Premorbid Conditions Research Articles

PREDICTORS AND PREMORBID CONDITIONS OF THE DEVELOPMENT OF FEMALE GENITAL CANCER, IN PARTICULAR ENDOMETRY CANCER AND BREAST CANCER

Objective: to review a new potential diagnostic criteria for predictors and premorbid conditions of female genital cancer, including endometrial cancer and breast cancer.
 Materials and methods. Bibliographic, information-analytical methods were used in the work. Sources of information were data from the scientific literature on the topic of the study, modern gadleins, a review of randomized controlled trials.
 Results. The results of epidemiological studies suggest that the increased risk of cancer of the female reproductive system is the presence of obesity and type 2 diabetes. Potential mechanisms of their association are hyperinsulinemia, hyperglycemia, chronic inflammation, and insulin resistance. Because insulin is a major regulator of cell metabolism and is a tissue growth factor, hyperinsulinemia increases the risk of cancer. Hyperinsulinemia is associated with increased secretion of androgens by the ovaries and decreased levels of the protein that binds sex hormones, leading to higher concentrations of biologically active estrogens, which are also known to be risk factors for female genital cancer. In recent years, PFAA profiles have been found to be significantly altered in cancer and type 2 diabetes. Because cancer cells require certain amino acids to synthesize DNA, tumor growth factors, build new blood vessels, and duplicate all of their protein content, changes in PFAA profiles can be used as biomarkers of disease and different types of cancer at different stages.
 Conclusions. With the growing incidence of cancer, the issue of early diagnosis and detection of cancer in the pre-clinical stages remains relevant. Protein metabolism in cancer remains unclear and requires further research using a larger sample size. In addition, the biological mechanisms by which amino acids may contribute to the risk and progression of cancer or other premorbid conditions need to be elucidated. Determining the exact mechanism underlying changes in PFAA profiles has great potential for cancer diagnosis and treatment.

Open thoracotomy and decortication for chronic empyema thoracis: Our experience

Empyema thoracis is defined as the presence of pus in the pleural space or a purulent pleural effusion. Chronic empyema is characterized by thickened visceral and parietal peels, which hamper the ability of the affected lung to re-expand and require definitive surgical intervention. In a resource constraint environment like ours, open thoracotomy and decortication is the treatment of choice. We review our experience with cases of chronic empyema thoracis that had thoracotomy and decortication. This is a descriptive, retrospective, and observational study. Medical records of patients who had thoracotomy and decortication on account of chronic empyema thoracis in the Cardiothoracic surgery unit of our hospital between 2012 and 2020 were retrieved and reviewed. The information obtained from the records included sex, age, premorbid conditions, aetiology of empyema, cultures of pleural fluids, histology results of the cortex removed, duration of chest tube drainage, duration of hospital stay, postoperative complications, and outcome. One hundred and eighty-five patients diagnosed with empyema thoracis were seen in the study period. Sixty-five patients had thoracotomy and decortication on account of chronic empyema thoracis while the remaining 120 (64.9%) had closed tube thoracostomy drain insertion. Male: female was 5:1, mean age at presentation 24.24 years with age ranging from 2 years to 70 years. Fourteen (23.33%) were in the paediatric age group while the remaining (76.67%) were adults. The aetiology of empyema was pneumonia in 36 (60%). Strept pneumoniae was the commonest organism isolated from pleural fluids of these patients accounting for 23.33%. All patients underwent thoracotomy and decortication. The mean duration before surgery was 17 days with a range of 2 days to 40 days. The average duration of surgery was 2 hours. Chest tube was removed after an average of 7 days (range 5 to 33 days. Twenty-one patients (35%) had complications. The average duration of drainage was 18.87 days and that of hospital stay was 36.74 days. There were 3 mortalities (5%). The mean duration of follow-up was 3 months. Chronic empyema thoracis is still common in our environment and presentation is usually very late. In our series, open thoracotomy and decortication was found to be an excellent procedure with low morbidity and mortality. The majority of our patients had good functional outcome with few complications.

Макроелементи та їхня роль в організмі людини в умовах проживання на територіях, забруднених внаслідок аварії на ЧАЕС

The article shows the value of macronutrients, which, along with other food ingredients, form various structures of the body. The data on the content of macronutrients in the diets of the population of different age groups for the period 2004-2020, living in the settlements of the Kyiv region and exposed to the impact of the consequences of the Chernobyl accident, are presented. Aim of the Research. The aim of the study was to summarize data on the content of minerals in the diet of the population living under the influence of radiation exposure. The main attention is paid to organic elements (phosphorus, potassium, sulphur, chlorine, calcium, magnesium and iron), which form almost 98% of the chemical composition of the cell. Their total content is up to 1.9 % of the mass of the human body. Material and Methods. To achieve this goal, a set of methods was used, in particular: bibliographic — a theoretical analysis was carried out and the data from scientific literature was generalized; questionnairesurvey — the actual content of macronutrients in the diets of different age groups and mathematics were analyzed. Statistical data processing was carried out using modern methods of medical statistics. Results and Discussion. Regular provision of the body with all the necessary nutrients is of great importance for maintaining health, performance and active longevity of a person. Our longterm research conducted among the population of ecologically dangerous territories of Ukraine found that the content of macronutrients in the diets of adults, children and pregnant women did not meet physiological needs. Conclusion. The content of macronutrients in the diet of the surveyed population was unbalanced. Diets deficient in the content of calcium (Ca) and magnesium (Mg), the optimal ratio between macronutrients is disturbed, which can be the cause of premorbid conditions and be the reason for the formation of alimentary and alimentary-dependent diseases. The article is relevant for family doctors, hygienists, nutritionists, nutritionists and individuals interested in nutritional problems. Key words: minerals, nutrition, macronutrients, physiological role of macronutrients, recommended daily intake, sources of supply, population.

Boerhaave’s syndrome in a sixty-two-year-old Nigerian man

Boerhaave’s syndrome is a rare spontaneous transmural esophageal rupture from forceful vomiting. It is commonly misdiagnosed either from the non-specific presentation or its mimicking known premorbid conditions. Mortality could be very high and early with delayed diagnosis. We present a rare occurrence of this syndrome in which delayed diagnosis was due to premorbid conditions of bronchial asthma and hypertension and not symptom presentation and with a very good treatment outcome.

Identification of Mortality Predictors among Elderly Patients Admitted to Geriatrics and Gerontology Department, Ain Shams University Hospitals

Abstract Background Elderly persons are prone to frequent hospitalization for a longer period of time. It has been reported that approximately 5% of elderly die during hospital stay, whereas 20%– 30% die within one year following hospital discharge. Many factors including aging-associated diseases, chronic diseases, drug abuse, poly pharmacy, functional disability, feeding problems, prolonged length of hospital stay are associated with increasing mortality risk. In addition, symptoms and signs are significantly variable in the elderly and usually atypically represented. Objective To identify predictive factors associated with in-hospital mortality in elderly patients admitted to Ain Shams University Geriatric hospital wards and intermediate care unit. Methods A prospective cohort study of all Egyptian elderly patients (aged 60 years old or above) admitted at Geriatric Hospital (general ward and intermediate care unit), Ain Shams University Hospitals (Cairo, Egypt), over a period of 6 months (from April 2019 to September 2019). Patients were subjected to structured interview questionnaire including data pertaining socio-demographic data, past medical history, relevant physical examination, Short-form of Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) and SOFA score. Association between different risk factors and mortality rate was done to identify the most significant predictive factors leading to mortality in elderly in order to implement specific geriatric interventions in the future to prevent such fatal consequences. Results The present study included 140 patients, of whom 73 (52.1%) were females and 67 (47.8%) were males. Nearly, 80% of the studied sample were discharged, while 20% died during hospitalization. The most common pre-morbid conditions were hypertension (58.6%), diabetes mellitus (40%), gastrointestinal tract diseases (40.7%), cerebrovascular strokes (37.8%) and ischemic heart disease (35.7%). On admission, the mean SOFA score of the discharged group was (6±2.8) while the mean score of the deceased group was (8.9± 3.6). Evaluation of the general characteristics of the discharged and deceased groups revealed that the mortality rate is significantly associated with male gender (p = 0.018), depressive disorders (p < 0.001), hepatic diseases (p = 0.008), gastrointestinal tract diseases (p = 0.048), length of hospital stay (p = 0.001) and initial SOFA score on admission to acute care setting (p < 0.001). Conclusion Predictors of mortality during hospitalization of elderly patients include; male gender, depression, hepatic diseases, GIT diseases, length of hospital stay and initial SOFA score on admission. These factors must be evaluated to identify the potential candidates for specific geriatric interventions and specific plan of care.

Transitional types of response to the Martine-Kushelevsky test and their significance in the diagnosis of premorbid conditions of persons of different ages

The scientific work is devoted to the generalization of the results of the Martine-Kushelevsky test and the elucidation of the signs and causes of transient types of reactions and their significance for the early diagnosis of premorbid conditions. The experience of conducting and analyzing the results of 300 Martin-Kushelevsky tests was used to solve the set tasks. Among them - 88 people aged 18-55 years. This formation of the group (in the absence of complaints about health and contraindications to the test) made it possible to obtain a variety of types of reactions. The results were recorded using an electronic tonometer BAT41-2. It is their analysis that has become the subject of research in this paper. Classical normotonic, hypertonic, asthenic types were registered in 26 (30%) persons, respectively 19%, 7%. 3% of cases. Dystonic - absent. In others, 62 (70%) people registered transitional types, which we formed into 12 species. The vast majority of them had a pulse excitability of 80% or less and a recovery time of up to 3 minutes. Against this background, a slowing down of recovery time (more than 3 min) of ATs (31%), ATd (16%) after exercise and an increase in ATd immediately after it (26%) was most often registered, which indicates a predisposition to arterial hypertension. In 8% of the subjects there was a significant decrease in BP (more than 10 mm Hg) after exercise and a decrease below baseline after 3 minutes of rest (7%), indicating vascular dystonia. The negative phase of the pulse (4%) and recovery of the pulse for 3 minutes to indicators lower than the initial ones (4%) were less frequent, which was due to the violation of the coordinated activity of the sympathetic and parasympathetic parts of the autonomic nervous system. In 6% of cases with the normotonic type of response to exercise did not pay attention to the high output pulse (15,15,15 at ten-second intervals), and 3 minutes after exercise, it recovered and stabilized at baseline. In such cases, the patient should be referred to an endocrinologist.

Management of persistent sinus tachycardia during post-acute rehabilitation in a critical patient with COVID-19: a single-case study

BackgroundSinus tachycardia is a common arrhythmia in patients with COVID-19, and may pose challenges during rehabilitation.Case descriptionThis is a case report of a 39-year-old critically ill patient with COVID-19 with no premorbid conditions, who presented with intensive care unit-acquired weakness and persistent sinus tachycardia after their stay in an intensive care unit. The sinus tachycardia and exertional symptoms contributed to a severely limited exercise capacity (assessed through the 6-Minute Walk Test and 2-Minute Step Test), which impaired the progress of inpatient rehabilitation. This was addressed through the use of bisoprolol for heart rate control and a rehabilitation programme based on cardiac rehabilitation principles.ResultsThe patient's intensive care unit-acquired weakness improved with exercise-based rehabilitation, and the Functional Independence Measure motor subscore improved from 54/91 to 91/91 on discharge after 6 weeks of inpatient rehabilitation. After bisoprolol was started for sinus tachycardia, the patient's resting heart rate improved from 106 beats per minute to less than 90 beats per minute during this period of inpatient rehabilitation. During the same period, the patient exhibited concurrent improvement in exercise capacity on weekly 6-Minute Walk Test measurements. Improvements in the 2-Minute Step Test were also documented.ConclusionsPatient assessment using submaximal exercise testing with serial 6-Minute Walk Tests and 2-Minute Step Tests, along with using beta-blockers and cardiac rehabilitation principles, can be useful in the post-acute rehabilitation of patients recovering from COVID-19 with persistent sinus tachycardia.

Age-related macular degeneration and premorbid allergic diseases: a population-based case\u2013control study

Evidence indicates that age-related macular degeneration (AMD) is associated with the prior presence of allergic diseases; however, large-scale studies in the literature are limited. A case–control study was conducted to describe the relationship between premorbid allergic diseases and AMD using Taiwan’s National Health Insurance database. Eligibility criteria for inclusion of new adult AMD cases from 2000 to 2013 were set up. We defined the year of diagnosis as the index year. Age-, gender-, index year- matched controls who were drawn from the same database. The case control ratio was 1:4. For all participants, all premorbid conditions staring 1996 to index year were documented. Binary logistic regression was used to describe factors related to AMD occurrence. The AMD group consisted of 10,911 patients, and the comparison group consisted of 43,644 individuals. Patients with AMD showed significant associations with premorbid allergic diseases (aOR 1.54, 95% CI 1.47–1.61), specifically with allergic conjunctivitis (aOR 2.07, 95% CI 1.94–2.20), allergic rhinitis (aOR 1.32, 95% CI 1.25–1.39), asthma (aOR 0.99, 95% CI 0.93–1.06), and atopic dermatitis (aOR 1.04, 95% CI 0.94–1.17). Further analyses indicated that patients with more concurrent allergic diseases have higher associations with AMD than those with fewer concurrent diseases. Patients with more annual medical visits for their allergic diseases also showed higher associations with AMD than those with fewer visits. AMD is significantly associated with premorbid allergic diseases. The underlying mechanisms must be further investigated.

Open Thoracotomy and Decortication for Chronic Empyema Thoracis: Our Experience

Background: Empyema thoracis is defined as the presence of pus in the pleural space or a purulent pleural effusion. Chronic empyema is characterized by thickened visceral and parietal peels which hamper the ability of the affected lung to re-expand and requires definitive surgical intervention. In a resource constraint environment like our, open thoracotomy and decortication is the treatment of choice. The aim of this article is to review our experience with cases of chronic empyema thoracis that had thoracotomy and decortication Materials and Methods: This is a descriptive and observational study. Medical records of patients who had thoracotomy and decortication on account of chronic empyema thoracis in the cardiothoracic surgery unit of our hospital between 2012 and 2020 were retrieved and reviewed. The information obtained from the records included gender, age, premorbid conditions, aetiology of empyema, cultures of pleural fluids, histology results of the cortex removed, duration of chest tube drainage, duration of hospital stay, postoperative complications and outcome. Results: One hundred and eighty-five patients diagnosed with empyema thoracis were seen in the study period. Sixty-five patients had thoracotomy and decortication on account of chronic empyema thoracis while the remaining 120 (64.9%) had closed tube thoracostomy drain insertion. Male: female was 5:1, mean age at presentation 24.24 years with age ranging from 2 years to 70 years. Fourteen (23.33%) were in the paediatric age group while the remaining (76.67%) were adults. The aetiology of empyema was pneumonia in 36 (60%). Streptococcus pneumoniae was the commonest organism isolated from pleural fluids of these patients accounting for 23.33%. All patients underwent thoracotomy and decortication. The mean duration before surgery was 17 days with a range of 2 days to 40 days. The average duration of surgery was 2 hours. Chest tube was removed after an average of 7 days (range 5 to 33 days. Twenty-one patients (35%) had complications. Average duration of drainage was 18.87 days and that of hospital stay was 36.74 days. There were 3 mortalities (5%). The mean duration of follow-up was 3 months. Conclusion: Chronic empyema thoracis is still common in our environment and presentation is usually very late. In our series, open thoracotomy and decortication was found to be an excellent procedure with low morbidity and mortality. Majority of our patients had good functional outcome with few complications.

Clinical data analysis of dengue fever severity identification

Introduction: The dynamic nature of dengue fever demands rapid and repeated clinical detection based on the vital signs variables, blood profile, and symptoms for providing timely clinical treatment. Patients with or without warning signs are at risk of contracting the severe dengue; thus, this study aims to identify the vital signs and blood profile variables that would differentiate the severity levels of dengue fever among dengue patients. Methods: The patients were aged between 15 and 60 years and diagnosed with dengue infection. The infections were confirmed through laboratory tests positive either for the NS1 antigen or the dengue IgM antibody. The patients had no premorbid conditions. Results: Our results show that dengue fever without warning signs and severe dengue can be differentiated using the pulse rate on day 3 (p = 0.008), day 4 (p = 0.004), day 5 (p = 0.005), and day 6 (p = 0.011) and the white blood cell count (p = 0.008) on day 7 of illness. Statistically significant parameters on day 6 of illness, such as systolic blood pressure (p = 0.001), pulse rate (p = 0.001), and hematocrit (p = 0.001), distinguished dengue fever with warning signs from the severe dengue category. Hematocrit (p = 0.000) was also found to be statistically significant in dengue fever with warning signs versus severe dengue on day 8 of illness. In conclusion, pulse rate was found to be a common marker for day 3 to day 6 even though other parameters were found to be significant. However, for day 7 and day 8, pulse rate was not found to be a contributor, instead, white blood cells and hematocrit were significant factors. Conclusion: As the results of this study are based on a limited number of patients, it is recommended to further study the validity of the findings with a larger number of patients in the future.

Isometric Handgrip Exercise Training Improves Spirometric Parameters and Pulmonary Capacity.

Decline in normal physiological pulmonary function has been attributed to premorbid conditions such as prehypertension. Research evidence suggests that physical activity reduces age-related decline in pulmonary function and improves the efficiency of the lungs in prehypertensive patients. However, there is a scarcity of data evidence relating to isometric exercise and pulmonary function. Furthermore, the interrelationship between the intensity and duration of isometric exercise and pulmonary function in these patients is still uncertain. Therefore, this study was undertaken to investigate the effect of isometric handgrip exercise on pulmonary function capacity in adults with prehypertension. To determine the effectiveness of isometric handgrip exercise on pulmonary function capacity in adults with prehypertension. A quasi experiment using a pre- and post-exercise method was carried out in two out-patients hospital settings. The sample comprised 192 sedentary pre-hypertensive subjects, aged between 30–50 years, that were randomly distributed into three groups of 64 participants each. The subjects performed, for 24 consecutive days, an isometric handgrip exercise at 30% Maximum Voluntary Contraction (M.V.C.). At the end of the 24 days, group one (GP1) discontinued, while group two (GP2) continued the exercise protocol for another 24 consecutive days and group three (GP3) continued with the exercise protocol for another 24 consecutive days but at 50% M.V.C. Determinants of lung function (outcomes) were Forced Expiratory Volume in 1 s (FEV1), Forced Vital Capacity (FVC), FEV1/FVC Ratio and Peak Expiratory Flow Rate (PEFR). The study shows that there was no statistically significant difference in the pre- and post-exercise outcomes for FEV1, FVC, FEV1/FVC Ratio and PEFR after 24 days for group 1. In group 2, there was a statistically significant difference in the FVC [(mean = 0.12 ± 0.12), (p = 0.002)], FEV1 [(mean = 0.15 ± 0.17), (p = 0.003)] and PEF [(mean = 0.85 ± 0.35), (p = 0.001)] after 48 days. In group 3, there was a statistically significant difference (p = 0.001) in all the outcomes assessed after 48 days. There was a between groups difference in favour of group 2 compared with group 1 for outcomes of FEV1 [(mean = 0.142 ± 0.68), (p = 0.005)] and PEF [(mean = 0.83 ± 0.19), (p = 0.0031)]. There was statistically significant difference in favour of group 3 compared to group 2, by increasing the exercise intensity from 30% to 50% M.V.C., for outcomes of FVC [mean change = 0.10 ± 0.052), (p = 0.005)], FEV1/FVC [mean change = 3.18 ± 0.75), (p = 0.017)] and PEF [(mean change = 0.86 ± 0.35), (p = 0.001)] after 48 days. Isometric handgrip exercise (after 48 days at 30% to 50% M.V.C.) improves outcomes of pulmonary function capacity in adults with prehypertension. Meanwhile, duration and/or increase in intensity of the isometric effort significantly contributed to the affects attained.

Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score.

Approximately 10% to 20% of people with concussion experience prolonged post-concussion symptoms (PPCS). There is limited information identifying risk factors for PPCS in adult populations. This study aimed to derive a risk score for PPCS by determining which demographic factors, premorbid health conditions, and healthcare utilization patterns are associated with need for prolonged concussion care among a large cohort of adults with concussion. Data from a cohort study (Ontario Concussion Cohort study, 2008 to 2016; n = 1,330,336) including all adults with a concussion diagnosis by either primary care physician (ICD-9 code 850) or in emergency department (ICD-10 code S06) and 2 years of healthcare tracking postinjury (2008 to 2014, n = 587,057) were used in a retrospective analysis. Approximately 42.4% of the cohort was female, and adults between 18 and 30 years was the largest age group (31.0%). PPCS was defined as 2 or more specialist visits for concussion-related symptoms more than 6 months after injury index date. Approximately 13% (73,122) of the cohort had PPCS. Total cohort was divided into Derivation (2009 to 2013, n = 417,335) and Validation cohorts (2009 and 2014, n = 169,722) based upon injury index year. Variables selected a priori such as psychiatric disorders, migraines, sleep disorders, demographic factors, and pre-injury healthcare patterns were entered into multivariable logistic regression and CART modeling in the Derivation Cohort to calculate PPCS estimates and forward selection logistic regression model in the Validation Cohort. Variables with the highest probability of PPCS derived in the Derivation Cohort were: Age >61 years ([Formula: see text] = 0.54), bipolar disorder ([Formula: see text] = 0.52), high pre-injury primary care visits per year ([Formula: see text] = 0.46), personality disorders ([Formula: see text] = 0.45), and anxiety and depression ([Formula: see text] = 0.33). The area under the curve (AUC) was 0.79 for the derivation model, 0.79 for bootstrap internal validation of the Derivation Cohort, and 0.64 for the Validation model. A limitation of this study was ability to track healthcare usage only to healthcare providers that submit to Ontario Health Insurance Plan (OHIP); thus, some patients seeking treatment for prolonged symptoms may not be captured in this analysis. In this study, we observed that premorbid psychiatric conditions, pre-injury health system usage, and older age were associated with increased risk of a prolonged recovery from concussion. This risk score allows clinicians to calculate an individual's risk of requiring treatment more than 6 months post-concussion.

Identification of Multisystem Inflammatory Syndrome in Children Classes and Development of Hyperinflammation Score in Pediatric COVID-19.

The aim of this study is to describe characteristics and hospital course of children admitted with COVID-19 to a tertiary care pediatric center in Southeastern United States, and to present the frequency of three classes of multisystem inflammatory syndrome in children (MIS-C) and develop pediatric COVID-19 associated hyperinflammation score (PcHIS). A retrospective cohort study of 68 children was performed. Critical illness was defined as any child requiring respiratory or cardiovascular support or renal replacement therapy. PcHIS was developed by using six variables: fever, hematological dysfunction, coagulopathy, hepatic injury, macrophage activation, and cytokinemia. Centers for Disease Control and Prevention criteria were used to identify MIS-C, and three classes of MIS-C were identified based on the findings of recently published latent class analysis (Class 1: MIS-C without Kawasaki like disease, Class 2: MIS-C with respiratory disease, and Class 3: MIS-C with Kawasaki like disease). The median age was 6.4 years. Fever, respiratory, and gastrointestinal were common presenting symptoms. MIS-C was present in 32 (47%), critical COVID-19 illness in 11 (16%), and 17 (25%) were admitted to the PICU. Children with critical illness were adolescents with elevated body mass index and premorbid conditions. PcHIS score of 3 had a sensitivity of 100% and a specificity of 77% for predicting critical COVID-19 illness. Among MIS-C patients, 15 (47%) were in Class 1, 8 (25%) were in Class 2, and 9 (28%) were in Class 3. We conclude that most children with COVID-19 have mild-to-moderate illness. Critical COVID-19 is mainly seen in obese adolescents with premorbid conditions. Three Classes of MIS-C are identifiable based on clinical features. Validation and clinical implication of inflammation score in pediatric COVID-19 need further investigation.

512 A CASE OF AN IDIOPATHIC ACQUIRED HEMOPHILIA A IN AN ELDERLY WOMAN

Abstract Introduction Acquired Hemophilia is a bleeding diathesis caused by autoantibodies that interfere with factor VIII (FVIII). Reasons for autoantibodies production are not clear but may be related to gene polymorphisms and/or CD4+ T lymphocytes. 1.3 to 1.5 cases per million population per year are reported in the UK. Half of the cases are secondary to malignancy, pregnancy related conditions, connective tissue disorders or drug reactions while the rest are idiopathic. Case Report We report a case of an acquired hemophilia A in an 86-year-old lady with underlying type 2 diabetes, hypertension, and cognitive impairment, being treated as the left lower limb cellulitis with antibiotics. She was found to have a sudden hemoglobin drop and her CT (Abdomen) confirmed a spontaneous intra-abdominal hematoma. Clotting profile showed prolonged APTT to 168.5 seconds, being not corrected at mixing study, with normal PT and INR. The FVIII assay was reduced to 18.4 iU/dL with FVIII inhibitor concentration of 0.7 Bu. Viral and autoimmune screenings were negative. The idiopathic acquired hemophilia A was diagnosed. Red blood cell transfusions, bypassing agents (FEIBA) and oral tranexamic acid were given for acute bleeding episode. Concomitantly, oral prednisolone was used to reduce the inhibitor levels. Repeated FVIII assay showed 121 iU/dL and 199iU/dL on day 6 and 12, respectively. Steroid was continued for the next 4 weeks and then gradually tapered. No further bleeding episode was noted. Conclusion The diagnosis of acquired hemophilia should be considered in any elderly patient with prolonged APTT. Mixing study is to measure the presence of inhibitors of coagulation or to detect coagulation factor deficiency. Quantitative coagulation factor assays and Bethesda Assays are performed for definitive diagnosis. Immunosuppressive regimens are the mainstay treatment. However, premorbid conditions and co-morbidities should be taken into consideration before initiating the aggressive immunosuppressive therapy in the elderly patients.

MAIN PRINCIPLES OF ETIOPATHOGENETIC TREATMENT OF NEWBORNS WITH GASTROSCHISIS

Introduction. The paper focuses on the challenging issue of treatment of newborns with gastroschisis (GS) and a high level of intraabdominal hypertension in case of severe viscero-abdominal disproportion. The aim of the paper is to present the current state of the problem at the regional level based on our own clinical experience in observation and treatment of newborns with GS. Material and methods. The study is based on the analysis of examination and treatment of 29 newbornswith GS. The distribution of boys and girls was nearly the same: 16 (55.17%) boys and 13 (44.83%) girls. The number of premature babies was 23 (79.31%). The complex of diagnostic procedures included clinical laboratory examination, radiologic investigation (using contrast agents when required), ultrasound investigation and Doppler sonography, intraabdominal pressure measurement, histologic study of surgical specimens.Results. Prenatal information on the congenital anterior abdominal wall defect was obtained with the help of prenatal ultrasound. In most cases, fetal GS is diagnosed before 20 weeks of pregnancy. Prenatal ultrasound was performed in 13 (44.83%) pregnant women out of the researched group. Two false test results were obtained.Radiologic investigation of a child with GS is necessary to detect intestinal obstruction, necrosis or bowel perforation. Among patients under our study, two cases of ileal atresia were registered. The analysis of intraabdominal pressure indices in patients with GS showed a high level of intraabdominal hypertension in approximately 70% of cases. It proves that patients with GS have a high level of surgical and anesthetic risk. The main therapy measures include the following steps: appropriate preoperative preparation, anesthetic management, and the choice of appropriate perioperative techniques taking into account the level of intraabdominal hypertension and viscero-abdominal disproportion.Depending on the child's condition, type of GS and level of intraabdominal hypertension, there were twosurgical options:1. Primary radical surgery.2. Staged surgical treatment.Analyzing the results of the study, it may be noted that 8 newborns in total died after the surgery, which is 27.59%(it used to be 56-60% till 2005). The main causes of death were respiratory failure, neonatal sepsis and unfavorable premorbid conditions (very low gestational age, severe comorbidity, multiple congenital malformations).Conclusions. 1. Successful treatment of newborns with GS depends on the early diagnosis of the pathology, which must be prenatal, and elimination of contradictions in treatment tactics. 2. Before suturing the abdominal wall defect in newborns with GS, it is necessary to measure intraabdominal pressure, since intraabdominal hypertension leads to a significant deterioration in the mechanical properties of the lungs, hemodynamic abnormalities,oliguria, intestinal ischemia, decrease in organ perfusion, which must be taken into account when carrying out preoperative preparation and aesthetic management. 3. The level of intraabdominal hypertension in patients with GS,which is high in 68.96% of cases, must be an indication for choosing the method of surgical correction of the defect i.e.the refusal of radical plasty of the abdominal wall and the resort to staged intervention or other surgical techniquesthat involve an increase in the abdominal cavity volume. 4. The reduction in mortality in newborns with GS to 27.59%is possible due to the introduction of etiopathogenetic approaches to early diagnosis, preoperative management, anesthetic management and surgical correction of this pathology into the practice of neonatal surgery.

Clinical Evaluation and Treatment of Patients with Postconcussion Syndrome.

Postconcussion syndrome (PCS) is a complex set of symptoms occurring in a small percentage of patients following concussion. The condition is characterized by headaches, dizziness, cognitive difficulties, somatosensory issues, and a variety of other symptoms with varying durations. There is a lack of objective markers and standard treatment protocols. With the complexity created by premorbid conditions, psychosomatic issues, secondary gains, and litigations, providers often find themselves in a tough situation in the care of these patients. This article combines literature review and clinical insights with a focus on the underlying pathophysiology of PCS to provide a roadmap for evaluating and treating this condition.

Exploring Endothelial KCa Channel Activation as a Novel Strategy to Restore Cardiac Function Following Acute Myocardial Infarction in Mice

Endothelial dysfunction (ED) is a common underlying feature of several premorbid conditions (e.g. obesity, Type 2 Diabetes (T2D), atherosclerosis, hypertension) associated with the development of myocardial infarction (MI). The ability of an artery to dilate properly and oppose plaque formation within the vascular wall is compromised by ED, which ultimately leads to reduced blood flow. In the coronary circulation, ED can decrease blood supply to the working myocardium and the resulting prolonged ischemia can promote MI. Recent studies from our group have demonstrated that a small molecule activator of endothelial KCa2.3 and KCa3.1 channel activity (i.e. SKA-31) improves agonist-evoked vasodilation in resistance arteries from multiple vascular beds and species, and this effect remains robust in arteries from T2D tissues. We have further observed that prolonged administration of SKA-31 to aged rats improves both their cardiac and vascular functions. Thus, the goal of this project is to investigate the potential cardio-protective effects of SKA-31 in male mice (12-15 weeks of age, C57B1/6 strain) following an acute MI induced by permanent surgical ligation of the left-anterior descending coronary artery. Within 48 h post-surgery, MI and sham surgery mice were treated orally with either vehicle or 10 mg/kg of SKA-31 daily for 6 weeks. Myocardial damage in MI mice was confirmed by histological staining. Echocardiographic assessment of cardiac function 4 weeks post-surgery revealed that Ejection Fraction (EF) and Fractional Shortening (FS) were similar in sham animals treated with either vehicle or SKA-31 (Table 1). Similar results were observed for measurements of end systolic volume (ESV) and end diastolic volume (EDV). In contrast, the MI animals treated with vehicle displayed ~50% decreases in EF and FS, and significantly larger values for ESV and EDV. These functional and structural parameters thus confirm the presence of sustained cardiac dysfunction in the MI mice. Treatment of MI mice with SKA-31 did not lead to improvements in EF, FS, ESV or EDV compared with vehicle treated animals. Our preliminary findings indicate that SKA-31 treatment did not affect the healthy cohort, but also did not improve gross cardiac function in the MI group. Recent data indicate that an acute MI is typically followed by a robust inflammatory response within the injured myocardium that peaks 3 days post-MI and declines to baseline by 7-9 days. We speculate that this local immune response is exacerbated by SKA-31 administration within 48 h post-injury, thereby negating any potential benefit of SKA-31 at the level of the vasculature. Delaying SKA-31 administration to coincide with the full decline of the local immune response may prove more effective in restoring cardiac function.

Evolving changes in mortality of 13,301 critically ill adult patients with COVID-19 over 8months.

PurposeClinical characteristics and management of COVID-19 patients have evolved during the pandemic, potentially changing their outcomes. We analyzed the associations of changes in mortality rates with clinical profiles and respiratory support strategies in COVID-19 critically ill patients.MethodsA multicenter cohort of RT-PCR-confirmed COVID-19 patients admitted at 126 Brazilian intensive care units between February 27th and October 28th, 2020. Assessing temporal changes in deaths, we identified distinct time periods. We evaluated the association of characteristics and respiratory support strategies with 60-day in-hospital mortality using random-effects multivariable Cox regression with inverse probability weighting.ResultsAmong the 13,301 confirmed-COVID-19 patients, 60-day in-hospital mortality was 13%. Across four time periods identified, younger patients were progressively more common, non-invasive respiratory support was increasingly used, and the 60-day in-hospital mortality decreased in the last two periods. 4188 patients received advanced respiratory support (non-invasive or invasive), from which 42% underwent only invasive mechanical ventilation, 37% only non-invasive respiratory support and 21% failed non-invasive support and were intubated. After adjusting for organ dysfunction scores and premorbid conditions, we found that younger age, absence of frailty and the use of non-invasive respiratory support (NIRS) as first support strategy were independently associated with improved survival (hazard ratio for NIRS first [95% confidence interval], 0.59 [0.54–0.65], p < 0.001).ConclusionAge and mortality rates have declined over the first 8 months of the pandemic. The use of NIRS as the first respiratory support measure was associated with survival, but causal inference is limited by the observational nature of our data.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00134-021-06388-0.

Why is standing up for women’s equality still relevant in 2021?

It is 2021. The world is reeling from the ravages of a merciless pandemic that knew no borders and killed at will. When scientific collaboration, market forces and societal will resulted in the creation, testing, approval and deployment of multiple vaccines that may yet stop the virus in its tracks. Where most were forced to live apart, and yet joined up like never before.&#x0D; And yet, it has been a year where the privileges of a few were starkly overshadowed by the destitution of many. A year where inherent societal inequalities in many nations were held in sharp focus. Where the poor and disadvantaged were much more likely to be infected and die of the virus, and where untreated premorbid conditions hastened their demise. Many governments used the necessary restrictions of civil liberties to their advantage, and many congregated to protest.&#x0D; Where do women feature in this? The author explores the impact of inequalities on women and why women do need to stand up for equality and justice, now more than ever before.

Caligula: a neuropsychiatric explanation of his madness.

Gaius Julius Caesar Augustus Germanicus, better known as Caligula, (12 CE to 41 CE) was the third Roman emperor and ruled only four years. Throughout his life he experienced several traumatic events, and, in addition, historians mention some premorbid conditions that could cause him to become the monster that most historians know today. When Caligula was 25 years old, he suffered a near-fatal illness that turned his story around. One possible cause was lead poisoning due to the high consumption of wine, which contained lead, by Roman patricians. On the other hand, it is plausible that Caligula experienced epilepsy that began in childhood, later experienced status epilepticus in 37 CE, which triggered an epileptic psychosis with the consequent psychopathic and paranoid changes that led him to the madness noted by historians.