The purpose of this study was to assess the effectiveness of topical pre-closure application of tranexamic acid (TXA) to reduce postoperative blood loss and blood transfusion rates in primary total hip and knee arthroplasty (THA and TKA) in a private, high-volume orthopedic specialty hospital setting.This was a retrospective study examining 140 consecutive patients undergoing primary hip or knee arthroplasty at the sample setting by a single surgeon. The first 70 patients did not receive topical TXA (2 gm./20ml.), the final 70 did receive topical TXA. We compared the postoperative hemoglobin levels of both sample subgroups at postoperative days 1, 2, and 3.Overall, the postoperative hemoglobin levels were significantly higher in the TXA group on postoperative days 1, 2, and 3 (p < 0.05). When patients who underwent THA (n = 70) were investigated separately, the hemoglobin levels were significantly higher on postoperative days 1, 2, and 3 in the group that received TXA. In the TKA group (n = 70), there was not a significantly higher hemoglobin level in patients who received TXA. There were no blood transfusions in the entire study cohort. Possibly due to the more restrictive transfusion criteria employed in this study, the total estimated prospective cost savings from use of TXA was calculated at about $116 per patient.Based on these results from a high volume orthopedic specialty hospital, pre-closure topical TXA application may prove effective in reducing postoperative blood loss for some patients but have a relatively small impact on cost outcomes. The application of tranexamic acid (TXA) has become an emerging therapy proposed in the joint arthroplasty literature as surgeons have become increasingly aware of complications relating to allogenic blood transfusion .Traditionally, techniques for reducing blood loss in joint arthroplasty have included controlled hypotensive anesthesia, tourniquets with pressure-controlled pumps, autologous blood transfusion (i.e. collection and reinfusion of the patient’s own red blood cells), and local injections.TXA is a synthetic derivative of the amino acid lysine that carries out its effects through an antifibrinolytic pathway.Due to the antifibrinolytic mechanism of action of TXA, there have been concerns expressed in the literature about the thrombogenic side effects of its administration, particularly with intravenous (IV) use of the drug.In fact, some studies have suggested fewer thromboembolic events with the use of TXA.The aim of this study was to examine whether the pre-closure topical application of TXA helped to reduce postoperative blood loss and to evaluate whether topical TXA reduced the need for blood transfusion in a high-volume center. Additionally, a secondary goal of this study was to examine the validity of the debate on the effectiveness of topical TXA. A final goal of the study was to assess whether TXA is cost effective in primary total knee (TKA) or total hip arthroplasty (THA).Before data collection, the Michigan State University intuitional review board certified the study as exempt from full review. A retrospective analysis was performed on 140 consecutive de-identified joint arthroplasty patients meeting the inclusion criteria. Inclusion criteria included all patients undergoing primary THA or TKA at a single institution by a single surgeon from April 2015 to September 2015. This institution was an orthopedic surgery specialty hospital where in 2017 there were 426 THA, 752 TKA and 152 unicompartmental  knee arthroplasties completed for a total of 1,330 joint replacement surgeries.Preoperative hemoglobin levels as well as postoperative hemoglobin levels for the first three postoperative days were required for inclusion into the study. Patient demographic data collected included age and BMI were also collected to assess any potential subgroup differences. The initial 70 analytic sample patients had not received topical TXA and the final 70 patients did receive topical TXA at the conclusion of surgery.All TKA surgeries were performed by a single surgeon. The surgeries involved either spinal or general anesthesia as well as administration of standard preoperative antibiotics. A midline incision with a medial parapatellar arthrotomy was used. A tourniquet was utilized in all cases and bleeding was managed with electrocautery. Implants included a cruciate retaining, fixed bearing total knee system. A standard Hemovac drain was placed prior to arthrotomy closure but not compressed until two hours postoperatively to remove any fluid or blood build-up in the joint. The group receiving TXA had it administered topically prior to closure of the arthrotomy at a standard dose of 2g/20mL.The same surgeon performed all of the THA surgeries with spinal or general anesthesia used for all surgeries. All THA procedures were completed through a direct anterior approach with use of an orthopedic table and press fit components were used for all patients. A Hemovac drain was placed at the conclusion of the case but not compressed until two hours postoperatively. In the group receiving TXA, it was topically administered prior to closure of the hip capsule using the same standard dose of 2g/20mL.Postoperatively, hemoglobin and hematocrit levels were drawn for three consecutive days. All patients received standard physical and occupational therapy protocols and received 24 hours of postoperative antibiotics. Enoxaparin and sequential compression devices were used for DVT prophylaxis. Discharge was typically on postoperative day 3. Preoperative and postoperative hemoglobin levels as well as patient demographics were retrieved retrospectively.nd (BGB) and 4th author (SR) using GraphPad Prism version 7.00 for windows analytic software.Statistical analyses were completed by the 2A two-way ANOVA was utilized to examine the influence that two different variables independently exerted on the single selected continuous outcome . Additionally, Pearson’s correlation analyses were performed. A cut-off point of a p-value less than 0.05 was observed for all analytic procedures to indicate statistical significance.During the study, there were a total of 140 joint arthroplasty cases reviewed. There were no statistically significant differences found in age or BMI between patient subgroups that received TXA versus those that did not. (Table 1) This is important to note since a difference in these measures could have skewed subgroup outcome differences. Furthermore, using Pearson correlation analysis, there were no significant correlations found between age or BMI with postoperative hemoglobin levels (data not shown). While there was a statistically significant difference in hemoglobin levels between genders at each point measured, there was no difference in the percentage change of hemoglobin between males and females when compared to preoperative levels. Due to this, the analytic authors proceeded to group the genders for further analysis.The results of the 70 patients who underwent THA in the study are shown in Figure 1. Of these patients, 34 (49%) received topical TXA and 36 (51%) did not receive topical TXA. The mean hemoglobin of the patients who received TXA was 14.04 ± 1.12 g/dL preoperatively and 10.93 ± 0.79, 10.57 ± 0.72, and 10.72 ± 0.87 at postoperative days 1, 2, and 3 respectively. The mean hemoglobin of the group that did not receive TXA was 13.50 ± 1.22 g/dL preoperatively and 10.27 ± 1.11, 9.86 ± 1.12, and 9.87 ± 1.32 at postoperative days 1, 2, and 3 respectively. Statistical analysis demonstrated significantly higher hemoglobin levels in the group receiving topical TXA at postoperative days 1, 2, and 3 (p < 0.05) with no significant difference in preoperative hemoglobin levels.Data from the 70 patients who underwent TKA are shown in Figure 2. Of the 70 patients, 36 (51%) received topical TXA and 34 (49%) did not receive topical TXA. The mean hemoglobin of the patients who did receive TXA was 13.34 ± 1.03 g/dL preoperatively and 10.73 ± 1.03, 10.44 ± 1.22, and 10.36 ± 1.21 at postoperative days 1, 2, and 3 respectively. The mean hemoglobin of patients who did not receive TXA was 13.50 ± 1.22 g/dL preoperatively and 10.36 ± 1.34, 9.91 ± 1.46, and 9.70 ± 1.51 at postoperative days 1, 2, and 3 respectively. There was not a statistically significant difference between hemoglobin levels at postoperative days 1 through 3 and there was no significant difference in preoperative hemoglobin levels.Figure 3 shows the analytic results of all patients  comparing hemoglobin levels between those who did receive topical TXA with those who did not receive topical TXA. The mean hemoglobin of those patients who received TXA was 13.69 ± 1.12 g/dL preoperatively and 10.83 ± 0.92, 10.50 ± 1.01, and 10.53 ± 1.07 at postoperative days 1, 2, and 3 respectively. The mean hemoglobin of those patients who did not receive TXA was 13.66 ± 1.15 g/dL preoperatively and 10.31 ± 1.22, 9.89 ± 1.29, and 9.78 ± 1.41 at postoperative days 1, 2, and 3 respectively. Similar to the THA only group, the results of statistical analyses demonstrated significantly higher hemoglobin levels in the patients who received topical TXA at postoperative days 1 through 3 (p < 0.05).There were only six (4.3%) sample patients in which postoperative hemoglobin levels ever dropped below 8 g/dL and none of them required blood transfusion. Of these patients, four (67%) were in the THA subgroup and two (33%) in the TKA subgroup. None of these patients whose hemoglobin levels dropped below 8 g/dL had received topical TXA.These results demonstrate that topical TXA can be effective at reducing postoperative decreases in hemoglobin levels after either primary THA or TKA. Overall, postoperative hemoglobin levels were significantly higher in the cohort of patients that received TXA compared to those that did not at postoperative days 1, 2, and 3. The effect of TXA appears to have been more pronounced in the THA subgroup, as the postoperative hemoglobin was significantly higher at all three postoperative days compared to the TKA subgroup, which did not have statistically significantly higher hemoglobin levels on any of the postoperative days.In other settings, TXA has already been shown to be effective both topically and intravenously in multiple studies for both THA and TKA for reducing perioperative blood loss.Pursuant to institutional criteria, there were no patients in this study who required an allogenic blood transfusion. This 0% rate is significantly lower than the literature reported rates for blood transfusion for primary THA and TKA, which have been listed anywhere from 11 to 67%.Other studies have also advocated for more restrictive transfusion criteria, finding no benefit for transfusion in patients with a hemoglobin level >8 g/dL regardless of cardiovascular risk.In 2013, Tuttle et al. performed a cost-benefit analysis of topical TXA in primary THA and TKA.If a similar cost-benefit analysis was performed using our study data, using the same transfusion criteria of hemoglobin < 8 g/dL . This means that six (8.57%) out of 70 patients who had not received TXA would have been transfused and 0 (0%) of 70 non-TXA patients would have been transfused. Cost estimates based on a per patient transfusion of two units PRBC and with the reduction of 8.57% of allogenic units transfused ((787.37*8.57) x 2 units PRBC) totals $13,489.18.Factoring in the cost of TXA and subtracting 2 grams used per patient for every 100 patients , the cost savings would be $1,889.00 (per 100 patients treated) or $18.89 per patient. Assuming a transfusion of 1 unit of PRBC per patient, ((787.37*8.57) - 11600), the cost savings would have been $4,852.00 (per 100 patients treated) or $48.52 per patient. However, the use of the more restrictive transfusion criteria observed during this study period led to no patients being transfused and thus the total cost savings was $11,600.00 per 100 patients or $116 per patient.These results suggest that the use of TXA may not be as cost beneficial if a restrictive blood transfusion criteria is used. If less stringent transfusion criteria had been utilized, however, the cost of topical TXA would partially offset secondary transfusion costs. Furthermore, a greater benefit of TXA use may be realized at institutions that have higher transfusion rates. The main goal from TXA use for most surgeons is to ultimately decrease the number of blood transfusions.We acknowledge several limitations to this study. First, all surgeries were performed at a high-volume orthopedic specialty hospital by one fellowship-trained arthroplasty surgeon. Because of this, there were shorter operative times and lower blood loss than would be expected for a lower volume surgeon and center and may account for the zero-transfusion rate that we found. This fact could limit the generalizability of our results to other settings. These results may not be representative of the significant number of TKAs performed at lower-volume hospitals typically associated with higher transfusion rates.Second, the study sample was comprised of a relatively smaller number of THA and TKA patients in Pennsylvania. In addition, there is the possibility for numerous unmeasured confounding influences on these results . Finally, these were retrospective analyses subject to possible inherent weaknesses compared to prospective, randomized, and blinded data sources.Based on these results, pre-closure topical TXA application may prove effective in reducing postoperative blood loss but have less impact on transfusion rates or cost outcomes. Standardized doses of topical TXA were particularly shown to be effective in reducing perioperative blood loss in THA surgeries. These findings, however, failed to indicate any sizable cost savings derived from TXA use. Future studies are needed to analyze outcomes associated with topical TXA in varied orthopedic contexts such as high versus low volume joint arthroplasty settings, TXA use in revision cases, bilateral TKA procedures, etc.The authors declare no conflict of interest.


Awareness of these risk factors can reduce mortality due to severe pneumonia.Childhood pneumonia is a major public health problem. The aim of this prospective hospital-based study is to determine the incidence and risk factors for community-acquired severe pneumonia in children in Ujjain, India. The study includes 270 children, 161 (60%) boys and 109 (40%) girls, aged between 2 months and 5 years with World Health Organization defined and radiologically confirmed severe pneumonia. Considering the 270 children, 64%  57.9–69.4) have severe pneumonia. The following are identified as risk factors for severe pneumonia from the generalized logistic regression model: Born premature (adjusted odds ratio (AOR) 7.50; 95% CI 2.22–25.31;  Pneumonia is the most common illness affecting infants and children globally. It is the most common cause of under-5 (U-5) mortality and contributes to 15% of U-5 mortality in 2017, killing an estimated 808,920 children ,4. The ARI control program is dependent on the early identification and treatment of children with signs and symptoms suggestive of pneumonia, presuming a bacterial etiology. The WHO and United Nations Children’s Fund (UNICEF), in 2013, published the integrated Global Action Plan for Pneumonia and Diarrhea (GAPPD), which outlined a framework for ending preventable child deaths due to diarrhea and pneumonia by 2025  age of 18.5 (± 17.5) months were enrolled. The mean (±SD) duration of signs and symptoms before admission was 4 (±2.1) days. A total of 38 (14%) children required ventilatory support for a mean (±SD) duration of 36 (±5) h. Complicated pneumonia was diagnosed in 17 (6%) children, and 16 (6%) children died during the hospital stay.The association of socio-demographic and birth-related risk factors with severe pneumonia is depicted in The association of history-related risk factors with severe pneumonia is shown in The association between environmental covariates and severe pneumonia is depicted in p <0.001). Considering 270 children, 52% (n = 112) had normal leukocyte counts, 41% (n = 112) had moderate leukocytosis, and 7% (n = 18) had extreme leukocytosis. Severe pneumonia patients had significantly more moderate leukocytosis compared to pneumonia patients . Extreme leukocytosis was observed more commonly in pneumonia (61%) versus severe pneumonia (39%), but the difference was not statistically significant (p = 0.48). The mean neutrophil count among children with pneumonia and severe pneumonia was 68 (±1.64); 95% CI 66–72 and 68 (±1.27); 95% CI 66–71. The difference was not statistically significant (p = 0.051). The mean (±standard deviation) TLC count among children with pneumonia and severe pneumonia was 13,425(± 389); 95% CI 12,653–14,197 and 13,851 (±333); 95% CI 13,194–14,508, respectively (p < 0.001). The cut-off of 20 mg/L had a sensitivity of 63%, specificity of 90%, positive predictive value of 92%, and negative predictive value of 58% and correctly classified non severe pneumonia from severe pneumonia in 73% of cases. The mean CRP value among children with pneumonia and severe pneumonia was 14.13 (±0.59); 95% CI 12.95–15.32 and 21.38 (±0.56); 95% CI 20.26–22.51, respectively (The initial model characteristics were df = 29, AIC =183.6, and BIC = 287.9, whereas the final model characteristics were df = 12, AIC = 171.6, BIC = 214.8. Therefore, the predictive power of the final model was significantly better than that of the initial model.The present study included children with WHO-defined symptoms and other signs to define pneumonia and severe pneumonia . The othDuring our study, severe pneumonia was more common in children between two and 12 months of age compared with children between 13 and 60 months of age. The global prevalence of pneumonia is highest in the age group of 1–4 years . ChildreThe present study reported that prematurely born children had an increased risk of severe pneumonia. Similar results were reported in another community-based study . The undAmong the environmental risk factors, children living in kuccha houses had an increased risk of severe pneumonia. Kuccha houses are typically built by the poor and is a recognized risk factor for pneumonia in other Asian countries as well ,32. OverThe present study evaluated host biomarkers like theTLC count, which was useful only in the presence of moderate leukocytosis. Generally, like the conclusion in other studies, it can be concluded that TLC and neutrophil percentage were not useful in distinguishing pneumonia from severe disease . HoweverA primary limitation of this study was that the study did not ascertain the etiology of pneumonia in children, because it was not the primary study objective. Other limitations included the absence of blood investigations of the children due to the non-specific nature of the leukocyte count and C-reactive proteins in distinguishing pneumonia from severe pneumonia and the non-presentation of antibiotic use data as all children were managed using standard IndiaCLEN treatment guidelines. Another limitation of the study is the data are from a single teaching hospital. The results are generalizable to similar resource-limited settings, but hospital-to-hospital variations are expected.Childhood pneumonia has been identified as the major “forgotten killer of children” by UNICEF and the WHO. Multiple modifiable risk factors for severe pneumonia have been identified in this study. Pediatricians and other health care workers, including the grassroot health workers, should be aware of these risk factors of severe pneumonia when managing the patient with pneumonia. The management of the modifiable risk factors may reduce mortality due to severe pneumonia.


Limited population-based studies have investigated the secular trend of prevalence of gestational diabetes mellitus (GDM) in mainland China. Therefore, this study aimed to estimate the prevalence of GDM and time trends in Chinese female population.Based on Diabetes Surveillance System of Zhejiang Province, 97,063 diagnosed GDM cases aged 20–50 years were identified from January 1, 2016 to December 31, 2018. Annual prevalence, prevalence rate ratios (PRRs) and average annual percentage change with their 95% confidence intervals (CIs) were reported.The age-standardized overall prevalence of GDM was reported to be 7.30% (95% CI 7.27–7.33%);9.13% (95% CI 9.07–9.19%) in urban areas and 6.24% (95% CI 6.21–6.27%) in rural areas. Compared with 20–24 years age group, women in advanced age groups (25–50 years) were at higher risk for GDM (PRRs ranged from 1.37 to 8.95 and the 95% CIs did not include the null). Compared with rural areas, the risk for GDM was higher in urban areas . The standardized annual prevalence increased from 6.02% in 2016 to 7.94% in 2018, with an average annual increase of 5.48%, and grew more rapidly in rural than urban areas (11.28% vs. 0.00%).This study suggested a significant increase in the prevalence of GDM among Chinese female population in Zhejiang province during 2016–2018, especially in women characterized by advanced age and rural areas. Gestational diabetes mellitus (GDM) is characterized by high blood glucose levels during any time of pregnancy . Based on up-to-date estimates from the International Diabetes Federation (IDF), 20.4 million or 15.8% of live births to women in 2019 had some form of hyperglycaemia in pregnancy, of which, 83.6% were due to GDM , 11. AsiData used in this study came from the Diabetes Surveillance System of Zhejiang province, which was a population-based diabetes registry system established in 2001 by Zhejiang Provincial Center for Disease control and Prevention (CDC). At the beginning of establishment, the system covered 30 representative surveillance districts and over 16 million residents. As early as 2009, the surveillance system has extended to all 90 districts throughout the province, with approximately 48 million residents. The surveillance procedures and quality control measures have been described elsewhere , 22 and In this study, GDM cases were diagnosed with the one-step method according to “The Diagnostic Criteria for GDM (2014)” published by the Chinese Medical Association . SpecifiDue to the lack of direct data on births in this study, we used the number of children to evaluate the number of births given the small probability of a multiple birth. The number of children in each year was evaluated according to the number of childbearing female population (20–50 years) in a year multiplied by the fertility rate of population, which is the average number of children that would be born to a woman over her lifetime. The data on female population of childbearing age in each year were obtained from the Zhejiang Provincial Statistics Bureau and were calculated with the female resident number estimated at the beginning and end of each year . The age-specific fertility rates data in Zhejiang province were from the sixth population census in China, 2010.Descriptive statistics were used to describe the baseline characteristics of 2016–2018 GDM cases included in the present study with frequency and proportion. The crude prevalence was calculated as the number of GDM cases divided by the number of births. The prevalence was calculated for each age group  and calendar year (2016–2018), stratified by residence area . The standardized prevalence was calculated using the direct standardization method according to the sixth population census in Zhejiang, 2010. To explore the effects of diagnosis year, age and residence area on prevalence, Poisson regression models were conducted with reporting the prevalence rate ratio (PRR) and 95% confidence intervals (CIs). Within the model, the calendar year was treated as a dummy variable. To examine the time trends of T2DM, the average annual percentage change in prevalence was calculated in multivariable Poisson regression model. Meanwhile, within the model, the calendar year was treated as a continuous variable and the statistical significance of the regression coefficient was tested. All analyses were performed using SAS statistical package .Overall, 97,063 GDM cases aged 20–50 years diagnosed between January 1, 2016 and December 31, 2018 were included in this analysis. The mean age at diagnosis was 31.37 (4.86) years. The detailed baseline characteristics of GDM cases included in the study were shown in Table During 2016 and 2018, the crude overall prevalence of GDM was 10.01% (95% CI 9.95–10.07%). Standardized overall prevalence of GDM during the same period was estimated at 7.30% (95% CI 7.27–7.33%); 9.13% (95% CI 9.07–9.19%) in urban areas and 6.24% (95% CI 6.21–6.27%) in rural areas  to 24.56% (95% CI 23.99–25.13%) in total; 3.59% (95% CI 2.99–4.26%) to 32.99% (95% CI 32.46–33.51%) in urban areas, and 1.94% (95% CI 1.88–2.01%) to 21.47% (95% CI 20.78–22.17%) in rural areas. The highest GDM prevalence was seen in 40–44 years age group, followed by 35–39, 30–34, 25–29, 45–50, and 20–24 years age groups  among Chinese women aged 20–50 years. Although with different GDM diagnostic criteria, study designs, population characteristics, study periods and statistical methods, our results were comparable to those findings from the published studies at present. Using the 1999 WHO criteria, two population-based studies in Tianjin of China reported that the adjusted prevalence of GDM among women living in urban districts between time-points 1999–2008 and 2010–2012 was 4.9% and 8.1%, respectively , which wIn our study, the age-standardized annual prevalence of GDM increased from 6.02% in 2016 to 7.94% in 2018, with the average annual percentage change of 5.48%, which was similar to other results in previous literature. Of 156,144 women who gave birth in southern Sweden, a study showed that the prevalence of GDM was 1.9% in 2003 and 2.6% in 2012, which rose at an annual rate of 3.4% . AnotherAge disparities in GDM prevalence have been observed in previous reports , 42. In Our study had several strengths. This is one of the few studies to investigate the prevalence and time trend of GDM among Chinese female population in mainland China. Data analyzed in the study were extracted from the computerized diabetes surveillance system, which was continually able to monitor the odds of GDM among province-wide population. With a relatively larger sample of 97,063 cases diagnosed by certificated health practitioners, the prevalence and time trends of GDM during 2016–2018 were reported eventually. Meanwhile, some limitations must be considered in this study. The greatest weakness of the study is that our reported data on GDM prevalence might be under-estimated. First, due to the lack of direct data on births, we used the number of children to evaluate the number of births, with neglecting the small probability of a multiple birth. Second, we have conducted several rounds of under-reporting investigations and based on the relevant data in 2007 and 2016 , 45, theIn conclusion, this study suggested a significant increase in the prevalence of GDM among Chinese female population in Zhejiang province during 2016–2018, especially in women characterized by advanced age and rural areas.


Our preliminary data showed a slight decrease of estimated glomerular filtration rate (eGFR) after direct-acting antivirals (DAAs) treatment in chronic hepatitis C (CHC). However, long-term outcome of renal evolution after DAAs has not been well documented.To assess the renal function under DAAs treatment in CHC patients of an Asian population at 6 months and 1 year after complete treatment.24) and 48 weeks after treatment (SVR48) were evaluated. We compared eGFR at baseline, SVR12, SVR24 and SVR48, and defined renal function deterioration as decrease of eGFR >25% from baseline to SVR24 and SVR48.A cohort of 1536 CHC patients who received therapies with DAAs were analyzed. Serial eGFR levels at 24 weeks after treatment . This trend of decline was similar in all groups. Multivariate analysis for deterioration in renal function from baseline to SVR24 showed liver transplantation, hypertension and baseline eGFR < 60 mL/min/1.73m2 were independent risk factors. Multivariate analysis for persistent deterioration in renal function from baseline to SVR48 showed liver transplantation, baseline eGFR < 60 mL/min/1.73m2 and DCV/ASV use were independent predictive factors.Overall, there was decline of eGFR from SVR2 were independent predictive factors of persistent deterioration in renal function from baseline to SVR48. Close monitoring renal function in these patients was suggested.There is a trend of decline in eGFR at 1-year after DAAs treatment regardless of baseline renal function or DAAs. Liver transplantation and baseline eGFR < 60 mL/min/1.73m Chronic hepatitis C virus (HCV) infection is a worldwide problem, that affects about 71 million people globally. Approximately 399000 people die from hepatitis C each year, mostly from cirrhosis or hepatocellular carcinoma (HCC). 12) [24) and 1 year (SVR48) after treatment.In addition to liver disease, recent studies demonstrated that chronic HCV infection also affect kinds of organs other than the liver. The relationship between HCV and chronic kidney disease (CKD) is also under investigation.  Among th12) . HoweverThis retrospective cohort study was inducted by collecting data from four institutions of Chang Gung Medical Hospitals in Taiwan . This study protocol had previously been approved by the ethical committees of Chang Gung memorial Hospital (IRB number 201900673B0). The requirement for informed consent was waived by the IRB. The data were analyzed anonymously. All CHC patients who were naïve with treatment of DAAs between Jan. 2015 and Dec. 2017 were identified and reviewed to confirm its feasibility. These regimens included sofosbuvir (SOF) or combination with ledipasvir (LDV), paritaprevir/ritonavir, ombitasvir, dasabuvir (ProD), daclatasvir plus asunaprevir (DCV/ASV), and grazoprevir plus elbasvir (GRZ/EBR). The use of DAAs was determined by the individual physicians’ decision according to a nationwide government-funded program Taiwan. The inclusion criteria were treatment with at least 12 or 24 weeks DAAs. Those who met the following criteria were excluded: history of end stage renal disease under hemodialysis therapy, organ transplantation (liver transplantation was not excluded), human immunodeficiency virus (HIV) infection, chronic hepatitis B infection, hepatitis D infection and loss of follow-up.24) and 48 weeks after treatment (SVR48) from Jan. 2015 to Dec. 2017. The IDMS-MDRD equation is: eGFR = 175 x (creatinine)− 1.154 x (age)− 0.203 x  x (1.212 if patient is black). Serum creatinine data was recorded from outpatient department.Assessment of renal function was based on eGFR using the isotope dilution mass spectrometry (IDMS) traceable Modification of Diet in Renal Disease (MDRD) at 24 weeks after treatment . The differences in continuous and categorical variables across the four groups were assessed using ANOVA and Chi-square, as appropriate. The change in eGFR among SVRA total of 1536 CHC DAA-naive patients treated in four institutions of Chang Gung Medical Hospital in Taiwan  were included for this study. Of them, 835 persons were in the ProD group, 265 in DCV/ASV group, 218 in SOF-based group, and 218 in GRZ/EBR group. Overall, 45%, 59%, and 14% of subjects were male, liver cirrhotic, and had HCC, respectively. The majority of patients were infected with genotype 1b HCV (88%). The patients of SOF-based group had higher level of AST, ALT, total bilirubin and HCV RNA than others. On the other hand, the patients of GRZ/EBR group had higher level of baseline creatinine than others. Detailed baseline characteristics of the four study groups are presented in 48 was shown as 12 as described in previous study [12 to SVR24 (84.30 ± 27.00 -> 79.98 ± 29.40 mL/min/1.73m2), SVR24 to SVR48 (79.98 ± 29.40 -> 73.20 ± 28.67 mL/min/1.73m2) and SVR12 to SVR48 (84.30 ± 27.00 -> 73.20 ± 28.67 mL/min/1.73m2). This trend of decline was similar in all treatment regimens. In the subgroup analysis of patients with baseline eGFR ≥60 mL/min/1.73m2, the trend of eGFR change from baseline to SVR48 was the same (91.95 ± 19.48 -> 82.91 ± 22.04 mL/min/1.73m2)(The evolution of means levels of eGFR from baseline to SVRus study . Consequn/1.73m2). In patin/1.73m2).48 minus baseline then divided by baseline, in order to present the amplitude of change in eGFR. There was a significant negative correlation between percentage of eGFR change and baseline eGFR in the group of all patients (p = 0.01)(2 showed positive association without significant difference (p = 0.463). (We defined percentage of eGFR change as SVRp = 0.01). In patip = 0.22). In cont 0.463). 24. Among all patients, 34 (34/831 = 4.09%) in ProD group, 12 (12/265 = 4.53%) in DCV/ASV group, 26 (26/222 = 11.7%) in SOF-based group and 14 (14/219 = 6.39%) in GRZ/EBR group suffered from deterioration of renal function from baseline to SVR24. Univariate analysis demonstrated that liver transplantation , hypertension , baseline eGFR < 60 mL/min/1.73m2  and SOF-based DAA  were significant risk factors for deterioration of renal function from baseline to SVR24. Further multivariate analysis indicated that liver transplantation , hypertension  and baseline eGFR < 60 mL/min/1.73m2  were independent predictive factors for deterioration of renal function from baseline to SVR24. in ProD group, 26 (26/265 = 9.81%) in DCV/ASV group, 28 (28/222 = 12.61%) in SOF-based group and 11 (11/219 = 5.02%) in GRZ/EBR group suffered from persistent deterioration of renal function from baseline to SVR48. Univariate analysis demonstrated that liver transplantation , hypertension , baseline eGFR < 60 mL/min/1.73m2  and DCV/ASV use  were significant predictive factors for deterioration of renal function from baseline to SVR48. Further multivariate analysis indicated that liver transplantation , baseline eGFR < 60 mL/min/1.73m2  and DCV/ASV use  were independent predictive factors for persistent deterioration of renal function from baseline to SVR48. [24 and SVR48. This is a novel finding that has not been reported. The decline of eGFR was evident even in patients without CKD at baseline and it was still there when all the risk patients including diabetes mellitus, hypertension, hepatocellular carcinoma and liver transplantation were excluded for analysis  . But suranalysis . So, the24. But only 88 (5.73%) patients fitted the criteria of >25% of decrease in eGFR. Similarly, 357 (23.24%) patients developed decrease of eGFR from baseline to SVR48. Only 93 (6.05%) patients fitted the criteria. These results indicated that most deterioration of renal function might not be clinically significant. Of the 93 patients with >25% of decrease in eGFR from baseline to SVR48, none of them developed into end stage kidney disease and need dialysis until now. Therefore, longer follow-up study is needed to clarify this issue.As we know, small fluctuations in eGFR are common and might not necessarily indicate deterioration of renal function. Some experts suggested that an assessment of >25% of decrease in eGFR was adopted to define renal function deterioration in clinical practice. Based on this definition, 626 (40.76%) patients suffered from decrease of eGFR from baseline to SVR48. Total 196 (12.63%) patients developed increase of eGFR from baseline to SVR48, which is less than the number of patients with decrease of eGFR. The multivariate analysis showed no significant predictive factors for renal function improvement. The possible explanation is too short follow-up period to express the power to predict the renal function improvement. For those patients with renal function improvement, the other possible reason is that the value of eGFR is affected mainly by serum creatinine value, age and sex. Creatinine is derived from creatine which is taken up by muscle [et al. demonstrated that female sex, impaired liver function, and decreased muscle mass in males are independent risk factors of overestimation of renal function. Cystatin-C based eGFR is recommended to trace the renal function in these patients, especially in male patients with cirrhosis and sarcopenia [Except for patients with deterioration of renal function, some patients developed improvement of renal function at time of SVRy muscle . As a rercopenia . In addiotal 196 .63% patiet al observed that four patients had worsening renal function after sofosbuvir-based DAA use, which included 2 out of 21 patients (9.5%) with CKD stage 3A and 2 out of 7 patients (28.6%) with CKD stage 3B [et al also showed that sofosbuvir-based DAA treatment induced worsening of renal function in 29(2%) patients. Furthermore, patients with baseline eGFR ≤ 45 mL/min/1.73m2 was an independent risk factor for deterioration of renal function compared with patients with baseline eGFR > 45 mL/min/1.73m2 [et al reported that sofosbuvir-based therapy for genotype 1b chronic hepatitis C patients did not deteriorate serum creatinine levels, irrespective of baseline eGFR levels [et al. reported a study of renal function from the ERCHIVES trials, where ProD group had higher proportion of eGFR decline [et al. demonstrated that only the subset of HIV-infected individuals showed significant decline in eGFR after ProD therapy for 12 weeks [48 was noticed especially in SOF-based therapy, but it was not an independent risk factor of renal function deterioration. It is mandatory to suggest that clinical physicians should closely monitor the renal function in SOF-based treated patients.Among our regimens of DAA, sofosbuvir is the only DAA which is excreted by kidney. Many previous studies had noticed the renal safety of sofosbuvir-based DAA in patients with chronic kidney disease, but the results were controversial. Shin stage 3B . Saxena n/1.73m2 . In contR levels . In addi decline . Alvarez12 weeks . In the 24) of renal function revealed that liver transplantation, hypertension and baseline eGFR < 60 mL/min/1.73m2 are predictive factors. It is reasonable that patients underwent liver transplantation have received different kinds of immunosuppressive agents, which might affect renal function. Multivariate analysis for persistent deterioration (a decrease of eGFR >25% from baseline to SVR48) of renal function showed liver transplantation, baseline eGFR < 60 mL/min/1.73m2 and DCV/ASV use are risk factors. The possible explanation for DCV/ASV risk was unclear. We supposed it is related to longer treatment duration than other regimens: the mean treatment duration of DCV/ASV was 24 weeks; in contrast, the mean treatment duration of other DAAs were 8 to 12 weeks. In other recent studies, Sise M. E. et al also reported that diabetes mellitus was a predictive factor of deterioration of renal function in the cohort with stage 3 chronic kidney disease [In the present study, multivariate analysis for the deterioration . The results indicate again that the decline of eGFR less than 25% might not be clinically relevant. Longer period of observation is needed to clarify this issue.It is interesting that baseline eGFR <60 mL/min/1.73mThere are limitations in our study. First, it is a retrospective study that there is missing data in some of the patients during follow up. Second, there is a lack of control group of patients who are not treated with DAA, as well as patients treated with interferon-based therapies. Further prospective case controlled study is warranted to clarify this issue.2 are independent risk factors of the deterioration of renal function. We suggested that it is important for patients with risk factors to receive regular renal function test after DAA treatment.In our study, there is a decline of eGFR at 1-year after DAAs treatment. Liver transplantation and baseline eGFR < 60 mL/min/1.73mS1 Data(XLSX)Click here for additional data file.S2 Data(PDF)Click here for additional data file.


Hemolysis, Elevated Liver Enzymes, Low Platelet count syndrome refers to biological syndrome occurring in pre-eclamptic and eclamptic women. There is a higher rate of maternal and perinatal morbidity and mortality due to the syndrome. So, the objective of the study is to find the prevalence and maternal- perinatal outcome in the syndrome.st April 2017 to 30th March 2018 after obtaining ethical clearance from the Institutional Review Committee. The inclusion criteria were patients giving consent for participation and those who delivered in our hospital. Patient with the syndrome who delivered outside and referred in the postpartum period was excluded because details of the neonate may not be available. The Statistical Package for Social Sciences version 21 was used for the analysis of the data. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.A descriptive cross-sectional study was done in a tertiary care hospital from 1Out of 11974 deliveries, the prevalence of Hemolysis, Elevated Liver Enzymes, Low Platelet count syndrome was 83 (0.69%) at 95% Confidence Interval (59.06-78.94). Maternal complications were seen in 19 (22.9%) and common complications being acute renal failure 9 (47.37%) followed by postpartum hemorrhage 4 (21.05%). Nearly 27 (33%) of patients required maternal ICU stay and there was one maternal mortality.Hemolysis, Elevated Liver Enzymes, Low Platelet count syndrome is one of the major causes of maternal and perinatal morbidity and mortality. Hence early recognition and prompt management may improve maternal and fetal outcomes. The secondary outcome was the mode of delivery, need of Intensive Care Unit, Neonatal admission rate.st April 2017 to 30th March 2018 after obtaining ethical clearance from the Institutional Review Committee of BPKIHS.We conducted a descriptive cross-sectional study at the Department of Obstetrics and Gynecology BP Koirala Institute of Health Sciences for one year from 1The sample size was calculated using the formula,2 × (p × q)/e2n = Z2 × (0.66 × 0.34) / (0.132)2   = 1.96   = 0.862 / 0.017   = 50.5   = 51where,n = required sample size4 the prevalence of acute kidney injury in HELLP syndrome was 66%,p = According to a study done by Abroug et al,q = 1-pe = margin of error, 13.2%Z = 1.96 at 95% Confidence IntervalAdding a non-response rate of 10% the final sample size was 56. We enrolled 83 patients with HELLP syndrome during the study period.The inclusion criteria were patient giving consent for participation and those who delivered in our hospital. Patient with HELLP syndrome who delivered outside and referred in the postpartum period was excluded because details of the neonate may not be available. Our hospital is a tertiary hospital so many patients with hypertension are referred from another centre. After admission, all hypertensive patients were investigated and managed according to the hospital protocol, and those who met the criteria for HELLP syndrome and meeting inclusion criteria were included in the study.2 this syndrome is characterized by the presence of all of the three following criteria: hemolysis , elevated liver enzymes (serum aspartate aminotransferase > 70 U/l), and low platelet count . Partial HELLP syndrome (PHS) is defined by the presence of one or two of the criteria. We had diagnosed HELLP syndrome according to these criteria. They were followed up till the discharge from the hospital and maternal and perinatal outcomes were recorded in the proforma.According to criteria developed at the University of Tennessee,5 with complaints of vaginal bleeding, abdominal pain, hypotension, increased tone, or retroplacental clots during delivery of the placenta. Postpartum haemorrhage was defined as a blood loss of 500 ml or more within 24 hours after birth according to WHO.6 Acute kidney injury was diagnosed according to the AKIN7,8 criteria which are defined as Abrupt (within 48 h) reduction in kidney function currently defined as an absolute increase in serum creatinine of 0.3 mg/dL or more (>26.4 //mol/L) or a percentage increase in serum creatinine of 50% or more (1.5-fold from baseline) or a reduction in urine output (documented oliguria of < 0.5 mL/kg/h for >6 h). Statistical Package for Social Sciences version 21 was used for the analysis of the data and point estimate at 95% Confidence interval was calculated along with frequency and proportion for binary data and the analysis was done.Abruptio placenta was diagnosed by clinical assessmentThe total number of deliveries within the study period was 11974 and there were 83 patients with HELLP syndrome. Hence, the prevalence of HELLP syndrome was 83 (0.69%) of total deliveries. Out of the 64 (77.1%) had partial and 19 (22.9%) had complete HELLP syndrome.Similarly 27 (32.5%) mothers required ICU stay, 56 (67.5%) did not. 22 (26.5%) required blood transfusion. One (1.2%) patient expired .Nine (47.37%) mothers had acute renal failure, 2 (10.53%) had abruptio placenta, 3 (15.79%) had pulmonary oedema and 4 (21.05%) had postpartum haemorrhage .*One patient had developed both abruption and postpartum haemorrhage and another one had both postpartum haemorrhage and acute renal failureEighty (87.9%) survival and 11 (12.09%) Intrauterine fetal death was seen .Twenty-six (32.5%) newborn required neonatal admission. And there were 2 (2.5%) neonatal death. The most common cause of neonatal admission was the low birth weight (53.84%) followed by respiratory distress (26.92%). The mean birth weight was 2199.84gm± 703.46gm. Median APGAR scores at 1 and 5 minutes among live newborns were 7 and 8 respectively.2HELLP syndrome is a life-threatening complication, considered to be a severe variant of hypertension in pregnancy, which is one of the major causes of a higher rate of maternal and perinatal morbidity and mortality. In this study prevalence of HELLP syndrome was 83 (0.69%) of total pregnancies which are comparable to the study done by Haram et al.9 this disorder is diagnosed antenatally in 70% of the women. Mean maternal age in our study: 24.84±5.90 years which is comparable to the study conducted by Nigar Sadaf et al, i.e, 28.23±5.9 years.10 It has been shown that maternal mortality decreasing up to 1% with treatment although complications as placental abruption, acute kidney injury, subcapsular liver hematoma, retinal detachment occur in about 25% of women.All women enrolled were in the antenatal period in our study with an average gestational age at presentation being 36.17±3.55 weeks. And 60% of the patient had presented before 34 weeks of gestation. According to a study by Rahman & Wendon10 where acute renal failure was the most common maternal complication followed by abruptio placenta. Another study was done by Kestutis et al.11showed placental abruption in 14.7% of the cases with complete HELLP syndrome. Maternal mortality is as high as 37% as shown in the study done by P Tiwari et al. which is seen in only 1.2% of cases in our study.12 Less maternal mortality in our study could be due to the enrollment of fewer cases of complete HELLP syndrome (23%) because morbidity and mortality are more in complete than in partial HELLP syndrome.In this study maternal complications were seen among 22.9% of the patient and most common being an acute renal failure (47.37%) followed by postpartum haemorrhage (21.05%). This result is also similar to the study done by Nigar Sadaf et al.10. Perinatal mortality and morbidity are considerably higher in this syndrome and are primarily dependent on the gestational age when the condition develops. The perinatal mortality rate related to HELLP syndrome is between 7.4% and 34%.13 Perinatal morbidity and mortality are associated with fetal growth restriction, oligohydramnios, non-reassuring fetal heart rate, preterm birth, low birth weight, birth asphyxia, stillbirth, and intrapartum death. And this is believed to be caused by placental insufficiency and generalized endothelial damage.14 In our study perinatal death is around 15% and the neonatal admission rate is 28.5% and a common cause for admission was low birth weight and respiratory distress, which is comparable to the study done by Zen et al. who reported perinatal mortality of 29% with HELLP syndrome.15 We have enrolled both partial and complete HELLP syndrome patients in this study which might have some influence on the maternal and perinatal outcome. If we would have taken the cases of complete HELLP syndrome result might have been more significant. This is an only descriptive study, it would have been better if we could have compared the findings between HELLP and non HELLP patients among hypertensive disorder.In this study, 51.8% of the patient underwent cesarean section and the most common cause for cesarean was non-reactive fetal heart tracing (44%) followed by failed induction. Which is similar to other studies done by Nigar Sadaf et alHELLP syndrome is a life-threatening complication of pregnancy, though its incidence is less it is associated with high maternal and perinatal morbidity and mortality. Hence early diagnosis and prompt management are required for the good maternal and perinatal outcome, as the delivery of the fetus is the best way to prevent complications.None.


BackgroundAcute myocardial infarction (AMI) is the most life-threatening manifestation of coronary artery diseases. The majority of deaths in AMI are due to arrhythmias. Therefore, the aim of this study was to evaluate the incidence and risk factors and outcomes of cardiac arrhythmias in AMI patients undergoing primary percutaneous coronary intervention (PCI) during the first 24 hours of the index hospitalization.MethodologyThis prospective observational study was conducted at the adult cardiology department of the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Patients undergoing primary PCI were included in this study. All the patients were kept under observation for the first 24 hours of AMI and monitored through telemetry system monitoring and the incidence of cardiac arrhythmias and the outcomes were recorded.ResultsA total of 110 patients were included; the mean age was 59.6±13.1 years. Most of them were male (70.9%). Arrhythmias were observed in 89.1% of the patients, with 169 episodes. The accelerated idioventricular rhythm was the most common type of arrhythmia (37.3%) followed by sinus tachycardia (36.4%), ventricular tachycardia (22.7%), and complete heart block (20.0%). Lethal arrhythmias were observed in 64.5% (71) of the patients. During the hospital course, 65.5% developed arrhythmias during arrival to balloon time, 30% during the procedure, and 53.6% within 24 hours of the procedure. The in-hospital mortality rate was 15.5% with a significant association with the development of lethal arrhythmias within 24 hours of the procedure .ConclusionsThe incidence of arrhythmias within 24 hours of hospitalization is high in patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI, and it has been observed to be associated with an increased rate of in-hospital mortality. Globally, ischemic heart disease (IHD) is the leading cause of morbidity and mortality . Among tFatal arrhythmias that can result in heart collapse and are major complications of AMI are ventricular arrhythmias (VT/VF) . In patiSudden arrhythmic death, often followed by 'warning' ventricular arrhythmias, can exacerbate the acute phase of AMI . The conThe developing world has about 30% of the total yearly deaths due to cardiovascular diseases , which iThis was a prospective observational study conducted at the adult cardiology department of a tertiary care cardiac center in Karachi, Pakistan, from November 2019 to June 2020. A sample size of 101≈110 was estimated taking the frequency of cardiac arrhythmias as 78.7%  of patie2), gender, obesity, smoking, diabetic mellitus, family history of CAD, and hypertension were recorded. Cardiac arrhythmias were diagnosed on the basis of ECG. All the patients were kept under observation for the first 24 hours of MI; all patients were monitored through telemetry system monitoring, and incidence of cardiac arrhythmias and outcomes were recorded. Confounding variables and bias were controlled by strictly following inclusion and exclusion criteria and stratification. Patient information was kept secured and accessible to authorized persons only.Approval of the ethical review committee of the institution was taken prior to data collection. Prior to inclusion, the purpose and benefits of the study were explained to all participants and verbal informed consent was taken. Demographic and clinical characteristics of the patients such as age (years), weight (kg), height (cm), body mass index (BMI)  version 23 . Numeric variables were presented as mean ± standard deviation (SD) or median (interquartile range). Frequency and percentages were calculated for categorical variables. Risk factors, angiographic and procedural characteristics, and outcome  were compared with the incidence of lethal arrhythmias within 24 hours of the procedure using the chi-square test or Fisher's exact test. Lethal arrhythmias included any arrhythmia other than accelerated idioventricular rhythm, sinus tachycardia (ST), or sinus bradycardia (SB). A P-value of ≤ 0.05 was taken as the criterion of statistical significance.2 (range: 19.0-34.6 kg/m2). Only 10 (9.1%) patients were obese (BMI>27.5 kg/m2), 53.6% had hypertension, 46.4% had diabetes mellitus, 1.8% had a family history of MI, 3.6% had a family history of coronary artery disease (CAD), 32.7% were smokers, and 1.8% were alcohol consumers. All of the patients were presented with chest pain, and the median duration of chest pain was reported as 267.50 minutes with an interquartile range of 120 to 675 minutes. At the time of admission, the mean heart rate was 86.4±29.7 beats/mins and the mean serum creatinine level was 1.35±0.87 mg/dL. Most of the patients had three vessels disease (3VD) (43.6%) and the most frequent culprit vessel was the left anterior descending artery (LAD) (43.6%). Pre-procedure thrombolysis in myocardial infarction (TIMI) flow grade was 0 in most of the patients (94.5%). The clinical and demographic characteristics of the patients are presented in Table A total of 110 patients were enrolled in the study. The mean age of the patients was 59.6±13.1 years (range: 22-100 years). Most of the patients were males (70.9%). The mean BMI was estimated as 25.0±2.5 kg/mArrhythmias were observed in 89.1% of the patients with 169 episodes. Accelerated idioventricular rhythm was the most common type of arrhythmias (37.3%) followed by sinus tachycardia (36.4%), ventricular tachycardia 22.7%), and complete heart block (20.0%). Lethal arrhythmias were observed in 64.5% (71) of the patients. The distribution of arrhythmias by type of myocardial infarction is presented in Table 2.7%, andThe mean hospital stay was 3.19±2.07 days with about 31.8% of the patients with prolonged hospital stay (≥4 days). During the hospital course, 65.5% developed arrhythmias during arrival to balloon time, 30% developed during the procedure, and 53.6% developed arrhythmias within 24 hours of the procedure. The frequency distribution of arrhythmias during the hospital course is presented in Figure The frequency distribution of in-hospital outcomes stratified by the patients who developed arrhythmias within 24 hours of the procedure is presented in Table Acute myocardial infarction is a debilitating disease leading to multiple complications. Among them, arrhythmia is a frequently observed complication leading to death. In the present study, the mean age of patients was 59.59 ± 13.1 years old. It has been evident that older age is a risk factor for developing arrhythmias -13. MaleIn our study, a total of 89.1% of the patients were observed to have arrhythmias along with MI, out of which 64.5% had lethal arrhythmias, which included ventricular tachycardia (22.7%), complete heart block (20.0%), ventricular fibrillation (9.1%), and atrial fibrillation (8.2%), while among non-lethal arrhythmias, accelerated idioventricular rhythm were observed in 37.3%, sinus tachycardia in 36.4%, and sinus bradycardia in 5.5% of the patients. The in-hospital mortality rate for the patients who developed lethal arrhythmias during 24 hours was significantly higher than those with non-lethal arrhythmias with a mortality rate of 21.1% vs. 5.1%; p=0.026.Similar to our study, the overall incidence of arrhythmias after STMI is reported to be as high as 78% to 83% ,16-18. TIn accordance with the results of our study, Albanese M et al. observed that most of the malignant arrhythmias occurred within 96 hours of MI and found to be associated with an increased mortality rate .This study has several limitations at the design stage, such as a single center-based study, small sample size, and lack of Holter monitoring. Secondly, at the execution stage, telemetry monitoring is not a routine clinical practice for all patients at our center, hence, patients who have undergone telemetry monitoring are suspected high-risk patients, which may have influenced the in-hospital mortality rate.The incidence of arrhythmias within 24 hours of hospitalization in patients with STEMI undergoing primary PCI is as high as 89.1%, and it has been observed to be associated with an increased rate of in-hospital mortality.


The aim of this study is to assess the prevalence of abnormal urine analysis and kidney dysfunction in COVID-19 patients and to determine the association of acute kidney injury (AKI) with the severity and prognosis of COVID-19 patients.The electronic database of Embase and PubMed were searched for relevant studies. A meta-analysis of eligible studies that reported the prevalence of abnormal urine analysis and kidney dysfunction in COVID-19 was performed. The incidences of AKI were compared between severe versus non-severe patients and survivors versus non-survivors.A total of 24 studies involving 4963 confirmed COVID-19 patients were included. The proportions of patients with elevation of sCr and BUN levels were 9.6% (95% CI 5.7–13.5%) and 13.7% (95% CI 5.5–21.9%), respectively. Of all patients, 57.2% (95% CI 40.6–73.8%) had proteinuria, 38.8% (95% CI 26.3–51.3%) had proteinuria +, and 10.6% (95% CI 7.9–13.3%) had proteinuria ++ or +++. The overall incidence of AKI in all COVID-19 patients was 4.5% (95% CI 3.0–6.0%), while the incidence of AKI was 1.3% (95% CI 0.2–2.4%), 2.8% (95% CI 1.4–4.2%), and 36.4% (95% CI 14.6–58.3%) in mild or moderate cases, severe cases, and critical cases, respectively. Meanwhile, the incidence of AKI was 52.9%(95% CI 34.5–71.4%), 0.7% (95% CI − 0.3–1.8%) in non-survivors and survivors, respectively. Continuous renal replacement therapy (CRRT) was required in 5.6% (95% CI 2.6–8.6%) severe patients, 0.1% (95% CI − 0.1–0.2%) non-severe patients and 15.6% (95% CI 10.8–20.5%) non-survivors and 0.4% (95% CI − 0.2–1.0%) survivors, respectively.The incidence of abnormal urine analysis and kidney dysfunction in COVID-19 was high and AKI is closely associated with the severity and prognosis of COVID-19 patients. Therefore, it is important to increase awareness of kidney dysfunction in COVID-19 patients. Previous publications have shown that AKI developed in 5 to 15% cases and carried a high mortality rate (60 to 90%) in SARS and MERS-CoV infections . The incIn order to fully understand the prevalence and the clinical characteristics of kidney impairment in COVID-19 patients, we have provided in this article a systematic review not only to evaluate the prevalence of acute renal impairment, but also to assess the risk of AKI in severely ill patients and non-survivors compared to non-severely ill patients and survivors, respectively. The findings in this article will help the clinicians to increase awareness of kidney impairment in COVID-19 patients.We conducted a systematic search on PubMed and Embase from December 2019 to May 2020 and have used terms “COVID-19” and “novel coronavirus” in combination with terms including “clinical characteristics,” “kidney injury,” and “renal impairment” as keywords for literature search. The exclusion criteria included , studiesAfter literature retrieval, we extracted the following parameters from 24 articles: sCr, BUN, elevation of sCr, elevation of BUN, incidence of AKI, proteinuria, proteinuria +, proteinuria ++/+++, the incidence of AKI in severely  and non-severely (including mild and moderate cases) ill patients, the incidence of AKI in survivors and non-survivors, application of CRRT in severely ill and non-severely ill patients, and application of CRRT in survivors and non-survivors. The characteristics of these studies are shown in Table I2: an I2 smaller than 25% represents insignificant heterogeneity, an I2 between 25% and 50% represents low heterogeneity, an I2 between 50% and 75% represents moderate heterogeneity, and an I2 larger than 75% represents high heterogeneity [I2 < 50%, and a random effect model (DerSimonian-Laird) was used if I2 > 50% [All analyses and plots were performed and made with the R version 3.6.3. For studies that did not provide mean and standard deviation but provided median (m) and upper (q3) and lower quartiles (q1) instead, the mean was estimated by (q1 + m + q3)/3, and the standard deviation was estimated by (q3 − q1)/1.35 . Forest ogeneity . A fixedI2 > 50% . The thrWe initially identified 306 articles based on the search results, and 102 articles were recognized to be duplicates. After removing the duplicates, the team members have carefully reviewed the titles, the abstracts, and the tables of the remaining 29 articles, and identified 24 articles , 17–28 tI2 indexes were between 69.1 and 96.9%, which were all above 50%. The I2 index of 8.40%  of the proteinuria ++ or +++ indicated that homogeneity was included.Meta-analyses of these studies have shown that 9.6% (95% CI 5.7–13.5%) and 13.7% (95% CI 5.5–21.9%) of the patients showed an elevation in the sCr level and BUN level, respectively  of COVID-19 patients had AKI  and 2.83 , respectively.  severe patients, 0.1% (95% CI − 0.1–0.2%) non-severe patients  as well as moderate or severe proteinuria (++ to +++) account for 38.8% and 10.6%, respectively. Cheng’s study has found that compared with patients without proteinuria, patients with proteinuria+ and ++ to +++ had a 1.5-fold and fivefold increased risk of death, respectively, indicating that proteinuria is an independent risk factor for in-hospital death of COVID-19 patients [Another main kidney damage manifestation was elevated sCr and BUN levels with incidence rate of 9.6 and 13.7%, respectively. Elevated sCr and BUN levels may be due to chronic kidney disease or AKI. Cheng’s study showed that the baseline sCr was elevated in 15.5% COVID-19 patients on admission; patients with elevated baseline of sCr were more likely to develop AKI and more severe AKI. Meanwhile, elevated baseline sCr and BUN levels was an independent risk factor for hospital mortality . TherefoOur meta-analysis showed that the averaged incidence of AKI was 4.5%, ranging from 1.3 to 36.4% dependent on the different severity of the illness. The exact pathogenesis of COVID-19-associated AKI is unclear. Based on the results of our meta-analysis in combination with our frontline experience, we consider that the etiology of renal impairment is likely to be diverse and multifactorial. Besides the direct attack by the SARS-CoV-2, hypoxia and hypercoagulability also contribute to kidney damage.It has been reported that in the kidney, angiotensin-converting enzyme2 (ACE2) is highly expressed in the brush border of proximal tubular cells but not in glomerular endothelial and mesangial cells , which cIn contrast to the previous study showing that median time for the occurrence of AKI from symptom onset were 20 and 16 days in SARS and MERS patients, respectively [Our meta-analysis also showed 15.6% non-survivors received CRRT, while 0.4% survivors needed CRRT, which indicated that COVID-19 patients complicated with AKI have a poor prognosis once CRRT is applied. As existing studies have not provided detailed information about survivors and non-survivors experiencing CRRT, further research is needed to determine whether early renal replacement therapy could improve the prognosis of COVID-19 patients complicated with AKI.The number of studies included was limited in terms of sample size, data availability, and methodologic quality, as most of the patients were from China. It will be better to include more studies with a broad geographic scope, to get a more comprehensive understanding of acute renal impairment in COVID-19. In addition, more detailed patient information, particularly regarding the risk of AKI and the relationship of comorbidities with AKI, was not available in most studies at the time of analyses. Another limitation of this study is that some articles have provided median and interquartile ranges but not mean and standard deviation of the sCr and BUN values. The mean and standard deviation for those data has been estimated in this study based on the median and the interquartile range, which might lead to inaccuracy to some extent.Although ARDS was the main feature of COVID-19, our meta-analysis identified the high prevalence of abnormal urine analysis and kidney dysfunction in COVID-19 patients. The overall incidence of AKI in COVID-19 patients was 3.7%, and the degree of AKI is closely associated with the severity and prognosis of COVID-19 patients.We consider renal tubule as the main part of injury in COVID-19 patients and the etiology of renal impairment in COVID-19 patients is likely to be diverse and multifactorial. Apart from direct attack by the SARS-CoV-2, hypoxia and hypercoagulability may also contribute to the occurrence of renal injury.Our findings indicate that it is important to increase awareness of kidney impairment in COVID-19 patients. Screening of the urine analysis, more frequent measurement of sCr, optimization of fluid volume, and appropriate anticoagulant therapy during the management of COVID-19 are essential.Additional file 1 : Supplementary Figure 1. Meta-analysis of the mean value of serum creatinine and BUN in COVID-19 patients. Heterogeneity is defined based on the calculated I2 index, and random effect models are used to calculate the weights. The forest plots represent mean values of serum creatinine  and BUN .Additional file 2 : Supplementary Figure 2. A: Forest plot of average AKI incidence in non-survivors. B: Forest plot of average AKI incidence in survivors. Heterogeneity is defined based on the I2 index calculated. A fixed effect model is used to pool the average AKI incidence in non-survivors, and a random effect model is used to pool the data of AKI incidence in survivors.Additional file 3 : Supplementary Figure 3. A: Forest plot of average proportion of severe patients who required CRRT. B: Forest plot of average proportion of mild patients who required CRRT. Heterogeneity is defined based on the I2 index calculated. Fixed effect models are used to pool data of both groups.Additional file 4 : Supplementary Figure 4. A: Forest plot of average proportion of non-survivors who required CRRT. B: Forest plot of average proportion of survivors who required CRRT. Heterogeneity is defined based on the I2 index calculated. Fixed effect models are used to pool data of both groups.


Helicobacter pylori strains isolated from patients who resided in Tolima Department, Colombia, diagnosed with chronic gastritis. The genomes present an average length of 1.6 Mbp and 1,546 genes and correspond to different H. pylori subpopulations.We present the complete genome sequences of three  Helicobacter pylori strains isolated from patients who resided in Tolima Department, Colombia, diagnosed with chronic gastritis. The genomes present an average length of 1.6 Mbp and 1,546 genes and correspond to different H. pylori subpopulations.We present the complete genome sequences of three  Helicobacter pylori colonizes over 50% of the human population, and it is estimated that in Colombia, 70 to 80% of the adult population is infected  at 37°C for 3 to 15 days under microaerophilic conditions. Each isolate was obtained from a single colony that was grown under the same conditions for 3 days, and genomic DNA was obtained from established growth using a DNeasy blood and tissue kit (Qiagen). Sequencing libraries were prepared with a TruSeq Nano DNA kit (Illumina), and genomes were sequenced using the 2 × 150 paired-end protocol of the Illumina NovaSeq platform . Read data sets were trimmed to improve quality with the software package Trimmomatic version 0.39 (de novo with SPAdes version 3.13.1 (This study was approved by the Tolima University Bioethics Committee (act number 02 of 31 July 2018). Informed consent and histopathological diagnosis were recorded for all participants. Gastric biopsy specimens were collected from patients at Javeriana Clinic during upper gastrointestinal endoscopy as part of the treatment of dyspepsia. The gastric biopsy specimens were grown on blood agar supplemented with sodium carbonate, hydrolyzed casein, tryptone, activated carbon, 10% fresh horse blood serum, and 1% Vitox and n 3.13.1  based onn 3.13.1 , and Muñn 3.13.1 .H. pylori.On average, the genomes have 39% GC content, 1.6 Mbp size, and 1,564 genes. Although the strains are from patients who reside in the same department, the population of each strain was different ; the GCTThe sequence read files and the genome sequences of the strains have been deposited in the GenBank database under the accession numbers shown in


This study aims to evaluate the diagnostic accuracy of digital breast tomosynthesis-guided vacuum assisted breast biopsy (DBT-VABB) of screening detected suspicious mammographic abnormalities comprising of calcifications, asymmetric densities, architectural distortions and spiculated masses. In this institutionally approved study, a total of 170 (n = 170) DBT-VABB were performed, 153 (90%) were for calcifications, 8 (4.7%) for spiculated mass, 5 (2.9%) for asymmetric density and 4 (2.4%) for architectural distortion. All these lesions were not detected on the corresponding ultrasound. Histopathology results revealed 140 (82.4%) benign, 9 (5.3%) borderline and 21 (12.4%) malignant lesions. The total upgrade rate at surgery was 40% for atypical ductal hyperplasia and 5.9% for ductal carcinoma in-situ. 3.6% discordant benign lesions showed no upgrade. DBT-VABB showed 100% specificity, 91.3% sensitivity and 100% positive predictive value (PPV) for detecting malignant lesions. The negative predictive value (NPV) was 80%. 2 (1.2%) patients had mild complications and 1 (0.6%) had severe pain. Our study showed that DBT-VABB was a safe and reliable method, with high sensitivity, specificity, PPV and NPV in the diagnosis of non-palpable benign and malignant breast lesions. Our data also confirmed the accuracy of DBT-VABB in detecting malignant lesions and we suggest further surgical excision in borderline lesions for a more accurate diagnostic evaluation. It accounts for 34.1% of all cancer among Malaysian females with the age-standardised incidence rate (ASR) increased from 31.1 in previous report to 34.1 per 100,000 populations. The incidence is highest among Chinese followed by Indians and Malays6. Mammography and ultrasound (US) are widely used imaging modalities for breast screening whereas magnetic resonance imaging (MRI) breast is reserved for screening of high-risk patients. Breast cancer awareness campaign and advocates have lead to a surge in patients coming for screening and hence, increases the detection rates of various lesions. Screen detected lesions are mostly non-palpable and commonly manifest as calcifications + /- mass. Management of uncertain breasts calcifications are challenging, and histopathological (HPE) confirmation are often required.Early detection of breast cancer reduce morbidity, mortality and improve the survival rate of breast cancer patients9. According to local cancer registry, 80% of ductal carcinoma in-situ (DCIS) cases are found during screening mammography without palpable lump and their earliest sign is microcalcifications10. Other less common mammographic abnormalities are masses, architectural distortion and asymmetries. Breast Imaging Reporting and Data System (BI-RADS) by American College of Radiology (ACR) guidelines 5th edition, 2013 helps to stratify the microcalcifications and aids in their subsequent management.Breast calcifications are one of the most common findings on mammography. Both benign and malignant lesions can produce mammographically suspicious calcifications and it is an important indicator in the early stage of breast cancer13. Vacuum assisted breast biopsy (VABB) is a newer technique and is currently the preferred method over core needle biopsy (CNB) for diagnostic evaluation.VABB is a minimally invasive procedure that is able to obtain larger samples without repositioning or reinsertion. It has been demonstrated to be a safe alternative to open surgical biopsy and shows numerous advantages over surgical excision including desirable cosmetic results, fewer complications, less psychological stress, more cost-effective and less hospital stay12. It can be done either under stereotactic, ultrasound or MRI guidance.Stereotactic guidance percutaneous biopsy has widely replaced surgical excision for histologic verification of indeterminate or suspicious lesions detected only on mammogram15.Diagnostic underestimation of DCIS and borderline lesions, especially atypical ductal hyperplasia (ADH), are not uncommon in stereotactic guidance percutaneous biopsy. A wide range of percentages have been reported and the majority of published literature concluded that CNB has a higher rate of diagnostic underestimation compared to VABBIn Malaysia, DBT-guided stereotactic VABB (DBT-VABB) is not widely used for diagnostic purposes as it is not readily available in all hospitals. It is currently mostly being utilized in tertiary referral hospitals with breast surgery and oncology subspecialties. In this study, we present our experience of utilizing DBT-VABB and evaluate the diagnostic accuracy of this method in non-palpable mammographic breast lesions.This was a single-center retrospective cross-sectional study, involving all patients with BI-RADS category 4 and 5 mammographic lesions who underwent DBT-VABB from 1st March 2017 to 31st July 2019. These lesions were detected on routine screening mammogram, occult on US and include calcifications, asymmetric densities, spiculated masses and architectural distortions. The study was performed in adherence with the approved guidelines from Medical Ethics Committee of University Malaya Medical Centre (MECID No: 2018724–6517). All experimental protocols were approved by Medical Ethics Committee of University Malaya Medical Centre and all subjects provided written informed consent. Information on the location, morphology and distribution of lesions and patients’ clinical data including age, risk factor, number of samples, residual lesion, tissue marker insertion, complications, HPE findings and any subsequent surgery were collected. Pain scoring assessment post-VABB was also recorded. Patients with confirmed breast cancer on the contralateral breast were excluded.All patients were examined on DBT . Patients subsequently had supplementary ultrasound evaluation of the breasts and both axilla using diagnostic B-mode greyscale and colour, medical grade US system  with a high frequency (i.e. 12.5 MHz) linear transducer probe. Ultrasound scans were performed by final year radiology trainee and the findings were verified by radiologists in-charge of the posting. DBT-VABB were performed by consultant radiologists with more than 10 years experience using the Mammotome system . Few cases were done using EnCore Enspire system (Bard BD). 10G stereotactic biopsy needles were used for both systems.The biopsy procedure was done in the upright position. Scout images were taken to confirm the presence of lesion within the field of projection and determined the puncture target. In patients with diffuse and regional calcifications, puncture target was made at the site with the densest distribution of  calcifications. Pre-fire and post-fire images were taken before DBT-VABB was performed. For calcifications, specimen radiograph was performed to confirm the presence of calcifications. Post-procedure mammogram was also performed to confirm on the complete or partial removal of lesion.Data were retrieved from local picture archiving and communication system (PACS) and two readers , blinded to the pathology results, categorised the findings according to ACR-BIRADS 5th edition (2013) mammogram lexicon; WYC and MTRH (with 5 and 10 years of mammography experience). HPE results were classified as benign, borderline or malignant (DCIS + invasive carcinoma). Final surgical pathology were also documented for patients who underwent subsequent surgical excision. Post-VABB complications were documented. Patients’ pain were scored using Numeric Rating Scale (0–10) and categorised as none (0), mild (1–3), moderate (4–6), severe (7–9) and worst pain (10).n) and per cent distribution (%). Diagnostic underestimation was calculated by dividing the number of upgrade in surgical HPE by the number of ADH or DCIS in VABB, respectively. Differences between proportions were tested using a Pearson’s chi-square test. Fisher exact tests were used when any assumptions of Pearson’s chi-square test were violated. A p-value of < 0.05 was applied as a threshold for statistical differences.Statistical analysis was performed with a statistic software, using Statistical Package for the Social Sciences (SPSS) for Windows Version 23.0 . For quantitative data, range and median were reported. Descriptive statistics were used and data were presented as frequency  patients recruited. The age ranged were between 34 to 77 years old, with a mean of 56.6 (SD 10.1) years. The most frequent age range was 50–59 . 73 (42.9%) had previous history of breast cancer, 18 (10.6%) had a strong family history of breast cancer and 79 (46.5%) had no risk factor.n = 92 (54.1%). 9 (42.9%) malignant lesions were seen in the right and 12 (57.1%) in the left breast. 60 (40.3%) benign lesions were seen in the right and 89 (59.7%) in the left breast.There was no preponderance of site for breast lesions with 69 lesions on the right and 101 lesions on the left. The majority of the lesions were seen in the upper outer quadrant, For BI-RADS breast density category, there were 9 (5.3%) patients in density category A, 58 (34.1%) in category B, 85 (50%) in category C and 18 (10.6%) in category D.The majority of lesions were calcifications 153 (90%), followed by spiculated mass 8 (4.7%), asymmetric density 5 (2.9%) and architectural distortion 4 (2.4%).For calcifications morphology, coarse heterogeneous type was the most commonly seen with 55 (35.9%) lesions, followed by fine pleomorphic in 52 (34.0%), amorphous in 38 (24.8%) and fine linear in 8 (5.2%). For distribution of calcifications, most were seen in the grouped category, 76 (49.7%) and the least were in the diffuse category, 13 (8.5%).In the final BI-RADS assessment category, they were 103 (60.6%) BI-RADS 4a, 39 (22.9%) BI-RADS 4b, 25 (14.7%) BI-RADS 4c and 3 (1.8%) BI-RADS 5 lesions.154 (90.6%) lesions were biopsied using Mammotome machine and 16 (9.4%) using Bard Encor machine. The number of specimens collected from the lesions during VABB ranged from 5 to 27 with a mean of 6.8 (SD2.6).Tissue marker clip was inserted in all lesions with clip migration occurring in 11.8% of patients. The distance of clip migration from the biopsy site ranged from 0.4 cm to 4 cm.Overall, only 2 patients developed a small haematoma confined to the biopsy site, measuring less than 2 cm. No severe complication was recorded.n = 94, 55.4%) only experienced mild pain. 1 (0.6%) patient had severe pain and this was associated with high number of specimens sampled, n = 24 and the resultant development of a small haematoma. These data were presented in Table For pain assessment, most patients (n = 59 (34.7%). Out of these benign lesions, there were 9 borderline lesions, majority being ADH (n = 7). For malignant lesions, they were 17 DCIS (10%) and 4 invasive carcinomas (2.4%). Detailed HPE data are shown in Table There were 149 (87.6%) benign and 21 (12.4%) malignant lesions. The most common benign lesions were fibrocystic disease, VABB HPE results in relation to mammographic findings were presented in Table With regards to morphology, 87.6% calcifications and all asymmetric densities were benign. Malignancy were seen in 1 of 4 patients with architectural distortion and 1 of 8 patients with spiculated mass. Figure For calcifications’ morphology, the probability of malignancy (PPV) was higher in fine linear (25%). For calcifications’ distribution, the probability of malignancy was 26.7% in linear category and 15.8% in segmental category. Figure We further explored the relationship between VABB and surgical HPE for 32 patients who underwent surgical excision due to malignant, borderline and imaging-pathology discordant lesions Table . UnderesThere were 5 3.6%) benign discordant lesions with no change in HPE after surgery. 6 out of 9 borderline lesions proceeded with surgery. 2 ADH were upgraded to DCIS representing 33.3% of diagnostic underestimation.The images of these cases were shown in Figs. % benign In the malignant group, only one high-grade DCIS was upgraded to invasive lobular carcinoma at surgery representing 5.9% of diagnostic underestimation. The mammographic findings of this patient were illustrated in Fig. Overall, when comparing the VABB HPE with surgical HPE of the 32 patients, the underestimation rate was 9.4% (3/32), with 18.2% (2/11) false negative rate. Our study also revealed that VABB was specific (100%), sensitive (91.3%) and have high PPV (100%). in detecting malignant lesions. VABB also have high NPV (81.8%) in detecting benign lesions Table .Table 5T12. In our study, we found that the distribution of malignancies in BI-RADS category is similar with the standard guideline by American College of Radiology16. Our results corroborate with the findings of other studies which showed that the likelihood of malignancy increases with BI-RADS category18.Non-palpable mammographic lesions are one of the major challenges in diagnosis of breast cancer. Calcifications are the most frequent mammographic finding for early diagnosis of breast cancer7. The prediction of benign or malignant calcifications are possible by following ACR BI-RADS mammography lexicon guidelines. Previous study by Jun Liu et al. showed that the probability of malignancy in calcifications’ morphology was higher in fine pleomorphic (44.7%) while with respect to distribution, the highest percentage were in segmental distribution (78%) and 68% in linear distribution7. These findings were similar to our study.Although calcifications play a crucial role in early breast cancer diagnosis, they are also associated with 63.2% of benign pathology19. Tsai et al. reported that stereotactic VABB has a sensitivity of 95.24%, false-negative rate of 4.76% and NPV of 99.61% in 817 patients within 5 years duration11. Similarly, Kettritz et al.achieved sensitivity and NPV of more than 99%17. We postulate that our study produced a higher false-negative rate of 20% due to a smaller sample size (2/10) as compared to other studies. However, in line with previous literatures, we found that VABB shows high specificity (100.0%) and sensitivity (91.3%). We also proved that VABB has high PPV (100.00%) for malignancy and high NPV (81.8%) for benignity. This study also demonstrates that DBT-guided VABB is safe and reliable despite not having prior experience with the procedure.Majority of previous literatures confirmed that VABB is a safe procedure, highly accurate technique and comparable to surgical biopsy for histopathological diagnosis in non-palpable breast lesions. A study performed by Penco et al. reported that the sensitivity of VABB ranged from 99.7% to 100% and false negative rate of 1.7% to 7.1% in 4086 patients within 10 years duration14. Unfortunately, stereotactic core needle biopsy is still the main choice for obtaining histological diagnosis in majority of hospitals in Malaysia due to cost. However, in the long run, VABB will reduce the need for surgery and reduce the incidence of delayed in diagnosis of cancer due to underestimation, which will then further burden the healthcare system.As it is generally known, diagnostic underestimation and false-negative rate is higher in core needle biopsy (CNB) compared to VABB. According to previous literature, range of diagnostic underestimation by CNB for DCIS was from 27 to 59% and approximately 11.5% to 88% for ADH11, the DCIS underestimation rate was 16.7% while another study by Kettritz et al.17 revealed that underestimation of ADH and DCIS were 24% and 12%, respectively. Another recent study by Badan et al. reported the underestimation rate of ADH was 25% and DCIS was 14.28%13. According to Inyoung Youn et al., the underestimation rate of ADH was 33.3% on VABB although all microcalcifications were completely removed20. Our data confirmed the accuracy of VABB in detecting malignant lesions and we suggest for further surgical excision in borderline lesions for a more accurate diagnostic evaluation. This has become a normal practice in our centre. However, according to the international consensus for borderline lesions, surveillance instead of surgical excision is possible in older age groups since most of the invasive cancers that develop after ADH progress slowly21.We found that the DCIS and ADH underestimation rate of our VABB were in line with previous studies. In a previous study by Tsai et al.22. In our study, the number of specimens ranged from 5 to 27 specimens with mean of 6.8. Similarly, the mean number of core was 8.5 in previous study by Esen Gul et al. but they have proven that although the average core number was low, their false negative rate was 0% with the total excision rate of  almost 44%22.All benign lesions in our study were mostly followed-up until 48 months and were found to be true negative. This can obviate unnecessary operations for benign lesions diagnosed by VABB. The diagnostic accuracy does not depend on obtaining a large number of specimens, instead an adequate number of correctly targeted specimens is essential. Previous studies showed that even with standardized retrieval of 20 specimens per lesion, underestimation can still occur18. The commonest complication of stereotactic VABB was haematoma which was well-controlled by manual compression and none of the previous study had reported patient requiring any surgical intervention for management of the complications23. In our study, 98.8% of our patients had no complications and 1.2% have a small haematoma of less than 2 cm.The complication rate of stereotactic VABB is low, approximately 3.7%24.VABB is a well-tolerated procedure in our study. The majority of our patients only experienced mild pain (55.4%) and 25.9% of them did not experienced any pain during the procedure. Only 0.6% of the patients in our study complained of severe pain which was associated with larger sample size. This finding is in line with previous study conducted by Seely et al. which revealed an average pain score of 3.1 with stereotactic VABB which is in mild categoryThere are several limitations in our study. Firstly, due to the nature of the retrospective database at a single institution, some useful patient data were not well recorded. Our study has small sample size and may be insufficient in providing an accurate overall picture. Further clinical studies with multicenter collaborations may provide more accurate conclusion. Secondly, the benign lesions underestimation was mainly evaluated based on clinical follow-up at a maximum of 2 years duration in our study. A long-term follow-up is necessary for more accurate results.Our study has shown that DBT-VABB is reliable in the diagnosis of non-palpable breast lesions. DBT_VABB is also a tolerable procedure without major complication. It has high sensitivity, specificity, PPV and NPV in detecting malignant as well as benign lesions. Benign lesions diagnosed by VABB can be safely followed up without any surgical interventions and malignant diagnosis on HPE should undergo definitive surgical treatment. Subsequent surgical excision for all borderline lesion, especially ADH should be recommended regardless of complete removal of calcifications in VABB. Our study also confirmed that BI-RADS category assessment is effective to anticipate the probability of malignancy.The promising results in our study supported the implementation of VABB as a standard tool for diagnosis of non-palpable mammographic lesions in all tertiary referral hospital.


Polycystic ovarian syndrome is considered to be one of the most common endocrine disorders among women of reproductive age. Characterized by a triad of androgen excess, anovulation, infertility, and obesity the disease can lead to several complications like infertility, endometrial carcinoma. This study aims to find out its prevalence among female medical undergraduates.st to 7th February 2018. Ethical approval was taken from the Institutional Review Committee (reference number 10012018). The sample size was calculated. Systematic random sampling was done. Statistical Package for the Social Sciences version 20.0 was used. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.A descriptive cross-sectional study was conducted among female undergraduate medical students in a tertiary care hospital from 1Out of 381 participants, the prevalence of polycystic ovarian syndrome was found to be 35 (9.18%) at 95% Confidence Interval (6.28-12.08). Eighty (20.99%) participants were reported to have prolonged menses, 28 (7.34%) tended to grow dark, coarse hair, 79 (20.73%) reported being obese or overweight, and milky discharge from nipple was present in 4 (1.049%).The prevalence of polycystic ovarian syndrome was found to be similar to other studies conducted in similar settings. But still, it is a growing endocrinological problem in the females of the reproductive age group. Early screening is necessary to prevent lifelong complications. Some of the women who develop cardiovascular disease (CVD), hypertension, endometrial cancer, and type II diabetes later in life appear to have suffered from PCOS in earlier years.4 Also, Nepal lacks accurate prevalence data of PCOS.5PCOS is becoming a more prevalent disorder among women of reproductive age with lifelong complications.Hence, this study was conducted with the aim of finding the prevalence of PCOS among medical students which included females of reproductive age group.st to 7th February 2018. Those students that were already diagnosed with PCOS, thyroid disorder, or pituitary disorder were excluded. Those who did not give their consent were also excluded. The sample size was calculated using the formula,A descriptive cross-sectional study was conducted in Kathmandu Medical College and Teaching Hospital (KMCTH), Sinamangal, Kathmandu, Nepal. After taking the ethical clearance from the Institutional Review Committee of KMCTH with reference number 10012018, data was collected from female medical students  from first to a final year studying at KMCTH from 12 × p × (1-p)/e2n= Z2 × 0.0913 × (1- 0.0913)/0.022= 1.96= 0.3187/0.0004= 796.75= 797n= required sample size1p= prevalence 9.13%, taken from the previous studye= margin of error, 2%Z= 1.96 at 95% Confidence IntervalWhere,Taking the finite population i.e. total female students of Kathmandu Medical College (N)= 520Adjusted sample size= n/[1+(n-1)/N]= 797/[1+(797-1)/520]= 314.92= 315Therefore, the calculated sample size was 315. Adding a non-response rate of 10%, the sample size was 346.5 i.e. 347.6 was used for screening of PCOS. This questionnaire included questions regarding PCOS clinical symptoms, which is the clinical tool for the diagnosis. Positive scoring was given to prolonged menses, hirsutism , and obesity now or sometime in the past. Milky discharge from nipple is kept for the exclusion of other endocrine abnormalities that mimics PCOS symptoms and hence if present gave a negative score. Finally, a cumulative score of two or more, indicates that the participant has clinical PCOS. Height and weight were recorded by standard procedures that are, the digital weighing scale for weight and stadiometer for height. Body Mass Index (BMI) was calculated.A total of 381 students were taken in the study. Systematic random sampling was done. A self-administered closed-ended questionnaire was distributed. A clinical tool for diagnosis of PCOS by Pedersen SD, et al.Information bias, reporting bias, social desirability bias, and non-response bias were encountered. The collected data were coded and entered in IBM Statistical Package for the Social Sciences version 20.0.Out of the 381 female students included in the study, the prevalence of PCOS was found to be 35 (9.18%) at 95% Confidence Interval (6.28-12.08).Eighty (20.99%) participants reported that they had prolonged menses i.e. cycle more than 34 days or a totally variable cycle. 28 (7.34%) said they had the tendency to grow dark, coarse hair in three or more sites. 79 (20.73%) participants reported being obese or overweight now or sometime in the past. Milky discharge from nipple was present in four (1.049%) .Among the 381 participants, 40 (10.5%) said they had obesity, 14 (3.7%) said they had hirsutism, 168 (44.1%) had acne, 7 (1.8%) had hypothyroidism, 204 (53.5%) had anxiety, 34 (8.9%) had anorexia/bulimia. Similarly, hypertension was reported in 6 (1.6%) participants, diabetes in 2 (0.5%), alcohol intake in 120 (31.49%), 7 (1.8%) smoked, and 214 (56.2%) had bad mood whereas 203 (53.3%) lacked physical exercise. Migraine was present in 34 (8.9%) and 8 (2.1%) used oral contraceptive pills (OCPs). None of the participants reported infertility and dyslipidemia .Similarly, the family history of PCOS was present in 11 (2.9%), infertility in 10 (2.6%), diabetes in 182 (47.8%), CVD in 139 (36.5%), and carcinoma in 30 (7.9%). Eighty-one (21.3%) mothers of the participants had irregular menstruation .7 In our study, the prevalence was found to be 9.18% which is slightly higher than the worldwide prevalence.The worldwide prevalence of PCOS is estimated to be 6-7%.1 Similarly, a hospital-based study done among Omani women showed the prevalence of PCOS to be 7%.7 Again, another study was done among young women in Bhopal, Central India which was found to be 8.2%.8 These findings were quiet similar to our findings.In a study conducted in South India among health sciences, students the prevalence of PCOS was found to be 9.13%.9 Similarly, another study done among students of a tertiary care teaching hospital said that 32.11% met the criteria to be diagnosed as PCOS.10Our findings were considerably lower than these.Furthermore, the prevalence of probable PCOS was found to be high, 46.4% in a study done in Kashmir among reproductive age group women.4 Studies suggest that epidemiological transition and rapid urbanization have led to the greater propensity of endocrine disorders among young adults in South Asia.11 In our study out of 381 participants, 204 (53.5%) reported having stress. Hence, stress was seen high compared to other risk factors in our participants also.It is already known that PCOS has been attributed to several causes that include the change in lifestyle, diet, and stress.1 Another study adds even more attention to this problem saying that compared with other populations, South Asians have a greater propensity to insulin resistance and metabolic syndrome.11 In our study 40 (10.5%) reported to be obese currently or sometime in the past which was considerably lower than the study done in South India which reported 38.5% cases. Hence, education, self-empowerment, multidisciplinary care, and lifestyle intervention for prevention or management of excess weight are to be prioritized. Depressive and anxiety symptoms should be screened, assessed and managed.12As our city is also subjected to rapid urbanization, dietary and lifestyle habits are also changing to unhealthy ones. In our study comparatively high number of participants reported alcohol intake 120 (31.49%) and lack of physical exercise 203 (53.3%). Such changes in lifestyle habits predispose adolescents and young women to diseases with long term complications due to insulin resistance like type II diabetes mellitus, PCOS.5This was again supported by another study done in PCOS which showed that out of 80 known participants with PCOS, 59 % of patients were in the age group of 20-29 years6 and it is clear that PCOS is a common disorder among young female.1 Hence, our study targeted this age group with an aim to screen and help in lifestyle modification to prevent lifelong complications.A study done in Nepal shows that the mean age of patients with PCOS was 24 years indicating that it is a disease mainly of young age.7 However, as only a clinical symptoms questionnaire was used in the study, it does not provide a probable diagnosis of PCOS. For more accurate diagnosis ultrasonography is recommended.The present study had certain limitations. It was conducted in only one medical college hence the findings cannot be generalized among all the female population. Since a descriptive cross-sectional study was conducted, the probable risk factors could only be quantified but a link between these probable risk factors and PCOS could not be established. The questionnaire has sensitivity 85.4% and specificity 93.4%.The prevalence of PCOS was found to be similar to the previous studies done in a similar setting.PCOS is becoming one of the most common endocrinological problems. Hence, early screening, lifestyle modification, and intervention are necessary to prevent lifelong complications. There is a paucity of research providing accurate data on the prevalence of PCOS in our country. Another study also suggests that the study of PCOS on a large scale would be helpful to provide a more accurate picture of the disease. Hopefully, this study will help identify the proportion of PCOD cases so that they can be subjected to further diagnostic tests, and thus apply lifestyle modification and treatment as early as possible to prevent lifelong complications. This a study involving a larger area and a larger sample size is recommended.None.