Conclusions: the use of automated systems such as the MiniMedTM780G system brings glucometric results closer to those recommended by consensus, especially in age at T1D onset >4 years. However, the management in pediatrics continues to be a challenge even after the implementation of these systems, especially in terms of hyperglycemia and glycemic variability.Background: The integration of continuous glucose monitoring systems with insulin infusion pumps has shown improved glycemic control, with improvements in hyperglycemia, hypoglycemia, Hb1Ac, and greater autonomy in daily life. These have been most studied in adults and there are currently not many articles published in the pediatric population that establish their correlation with age of debut. Methods: Prospective, single-study. A total of 28 patients  were included and divided into two groups according to age at T1D onset (≤4 years and >4 years). Follow-up for 3 months, with glucometric variables extracted at different cut-off points after the start of the closed-loop . Results: Significant improvement was evidenced at 1 month and 3 months after closed-loop system implantation, with better glycemic control in the older age group at baseline at TIR (74.06% ± 6.37% vs. 80.33% ± 7.49% at 1 month,  Type 1 diabetes (T1D) continues to pose an elevated risk for mortality and cardiovascular disease. Patients who develop type 1 diabetes between 0 and 10 years of age have a hazard ratio of 4.11 95% CI 3.24–5.22) for all-cause mortality, 7.38 3.65–14.94) for cardiovascular mortality, 3.96 (3.06–5.11) for non-cardiovascular mortality, 11.44 (7.95–16.44) for cardiovascular disease, 30.50 (19.98–46.57) for coronary heart disease, 30.95 (17.59–54.45) for acute myocardial infarction, 6.45 (4.04–10.31) for stroke, 12.90 (7.39–22.51) for heart failure and 1.17 (0.62–2.20) for atrial fibrillation [4–5.22 fo5–14.94 fClosed-loop systems offer the greatest benefit in terms of time in range (TIR) and protection against hypoglycemia and hyperglycemia ,9,10,11,TM780G device. It features an advanced hybrid closed-loop (AHCL) algorithm that includes automatic delivery of basal insulin every 5 min, adjustable targets of 100 (5.50), 110 (6.10) and 120 (6.70) mg/dL (mmol/L), and automatic delivery of correction boluses every 5 min. Meal information must be input by the user or caregiver. Autocorrection every 5 min improves daytime blood glucose by mitigating inaccuracies in carbohydrate estimation and late or missed meal boluses, and adapts to interday glucose variability without user intervention. This system was approved by the European Commission in June 2020 and is indicated for individuals with T1D aged 7 to 80 years, whose minimum total daily insulin dose is 8 U/day [One of the closed-loop systems is the Medtronic MiniMedTM780G system in children and that thus far its correlation with age at debut has not been clearly established, we aimed to analyze whether age at onset influences glycemic outcomes after implantation of this AHCL system.Given the limited number of studies of MiniMedTM, Medtronic MiniMed, 18000 Devonshire Street, Northridge, CA 91325, USA) and intermittently scanned continuous glucose monitoring (isCGM)  and had this system replaced with the MiniMedTM780G AHCL system with Guardian 4TM sensor (G4S) between December 2021 and April 2022. All the patients were followed by a multidisciplinary team comprising pediatric endocrinologists and diabetes nurses. Those with an interstitial glucose sensor system other than the one previously described were excluded.This was a prospective, single-center study carried out in the diabetes unit of a tertiary hospital in Spain  and based on data retrieved from digital medical records during the 6-month follow-up period. We included pediatric and adolescent patients aged 7 to 17 years, diagnosed with T1D according to the latest ADA and ISPAD criteria ,14, who ®  and CareLink®  download platforms at the start of the study and at different cut-off points after reaching a daily time greater than 90% in auto mode (1 month and 3 months). Baseline sensor and insulin pump data were downloaded for the 2 weeks prior to the implementation of the AHCL using the Libreview and Carelink System platforms, respectively.Metabolic control variables were extracted using the LibreView-Time in Range (TIR): percentage of time in which interstitial blood glucose levels are between 70 and 180 mg/dL.-Time Above Range 1 (TAR1): percentage of time in which interstitial blood glucose levels are between 180 and 250 mg/dL.-Time Above Range 2 (TAR2): percentage of time in which interstitial blood glucose is above 250 mg/dL.-Time Below Range 1 (TBR1): percentage of time in which interstitial blood glucose levels are between 70 and 54 mg/dL.-Time Below Range 2 (TBR2): percentage of time in which interstitial blood glucose is below 54 mg/dL.The variables studied were as follows:Other parameters included were the percentage of time in auto mode, coefficient of variation (CV), daily insulin dose (U/kg/day), percentage of insulin in basal or bolus form, the amount of insulin administered as automatic correction, glycated hemoglobin (Hb1Ac), glucose management indicator (GMI) and mean glucose.Quality of life variables (sleep and satisfaction with treatment) were also studied through questionnaires completed in person by the main caregivers both at baseline and 3 months after initiation of the closed-loop system.Pittsburgh Sleep Quality Index (PSQI): The sum of the scores of the 19 questions, or the total score, indicates the overall sleep quality of the person being evaluated. This total score can range from 0 to 21 points. The higher the total score, the worse the sleep quality. Thus, a total score less than or equal to five on the Pittsburgh scale indicates that, in general, sleep quality is optimal, while a total score greater than five suggests sleep disturbances, of greater or lesser severity .Diabetes Treatment Satisfaction Questionnaire (DTSQ) index: assesses satisfaction  and change in satisfaction  with treatment for T1D. DTSQ-s scores range from 0 to 48, and DTSQ-c scores range from −24 to +24, with higher scores indicating greater satisfaction .To test the relationship between age at onset and the above variables, patients were divided into two groups: ≤4 years (group 1), >4 years (group 2) .The study protocol was in accordance with the Declaration of Helsinki. All participants and their caregivers were informed of the study and signed a consent form. The included patient under 7 years was 6 years and 6 months old. The patient’s parents were informed of the gap of 6 months from the minimum age limit for device use. The protocol was approved by the ethics committee of our center.https://www.r-projetc.org/, accessed on 20 October 2022). A Shapiro–Wilk test analysis was performed to determine the normality of the study variables. Results are presented as mean ± SD values in normal distributions or as median (IQR) in non-normal distributions. A Wilcoxon signed-rank test was performed to analyze differences in the non-normal distributions, and the paired t-test was used in the normal distributions. Correlation analyses were performed using Pearson’s correlation coefficient in parametric variables and Spearman’s correlation coefficient in non-parametric variables. A chi-square test was used to perform a bivariate analysis. A p-value < 0.05 was considered statistically significant. p-values were adjusted using the Benjamini–Hochberg correction for multiple comparisons.Data analysis was performed using free R 4.0.2 software (R-CoreTeam 2020)  belonged to group 1 (age at onset ≤4 years), and the remaining 42.86% (12 patients) belonged to group 2 (>4 years). The mean age at diabetes debut in group 1 was 2.46 ± 1.05 years and 6.43 ± 1.68 years in group 2. The median age at MiniMedp = 0.4344) or at 3 months (p = 0.6474) when comparing the percentage of autocorrection in the two groups.The median total insulin before the system change was 0.87 U/kg/day (group 1) and 0.81 U/kg/day (group 2). We observed a non-significant increase in the total amount of insulin in both groups during follow-up. No differences were observed either at 1 month (p < 0.003).We calculated the mean glucose obtained with CSII-isCGM and after initiation of the new system. Significant differences were only observed between the two age groups at baseline (p < 0.011), although this was not so 3 months after closed- loop implantation (p = 0.5082).Baseline HbA1c was 7.34% in group 1 and 6.68% in group 2, and at 3 months 6.94% and 6.65%, respectively. When assessing the impact of age at onset on this parameter, we observed significant differences between the two groups at baseline (p < 0.05).Regarding CV, we found that, at baseline, patients had a percentage of up to 39.83% (group 1) and 38.03% (group 2). Analyzing the relationship with age at onset, only differences in CV were observed between the two groups at 3 months .When assessing TIR, we observed that after the implementation of the closed-loop system, there was a significant increase in the average percentage of this value during the follow-up, in both age groups. When evaluating the relationship between age at onset and TIR, significant differences were observed between the two groups at all cut-off points , which was not significant when comparing TIR with duration of diabetes (p = 0.431) and age at AHCL device installation (p = 0.147).A statistically significant and directly proportional relationship was observed between age at onset and TIR at 3 months .With respect to TAR1, we noted a decrease after the implementation of the new system, both at one and three months, and it was also statistically different depending on the age of onset .Concerning TAR2, our patients presented a reduction of this percentage both after one month and three months of the new system. Significant differences were observed at all cut-off points when evaluated according to age groups at debut .In relation to TBR1, no significant differences were observed at any of the cut-off points studied .Finally, when TBR2 was assessed, no significant differences were observed at any of the cut-off points studied (baseline The mean score for the DTSQ prior to the change in system (DTSQ-s) was 37.62 (IQR 37–39) in group 1 and 33.91 (IQR 33-35) in group 2. Three months after its implementation (DTSQ-c), a mean score of 13.50 (11.75–15) was obtained in group 1 and 12.25 (IQR 9–15.75) in group 2.p < 0.016), but not with the MiniMedTM780G system (p = 0.5954).In relation to the DTSQ prior to the system change (DTSQ-s), the mean score obtained was 37.62 (IQR 37–39) in group 1 and 33.91 (IQR 33–35) in group 2. At 3 months after closed-loop system implantation (DTSQ-c), a score of 13.50 (11.75–15) was obtained in group 1 and 12.25 (IQR 9-15.75) in group 2. When studying the impact of age at onset on treatment satisfaction, significant differences were observed with the CSII-isCGM treatment (p = 0.1886) or at 3 months (p = 0.8577).The questionnaire on the sleep quality of both parents (PSQI) showed a baseline value of 4.91 (IQR 2–6.50) in group 1 and 8.44 (IQR 4–12) in group 2. Three months after the implementation of the new system, the result for group 1 was 4.14 (IQR 3.50–4.05) and, for group 2, it was 5.75 (IQR 2–10). No statistically significant improvements were observed either at baseline . Nevertheless, significant differences remained between the two groups at the different cut-off points (1 month and 3 months) in favor of the patients who were over 4 years of age at onset.Our study shows more favorable results in the achievement of consensus targets in patients with T1D with onset after 4 years of age, both at 1 and 3 months after AHCL system implantation. At baseline before closed-loop system implantation, significant differences in mean glucose percentage, TIR, TAR1 and TAR2 were found between these two groups. After implantation of the MiniMedRegarding TAR1 there were also significant differences between the groups at baseline. The implementation of AHCL enabled the mean consensus-recommended percentage of TAR1 to be met in both groups, although with significant differences between the two groups, with a lower TAR1 in the patients who were over 4 years of age at onset, both 1 and 3 months of follow-up.In TAR2 there were also significant differences at baseline, with neither group reaching the consensus target. The use of the Medtronic system allowed the consensus-recommended percentage of TAR2 (<5%) at 1 month to be met in both groups, although with significant differences in favor of better control in the group over 4 years of age at onset. These significant differences were maintained at 3 months. In addition, at this cut-off point, the group with onset before the age of 4 years had a higher mean TAR2 than the consensus recommendation.There were no differences between these two groups at baseline or at follow-up in hypoglycemia parameters (TBR1 and TBR2). There were significant differences in glycemic variability measured by CV at 3 months after AHCL implantation, with greater variability in the group with onset before 4 years of age, although the figures are very close to those recommended.Published studies on children with AHCL systems do not classify by age at onset as established in our work, but by age at implantation. One example is the study by Ng et al., in which a group of 251 children with a median age of 12.30 years (IQR 2-19) using AHCL systems  showed improvements in glycemic control, TIR, percentage of hypoglycemia, fear of hypoglycemia and sleep quality when using AHCL therapy for 6 months. Fear of hypoglycemia and sleep quality also improved for their parents and caregivers at 6 months. These data are consistent with our results of increased TIR and improved sleep quality .n = 3211) were an estimated HbA1c 6.80% ± 0.30% and TIR 73.90% ± 8.70. The TBR was within the consensus target of less than 4% (3.20%). These results were maintained during the 6-month follow-up [TM780G system. Microboluses and autocorrection boluses were analyzed hourly for two age groups: under 9 years and over 9 years. The proportion of microboluses was significantly higher in children younger than 9 years than in children older than 9 years (p < 0.003) [In the study by Arrieta et al., results at the first month of follow-up in users aged 15 years or younger  with the MiniMed™670G system (SHCL) and the 780G system (AHCL) at baseline and after 3 and 6 months. They concluded that children under 14 years of age appear to benefit the most from the AHCL systems, as do people with the worst glycemic control. Significant differences in HbA1c were found between SHCL and AHCL users in children aged 7–14 years (7.70% vs. 7.10% at 6 months) and in those with worse glycemic control (HbA1c > 8%) at baseline (8.10% vs. 7.10% after 6 months). All sensor-specific measures of glycemic control improved from manual to automatic mode in both SHCL and AHCL users, with no increase in time to hypoglycemia. However, the percentage of patients with TIR > 70% increased significantly in AHCL users ,20. In op < 0.001), and this improvement was maintained for 6 months. HbA1c was 7.20% ± 0.70% (55 mmol/mol) at baseline and improved significantly after 3 months  and 6 months . TIR was higher in individuals >13 years at all time periods (p < 0.001). A glycemic target <120 mg/dL was associated with better TIR [Piccini et al. showed that the AHCL MiniMed™780G allowed rapid and sustained improvement of glycemic control in 44 children with T1D. Adolescents had good adherence to this technology with optimal TIR, which was better maintained over time compared to younger children. Tighter glycemic target settings were associated with better metabolic control, with no increase in severe hypoglycemia episodes. The mean TIR at 14 days in automatic mode was 76.30% ± 9.60% vs. 69.30% ± 12.60% in manual mode (tter TIR .In a literature review of the last 10 years, we found that most of the studies focused on the age at device implantation without taking into account age at debut. Some studies are beginning to mention differences in metabolic control of T1D according to age at onset . This thIn recent years, we have observed epidemiological changes, with a statistically significant increase in the presentation of T1D in Spain in the youngest age group, represented by ages under 4 years, with respect to previous periods 2015–2019 . The epiTM780G system brings glucometric results closer to those recommended by consensus. However, the management of this group of patients continues to be a challenge even after the implementation of these systems, especially in terms of hyperglycemia and glycemic variability. Further development and analysis of automated algorithms in younger patients is necessary. These patients have a strong need for glycemic accuracy to combat metabolic memory and an increased cardiovascular risk that is closely linked to earlier age at debut.This study enables us to focus on prioritizing the group of patients who debut at an earlier age, as they represent a challenge in metabolic control. Undoubtedly, the use of automated systems such as the MiniMed


Dental Anxiety (DA) was the most frequent problem which can lead to the avoidance of treatment. Therefore, is to evaluate the DAlevel among patients of different treatments. A questionnaire was distributed among the participants. The Modified Corah DentalAnxiety Scale (MDAS) was used to measure dental anxiety. In gender differences, it has been found that females were more anxious thanmale participants. The younger age group (18-30 years) was less anxious than the older age groups (P < 0.05). Most of theparticipants in all conditions were slightly anxious. Male participants exhibited less dental anxiety than females. This might be dueto males being more stable emotionally. The common condition which is associated with surgical and medical risks and avoidance of dental treatment is Dental anxiety. In astressful condition, as a physiological response, it can increase blood pressure and heart rate, dizziness, excessive sweating,pallor, dizziness and flight response.  DA is alAfter getting an ethical clearance from Scientific research Ethical Committee (442-40-44056 DS) a questionnaire was distributed among795 patients who were having any type of restorative and endodontic treatment at different dental centers of Najran. The questionnairehad two parts. The 1st part contained the questions about demographic details including the experience of a past dental visit. Thesecond part had questions about different situations related to dental treatment that can cause anxiety. The aim of the study wasclearly explained to the participants. Descriptive statistics in terms of frequency and percentage were used to analyze the compileddata and for correlation chi-square test was used with SPSS.A total of 795 people participated in this survey. 564 were female and 231 were male. 571 were aged between 18-30 years, 186 were31-40 years old and 38 participants were aged more than 40 years. Most of the people (569) had bachelor-level education. Only 4participants were not educated. In context with their nationality, only 11 persons were non-Saudi. A large number of participants (758)had an experience of a past dental visit. Out of those 758 participants, 390 had an excellent while 32 had a bad experience .Among female participants, 220(27.7%) were slightly anxious when they have a dental visit while most of the male participants 131(16.5%)were not anxious. 215(27.0%) female participants said they will feel slightly anxious while sitting in the waiting room for dentaltreatment and 124(15.6%) male participants were not anxious. About the question of tooth drill, 190(23.9%) were slightly anxious and 40(5.0%) were extremely anxious while 115(14.5%) males were not anxious and only 1(0.1%) participant responded extremely anxious. 135(17.0%) and 187(23.5%) female participants were not anxious and slightly anxious when they will have tooth restoration. Most of thefemale participants 155(19.5%) were fairly anxious while most of the male participants 94(11.8%) were not anxious about the localanaesthetic injection. All responses to this comparison showed significant (P<0.01) relation (Table 1-see PDF). When the response ofpatients was observed in comparison with their age, the result showed that 219 (27.5%) participants 18-30 years old were not anxiouswhen they have a dentist visit and 11 (1.4%) participants of the same age group were extremely anxious. Among the group more than 40years old 9 (1.1%) were not anxious, 16(2.0%) were fairly anxious and 1(0.1%) were extremely anxious about their dental visit. Whilesitting in the waiting room for dental treatment, 188 (23.6%), 80 (10.1%) and 14 (1.8%) from the age group of 18-30 years, 30-40 andmore than 40 years were fairly anxious respectively. Most of the participants were from every age group, 190 from 18-30 years. 65 from30-40 years and 11 from more than 40 years said that they will feel slightly anxious about tooth drill. About the question of restorationand polishing of teeth, 208(26.2%) people aged between 18-30 years said they will not feel anxious while 23(2.9%) were extremely anxious.44(5.5%) participants said that they will feel not anxious among the age group of 30-40 years and 5(0.6%) from more than 40 years respondedin the same way. A large number of participants 205(25.8%) from all age groups agreed on being slightly anxious when they have the localanaesthetic injection in their gums (Table: 2-see PDF). All responses to this comparison were significant (P<0.05). A total of 795 peopleparticipated in this survey. About the dental visit, the percentage of participants who were slightly anxious was the highest (35.8%)and the lowest percentage for those who were extremely anxious (2.1%). While sitting in the waiting room the highest percentage ofparticipants (37.1%) were not anxious and 2.8% were extremely anxious. Most of the participants (33.5%) were slightly anxious when theyhave tooth drill, followed by the not anxious (27.7%), fairly anxious (22.0%), very anxious (11.7%) and extremely anxious (5.2%).Thesame trend was found in the response about restoration and polishing of teeth. The percentage for slightly anxious, not anxious, fairlyanxious, very anxious and extremely anxious was 33.0, 32.3, 18.5, 11.9 and 4.3 respectively. The majority of the participants (25.8%)were slightly anxious about LA injection while only 10.7% were extremely anxious .In the present study, the comparison between male and female participants showed that females experienced more Dental Anxiety thanmale participants when they have any kind of dental treatment. The majority of the male was not anxious and only a few were extremelyanxious. Same-gender differences were also reported in previous reports on dental anxiety that in comparison to males, females had morefear of the dentist. These res Overall it has been concluded from the results that in all conditions most of the participants were slightly anxious and only a fewpatients were extremely anxious. However, female patients exhibited more dental anxiety than males and people of the young age were moreanxious than other age groups.All authors have declared that no financial support was received from any organization for the submitted work.All authors have declared that they have no financial relationships at present or within the previous three years with anyorganizations that might have an interest in the submitted work.All authors have declared that there are no other relationships or activities that could appear to have influenced the submittedwork.The authors did not cite the following article: Udoye CI et al. J Contemp Dent Pract. 2005 May 15; 6(2):91-8. PMID: 15915208.https://pubmed.ncbi.nlm.nih.gov/15915208/


Ankylosing spondylitis (AS) is an inflammatory rheumatic disease characterized by spinal and/or peripheral involvement, enthesitis, dactylitis, and several extra-articular manifestations. Chronic inflammation often leads to reduced spinal mobility and functional disability. The frequency of psychological problems has increased in AS patients.The objective of this study was to determine the prevalence of symptoms of anxiety and depression among AS patients and explore the underlying associated factors.The Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and other clinical measures were collected during the clinical trial. We evaluated also the hospital anxiety and depression scale (HADs). P values < 0.05 were considered statistically significant.Sixty-two patients with AS were included in the study. The average age was 41 years [18-65]. The diagnostic delay varied from one year to 26 years with an average of 4 years. Twenty-nine years is the average age of onset of symptoms with a standard deviation of 10 years. The mean duration of the disease was 10 ± 8 years. At baseline, the mean BASFI score was 53.9 ± 2 and BASDAI was 4.5± 2.Clinically significant symptoms of anxiety and depression were present in 48.4% and 54.8% of patients, respectively. Depression was noted with a mean HADS depression of 10,5 ± 5,2. Anxiety was noted with a mean HADS anxiety of 11,3 ± 4,6.In univariate analysis, anxiety was associated with the low educational level of patients (p = 0.038) and with CRP level (p= 0.041). There was a significant association between depression and anxiety (p=0.000). There was no relationship between these psychiatric disorders and disease activity, treatment modalities or functional status (p>0.05)In patients with Ankylosing spondylitis, the prevalence of risk of mental disorders is high.Anxiety and depression are common in AS and even alter the quality of life.Patients should be regularly screened for these disorders.None Declared


Stroke is the second most common cause of mortality after ischemic heart disease and the leading cause of morbidity around the world. This study aimed to find out the stroke among patients admitted to a tertiary care centre.A descriptive cross-sectional study was conducted in the Department of Internal Medicine and Neurosurgery from 15 July 2021 to 15 June 2022 after taking ethical approval from Institutional Review Committee (Reference number: 78/79-083). Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated.Among 5034 patients, 149 (2.95%)  patients had stroke. Out of 149 cases, male to female ratio was 1.06 with a mean age of 65.05±14.06 years. The most common presentation was hemiparesis 128 (85.90%). Hypertension 106 (71.14%) was the most common underlying condition. The frontal area 17 (32.02%) was the most common site of ischemic stroke. Putamen (55.26%) was most common site in hemorrhagic stroke. The mean hospital stays was 6.3±5.18 days. There were 5 (3.40%) cases of in-hospital mortality.The prevalence of stroke was similar to other studies done in similar settings. Stroke leads to long-term disability and a high economic burden to the family and society.2 Stroke is the 2nd most common cause of mortality and the leading cause of morbidity in the world.3 Hemiplegia is the most common presentation of stroke. Ischemic stroke accounts for 50-85% of total strokes in the world. Hypertension, diabetes mellitus, dyslipidemia, and smoking were the most common modifiable risk factor for stroke.4In Nepal, among the total patients admitted to hospitals, 2.25% are stroke patients.The aims of this study was to find out the stroke among patients admitted to a tertiary care centre.This was the descriptive cross-sectional study conducted in the Department of Internal Medicine and Neurosurgery in Chitwan Medical College Teaching Hospital (CMCTH), from 15 July 2021 to 15 June 2022. The study was done after ethical approval from the Institutional Review Committee (IRC) of CMCTH (Reference number: 78/79-083). All the patients above age 18 yrs and having clinical and computed tomography (CT) confirmed diagnosis of stoke was included in the study. Patients with incomplete medical record, patients with transient ischemic attack (TIA), and patients who leave the hospital against medical advice were excluded from the study. A convenience sampling was used. Sample size was calculated by using the following formula:Where,n = minimum required sample sizeZ = 1.96 at 95% Confidence Interval (CI)p = prevalence taken as 50% for maximum sample sizeq = 1-pe = margin of error, 2%The calculated sample size was 2401. After doubling sample size, the total sample size was 4802. However, total 5034 sample size was taken.6Dyslipidemia was defined as the presence of any of the following: patients on lipid-lowering drugs or total cholesterol >240 mg/dl, triglycerides (TG) >150 mg/dl, low-density lipoprotein >130 mg/dl, and high-density lipoproteins (HDL) <50 mg/dl for female and <40 mg/dl for male. Diabetes Mellitus was defined as symptoms of diabetes, random blood sugar >200 mg/dl or HbA1C level >6.5 or if a patient was on oral hypoglycemic agents. Hypertension was defined as systolic blood pressure >140 and/or diastolic >90 mmHg and/or on anti-hypertensive treatment.Data were collected retrospectively from medical records 15 July 2021 to 15 June 2022. The age, sex, Glassgow Coma (GCS) at admission, blood pressure, clinical presentation, comorbidities, risk factors, family history, past history of stroke, anticoagulant drugs, lipid profiles, random blood sugar, and radiological findings were collected from patients' case note from the medical department of the hospital and electronic data registry system (Midas) in the proforma.Data were entered in Microsoft Excel Version 2010 and analyzed using IBM SPSS Statistics version 21.0. Point estimate and 95% CI were calculated.Among 5034 patients, 149 (2.95%)  had a stroke. Among these, 46 (30.87%) cases were from Neurosurgery Department and 103 (69.12%) cases were from Internal Medicine Department. A total of 77 (51.67%) patients were males and 72 (48.32%) were females with a ratio of 1.069. Patients' ages range from 32 to 96 years with a mean age of 65.05±14.06 years. CT findings showed 103 (69.12%) had ischemic stroke whereas 46 (30.87%) had a hemorrhagic stroke. A total of 89 (59.73%) patients had left-sided strokes. Out of which 60 (67.41%) had ischemic stroke and 29 (32.58%) had a hemorrhagic stroke. The mean age of patients with hemorrhagic stroke was 61.20±14.29 years and those with ischemic stroke were 66.78±13.67 years .GCS below 8 was found in 10 (6.71%) patient with stroke .The most common presentation was hemiparesis which was 128 (85.90%) followed by slurred speech 73 (49%) and facial deviation 59 (39.59%) .Of the total 149 patients, the most common underlying condition was hypertension 106 (71.14%) followed by dyslipidemia 47 (31.54%) and diabetes mellitus 31 (20.80%). The mean systolic and diastolic blood pressure for hemorrhagic stroke was 168.04±28.64 mmHg and 99.35±12.89 mmHg. The mean systolic and diastolic blood pressure for ischemic stroke was 147.67±31.629 mmHg and 87.77±15.01 mmHg respectively .In our study, the most common site of hemorrhagic stroke was the putamen 21 (55.26%) followed by the thalamus 7 (18.42%). Similarly, the most common site of ischemic stroke was the frontal region 17 (32.05%) followed by basal ganglia 10 (18.86%). The mean hospital stays was 6.3±5.18 days. There were 5 (3.4%) cases of in-hospital mortality. Of which, 3 (2.01%) died due to ischemic stroke and 2 (1.34%) with hemorrhagic stroke .2 The incidence of stroke is increasing.4 The mean age of stroke was 65.05 with most patients lying within the range of 61-70 years. A comparable age was also present in studies done in Nepal and India.7'13In our study, the prevalence of stroke was 2.95% which is similar to the other studies.15In our study, patients aged less than 40 years comprised 10.7% of the total patients which was comparable to the study done in Yemen (13.6%), and Nepal (11.74%).4 The most common type of stroke in our study was ischemic (61%) which was similar to the other study done in Nepal.17 However, a population-based study done in neighbouring country China had an ischemic stroke of 91.7% which was attributed due to well-controlled hypertension among the population.18Ischemic strokes account for 50-85% of all strokes worldwide.9Clinical presentation of stroke depends on the type of stroke and artery involvement which supplies specific areas of the brain. In our study, the most common presentation was hemiparesis (85.9%) followed by slurred speech (49%). Similarly, a study done in Kathmandu had hemiparesis (90.2%) followed by slurring of speech (33.33%) as the most common presentation.19 However, another study done in Nepal revealed smoking  as the most common risk factor.15 The relatively low prevalence of smoking 24 (16.10%) in our study might be due to the failure to record the smoking history of the patients. However, dyslipidemia accounts second most common risk factor in our study which is probably due to changes in the dietary habit of Nepalese. A study done in China had dyslipidemia as a major risk factor with a prevalence of 57.1%.18 This revealed that smoking and dyslipidemia are the most important modifiable risk factor of stroke in the context of Nepal after hypertension. The INTERSTROKE study showed atrial fibrillation leads to 9% of the ischemic stroke with variation among different regions; high-income countries (23%), South America (13%), Africa (7%), India (6%), and Southeast Asia (5%).3 Atrial fibrillation was present in 10.06% which was comparable to another study done in Nepal with a prevalence of 12.5%, 8%, and 9%, respectively.15 In this study,10% of total patients had a history of stroke which was comparable to another study done in Nepal (8.3%)11 and Yemen (12.2%).14As per the study, ten risk factor was associated with a 90% risk of stroke. In our study, hypertension (71.14%) was the most common modifiable risk factor followed by dyslipidemia (31.54%). Some studies done in Nepal had hypertension  as the most common modifiable risk factor which was followed by smoking .13 Similarly, the most common site of hemorrhagic stroke in our case was the putamen (55.26%) followed by the thalamus (18.42%) however, basal ganglia (43.9%) was followed by the thalamus (14.61%) in the same study done in India as the most common site of bleeding.13In our study, the most common site of ischemic stroke was the parietal (32.05%) followed by basal ganglia (18.86%) which was consistent with the study done in India with parietal (41%) most followed by basal ganglia (16%).11 Another study was done in a similar setting also had a higher hospital stay for hemorrhagic stroke(10±9.4 days) than ischemic stroke (7.1 ±8.1 days).19 In our study, the in-hospital mortality rate was 3.4% which was similar to another study done in Nepal (5.7%).2The hospital stays range from 1 to 36 days with a mean stay of 6.3 days. Similarly, a study done in Nepal also stated the range of 1 to 33 days with a mean of 6.11 days.Our study could not find a significant association between the majority of risk factors, clinical presentation and laboratory values. This was a singlecentred based descriptive cross-sectional study so a more robust, extensive and multicentered prospective study should be done to address the magnitude of disease and its association with different variables in the context of the Nepalese population.The prevalence of stroke was similar to other studies done in similar settings. Stroke is a public health problem with male predominance. Though stroke was regarded as a disease of old age, its prevalence in young patients is on an increasing trend. Health policymakers must emphasize effective preventive measures for stroke and its modifiable risk factors  to decrease mortality, morbidity and economic burden among the patients as well as in the nation.


During the COVID-19 pandemic, there has been a peak of occupational dermatoses associated with Personal Protective Equipment (PPE) among healthcare workers (HCWs). The resulting dermatological damage might have an impact on the quality of life.We aimed to evaluate the dermatological life quality of the HCWs due to PPE use.The study was conducted in a group of HCWs from Hedi Chaker hospital in Sfax, Tunisia. Data were gathered between march and may 2021 using a self-administered questionnaire including socio-professional characteristics, evaluation of skin lesions, evaluation of the infection-prevention practices and the Arabic version of the Dermatology Life Quality Index (DLQI).Our sample was composed of 190 HCWs. The respondents’ mean age was 32.5 ± 6.5 years and 54.7% were female. The average job tenure was 6.6 ± 5.8 years. Doctors represented 22.1 %, nurses 13.6% and cleaning staff 64.3 % of participants. The prevalence of skin lesions due to PPE among HCWs was 51.6%. The mean time of mask use was 15.4 ± 9.1 hours. The daily hand washing frequency was >10 times/day in 85.3 % of participants. The mean DLQI score was 3.3 ± 4.3. According to this index, it was found that these skin lesions had no effect, small effects, moderate effects and very large effects on the lives of 43.9%, 34.7%, 12.2%, and 9.2% of participants, respectively. The DLQI was correlated with hand washing frequency  and the time of mask use .Skin lesions among HCWs are frequent during the covid-19 pandemic. These lesions influence the quality of life of the HCWs. This risk gets higher with excessive preventive measures. It is critical to provide training on the prevention of skin lesions associated with PPE wearing and hand hygiene before and during the period of use of preventive measures.None Declared


Chemoimmunotherapy (CT-IO) is the standard first-line treatment of advanced small cell lung cancer (SCLC). However, very limited efficacy data from real-life use of this combination are available. Moreover, patients included in pivotal phase III trials were highly selected. We conducted a retrospective multicentric (six academic centers) case–control study (n = 153), comparing two cohorts of patients who received first-line treatment, one treated with chemotherapy alone (between January 2017 and December 2018) and one with CT-IO (between January 2019 and December 2020), for an advanced SCLC. CT-IO confirmed its superiority compared to chemo alone. Interestingly, we showed that CT-IO was efficient in patients with brain and liver metastases. However, patients ≥70 years old and with a PS ≥2 did not benefit from CT-IO. This real-life study in one of the largest published to our knowledge on first-line CT-IO for advanced SCLC, with a large focus on specific populations .The current first-line standard treatment for advanced small cell lung cancer (SCLC) is a combination of chemotherapy and immunotherapy. However, few efficacy data are available in a real-life settings, including frail patients. The aim of this study is to describe the real-life efficacy of chemoimmunotherapy in an unselected SCLC population. We conducted a retrospective multicenter study, which compared two cohorts of patients with treatment-naive metastatic SCLC treated in six academic centers in the Greater Paris area. Cohort 1 included patients treated with chemotherapy between January 2017 and December 2018, and cohort 2 included patients treated with chemoimmunotherapy between January 2019 and December 2020. A total of 153 consecutive patients were included . Clinical characteristics were similar between the two cohorts. Overall survival (OS) was statistically higher in cohort 2  than in cohort 1  (p = 0.0001). OS for patients with a performance status ≥2 and for patients ≥70 years old was not statistically different between the two cohorts. Chemoimmunotherapy efficacy was better compared to chemotherapy alone in case of brain or liver metastases. In conclusion, the combination of chemoimmunotherapy in metastatic SCLC appears to provide a real-life OS benefit. Dedicated clinical trials are needed to test this strategy in patients with impaired performance status or advanced age.  Lung cancer is the leading cause of cancer deaths worldwide. Small cell lung histological subtype represents about 15% of lung cancers . ApproxiAll consecutive patients with histologically or cytologically confirmed metastatic SCLC, who were treatment-naive, treated with CT alone (between 1 January 2017 and 31 December 2018) or with CT-IO (between 1 January 2019 and 31 December 2020) in six French academic centers were collected.In both cohorts, patients had to be older than 18 years, have a measurable disease according to the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, and have received at least one cycle of treatment. In both cohorts, patients with corticosteroid therapy greater than 20 mg per day and patients with history of autoimmune disease were excluded. Patients with stable intracranial metastatic lesions were eligible for inclusion.2) or carboplatin (AUC 5)) in combination with etoposide  every 21 days for a total of 4 to 6 cycles.Patients in cohort 1  received platinum-based chemotherapy  and atezolizumab (intravenous administration of 1200 mg on D1) every 21 days for a total of 4 cycles, followed by maintenance atezolizumab (intravenous administration of 1200 mg every 21 days).Patients in cohort 2 received chemotherapy with carboplatin (AUC 5), etoposide . Tumor evaluation was performed every 2 or 3 cycles, depending on the center, using thoracic–abdominal–pelvic CT scan and brain imaging (CT or brain MRI).The primary endpoints were OS (time from diagnosis to death from any cause) and PFS  in both cohorts.Secondary endpoints were objective response rate and PFS with second-line therapy .We also retrospectively collected adverse events according to the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 to evaluate the real-life safety of chemoimmunotherapy in this setting of metastatic SCLC in first-line therapy.Kaplan–Meier methodology was used to estimate the probability of OS and PFS. OS and PFS results were compared using the log-rank test. Objective response rates were compared using a Fisher test. A comparison of the clinical data was performed using a Chi-2 test or Fisher test for variables with n < 5. The cut-off date was 1 April 2022. A total of 153 consecutive patients were included . The characteristics of the patients in the two cohorts were comparable . The patMedian follow-up was 11.9 months. At the time of analysis, 92 patients (95.8%) in cohort 1 and 36 patients (63.2%) in cohort 2 were deceased.p < 0.0001). OS in cohorts 1 and 2 were 34.3% and 57.9% at 1 year, respectively. Survival at 2 years in the different cohorts was 14.5% and 42.1%, respectively  than in cohort 1 (median 9.5 months) (ectively .p = 0.57). PFS in cohorts 1 and 2 were 17.7% and 22.8% at 1 year, respectively. PFS at 2 years in the different cohorts was 12.5% and 19.3%, respectively  in cohort 1 and 47 patients (82.4%) in cohort 2 had tumor progression or died. PFS in cohort 2 (median 6.73 months) was not statistically different from that of cohort 1 (median 6.7 months) (ectively .p = 0.09) (p = 0.043).The objective response rate in the cohort 1 was 61.2% and 81% in cohort 2 ( = 0.09) . The comp = 0.23) (p = 0.09) (Forty-nine patients (51%) in cohort 1 and 30 patients (52.6%) in cohort 2 received a second-line treatment at progression. PFS with the second-line treatment was not statistically significant between cohorts 1 and 2  ( = 0.23) . In coho = 0.09) .n = 34) in cohort 1 and 25% (n = 14) in cohort 2 had brain metastases at diagnosis. The median OS in cohort 1 without brain metastases was 9.7 months vs. 7.8 months with brain metastases (p = 0.406). In cohort 2, the median survival without brain metastases was 15.4 months vs. 15.5 months with brain metastases (p = 0.62). Patients with brain metastases had a significantly better OS under chemoimmunotherapy vs. chemotherapy alone . In patients without brain metastases, OS was also longer with chemoimmunotherapy vs. chemotherapy alone  (Thirty-five per cent ( 0.0002) .n = 43) in cohort 1 and 44% (n = 25) in cohort 2 had liver metastases at diagnosis. The median OS in cohort 1 without liver metastases was 10.3 months vs. 7.7 months without liver metastases (p = 0.054). In cohort 2, the median survival without liver metastases was 15.4 months vs. 11.4 months with liver metastases (p = 0.33). Patients with liver metastases had a better OS under chemoimmunotherapy . In patients without liver metastases, OS was also longer with chemoimmunotherapy  (Forty-five per cent (= 0.001) .n = 73) in cohort 1 and 90% (n = 51) in the cohort 2 were PS 0–1. The median OS in cohort 1 with PS 0–1 was 9.8 months vs. 4.5 months if PS was 2–3 (p = 0.018). In cohort 2, the median OS with PS 0–1 was 16.8 months vs. 8.9 months if PS was 2–3 (p = 0.329). Patients with PS 0–1 had a better OS under chemoimmunotherapy  (Seventy-six per cent (= 0.001) .p = 0.092)  .n = 27) in cohort 1 and 44% (n = 25) in cohort 2 were more than 70 years old. In the cohort 1, the median OS was 10.9 months (≥70 years old) vs. 8.4 months (<70 years old) (p = 0.189). In cohort 2, the median survival was 9.4 months (≥70 years old) vs. 24.3 months (<70 years old) (p = 0.031). For elderly patients (>70 years old), there was no significant difference in OS in cohort 1 vs. cohort 2 (p = 0.43). In patients < 70 years old, OS was significantly better in cohort 2 (p = 0.0001) (Twenty-eight per cent ( 0.0001) .A total of 94 patients (97.9%) in cohort 1 and 55 patients (96.5%) in cohort 2 experienced treatment-related adverse events .Endocrinopathy-type adverse events were noted in cohort 2, including four cases of thyroiditis, one case of diabetes, one case of hypophysitis, one case of adrenal insufficiency, and two cases of pancreatitis. There were three cases of interstitial lung disease. There were no treatment-related deaths in cohort 2.Our study confirms, in a large multicentric real-life cohort, that the combination of atezolizumab with platinum-based CT significantly improved OS compared to a control group of patients treated with CT alone. OS in our study (15.5 months) was comparable to OS in the IMpower—133 trial (12.3 months) that tested atezolizumab in association with chemotherapy in selected patients . Importan = 907), the age at initiation of nivolumab did not impair OS [A few studies have looked at the efficacy of immunotherapy in elderly patients with lung cancer, mainly NSCLC ,15, and mpair OS . A meta-mpair OS . For SCLmpair OS . Howevern = 104) showed a better OS with chemoimmunotherapy vs. chemotherapy (11.8 vs. 6.5 months) in SCLC patients [Regarding performance status, some studies suggest a benefit of immunotherapy in patients with an impaired state (PS > 1) in contrast to the results obtained in our study. A monocentric retrospective single center in Israel . The clinical characteristics of the patients were similar between the two cohorts. Moreover, the timing of the tumor evaluation may have varied according to the centers, which may have potentially slightly changed between the two time periods selected in our study. This could partially explain the absence of difference in terms of PFS between the two cohorts in our study. Furthermore, the staging work-up and the treatment strategy may have varied in these different time periods. In addition, the lack of centralized image review can also limit the interpretation of the tumor response and PFS in our study. However, we were able to provide concordant data on the OS benefit with the association of atezolizumab and chemotherapy. The main strengths of our study were its multicenter design, as well as the inclusion of elderly patients and patients with impaired general condition and brain metastases who were excluded from clinical trials. The main results obtained corroborate those of the major international multicentric phase III trials that evaluated atezolizumab and durvalumab in the first-line treatment of metastatic SCLC.The results of our real-life multicentric study validate those from the phase III IMpower 133 trial. Dedicated prospective trials should be conducted in elderly patients and those with poor PS to evaluate the efficacy of CT-IO in these populations. Further studies are also needed to better individualize patient subgroups who benefit the most from IO-CT in order to better personalize the treatment strategies in advanced SCLC. Recent studies are also looking at new therapeutic targets, in particular phase I/II studies looking into the use of anti-DLL3 antibodies, the results of which could prove promising. The search for new molecular signatures is likely to pave the way for new anti-cancer therapies in this field.In conclusion, the results of our multicentric study on the combination of chemo- and immunotherapy in real life validate those of the IMpower 133 phase III trial and support the use of CT and IO as standard first-line treatments for patients with metastatic SCLC.


Surgical masks remain a focal part of the CDC guidelines to decrease COVID-19 transmission. Evidence refuting significant effects of masking on ventilation is mostly limited to small studies, with a paucity of studies on children, and none comparing children to adults.A total of 119 subjects were enrolled  in a prospective interventional study with each subject serving as their own mask-free control. End tidal CO2 (ETCO2), inspired CO2 (ICO2), and respiratory rate were measured by nasal cannula attached to an anesthesia machine D-fend module. Pulse oximetry and heart rate were also followed. After the mask-free period, an ASTM Level 3 disposable surgical mask was donned and 15 min of mask-worn data were collected.p < 0.001) after masking in all age groups. The increase in ICO2 for the 2- to 7-year-old group of 4.11 mmHg (3.23–4.99), was significantly higher (p < 0.001) than the final ΔICO2 levels for both the 7- to 14-year-old group, 2.45 mmHg (1.79–3.12), and adults, 1.47 mmHg (1.18–1.76). For the pediatric group there was a negative, significant correlation between age and ΔICO2, r = −0.49, p < 0.001. Masking resulted in a statistically significant (p < 0.01) rise in ETCO2 levels of 1.30 mmHg in adults and 1.36 mmHg in children. The final respective ETCO2 levels, 34.35 (33.55–35.15) and 35.07 (34.13–36.01), remained within normal limits. Pulse oximetry, heart rate, and respiratory rate were not significantly affected.A steady state was confirmed for ETCO2 and ICO2 over the masked period, and mean ICO2 levels rose significantly (vs ICO2. The methodology and results are compared to previously published studies which detracted from the physiologic safety of surgical masking.The physiology of mechanical dead space is discussed, including the inverse relationship of subject age The wearing of a surgical mask results in a statistically significant rise in ICO2 and a smaller rise in ETCO2. Because ETCO2 and other variables remain well within normal limits, these changes are clinically insignificant. Extensive evidence accumulated in 2020 revealing that surgical masks were effective in mitigating the spread of respiratory viral pathogens and specifically SARS-CoV-2, and these masks were similar in effectiveness to N95 filtering facemask respirators . By the The primary aim of this study is to compare the physiological effects of surgical masks on children and adults in the largest study on this topic to include physiologic endpoints. End tidal CO2 will be measured as the primary endpoint, with secondary endpoints of inspired CO2, respiratory rate, oxygen saturation, and heart rate. As the first to include broad age ranges, this study will investigate the relationship between age and mechanical dead space effects. Because a tidal volume brings in a large volume of fresh air, it is hypothesized that end tidal CO2 levels will remain within the normal range for all age groups. Because the dead space to tidal volume ratio is higher in pediatric patients , it is hClinicalTrials.gov website (identifier: NCT05114993). Healthy volunteer adults and parents with children were recruited for the study. No remuneration or other direct benefits were provided. Inclusion criteria included age 2 to 14 years (inclusive) or 18 to 80 years (inclusive). Exclusion criteria included significant cardiopulmonary disease, symptoms of active respiratory infection, intolerance to wearing a nasal canula, or intolerance to wearing a surgical mask. A preliminary power determination recommended adult and pediatric group sizes of 38 participants each. Interest in participation was high, therefore enrollment of subjects continued until all interested parties were able to participate, reaching group numbers comparable to or exceeding prior studies on this topic. Written consent was obtained from adults and parents of study subjects. Children aged seven and older provided written assent, with verbal assent obtained from younger subjects.This is a prospective interventional study with each subject serving as their own mask-free control. Subjects were sequentially assigned to the experimental arm of the study after donning a disposable surgical mask. The protocol was approved by the Missouri State University Institutional Review Board  and was listed on the The study took place at the Missouri State University School of Anesthesia Simulation Operating Room. Three separate anesthesia machine monitors allowed for evaluation of up to three subjects simultaneously, allowing children and parents to participate seated in the same room. An anesthesia machine D-fend module measured end tidal carbon dioxide (ETCO2), inspired carbon dioxide (ICO2), and respiratory rate (RR) by way of nasal canulae. Oxygen saturation (SpO2) and heart rate (HR) were followed by pulse oximetry. These five physiologic variables were recorded each minute over a 5-min control period while subjects were unmasked. The subjects were then assisted in donning a DemeTECH ASTM Level 3 Surgical Disposable Mask. Appropriate fit was confirmed, using masks of either regular or small size. These three-layer masks provide >98% filtration efficiency and >98% sub-micron particulate filtration efficiency at 0.1 micron. The masks fully covered the mouth and nose, with the nose wire formed around the nose and cheek to close any gap. Each subject used a new nasal canula and a new surgical mask for the study. The five physiologic variables  were then measured on masked participants each minute for 15 min. This duration was chosen based on a pilot study which showed stability of ETCO2 and ICO2 levels over a 15-min masked period.f = 0.19) as statistically significant (p < 0.05) for our primary endpoint, an a priori power analysis was conducted with the G*Power statistical program using a within-subject design, alpha of 0.05, and power of 0.80. Results showed that 38 participants for each age group (pediatrics and adults) were required to achieve a significant effect with adequate power. Secondary endpoints included the remaining physiologic variables of ICO2, RR, SpO2, and HR.Looking to detect a rise of ETCO2 of 1.0 mmHg , Similarly, no significant differences were noted in comparisons between each masked period’s ICO2 levels (p > 0.320) or ΔICO2 levels (p > 0.826)   and 3.p < 0.01) increased in comparisons between any of the 5-min masked periods and the unmasked control period . The ETCO2 levels remained within the normal range with a value of 35.25 mmHg (33.78–36.72). For this subgroup of youngest subjects, the respiratory rate significantly (p < 0.001) increased after masking from 18.48 (16.93–20.03) to 21.63 (19.55–23.71), yet the respiratory rate remained normal throughout the masked evaluation period. The respiratory rate improved during the last 5 min of masking, resulting in final masked respiratory rates having no significant difference in comparison to the unmasked rates in these youngest subjects (p = 0.241): 18.48 (16.93–20.03) to 19.97 (16.87–23.07)   and 4.p < 0.001) increased in comparisons between the unmasked control period and any of the 5-min masked periods. In comparisons between age groups, the Final ΔICO2 was significantly higher (p < 0.001) in children, 3.16 mmHg (2.64–3.67), compared to adults, 1.47 mmHg (1.18–1.76) (n = 20), children >7 to 14 years of age (n = 28), and adults (n = 71). Prior to masking, there were no significant differences in the mean ICO2 levels between the three age groups (p > 0.3). However, the final 5-min masked period ΔICO2 for the 2- to 7-year-old group of 4.11 mmHg (3.23–4.99), was significantly higher (p < 0.001) than the final ΔICO2 levels for both the 7- to 14-year-old group, 2.45 mmHg (1.79–3.12), and adults, 1.47 mmHg (1.18–1.76). Additionally, the final 5-min masked period ΔICO2 was significantly higher for the 7- to 14-year-old group compared to adults (p = 0.018)  . With IC= 0.018) .p = 0.332. For the pediatric group, however, there was a negative, significant correlation between the two variables, r = −0.49, p < 0.001.These exploratory analyses should be taken with caution as the sample size for the pediatric subgroups compared to adults was small. Therefore, a Pearson’s correlation coefficient was computed to assess the linear relationship between age and ΔICO2. For the adult group, there was no linear correlation between ΔICO2 and age, r = −0.12, In the main two groups of adult and children, there was no significant change in respiratory rate, pulse oximetry, or heart rate after masking –6.https://www.aap.org, Accessed July 20, 2021). At the time of submission of this manuscript, the peak of the COVD-19 pandemic had passed, yet the CDC continued to include recommendations for surgical masking for high risk individuals, those with confirmed or suspected exposure to an infected person for 10 days, all infected persons when around others at home and in public for 10 days, and all citizens during high COVID-19 community levels , therefore this study focused only on surgical masks.Surgical-type facemasks have been in use for over one hundred years, with the first major study performed by Doust in 1918 evaluating their use in the prevention of respiratory pathogen transmission . Airborny levels . FDA guiThe first 90 years of surgical mask use passed with minimal concerns regarding ventilation or oxygenation. Assessments of carbon dioxide levels in masked participants were quite rare prior to the COVID-19 pandemic. A 2012 study evaluated twenty adult participants unmasked on a treadmill for 1 h followed by 1 h while masked, finding clinically insignificant increases in respiratory rate and transcutaneous carbon dioxide levels . During Physiologic assessments of pediatric participants wearing surgical masks are even less common, with none identified prior to the COVID-19 pandemic. A 2021 study evaluated triple layer surgical face masks on 47 children, including many younger than 2 years of age . The masA later 2021 study focused on an ETCO2 endpoint and suggested masks caused physiologic harm, although the study model did not include any live subjects. Using a lung simulator and intubation head, the simulation resulted in an average ETCO2 increase of 17.4 mmHg . No attePublications like the above retracted study fueled increasing claims about physiologic harm caused by mask wearing. Multiple lawsuits against Ohio school districts  have citvs adults. Measurement of PaCO2 levels is invasive and impractical in volunteer subjects, but sidestream ETCO2 monitoring by nasal cannula has proved accurate as an assessment of PaCO2 in adults and children . No such correlation was seen in the adult subjects, whose large tidal volume to deadspace ratio can easily tolerate small additions of mechanical deadspace. Although an inverse relationship between age and masked ICO2 levels was confirmed, the increased ICO2 did not have clinically significant effects on the ETCO2 even in the youngest subgroup, since ETCO2 rose by only 1.1 mmHg and remained in the normal range.Increases in mechanical dead space (or apparatus dead space) are of particular importance in pediatric patients because of their larger dead space to tidal volume ratio . AnatomiClinically, it is well known that an increase in mechanical dead space can have significant effects on PaCO2 levels, especially in the youngest of pediatric patients. In a study of infants and young children, adding a heat and moisture exchanger (HME) into the ventilation circuit increased the PaCO2 inversely proportional to weight and age. In healthy pediatric patients weighing more than 25 kg, however, the additional 22 ml of dead space from the HME had no effect . SupraglThe retracted 2021 study  and a siThe argument in the 2021 Kisielinski review article , that anLimitations of the study include a masked observation period limited to 15 min, and the evaluation of subjects only at rest. Longer observation times and the effects of masking during exercise have been reported in other smaller studies, as noted above. In this study, ETCO2 and ICO2 levels were significantly increased from baseline within the first 5 min of masking, and pairwise comparisons between each 5-min masked period thereafter confirmed the ETCO2 and ICO2 levels were at equilibrium  and 3. WCompared to a mask free period, wearing an ATSM 3 triple layer surgical mask resulted in a small increase in ICO2 consistent with the mechanical deadspace behind the mask. The rise in ICO2 levels varied inversely with subject age, reflecting the known increase in dead space to tidal volume ratio of the youngest subjects. ETCO2 increased in all age groups by a lesser amount, but most importantly, ETCO2 levels remained in the normal range even in the youngest subject subgroup. These small, clinically insignificant changes in ETCO2 were not enough to prompt a sustained increase in respiratory rate. Oxygen saturation and heart rate were unaffected by surgical masking.During pandemics current and future, the wearing of surgical masks may be encouraged in adults and children over age 2 without concerns of the effects of carbon dioxide retention or impaired oxygenation.10.7717/peerj.15474/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.15474/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.15474/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.15474/supp-4Supplemental Information 4Click here for additional data file.


Being well informed about the pandemic and how the virus spreads help to prevent and control the pandemic. Health authorities should monitor community practice to prevent the pandemic to identify gaps and minimize risks. This study was, therefore, designed to assess community knowledge, attitude and practices (KAP) related to COVID-19 prevention and its associated factors in urban settings.Community based cross-sectional study was conducted in southern Ethiopia. Twelve towns with high population density and mobility and 1162 participants were included in the study using multi-stage sampling. Semi-structured questionnaire was used to collect data. Mask use was assessed by observation while social distancing and handwashing were assessed by interview. Good practice was defined as wearing face mask, keeping social distance and handwashing. Data was collected by health professionals who have BSc and above  and analyzed using SPSS version 25. Descriptive statistics and binary logistic regression at 95% confidence level were performed.From 1162 respondents, about three fifths, 714 (61.4%), were females and 829 (64.2%) were married. The mean knowledge score was 69.7 (SD±17.87) while mean score for attitude was 80.6 (SD±6.29). Only about one third, 380 (32.7%), had good practice. Occupation, age and overall knowledge about COVID-19 and its prevention were associated with good COVID-19 prevention measures.Knowledge and attitude related to COVID-19 prevention and control were moderate while practice was low. The risk communication strategy should be strengthened using precautionary advocacy. The Coronavirus disease 2019 (COVID-19) is highly infectious viral disease that can cause mild to serious respiratory illness . AlthougIn developing countries especially in in urban settings, the COVID-19 prevention has been challenging because of dense population, small informal dwellings, lack of access to clean water, multi-generational households with shared sanitation facilities, high level of social mixing, and transient residents , 8.According to the World Health Organization, being well informed about the disease and how the virus spreads helps to prevent and control the pandemic . Since eThis community-based cross-sectional study was carried out from October 15 to November 05, 2020 in selected 12 towns of SNNPR. After previous survey, the region was administratively divided in to two regions, Sidama and SNNPR. The new SNNPR was the third largest administrative region of Ethiopia representing about 15% of the country’s population comprising 16 zones and 7 special woredas (districts). Currently, after this study, the region was redivided in to two regions: Southwest Ethiopia and SNNPR.Sample size was estimated using a single population proportion formula at 95% confidence level assuming proportion of population with good practice to be 48.9% from previous survey [We used similar methods of sampling , data coFew questions were added to previous questions considering responses from previous survey. Twelve questions were used assess knowledge and questions with multiple responses were operationalized as presented in Nine data collectors who had BSc degree and above  and have experience in data collection, including previous survey, conducted interviews keeping COVID-19 prevention measures. Online monitoring and field supervision were done daily to maintain data quality.Excel file downloaded from SurveyCTO server was imported to SPSS version 25 for data management . VariablEthical clearance was obtained from the ethical review committee of the regional health bureau (Reference number: የወ6-19/6193). Informed verbal consent was approved and used because of its popularity in study settings and to minimize contamination during the pandemic. Questionnaire on SurveyCTO was set only to open questions if participant agreed to continue after data collectors read the information  on information sheet, and SurveyCTO closed survey form if consent was disagreed. No personal identifier was collected, and all collected data are kept confidential.Overall, 1162 respondents were included in the study, with response rate of 92.4%; non-response mainly to social distancing. About three fifths, 714 (61.4%), of respondents were females and 829 (64.2%) were married. About one third, 398 (34.3%), of respondents were Orthodox followers and about two thirds, 783 (67.4%), were from households with family size of five or less .The knowledge score ranged from zero to 100% with mean score of 69.7% (SD±17.87). Highest scores were recorded on questions regarding transmissibility of the disease and isolation of suspects while lowest scores were recorded on questions about sign and symptoms and port of entry when three items were considered for each question . For thiRespondents answered multiple methods as part of COVID-19 prevention. The most common method was handwashing (89.2%), followed by wearing face mask (55.1%) . ConsideEducational level, occupation, age, level of knowledge and attitude were associated at bivariate level and considered for multivariable regression. After running multivariable binary logistic regression, occupation, age and overall knowledge about COVID-19 and its prevention were associated with good COVID-19 prevention measures .Employees and pensioners were 1.83 and 3.57 times more likely to practice COVID-19 prevention as compared to students; AOR at 95%CI: 1.83 (1.07–3.10) and 3.57 (1.25–10.24) respectively.Age categories from 31–35 and 36–40 were 51% and 43% less likely to practice COVID-19 prevention while those who do not know their age were 3.17 times more likely to practice COVID-19 prevention as compared to age groups less or equal to 25 years; AOR at 95%CI: 0.49 (0.29–0.83), 0.57 (0.33–0.97) and 3.17 (1.74–5.77) respectively.Respondents who had medium and good level knowledge scores were 2.14 and 3.38 times more likely to practice COVID-19 prevention measures as compared to respondents with poor knowledge scores; AOR at 95%CI: 2.14 (1.51–3.03) and 3.38 (2.36–4.84) respectively.This study was done with the objective of assessing KAP related to COVID-19 and factors associated with COVID-19 prevention practices. Major finding included that the level of knowledge was improved while fear towards the disease and good prevention practices were decreased as compared to results of study done during early introduction of the pandemic to the region. Only about one third of participants were practicing COVID-19 prevention measures in a good way, and it was associated with occupation, age and overall knowledge about COVID-19 and its prevention.The adherence to public health recommendations to control COVID-19 spread is influenced by KAP of the public . KAP surThe overall knowledge score increased from 52.3% in previous survey  to 69.7%The mean attitude score was almost equal with previous survey, 80.8%  vs 80.6%The good COVID-19 prevention practice, however, decreased from previous survey. In previous survey, the good practice defined as practicing social distancing, using face mask and handwashing was 48.9% while it was only 32.7% in current survey using similar method of measurement. During previous survey, people tried to practice even with poor knowledge. A study done in Pakistan also reported high level of good practices (95.0%) with lower level of knowledge (67.4%) . A studyEmployees were 1.83 times more likely to practice COVID-19 prevention as compared to students; AOR at 95%CI: 1.83 (1.07–3.10). In addition, respondents who had medium and good level knowledge scores were 2.14 times and 3.38 times more likely to practice COVID-19 prevention measures as compared to respondents with poor knowledge scores; AOR at 95%CI: 2.14 (1.51–3.03) and 3.38 (2.36–4.84) respectively. The level of education and level of knowledge have been positively reported as significant factor for good COVID-19 prevention practices in studies conducted in Sidama, Tigrai and Southwest regions of Ethiopia –24 and pThose participants who did not know their age were 3.17 times more likely to practice COVID-19 prevention as compared to age groups less or equal to 25 years, AOR at 95%CI: 3.17 (1.74–5.77). Although participants who did not know their age can fall in any age categories, these groups are usually people in old ages. Pensioners were also 3.57 times more likely to practice COVID-19 prevention as compared to students, AOR at 95%CI: 3.57 (1.25–10.24). Since pensioners are also usually aged people, this could be due to seriousness of illness among old ages and intensive health educations targeted towards old ages. Furthermore, age categories from 31–35 and 36–40 were 51% and 43% less likely to practice COVID-19 prevention as compared to age groups less or equal to 25 years, AOR at 95%CI: 0.49 (0.29–0.83) and 0.57 (0.33–0.97) respectively. This might be due to the reason that the age group between 31 and 40 years are highly productive and their engagements in different activities that challenge them to properly practice COVID-19 prevention measures like social distancing.Risk communication activities can modify the successful implementation of public health interventions . Risk coAlthough we covered major towns in the region, the study was limited in addressing smaller towns and rural areas that account for majority of regional population. In addition, some of reported practices like social distancing and handwashing might have been knowledge and may not be actual practice of respondents due to social desirability bias.Knowledge and attitude related to COVID-19 prevention and control were moderate while COVID-19 prevention practice was low. Occupation, age and overall knowledge about COVID-19 and its prevention were associated with practicing COVID-19 prevention measures. The risk communication should be strengthened and its strategy should be shifted from crisis communication  to precautionary advocacy.S1 Data(SAV)Click here for additional data file.


Early detection of liver transplantation (LT) vascular complications enables timely management. Our aim was to assess if routine Doppler ultrasound (rDUS) improves the detection of hepatic artery thrombosis (HAT), portal vein thrombosis (PVT) and hepatic venous outflow obstruction (HVOO). We retrospectively analysed timing and outcomes, number needed to diagnose one complication (NND) and positive predictive value (PPV) of rDUS on post-operative day (POD) 0,1 and 7 in 708 adult patients who underwent primary LT between 2010–2022. We showed that HAT developed in 7.1%, PVT in 8.2% and HVOO in 3.1% of patients. Most early complications were diagnosed on POD 0 (26.9%), 1 (17.3%) and 5 (17.3%). rDUS correctly detected 21 out of 26 vascular events during the protocol days. PPV of rDUS was 53.8%, detection rate 1.1% and NND was 90.5. Median time to diagnosis was 4 days for HAT and 47 days for PVT and 21 days for HVOO. After intervention, liver grafts were preserved in 57.1%. In conclusion, rDUS protocol helps to detect first week’s vascular events, but with low PPV and a high number of ultrasounds needed.  With an impressive evolution over the past 50 years, liver transplantation (LT) has changed the quality of life and survival of many patients with acute liver failure, end-stage liver disease and hepatocellular carcinoma. The continuous improvements in patient selection, surgical techniques, perioperative management and immunosuppression have led to an increased liver graft and patient survival over time. Although the increased experience and proficiency has resulted in a change of the incidence, nature and outcome of vascular complications, they remain the most feared complications of LT as they can lead to graft dysfunction or even graft loss and patient death.Hepatic artery thrombosis (HAT) is an infrequent (incidence around 5%) but potentially devastating  complicaEarly detection of these vascular complications is of paramount importance for timely management in order to achieve favourable outcomes in LT patients. Hereto, there are well-accepted standards including early post-LT sequential ultrasound evaluation of the vascular patency. The specifics regarding implementing them, however, differ according to centre as there are ongoing debates regarding the frequency and use of routine liver vessel assessment.The aim of this study was to assess if routine Doppler ultrasound (rDUS), performed at day 0, 1 and 7 at our institution, improves the detection rate of early post LT vascular complications .® from 2010–2018 and the Philips Epiq 7G® from 2018–2022. Ultrasound examination included the evaluation of the hepatic artery by colour Doppler to assess patency and by pulse-wave technology to evaluate the wave pattern and calculate the resistive index (RI) of the hepatic artery at the level of the hilum and the right and left branch. The arterial anastomosis was considered patent when there was a normal wave pattern  and the RI was greater than 0.5 at all locations. The portal vein patency and flow direction  were evaluated by colour Doppler and the flow velocity by pulse-wave technology. The portal vein anastomosis was considered patent when the flow direction was hepatopetal, there was no intraluminal material and the acceleration between the pre-anastomotic and post-anastomotic portal vein velocity was less than three-fold. The patency and phase of three hepatic veins and the cavo-cavostomy were evaluated by colour Doppler. The outflow was considered sufficient when there was flow in all three hepatic veins and the cavo-cavostomy, the wave pattern in the hepatic veins were either triphasic or biphasic and the diameter of the hepatic veins was <10 mm. Whenever the patency of the hepatic artery, portal vein or hepatic vein was not considered sufficient or was debated, patients underwent a confirmatory CT (Computed Tomography). After discharge, all patients underwent life-long complete follow-up at our centre. All participants signed an informed consent before LT for retrospective data collection. The study adhered to the Declaration of Helsinki and is in concordance with the principles of the Declaration of Istanbul on Organ Trafficking and Transplant Tourism.All adult patients who underwent LT between January 2010 and September 2022 at our transplant centre were included. A routine Doppler ultrasound protocol was implemented in 2010 and consists of performing abdominal Doppler ultrasound by hepatologists with extensive ultrasonography experience during day 0 , day 1 and day 7 post LT. We used the Hitachi Hi Version PreirusThe following recipient variables were collected at time of transplantation: age, gender, BMI, indication for LT, calculated Model for End-Stage Liver Disease (MELD) score at time of LT, type of graft . We collected data on the occurrence of HAT, PVT and HVOO during the first 7 days post-LT and at any time thereafter. HAT was defined as a thrombotic occlusion of hepatic artery that led to the absence of hepatic artery signal at the hilum or the intrahepatic arterial branches on Doppler Ultrasound and/or a non-enhancing filling defect on contrast-enhanced CT scan. PVT was defined as thrombotic occlusion of the portal vein that led to a filling defect of portal blood flow on Doppler Ultrasound and/or a portal non-enhancing filling defect on contrast enhanced CT. HVOO included either thrombosis or stenosis at the level of caval anastomosis or hepatic veins diagnosed by US, CT or venography. For each vascular complication, we collected data on the first radiological imaging technique used to diagnose the complication  as well as the main indication for performing the imaging. These indications were either routine imaging on postoperative day 0, 1 or 7 or a clinical indication, defined as clinical deterioration, worsening graft function, ascites or other signs of portal hypertension, unexplained fever or abdominal pain, or hemodynamic changes. All patients with a rDUS suggestive of a vascular complication underwent subsequent CT to confirm the diagnosis. Furthermore, data on type of therapeutic intervention , total duration of hospitalization, need for re-LT within 7 days from liver vascular complication , and re-LT at any time point  were obtained.Statistical analyses were descriptive. Quantitative variables were expressed as medians with extreme values (range) and compared using Student’s t-test or Wilcoxon test as appropriate. Qualitative variables were expressed as numbers and percentages and compared using Chi-square or Fisher’s exact tests, as appropriate.Primary outcomes were the frequency of HAT, PVT and HVOO at different time points within the first week. Secondary outcomes were the use of surgical or interventional therapies as well as graft and patient survival.p-value of <0.05 was considered statistically significant.The diagnostic performance of protocol routine Doppler ultrasound in detecting HAT, PVT and outflow obstruction was expressed in terms of positive predictive value with CT as gold standard. Detection rate of rDUS was defined as number of vascular events detected/total number of ultrasounds performed. The number needed to image in order to detect one complication was calculated as (1/detection rate of rDUS). Due to the fact that a negative rDUS was not routinely followed by CT, it was not possible to calculate sensitivity, specificity and negative predictive value. All statistical analyses were performed using commercially available statistical software . A In total, 708 patients underwent primary liver transplantation and were followed for a median of 3.69 years (range 0–12.4). The baseline characteristics of the study population are presented in n = 445; 62.9%), with a median age of 55 (17–72) years, BMI of 25.5 kg/m2 (15.3–46.7) and laboratory MELD score of 22  at the time of first LT. Main LT indications were HCC  and cholestatic liver disease , followed by viral hepatitis in 117 (16.5%) and alcoholic liver disease in 106 (15%) patients. Machine perfusion was performed in 15.3%. Overall, 1, 5 and 10 years patient survival was 92.1% (95% CI: 91.1–93.1), 80.8% (95% CI: 79.1–82.5), and 68.2% (95% CI: 65.2–71.2). Graft survival was 87.5% (95% CI: 86.2–88.8), 73.9% (95% CI: 72–75.8), and 62.8% (95% CI: 60–65.6), respectively.Most of the patients were male (p = 0.28). Median time to diagnosis of any vascular event was 10 days , for HAT was 4 days , for PVT 47 days  and HVOO 21 days (0–1933). In total, 50 (7.1%) patients developed HAT, of whom 34 (68%) within the first week. PVT was found in 58 patients (8.2%), 21 of whom during the first week (36.2%), and HVOO was identified in 22 patients (3.1%) , n = 2 thrombosis in the IVC), 8 of those (36.3%) within the first week.Of the entire population, 112 (15.8%) patients developed at least one vascular complication within a median of 0.33 months (range 0–95.4) after LT, of whom 52 (46.4%) within the first week. The rate of vascular complications during the study time period is shown in The indication for the diagnostic CT within the first 7 days was a suspected vascular complication by rDUS in 40.4% of cases and laboratory changes in 34.6% of cases. Outside of the first week, imaging was either driven by clinical symptoms, laboratory changes or incidental, i.e., during re-evaluation for other indications  see .n = 14; 26.9%), 1  and 5 , followed by POD 4 , while at POD 7, only 3 patients were diagnosed (5.8%) , 21 with PVT (36.2%) and 8 with HVOO (36.3%). Eleven of these (21.1%) had more than 1 vascular complication at the same time. Most of the vascular complications during the first week were diagnosed on post-operative day (POD) 0 (.8%) see .n = 3 for laboratory changes and n = 2 for abdominal complaints). Therefore, the diagnostic yield of rDUS was 80.7% . In 18 patients, a vascular complication was suspected on rDUS, but not confirmed on the following CT , hence the positive predictive value was 53.8% (21/39). The total number of routine Doppler ultrasounds performed in the 708 patients was 1900 . Therefore, the vascular complication detection rate of rDUS was 21/1900 (1.1%) and the minimal number of DUS needed to detect one vascular complication was 90.5 (1900/21).In total, 26 patients (3.7%) had a vascular event on day 0, 1 and 7, which included 18 (69.2%) HAT, 10 (38.5%) PVT and 2 (7.7%) patients with HVOO. Twenty-one vascular events (80.8%) were detected by rDUS, and the remaining five were initially missed but detected on CT by indication the same day  in 14 patients (66.7%), while 7 (33.3%) were treated by anticoagulant therapy alone . This apn = 1), or recurrent occlusion of the hepatic artery (n = 2), while two patients required re-LT later due to ischemic biliopathy despite achieving initial arterial recanalization. Among the 7 patients who received anticoagulation alone , three (42.9%) patients with HAT had restored graft function, and other four (57.1%) underwent re-LT. Therefore, the majority of all re-transplantations for vascular complications were due to HAT , followed by PVT , HVOO + HAT  and HAT + PVT .Among the 14 patients who underwent surgical intervention, nine (64.3%) had a successful outcome , and five (35.7%) underwent re-transplantation . Of these, three patients needed urgent re-LT due to unsuccessful portal thrombectomy (n = 1), uncontrolled sepsis after second LT (n = 2), severe acute pancreatitis (n = 1) and malignancy (n = 2). Thus, in this group of vascular complications detected by rDUS, the 1, 5 and 10 years patient survival was 76% (95% CI 66.1–85.1), 76% (95% CI 66.1–85.1) and 57% (95% CI: 42.8–70.6); and graft survival was 51% (95% CI: 40.4–62.4), 40% (95% CI: 29–51) and 30% (95 %CI: 17.9–42.1), respectively  patients died, of whom only 1 because of early graft failure within 2 weeks post LT. All others died within a median time of 7.32 months (0.96–108.8) for causes unrelated to the vascular event, i.e., acute on chronic renal failure  and likewise, a high number of ultrasounds needed to detect one complication (90.5). Given the fact that the vast majority of cases occurred within the first 5 days, our rDUS protocol can be further optimised to include POD 0, 1 and 5 instead.Early detection of post LT vascular complications has always been considered important as these early complications can lead to fulminant graft failure . Re-tranAmong studies, the highest incidence of early HAT varies from day 1 to day 2 post LT , 11, witTo put some perspective to our findings, we applied the concept of number needed to treat (NNT) to the diagnostic setting. To identify one vascular complication, we needed 91 DUS examinations. Also, the positive predictive value of the DUS was rather disappointing, as almost half of the cases were found to be false positive at the confirmatory CT. Two other studies identified a much higher PPV of 92.3% and 88.9% for rDUS performed daily for either the first 7 days  or for tAcross time, we identified variations, albeit not significant, in the incidence of vascular complications during the first week. There may be several explanations for this variation. For one, this may be a reflection of variations in the use of more extended criteria grafts including DCD grafts (indeed our centre uses 36.2% DCD’s) or increasing acceptance of candidates with pre-LT PVT or other vascular complexities, which may change the risk of early vascular complications. However, it may also be that the implementation of an rDUS protocol contributed to an increased number of detected complications, like we observed in the early years. Most of these patients were clinically asymptomatic at the time of DUS. It may therefore well be that if we went by clinical judgment alone, these may not have been diagnosed at that time, but perhaps (much) later. This is especially true for days 0 and 1, during which time it is very challenging to know when early signs such as abdominal discomfort or laboratory changes are worrisome and when they are just part of the normal postoperative course. Despite the risk of false positive results during those early days, it seems reasonable to suggest that some form of diagnostic monitoring would still be desirable.One of the main strengths of our study was that we had a homogeneous single centre cohort in which patients were treated according to predefined protocols and no one was lost to follow-up. Another strength was that we not only examined the diagnostic ability of DUS to detect vascular complications  but also included data on the clinical consequences of their detection. One of the main limitations of our study is, however, that the true performance of the rDUS protocol could not be determined. This is due to the retrospective nature of the study and the fact that DUS is a standalone imaging modality not routinely requiring the confirmation in case of a normal result. Therefore, we could not calculate the true negative and false negative results.In conclusion, the majority of post-LT vascular complications occur during the first week. rDUS detects the majority of events during protocol days, but with low PPV and a high number of ultrasounds needed. However, a true clinical benefit in terms of graft and patient’s survival has yet to be shown.


Sci., 2023, https://doi.org/10.1039/d3sc03514j.Correction for ‘Liquid electrolyte chemistries for solid electrolyte interphase construction on silicon and lithium-metal anodes’ by Sewon Park  The authors regret that there is an error in Section 3.1.2 of the original article. The correct sentence is shown below.Multilayer SEI structuring is further discussed in Section 3.3.3.The Royal Society of Chemistry apologises for these errors and any consequent inconvenience to authors and readers.


The role of cigarette smoking as a prognostic factor for kidney cancer (KC) is unclear. In this population‐based study, we analyze cancer‐specific survival (CSS) outcomes among KC patients by smoking status at diagnosis in the diverse state of Florida.All primary KC cases from the Florida Cancer Registry diagnosed during 2005–2018 were analyzed. Cox proportional regression was conducted to assess the determinants of KC survival, including age, sex, race/ethnicity, socioeconomic status, histology type, cancer stage, and treatment received with a particular focus on smoking status .n = 6629), 32.9% were former smokers , and 48.8% were never smokers . Age‐standardized five‐year survival for current, former, and never smokers was 65.3 (95% CI: 64.1–66.5), 70.6 (95% CI: 69.7–71.5), and 75.3 (95% CI: 74.6–76.0) respectively. In multivariable analysis, current and former smokers had an estimated 30% and 14% higher risk of KC death compared to never smokers, respectively, after adjusting for potential confounders .Among all 36,150 KC patients, 18.3% were smokers at diagnosis (Smoking independently contributes to poorer survival, across all KC stages. Clinicians should encourage and facilitate participation in cigarette smoking cessation programs targeted at current smokers. Prospective studies are warranted to assess the role of different types of tobacco use and cessation programs on KC survival. FCDS has met or exceeded the North American Association of Central Cancer Registries (NAACCR) standards of quality, timeliness, and completeness (>95%) for every year since 1995.Histology was classified according to previous research2.1t‐test where appropriate  were either current or former smokers (Table p = 0.443). Among male KC patients, the proportion of ever smokers was 57.0% and among female KC patients 41.2% were ever smokers. Proportions of ever smokers varied by race/ethnicity with 54.7% in Whites, 43.6% in Blacks, and 39.4% in Hispanics. By insurance status, those under Medicaid were often (53.9%) ever smokers, followed by those under Medicare (53.1%) and those with private insurance (48.3%). In terms of histology, 62.6% of RTCC cases occurred among ever smokers. Among those diagnosed with chromophobe type, 38.8% were ever smokers. More than half of KC cases (64.9%) were diagnosed at a localized stage while 14.9% were diagnosed in regional stage and 14.6% in distant stage. The proportion of ever smokers was higher among those with distant stage (56.1%) followed by regional stage (53.5%) and localized stage (49.7%). Most patients received surgery (78.1%), while 8.2% received chemotherapy, and only 3.6% received radiation. Proportions of smokers also varied by primary tumor location: 50.3% of those with kidney cancer proper  and 62.4% of those with renal pelvis cancer (C65.9) were ever smokers. Of note, these proportions are lower than those reported for lung cancer.Most KC patients were White (74.0%), followed by Hispanic (13.8%), Black (10.4%), API (0.9%), and American Indian (0.1%). The largest proportion of KC cases (30%) was diagnosed in those 65–74 years old. The median age for KC in never smokers (66 years) was not significantly different from KC in ever smokers (67 years) (p < 0.0001)  deaths were due to KC recorded during 2005–2018, while 26,154 (72.3%) were alive at the end of the follow‐up or died of other causes. The age‐standardized five‐year KC specific survival for current smokers was 65.3% (95% CI: 64.1%–66.5%). For former smokers it was 70.6% (95% CI: 69.7%–71.5%) and for never smokers 75.3% (95% CI: 74.6%–76.0%)  (Table p < 0.0001). Similarly, in the multivariable analysis restricted to distant staged KC (Table p = 0.0284).In a direct comparison of current and former smokers in the multivariable analysis, current smokers had 13% greater risk of dying due to KC as compared to former smokers  and RTCC showed a disadvantage in survival in relation to other groups. The better survival outcomes of chromophobe cell KC were consistent with the existing aggregate literature.A major strength of this study is the use of all‐inclusive, racially, and ethnically diverse, state‐level data consisting of patients receiving care from a myriad of distinct healthcare facilities and presenting with various insurance statuses. Previous studies on this topic are primarily hospital or cohort‐based studies, in which there is potential for selection bias associated with referral patterns and willingness to participate, often resulting in a primarily Caucasian sample population, perpetuating limited generalizability of the findings for other marginalized populations. Furthermore, existing studies on smoking as a prognostic factor have been based on small samples, restricted to metastatic renal cell carcinoma treated with CNT, and limited to overall survival, thus including causes of death other than KC.In conclusion, this study highlights that smoking is an independent prognostic factor of KC survival, regardless of the stage at diagnosis. Current smokers, followed by former smokers, had a higher risk of KC mortality, as compared to never smokers in all stages of KC. Our findings can help clinicians identify patients who are at a higher risk of kidney cancer mortality and who may benefit from smoking cessation in addition to the recommended treatment strategies. Smoking cessation programs and counseling may be an important component of clinical management of KC patients and more successful outcomes. In addition, our study suggests that further research could focus on the impact of smoking cessation on clinical KC outcomes other than death such as recurrence, but also survivorship outcomes such as quality of life. The study also highlights the importance of addressing health disparities in kidney cancer outcomes. Patients on Medicaid have the worst survival outcomes of all insurance types, even after adjustment for socioeconomic status. Clinicians and researchers should consider interventions that address these disparities, such as improving access to healthcare and ensuring that all patients receive optimal treatment regardless of their insurance status. Further prospective studies are warranted to quantify this type of association, assess the role of distinct types of tobacco, and investigate the role of smoking cessation on survival outcomes of KC patients.Amrit Baral: Conceptualization (lead); formal analysis (lead); investigation (lead); methodology ; project administration (lead); visualization ; writing – original draft (lead); writing – review and editing . Hannah M. Cranford: Visualization (supporting); writing – review and editing . Janaki Sharma: Resources ; supervision ; validation ; writing – review and editing (supporting). Paulo S. Pinheiro: Conceptualization ; data curation (lead); formal analysis (supporting); funding acquisition (lead); investigation ; methodology ; project administration ; resources ; software ; supervision (lead); validation ; writing – review and editing .This work was partially supported by the Bankhead Coley Research Program of the State of Florida, Grant Number 20B16. This research was also supported by the National Cancer Institute Award Number P30CA240139.The authors declare no conflicts of interest.