19). A thorough understanding of the current body of evidence regarding the benefits and risks is required. OBJECTIVES: To continually assess, as more evidence becomes available, whether convalescent plasma or hyperimmune immunoglobulin transfusion is effective and safe in treatment of people with COVID-19. Search methods We searched the World Health Organization (WHO) COVID-19 Global Research Database, MEDLINE, Embase, Cochrane COVID-19 Study Register, Centers for Disease Control and Prevention COVID-19 Research Article Database and trial registries to identify completed and ongoing studies on 4 June 2020. Selection criteria We followed standard Cochrane methodology. We included studies evaluating convalescent plasma or hyperimmune immunoglobulin for people with COVID-19, irrespective of study design, disease severity, age, gender or ethnicity. We excluded studies including populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)) and studies evaluating standard immunoglobulin. Data collection and analysis We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane 'Risk of bias' tool for randomised controlled trials (RCTs), the Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tool for controlled non-randomised studies of interventions (NRSIs), and the assessment criteria for observational studies, provided by Cochrane Childhood Cancer for non-controlled NRSIs. MAIN RESULTS: This is the first living update of our review. We included 20 studies (1 RCT, 3 controlled NRSIs, 16 non-controlled NRSIs) with 5443 participants, of whom 5211 received convalescent plasma, and identified a further 98 ongoing studies evaluating convalescent plasma or hyperimmune immunoglobulin, of which 50 are randomised. We did not identify any completed studies evaluating hyperimmune immunoglobulin. Overall risk of bias of included studies was high, due to study design, type of participants, and other previous or concurrent treatments. Effectiveness of convalescent plasma for people with COVID-19 We included results from four controlled studies (1 RCT (stopped early) with 103 participants, of whom 52 received convalescent plasma; and 3 controlled NRSIs with 236 participants, of whom 55 received convalescent plasma) to assess effectiveness of convalescent plasma. Control groups received standard care at time of treatment without convalescent plasma. All-cause mortality at hospital discharge (1 controlled NRSI, 21 participants) We are very uncertain whether convalescent plasma has any effect on all-cause mortality at hospital discharge (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.61 to 1.31; very low-certainty evidence). Time to death (1 RCT, 103 participants; 1 controlled NRSI, 195 participants) We are very uncertain whether convalescent plasma prolongs time to death (RCT: hazard ratio (HR) 0.74, 95% CI 0.30 to 1.82; controlled NRSI: HR 0.46, 95% CI 0.22 to 0.96; very low-certainty evidence). Improvement of clinical symptoms, assessed by need for respiratory support (1 RCT, 103 participants; 1 controlled NRSI, 195 participants) We are very uncertain whether convalescent plasma has any effect on improvement of clinical symptoms at seven days (RCT: RR 0.98, 95% CI 0.30 to 3.19), 14 days (RCT: RR 1.85, 95% CI 0.91 to 3.77; controlled NRSI: RR 1.08, 95% CI 0.91 to 1.29), and 28 days (RCT: RR 1.20, 95% CI 0.80 to 1.81; very low-certainty evidence). Quality of life No studies reported this outcome. Safety of convalescent plasma for people with COVID-19 We included results from 1 RCT, 3 controlled NRSIs and 10 non-controlled NRSIs assessing safety of convalescent plasma. Reporting of adverse events and serious adverse events was variable. The controlled studies reported on adverse events and serious adverse events only in participants receiving convalescent plasma. The duration of follow-up varied. Some, but not all, studies included death as a serious adverse event. Grade 3 or 4 adverse events (13 studies, 201 participants) The studies did not report the grade of adverse events. Thirteen studies (201 participants) reported on adverse events of possible grade 3 or 4 severity. The majority of these adverse events were allergic or respiratory events. We are very uncertain whether or not convalescent plasma therapy affects the risk of moderate to severe adverse events (very low-certainty evidence). Serious adverse events (14 studies, 5201 participants) Fourteen studies (5201 participants) reported on serious adverse events. The majority of participants were from one non-controlled NRSI (5000 participants), which reported only on serious adverse events limited to the first four hours after convalescent plasma transfusion. This study included death as a serious adverse event; they reported 15 deaths, four of which they classified as potentially, probably or definitely related to transfusion. Other serious adverse events reported in all studies were predominantly allergic or respiratory in nature, including anaphylaxis, transfusion-associated dyspnoea, and transfusion-related acute lung injury (TRALI). We are very uncertain whether or not convalescent plasma affects the number of serious adverse events. Authors' conclusions We are very uncertain whether convalescent plasma is beneficial for people admitted to hospital with COVID-19. For safety outcomes we also included non-controlled NRSIs. There was limited information regarding adverse events. Of the controlled studies, none reported on this outcome in the control group. There is only very low-certainty evidence for safety of convalescent plasma for COVID-19. While major efforts to conduct research on COVID-19 are being made, problems with recruiting the anticipated number of participants into these studies are conceivable. The early termination of the first RCT investigating convalescent plasma, and the multitude of studies registered in the past months illustrate this. It is therefore necessary to critically assess the design of these registered studies, and well-designed studies should be prioritised. Other considerations for these studies are the need to report outcomes for all study arms in the same way, and the importance of maintaining comparability in terms of co-interventions administered in all study arms. There are 98 ongoing studies evaluating convalescent plasma and hyperimmune immunoglobulin, of which 50 are RCTs. This is the first living update of the review, and we will continue to update this review periodically. These updates may show different results to those reported here.

Convalescent plasma or hyperimmune immunoglobulin for people with COVID-19: a living systematic review.

Background

Rapid diagnostic tests (RDTs) for Plasmodium falciparum malaria use antibodies to detect either HRP-2 antigen or pLDH antigen, and can improve access to diagnostics in developing countries.

Objectives

To assess the diagnostic accuracy of RDTs for detecting P. falciparum parasitaemia in persons living in endemic areas who present to ambulatory healthcare facilities with symptoms suggestive of malaria by type and brand.

Search strategy

We undertook a comprehensive search of the following databases:Cochrane Infectious Diseases Group Specialized Register; MEDLINE; EMBASE; MEDION; Science Citation Index; Web of Knowledge; African Index Medicus; LILACS; IndMED; to January 14, 2010.

Selection criteria

Studies comparing RDTs with a reference standard (microscopy or polymerase chain reaction) in blood samples from a random or consecutive series of patients attending ambulatory health facilities with symptoms suggestive of malaria in P. falciparum endemic areas.

Data collection and analysis

For each study, a standard set of data was extracted independently by two authors, using a tailored data extraction form. Comparisons were grouped hierarchically by target antigen, and type and brand of RDT, and combined in meta-analysis where appropriate.

Main results

We identified 74 unique studies as eligible for this review and categorized them according to the antigens they detected. Types 1 to 3 include HRP-2 (from P. falciparum) either by itself or with other antigens. Types 4 and 5 included pLDH (from P. falciparum) either by itself or with other antigens. In comparisons with microscopy, we identified 71 evaluations of Type 1 tests, eight evaluations of Type 2 tests and five evaluations of Type 3 tests. In meta-analyses, average sensitivities and specificities (95% CI) were 94.8% (93.1% to 96.1%) and 95.2% (93.2% to 96.7%) for Type 1 tests, 96.0% (94.0% to 97.3%) and 95.3% (87.3% to 98.3%) for Type 2 tests, and
99.5% (71.0% to 100.0%) and 90.6% (80.5% to 95.7%) for Type 3 tests, respectively.

Overall for HRP-2, the meta-analytical average sensitivity and specificity (95% CI) were 95.0% (93.5% to 96.2%) and 95.2% (93.4% to 99.4%), respectively.

For pLDH antibody-based RDTs verified with microscopy, we identified 17 evaluations of Type 4 RDTs and three evaluations of Type 5 RDTs. In meta-analyses, average sensitivity for Type 4 tests was 91.5% (84.7% to 95.3%) and average specificity was 98.7% (96.9% to 99.5%). For Type 5 tests, average sensitivity was 98.4% (95.1% to 99.5%) and average specificity was 97.5% (93.5% to 99.1%).

Overall for pLDH, the meta-analytical average sensitivity and specificity (95% CI) were 93.2% (88.0% to 96.2%) and 98.5% (96.7% to 99.4%), respectively.

For both categories of test, there was substantial heterogeneity in study results. Quality of the microscopy reference standard could only be assessed in 40% of studies due to inadequate reporting, but results did not seem to be influenced by the reporting quality.

Overall, HRP-2 antibody-based tests (such as the Type 1 tests) tended to be more sensitive and were significantly less specific than pLDH-based tests (such as the Type 4 tests). If the point estimates for Type 1 and Type 4 tests are applied to a hypothetical cohort of 1000 patients where 30% of those presenting with symptoms have P. falciparum, Type 1 tests will miss 16 cases, and Type 4 tests will miss 26 cases. The number of people wrongly diagnosed with P. falciparum would be 34 with Type 1 tests, and nine with Type 4 tests.

Authors’ conclusions

The sensitivity and specificity of all RDTs is such that they can replace or extend the access of diagnostic services for uncomplicated P. falciparum malaria. HRP-2 antibody types may be more sensitive but are less specific than pLDH antibody-based tests, but the differences are small. The HRP-2 antigen persists even after effective treatment and so is not useful for detecting treatment failures.

Rapid diagnostic tests for diagnosing uncomplicated P. falciparum malaria in endemic countries

Attitudes, acceptance and hesitancy among the general population worldwide to receive the COVID-19 vaccines and their contributing factors: A systematic review.

Gall bladder cancer carries a dismal prognosis especially in advanced cases. Common sites of metastases include liver, lung and unusual sites have also been reported like orbit, cutaneous, adrenal, kidney, breast and thyroid. 66 years female diagnosed case of metastatic carcinoma gall bladder presented with bilateral inguinal lymphadenopathy. Cytology aspirate from inguinal node reported metastatic adenocarcinoma. Inguinal node metastases from gall bladder cancer is very rare and few case reports have been published. We present a case of a woman with advanced cancer of the gall bladder, who presented with bilateral inguinal metastases.

/pdf/inguinal-lymphadenopathy-in-carcinoma-gall-bladder-an-2y5gy2oz20.pdf

Inguinal Lymphadenopathy in Carcinoma Gall Bladder: An Unusual Site of Metastasis

The present study investigated the effects of alloying and nano-reinforcement on the mechanical properties (microhardness, tensile strength, and compressive strength) of Mg-based alloys and composites. Pure Mg, Mg-3Sn alloy, and Mg-3Sn + 0.2 GNP alloy-nanocomposite were synthesized by powder metallurgy followed by hot extrusion. The microstructural characteristics of the bulk extruded samples were explored using X-ray diffraction, field-emission scanning electron microscopy, and optical microscopy and their mechanical properties were compared. The microhardness, tensile strength, and compressive strength of the Mg-3Sn alloy improved when compared to those of monolithic Mg sample and further improvements were displayed by Mg-3Sn + 0.2 GNP alloy-nanocomposite. No significant change in the compressive strain to failure was observed in both the alloy and the alloy-nanocomposite with respect to that of the pure Mg sample. However, an enhanced tensile strain to failure was displayed by both the alloy and the alloy-nanocomposite.

/pdf/mechanical-characterization-of-graphene-nanoplatelets-75utfsnhw4.pdf

Mechanical Characterization of Graphene Nanoplatelets-Reinforced Mg-3Sn Alloy Synthesized by Powder Metallurgy

Objective:  India ranks second as medical travel destination in the world after Thailand, but still a very limited research has been done so far to assess the perception of international patients regarding travel to India for medical services. Objective: To assess the perception of the patients coming across international borders regarding their preference to chose India for medical services. Methods:  This was a cross sectional hospital based study which was conducted for a period of 3 months. It was an analytical type of research where 100 international patients were interviewed from 11 different hospitals spread across whole India (representing North and South India). A semi-structured interview scheduled with a five point Likert type scale was used fulfill the objective of the study. Results:  More than 80\% of patients were agree with the fact that there is deficiency of quality of care and proper infrastructure in health facilities in their country. majority (> 80\%) of patients were strongly agree or agree to the facts that India has top qualified medical professionals and latest technology for treatment, there is less waiting time for treatment procedure and the treatment is cost effective. Conclusion:  Considering the perception of international patients, there is need and scope to improve and expand the health service delivery in India to reap the benefits of medical travel to the maximum possible extent.

/pdf/perception-of-international-patients-regarding-cross-border-o7ve8c38h8.pdf

Perception of international patients regarding cross border movement for medical services in India

Introduction Due to the nature of the coronavirus disease 2019 (COVID-19) pandemic, final year medical undergraduate students have had to be involved in patient management in different countries. The same was the case with India. This study was conducted with the objective to analyze the effectiveness and efficiency of preparedness training to combat COVID-19 in pre-final and final-year medical students at a tertiary care institute in North India. Methods A pre-post study was conducted among final and pre-final year medical undergraduate students. Data was collected as pre-test and post-test multiple-choice questions (MCQs) and clinical vignettes. Results A total of 179 medical undergraduate students attended the training. Scores on general instructions, personal protective equipment (PPE) donning and doffing, hand hygiene, biomedical waste management, contact tracing, cleaning and disinfection, ECG, and COVID-19 management improved significantly after the training. Pre-test scores on ECG, simulation, COVID-19 management were 21.58±5.311, 17.05±4.501, and 23.84±4.067, respectively. Post-test scores on ECG, simulation, COVID-19 management were 28.01±6.826, 23.84±4.067, and 6.93±1.726, respectively. Pre-test and post-test scores were statistically significant (p=0.0001). Discussion Our preparedness training program was effective in delivering the intended skills. The efficiency of the training program was demonstrated through simulation. We created a trained pool of medical undergraduate students to assist clinicians in COVID-19-related supportive care.

/pdf/preparedness-of-undergraduate-medical-students-to-combat-2ljw7ooe.pdf

Preparedness of Undergraduate Medical Students to Combat COVID-19: A Tertiary Care Experience on the Effectiveness and Efficiency of a Training Program and Future Prospects

Background: Reproductive Tract Infections (RTIs) including Sexually Transmitted Infections (STIs) are ‘silent’ epidemics and are recognized as public health problem and rank second as the cause of healthy life lost among women of reproductive age after maternal morbidity and mortality in developing countries. Development and use of IEC material along with active participation by the community ensures delivery of appropriate information and knowledge to people which in turn empowers them to make informed decisions about their health. Methods: This was a ‘Multi-centric action research demonstration study’ to empower and engage the Self Help Groups (SHGs) women by creating awareness and sustaining interest through lesson plans in the IEC material regarding prioritized problem, required interventions and their access for syndromic recognition of the RTI/STIs. As an intervention, series of workshops were conducted with the help of pre-developed IEC material. 400 households (200 from each intervention and control sites) of SHG women were interviewed for baseline and endline each. Results: Intervention was found effective in the form of a significant improvement in the level of awareness about RTI/STI, correct knowledge about white discharge, capability to identify the symptoms of RTI/STI and health seeking behavior of the respondents. Conclusion: This study provides experience of the feasibility, efficacy and impact of health education interventions and point out that cost-effective strategies for prevention of RTI/STI are needed through information, education, and behavior change.

Manoj Kumar Gupta

Papers

Inguinal Lymphadenopathy in Carcinoma Gall Bladder: An Unusual Site of Metastasis

Mechanical Characterization of Graphene Nanoplatelets-Reinforced Mg-3Sn Alloy Synthesized by Powder Metallurgy

Perception of international patients regarding cross border movement for medical services in India

Preparedness of Undergraduate Medical Students to Combat COVID-19: A Tertiary Care Experience on the Effectiveness and Efficiency of a Training Program and Future Prospects

Research Article Empowerment and engagement of SHGs against RTI/STI in Karnataka, India: an interventional study