In the absence of a gold standard in France, the objective of our study was to validate our 5-level pediatric triage tool –pediaTRI to identify high-level emergencies (severity levels 1 and 2) was evaluated in comparison with a PEWS ≥ 4/9. Data from 2018–19 was used as an independent validation cohort.We prospectively included 100,506 children who visited the Pediatric Emergency Department at Lenval Children's Hospital  in 2016 and 2017. The performance of pediaTRI agreed with the PEWS score for 84,896 of the patients (84.5%): 15.0% (14.8–15.2) of the patients were over-triaged and 0.5% (0.5–0.6) under-triaged compared with the PEWS score. pediaTRI had a sensitivity of 76.4% (74.6–78.2), a specificity of 84.7% (84.4–84.9), and positive and negative likelihood ratios of 5.0 (4.8–5.1) and 0.3 (0.3–0.3), respectively, for the identification of high-level emergencies. However, the positive likelihood ratios were lower for patients presenting with a medical complaint .pediaTRI has a moderate to good validity to triage children in a Pediatric Emergency Department with a tendency to over-triage compared with the PEWS system. Its validity is lower for younger children and for children consulting for a medical complaint. The number of visits to emergency departments (ED) has been rising steadily for both adult and pediatric patients over the past decades  resultinThere are many triage tools around the world, all of which have five levels of triage ranging from a non-urgent consultation Level 5) to a life-threatening emergency (Level 1)  to a lif. HoweverRegardless of the triage algorithm, the identification of life-threatening emergencies is a common and implicit denominator. In a pediatric ED (PED) setting, a high-level emergency corresponds to a child presenting an immediate life-threatening risk that could lead to cardio-respiratory arrest or a related emergency, and thus requires rapid intervention. These patients, for whom a Level 1 or 2 is usually assigned by commonly used pediatric triage tools –13, can In France, there is no gold standard in pediatric triage and each hospital uses their own “home-made” triage system. Portas et al.  aimed topediaTRI – based on clinical items of inspection, interview, and analysis of vital signs  created a 5-level pediatric triage tool – the al signs . The iteal signs , a softwpediaTRI integrated into the TU® software against a reference standard, the PEWS system, in screening high-level emergencies.Our objective was to validate We conducted a cross-sectional observational study in the PED of the Lenval Children's Hospital in Nice, a tertiary level, University Teaching Children's Hospital. This PED is the only one in the southeast of France (1.140.000 inhabitants aged 0 to 19 in 2017) and is the 4th biggest PED in France with an average number of 60.000 visits per year (before the Covid 19 Pandemic) of patients from zero to 17 years of age. The hospital is a reference center for specific diseases including cystic fibrosis, neuromuscular diseases, sudden infant death syndrome, and psycho-trauma, and provides a complete medico-surgical and technical platform delivering 24/7 care for any emergency  with two operating rooms managed by pediatric anesthesiologists and surgeons. It has 180 beds including 10 belonging to the Intensive Care Unit (ICU) and 60 for outpatient care. The patient recruitment pool covers a radius of 90 miles from Nice. Although our PED is referenced as one of the two Level 1 pediatric trauma centers in the area, potentially life- threatening conditions remain rare and represent about 1% of the visits per year.All patients under the age of 18 who visited the PED of Lenval Children's Hospital between January 1, 2016 and December 31, 2017 (open 24/7) were included. Patients who were called back, patients treated in prehospital care, and patients who left without an assigned triage level were not included. Patients visiting the PED for psychological or psychiatric conditions, patients who left without being seen by a physician, whose recorded vital signs were considered as uninterpretable (not reliable or error measures), or for whom there was no information about outcome, were excluded. The study was approved by the French Data Protection Authority (CNIL) (registration number: 2157640v0) in accordance with the laws which govern “non-interventional clinical research” in France . Patient data were anonymized using a specific patient numbering procedure for the study. Informed written consent or ethics committee authorization was not necessary for this no-effect observational study collecting anonymized data on patient management.The Terminal Urgences® software was created in 2002 under the supervision of the Regional Health Agency, and is now used in more than 65 EDs (for both adult and pediatric patients) in the southeast of France . This soIn pediatric triage, the nurse follows a pre-established evaluation algorithm for triaging patients. Firstly, the nurse must identify whether the patient is in a critical condition  or judged to be at high risk . In those cases, the triage process is stopped at this point so that lifesaving care can be initiated. For the other children, the nurse collects details about the chief complaint covering all the triage items, and selects all the complaints that the child presents or that are reported by the parent(s). Each item is assigned to a triage level, although the triage can be moderated by risky situations/conditions and out-of-range values for vital signs. If several items are selected, the one with the highest level of severity determines the final triage level. If the nurse disagrees with the level assigned by the tool, they can change the triage level after consulting with the attending PED physician. The triage module is a user-friendly interface allowing the nurse to perform a quick triage within an optimal duration of 5 min.pediaTRI, is structured into five levels ranging from the most severe (Level 1) to the least severe (Level 5). Levels 1 (life-threatening emergency) and 2 (very urgent) are mainly assigned to patients for whom the vital and / or functional prognosis has already been engaged or will probably be engaged very quickly if no care is administered. These patients are defined as high-level emergencies. Low-level emergencies correspond to Levels 3 (urgent), 4 (consultation), and 5 (non-urgent) for which a vital or functional prognosis may not be engaged either in the short or medium term. However, according to resource utilization and to the architecture of the PED at Lenval Children's Hospital, some risky situations  or risky profiles  may be systematically attributed Level 2. Each triage level determines the optimal time (in min) for the patient to see a physician (fractile response)   accordinAll the nurses must have worked in the PED for at least 6 months and then undergone a 3-month supervision period by an experienced nurse before performing a triage alone.pediaTRI against other triage tools developed in this setting as the quality of evidence  to support their use is poor.We could not validate Among the existing scores for predicting mortality and morbidity in pediatrics, we opted for the PEWS system described by Akre et al.  as our rBased on data from previous years, approximately 200 patients classified as Level 1 (life-threatening emergency) visit our PED each year. Thus, we conducted a large cross-sectional study to allow for sufficient statistical power and detailed evaluation of specific categories of patients by analyzing patients visiting our PED over 2 successive years (2016–17).pediaTRI in classifying patients as a high-level emergency (pediaTRI Levels 1 or 2) or low-level emergency . In the same way, a PEWS score ≥ 4/9 defined a high-level emergency vs. a PEWS score ≤ 3/9 as a low-level emergency. Postoperative vomiting and aerosol administration were not assessed. The secondary endpoint was the performance of pediaTRI according to gender, age (divided into subgroups), type of complaint , and the main diagnosis. The final endpoint was the evaluation of the markers of severity such as length of stay (LOS) and hospitalization rates.The primary endpoint was the evaluation of the performance of pediaTRI with the level of triage (from 1 to 5), the PEWS score calculation, medical complaints , surgical complaints , final diagnosis and LOS in mins.Data from 2016–17 constituted the main dataset, and data from 2018–19 was used as an independent validation cohort. Patient data were collected prospectively in the TU® software: gender , age , data from The vital signs such as the pediatric Glasgow score (/15), heart rate (in number of beats per minute), respiratory rate (in number of breaths per minute), pulsed oxygen saturation (in %) with details of oxygen input or not (in ambient air or in L/min depending on the case) were collected into the triage module. The patient's outcome  was collected in the medical file module. The diagnoses were entered in the diagnosis and procedures rating module. We considered the vital signs to be normal if they were not entered by the triage nurse.pediaTRI triage level compared with PEWS. Conversely, under-triage corresponded to a lower triage level.The data, compiled exclusively as categorical comparisons, were evaluated using the chi-squared test. Over-triage was defined as a higher pediaTRI was evaluated vs. PEWS using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. The results are expressed in numbers and percentages with 95% confidence intervals. Taking into account our sample size, the significance level “p” was set at 0.001 to avoid random statistical significance  , 70,330 of whom [70.0% (95% CI 69.7–70.3)] presented medical complaints (< 0.001) .p < 0.001) (p < 0.001). Patients evaluated at Level 1 were more likely to be from 1 to 3 years old (29.0% (23.1–35.6) while those evaluated at Levels 2, 3, 4, or 5 were more likely to be 3 to 7 years old  (p < 0.001).Patients triaged as Level 4 (simple consultation) and Level 3 (urgent) were the most prevalent : 41.1% (< 0.001) . Boys weThe most common presentations for a medical complaint  were:Level 1: Pulmonary [42.9% (36.2–49.7)] and neurological [18.0% (13.1–23.7)] conditionsLevel 2: Pulmonary [31.0 (30.3–31.7)] and digestive [21.2% (20.6–21.8)] conditionsLevel 3: Digestive (23.8% (23.3–24.2) and pulmonary conditions [18.1% (17.7–18.5)], and infectious diseases [15.4 (15.0–15.8)]p < 0.001).Levels 4 and 5: Dermatological [12.3% (11.9–12.6) and 20.6% (19.7–21.6)], ENT conditions [14.8% (14.4–15.1) and 14.6% (13.8–15.4)], and infectious diseases [12.2% (11.9–12.6)] and 15.3% (14.5–16.1)] for Levels 4 and 5, respectively  of the patients presented with at least one of the 11 most frequently encountered diagnoses in our study . The mosp < 0.001). The ICU admission rates among patients defined as a “high-level emergency” (pediaTRI Levels 1 and 2) were significantly higher than those defined as “low-level.” PED LOS was also strongly associated with triage level: LOS decreased from 176 min in Level 1 to 96.6 min in Level 5 (p < 0.001). No deaths were reported in the PED during the study period.Overall, 94.0% of patients were discharged. The hospitalization rate significantly decreased with triage level, from 53.5% in Level 1 to 0.6% in Level 5 (pediaTRI were consistent with those defined by the PEWS score with an agreement of 84.5% (84.2–84.7) , and under-triaged 528 (0.5% (0.5–0.6)].The high- and low-level emergencies assigned by .2–84.7) . pediaTRpediaTRI had a sensitivity of 76.4 (74.6–78.2) and a specificity of 84.7 (84.4–84.9) for identifying high-level emergencies (pediaTRI was more sensitive for infants under 3 months – 100.0% (66.4–100.0) for newborns (under 28 days of age) and 100.0% (75.3–100.0) for infants from 28 days to 3 months – but less specific at 14.8% (12.8–16.9) and 46.8% (44.8–48.8), respectively, for the same age groups. The negative predictive value was high in the overall sample (99.4) and their values remained high whatever the subgroup (from 90.5 to 100.0). The positive likelihood ratio values were mostly higher in the overall sample and in the subgroups than the negative likelihood ratios .rgencies . The likpediaTRI were 45.2% (44.3–46.1), 32.2% (29.8–34.5), 69.5% (63.2–75.2) and 36.1% (34.2–38.0), respectively. High-level emergency cases for surgical reasons ranged from 0.0% (0.0–0.1) to 1.0% (0.4–2.2) for PEWS and from 2.0% (1.8–2.4) to 38.6% (34.6–42.6) for pediaTRI.The performance values differed according to the category of chief complaint. Specificity values for medical complaints, were moderate for pulmonary, cardiovascular system, neurology, digestive, urology-nephrology, and rheumatology conditions, and low for endocrinology-metabolism disorders, hematology, and poisoning. Specificity values for surgical complaints were mainly high contrasting with a lower sensitivity except for head and neck trauma and burns. The most frequent medical reason assessed by PEWS as a high-level emergency was pulmonary related , followed by cardiovascular disease , endocrinology-metabolism disorders , and finally neurology . The corresponding assessments by pediaTRI had higher specificity (73.3–97.0) than sensitivity (41.8–56.7) for ENT infectious diseases, acute gastroenteritis, Flu' and unknown fever. Sensitivity was higher than specificity for asthma and bronchiolitis . For surgical diagnoses, as few patients were classified by PEWS as high-level emergency, values of specificity varied from 59.4 to 97.0 while those of sensitivity were not systematically interpretable.For the main medical diagnoses, pediaTRI and PEWS between the two periods were also similar with an agreement of 84.9% (84.7–85.1), an over-triage of 14,522 patients [14.5% (14.3–14.8)], and an under-triage 528 patients (0.6% (0.6–0.7). We reported similar values of performance of pediaTRI between the two periods except for lower sensitivities for surgical reasons (46.2 vs.78.6%) and for digestive diseases (60.7 vs. 82.6) during the 2018–19 period.The patient characteristics per triage level were similar between the periods 2016–17 and 2018–19. Although LOS and the level of emergency followed the same downward trends, we reported significantly longer PED LOS during 2018–19 with 205 min, 146 min, 134.6 min, 118.6 min, and 107.2 min respectively from Level 1 to 5. Prevalence of high- and low-level emergencies between pediaTRI triage tool has an overall moderate validity compared to the PEWS system with a sensitivity of 76.4% and specificity of 84.7%. The agreement with PEWS was 84.5%, with over-triage in 15.0% of the patients and under-triage in 0.5% (mostly in one category).The pediaTRI varies according to the patient profile. In children under 3 months, sensitivity was high (100% for those under 28 days and 100% for 1 to 3 months) contrasting with a poor specificity  due to potential “risky” situations in this young population. The sensitivity for children with a medical history or existing chronic disease  was much higher than the specificity. For these particular cases, over-triage is necessary whatever the chief complaint so that these children do not wait too long before being seen by a physician as their clinical condition could deteriorate rapidly.However, the performance of pediaTRI also varies according to the subcategory of the chief complaint. Each subcategory contains many items, some of which are prevalent – such as fever , and vomiting  – whereas these items are not accurate enough to define a severity level. Thus, it would be necessary to do more in-depth analysis to assess the performance of each item and evaluate its relevance, or to reclassify or delete insufficiently relevant items.The performance of pediaTRI triage level: the severity profile decreased from Level 1 to 5.Severity outcomes  correlated inversely with the pediaTRI underlines the need to provide a framework to mitigate the risk of failing to identify critically ill patients. Consequently, we compiled a guide to ensure that patients are triaged safely. Firstly, the duration of the triage should be long enough to assess the patient adequately without unnecessarily delaying access to care. We recommend that the triage should initially focus on the recognition and management of critically ill children based on the ABCDE approach of the Pediatric Life Support of the European Resuscitation Council Guidelines  are missing for the triage process. The nurse can upgrade the triage level if they disagree with the one suggested by pediaTRI, but not downgrade the level. Finally, the nurses are encouraged to ask the on-call pediatrician to confirm the final triage level of a patient at any time if in doubt.The variability of the performance values of idelines . In the pediaTRI for over-triage and under-triage appears to be better than those estimated for MTS. Indeed, while 84.5% of the patients in our study were correctly triaged, 15% were over-triaged and only 0.5% under-triaged.Most triage tool validation studies are based on correlations with resource utilization rather than comparing performance against a gold standard  Appendi, mainly pediaTRI was more sensitive than MTS (100% vs. 50 – 79%) due to the over-triage setting by default as explained previously, the performance values of pediaTRI are in the range of those reported in the literature (pediaTRI: 75.6 – 84.4% vs. others: 65 – 67%). Unfortunately, we are not able to interpret our results concerning the performance of pediaTRI by subcategory of chief complaint or specific diagnosis in relation to other works, as these outcomes are missing in the literature.Except for patients under 3 months old, for whom terature , 34: i.eHowever, our reference standard differed from previous studies that used a benchmark triage tool for identifying high-level emergencies. The benchmarks were mainly created in situ by a committee of experts and differed from one study to another due to different practices. Although the performance of our reference standard (PEWS) may not be perfect, it has nonetheless been shown that a high PEWS score is correlated with a higher risk of patient morbidity and mortality that defines high-level emergency , 28, 35.Our study analyzed data from a large number of patients  over 2 successive years (2016–2017), thereby avoiding any bias related to temporality  and suggesting that our results are representative of all the pathologies encountered in a large-scale PED in France. Statistical analyses carried out on a large control cohort  served as validation for the sample cohort.The prevalence of our five severity levels were in line with those reported in previous studies, with prevalence ranging from 0.3–16.5%, 4.5–26.4%, 20.0–55.0% 17.2–52.1%, and 0.1–21.2% for Levels 1 to 5, respectively , 41, 42 The prevalence of medical diagnoses in our study were also similar to that of previous studies, from 1.1–5.4% for bronchiolitis , 44, 2.5pediaTRI tool shares the characteristics of the other large-scale tools: it is a computerized tool with five levels of severity that analyzes symptoms and vital signs. However, pediaTRI was specifically designed for evaluating pediatric patients while the existing pediatric triage tools are adaptations of tools designed for adult patients. Finally, pediaTRI can be used by any trained nurse without specific clinical skills.In the absence of a standardized pediatric triage tool in France, our PEWS can be applied to any PED to identify high-level emergencies. It is a simple and objective tool that scores the severity of patients based on three parameters: the neurologic, cardiovascular, and respiratory systems. No lab workup or complementary tests are required which means that the nurse can quickly triage their pediatric patients. The PEWS has been validated with good reproducibility , 45–47 dThere are some other limitations to our study. First, this was a single-center study which somewhat limits the generalizability of our results despite the large sample size.n = 217, 0.2%). Level 1 (immediate emergency requiring resuscitation and emergency care) is rare in pediatrics and our prevalence is in the lower range of those in the literature (from 0.3 to 16.5%) . These were considered as abnormal or alarming because of difficult conditions during the measurement as the children were crying or scared. The PED environment is not the ideal setting to record reliable vital signs  which iso 16.5%) . Differeo 16.5%) , 50 are pediaTRI tool with PEWS, a reference standard based on identifying patients at risk of clinical deterioration by classifying them into two groups: high-level vs. low-level emergencies. However, the PEWS screens for signs of severity and does not include analysis of the chief complaint suggesting that it might not be as efficient as pediaTRI for analyzing medical vs. surgical complaints. It would be interesting to use a modified PEWS that integrates pain and disability, for example. However, we considered that PEWS was an appropriate reference standard because of its practicability , and feasibility (using a simple score for triaging patients) even though its validity has been challenged in the literature  served as validation for the sample cohort.pediaTRI was comprehensively assessed according to the age of the patients, the type of complaint , and the category of complaint.The performance of This was a single-center study limiting its applicability in emergency departments across France.pediaTRI with previous studies.The PEWS, used as the reference standard, did not allow effective comparison of performance of The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. Verbal informed consent was provided.AT was responsible for protocol development, analyses, writing of the paper and the main author of the paper. PV supervised the protocol development, supervised the analyses, writing of the paper and had a main contribution in editing the paper. CR supervised the protocol development, data collection, and writing of the paper. ER was responsible for data collection. EF, EB, and OH supervised the writing of the paper. HH supervised the protocol development, and writing of the paper. CP and SG supervised the protocol development, analyses, and writing of the paper. All the authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Non-Communicable diseases are rapidly increasing in low- and middle-income countries. The number of patients with diabetes is estimated to reach 4.7 million in Ethiopia by 2045. Ensuring access to care is critical to improving the management and clinical outcome of diabetic patients. The study describes the characteristics of patients with diabetic ketoacidosis (DKA) and evaluates the relationship between the severity of clinical presentation and the travel time to the hospital. A retrospective cohort study was conducted on the charts of patients admitted for DKA at St. Luke Catholic Hospital (SLCH), Wolisso, Oromia Region (Ethiopia), between 01/01/2021 and 31/08/2021. Demographic and clinical data were collected. Negative binomial regression was used to explore the relationship between the incidence of admissions for DKA and travel time to the hospital. Logistic regression was used to estimate the odds of insulin treatment. Results were presented with 95% confidence intervals. During the study period, 651 patients were admitted, including 77 (11.8%) for DKA  and 44 males (57.1%)), with no differences based on diabetes type (p = 0.258). The mean age was 35 years (IQR 19.0-52.0). Mean BMI was 18.4 kg/m2 (IQR 15.6-19.5), with no differences based on diabetes type (p = 0.639). Cumulative incidence of hospitalizations was significantly correlated to travel time to the hospital (p = 0.039) with an Incident Rate Ratio of 1.01%[1.00-1.02]. The cumulative incidence ranged from 7.0%[4.5-10.3] in Wolisso to 30.8%[14.3-51.8] in Ameya, the most distant district. The relative probability of insulin treatment was higher with increasing time to SLCH (OR 1.11[1.02-1.21] p = 0.027). The hospitalization rate for DKA was significantly correlated with the travel time to the hospital. Access to care is therefore a key factor for health that should be taken into account by improvement programs and the spatial analysis of travel time could help focus on priority areas.• Spatial analysis can be a robust tool to tailor population healthcare needs on its own topography.• Health policies must consider that accessibility can influence the severity of clinical presentation.


IntroductionThe management of septic shock and refractory septic shock is essential in preventing sepsis-related death. The handheld vital microscope is a new modality of investigation for sepsis for microcirculatory assessment. This study aimed to identify predictors of inotrope requirements among patients with early sepsis and impending septic shock with particular reference to sublingual microcirculation assessment parameters.MethodologyWe conducted an observational cross-sectional hospital-based study in central India. The formal sample size was calculated to be 52 patients using a convenient sampling technique. The study was initiated with ethics approval (IHEC-LOP/2019/ MD0090) with consent from the patients. We used the MicroScan  Video Microscope System (No.16A00102) to obtain sidestream dark-field imaging along with the AVA 4.3C software .ResultsOf 51 cases, 60.8% were women, and 39.2% were men, and the study population had a mean age of 41.0 ± 14.9 years. Patients were recruited from medical wards (64.7%) and emergency departments (35.3%). The most common site of infection was gastrointestinal (33.3%), followed by respiratory infections (25.5%) and genitourinary infections (11.8%). The quick sequential organ failure assessment score was 2.0 ± 0.1. Eight patients required inotropes, and six patients died. High respiratory rates and lactate levels were important predictors of inotrope requirements in patients with early sepsis. Sublingual microcirculatory parameters at baseline did not significantly affect the requirement of inotropes consequently.ConclusionsSublingual microscopy is a suggested tool for the management of sepsis. However, without clearly defined cut-off values, handheld vital microscopy could not predict fluid responsiveness among patients with early sepsis. Also, it would be difficult to incorporate this technology into regular practice without equipment upgrades and image acquisition software. Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection ,2. A staOrgan dysfunction is an important part of sepsis, and its quantification is essential for diagnosis, management, and prognostication. Globally, the sequential organ failure assessment (SOFA) score is one of the most used scores in sepsis to quantify organ dysfunction . HoweverThe 2021 Surviving Sepsis management guidelines advocate immediate resuscitation with intravenous crystalloids and the administration of broad-spectrum antibiotics, source control of the infection, and sending appropriate laboratory samples for diagnostics. The guidelines also emphasize the use of dynamic measures of fluid response  rather than static measures  while assessing response to fluid resuscitation . MicrovaHandheld vital microscopes (HVMs) can directly visualize the microcirculation at the nail bed and dermal capillaries, and they are used to assess various shock states and monitor patients after cardiovascular surgery -20. HVMsWe conducted this observational cross-sectional study on hospitalized patients at the All India Institute of Medical Sciences in Bhopal from November 2019 to April 2021. The study was approved by the Institutional Human Ethics Committee of All India Institute of Medical Science, Bhopal (Ref: IHEC-LOP/2019/ MD0090). All participants provided written informed consent to participate. The study was briefly interrupted due to the coronavirus disease 2019 pandemic during its first wave (April 2020 to October 2020) and second wave (March 2021 to April 2021). For sample size estimation, we assumed a population size of 1,00,000 and an anticipated frequency of fluid-unresponsive shock to be 5%, a confidence interval of 95%, and a design effect of 0.7. The sample size was calculated to be 52 using Open Source Epidemiologic Statistics for Public Health (OpenEpi) .We included patients aged 18 or older with illness lasting <14 days with suspected infection and patients with SBP <100 mmHg but MAP >55mmHg and qSOFA score ≥ 2. Patients requiring intensive life support ventilated patients and patients who had received inotrope within 24 hours were excluded.We administered a structured questionnaire and recorded the demographic, clinical, and laboratory parameters from the patients that determine the presence or severity of sepsis  score, oxygen saturation, leukocyte count, serum lactate levels, platelet count, serum creatinine, total bilirubin, blood urea, aspartate aminotransferase, alanine transaminase, pH, partial pressure of carbon dioxide, and other arterial blood gasses parameters).We used the MicroScan  Video Microscope System (No.16A00102) with a universal serial bus (USB) 3 port to obtain sidestream dark-field imaging along with the AVA 4.3C software  to evaluate the microcirculation images. We performed the microcirculatory assessment based on the second consensus on the assessment of sublingual microcirculation in critically ill patients compiled by the ESICM task force. We took PPV values and De Backer density of large and small vessels for analysis per the second consensus on the assessment of sublingual microcirculation guidelines . ApproprMicrocirculation assessment is a new tool, and validated threshold values have yet to be established for this investigation. Various studies have reported different cutoffs of these variables between survivors and non-survivors of sepsis and healthy controls. De Backer et al. evaluated 252 patients and found that the mean PPV Small was 71%  in survivors vs. 50%  in non-survivors . For thiStatistical analysisThe study variables were collected in a structured data collection form as continuous or dichotomous variables. The data was entered into a Microsoft Excel spreadsheet . We used IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. to analyze the data. We used the chi-square test for dichotomous variables and the student’s t-test for continuous variables. P<0.05 was considered significant.Sixty-one cases fulfilled the inclusion criteria and were subsequently screened. Two of them denied consent and were excluded. Among the remaining 59 cases, six patients had to be excluded because of an inability to give adequate fluid resuscitation (30 ml/kg over three hours) as per management guidelines . Two participants had to be excluded because of equipment failure. We could finally analyze 51 cases. Eight patients ultimately required inotrope, and six patients died.The mean age of the patients was 41.0 ± 14.9 years, with a slight female predominance of 60.8% (n=31) with 39.2% males (n=20). All cases were recruited from emergency departments (35.3%) or various medical wards (64.7%). The most common suspected focus of infection was gastrointestinal (33.3%), followed by respiratory infections (25.5%), genitourinary (11.8%), skin and soft tissue infections (3.9%), and meningoencephalitis (2%). Undifferentiated tropical fever accounted for (23.5%) of the cases. The mean duration of illness was 6.6 ± 3.3 days . Twenty-six patients (50.9%) had tachycardia with a>100 beats per minute pulse rate at baseline. Twenty-five patients (49%) had SBP <90 mmHg. The respiratory rate was ≥22 breaths per minute in 94.1% of cases. Only two patients had a GCS score of ≤14. Seven patients (13.7%) had partial pressure of oxygen ≤ 95%. For all cases, the qSOFA score was ≥2. Details of baseline clinical parameters are provided in Table Of our 51 individuals, 10 patients had a lactate value >2 mmol/L (19.6%). Hyponatremia  was found in 33 of 51 patients (64.7%). Regarding the SOFA score variables, the partial pressure of oxygen to fraction of inspired oxygen ratio was <300 in six individuals (11.7%), while 15 (29.4%) individuals had a total platelet count of <150 x103/µL. Nine individuals (17.6%) had a total bilirubin of >1.2 mg/dL while 10 individuals (19.6%) had elevated creatinine values (>1.2 mg/dL). The SOFA score was ≥3 in 22 individuals (43.1%).Thirty of 51 cases (58.8%) had a PPV Small value of ≤70% at baseline. A PPV Small value of ≤50% was found in 12 of 51 cases (23.5%). Eight patients required inotropes at the end of the study period (24 hours).The individuals who required inotrope were younger (36.1 ± 13.5 years) than those who did not require inotrope (41.9 ± 15.2 years), but this was not statistically significant. Eighty percent of men and 87.1% of women did not require inotrope, and there was no statistically significant difference in inotrope need according to sex. The mean duration of illness at presentation to the hospital was slightly longer in the inotrope-requiring group than in those who did not require inotrope (6.1 ± 2.9 days vs. 6.7 ± 3.4 days) but without any statistical significance. Lactate levels were significantly higher in the inotrope-requiring group (2.1 ± 1.0 mmol/L) than in the non-inotrope requiring group (1.33 ± 0.6 mmol/L), as noted in Table PPV and PPV Small were lower in the inotrope-requiring group than in the non-inotrope-requiring group without any statistical significance. De Backer density and De Backer density Small were higher in the inotrope requiring group than in the non-inotrope requiring group without statistical significance. None of the four microcirculatory variables could predict the requirement of inotrope at the baseline, as noted in Table There was also no significant difference in these microcirculatory parameters among patients who survived compared to those who died.Most of our participants were recruited from the medical wards (64.7%), and the rest were recruited from emergency departments. Rasmy et al. from Egypt, De Backer et al. from Belgium, Edul et al. from Argentina, and most similar studies were conducted in intensive care unit (ICU) settings -26. Our We observed that 57.6% of patients were female, and the mean age was 41.0 ± 14.9 years. Shapiro et al. and Rasmy et al. had predominantly older male sepsis patients ,27. In SThe most common suspected foci of infection were gastrointestinal (33.3%), followed by respiratory 25.5%), and undifferentiated tropical fever (23.5%). This finding is consistent with other studies on sepsis carried out in other parts of the world [.5%, and Among the clinical parameters, the mean pulse was on the higher side (mean 97.6 ± 18.3 beats per minute), and the respiratory rate was also on the higher side (24.3 ± 3.5 breaths per minute). Our inclusion criteria can explain the lower SBP and DBP: we recruited patients with SBP <100 mmHg but MAP >55 mmHg. The rise in pulse rate is self-explanatory, being a compensatory mechanism to maintain homeostasis in the event of low blood pressure. The fever may also explain the higher pulse rate in these infectious syndromes. Lara et al. found their mean heart rate was also high (110 ± 21 beats per minute), similar findings to our study . The meaIn our study, eight cases required inotrope (15.68%) at the end of the observation period 24 hours). As this is a first-of-its-kind study, there were no studies in the literature against which we could compare our results. The individuals who required inotrope were younger (36.1 ± 13.5 years) than the non-inotrope requiring group (41.9 ±15.2 years), with an equal distribution between the sexes and a shorter duration of illness (6.1 ± 2.9 days vs. 6.7 ± 3.4 days). Rasmy et al. found that 21 of 36 patients (58.3%) required vasopressors, and the patients who required vasopressors were older  compared to the non-vasopressor requiring group . Rasmy et al. recruited participants from the ICU, where patients are usually more critical and older. These individuals had more severe diseases than our study participants, explaining the higher percentage of vasopressor use [ hours. AThe initial DBP and SBP were lower in the inotrope requiring group , which is self-explanatory. The mean pulse rate was higher in the inotrope requiring group than in the non-inotrope group (105.0 ± 23.6 beats per minute vs. 96.2 ± 17.1 beats per minute). Lactate levels were higher in the inotrope requiring group (2.1 ± 1.0 mmol/L vs. 1.3 ± 0.6 mmol/L). Rasmy et al. found similar differences in blood pressures, heart rates, and lactate levels between vasopressor requiring vs. non-vasopressor requiring groups .In our study, the mean PPV was 79%, and the mean PPV Small was 60%. De Backer et al. found that the PPV Small was 71% in survivors vs. 50% in non-survivors . We founOur study was conducted on patients with early sepsis, and the recruitment was done from both high- and low-priority areas. Therefore, the individuals in our study represented the patients we encounter on a day-to-day basis. SOFA, qSOFA score, and lactate levels were available at baseline, making the dataset more robust. However, our study was limited by its low sample size. Therefore, we could not define predictive cutoff values for the microcirculatory variables to predict a poorer prognosis or mortality.Sublingual microcirculatory assessment with HVMs is a new and exciting entry in managing patients with sepsis and septic shock. As there are no validated cutoff values of the various microcirculatory parameters in use, it is difficult to differentiate normal and abnormal values. Microcirculatory parameters obtained from sublingual microscopy at initial presentation could not predict the ultimate use of inotrope in patients presenting with early sepsis. There was a significant association of a high respiratory rate and high serum lactate values with a poorer prognosis, but microcirculatory values could not predict a poor outcome, according to our results.


To provide epidemiological data for cricket injuries in New Zealand.A retrospective analytical review using epidemiological cricket data obtained from the national Accident Compensation Corporation (ACC) for 2005–2016. Injury incidence was calculated per 1000 participants.There were 86 562 injuries  during the 12 years with higher injury incidence for males (64.1) than females (36.1). While cricket-related injury claims increased by 42.6%, the injury incidence decreased from 59.0 in 2006 to 42.8 in 2016. The pooled injury rate per 1000 participants was highest for hand/fingers (9.2) and lumbar (8.1) body regions, and for contact (44.7) activities. Players aged 10–20 years were more likely to experience injury.Analysis of 12 years of ACC cricket-related injury claims showed only minimal reductions in injury incidence over the years. Therefore, cricket-related contact injuries to the hand/fingers and head need to be the focus of injury prevention programmes , particularly in players aged 10–20 years. Existing injury surveillance research in cricket has focused on elite cricketers.These studies have reported high prevalence of non-contact type injuries attributed to playing and training workload.The 12-year analysis of cricket injury data from our study revealed a high injury incidence of contact type injuries across all age groups and male and female participants.Cricket coaches at all levels of play need to emphasise use of protective gear and correct technique to reduce risk of contact type injuries.Injury prevention programmes focused on youth cricket players are needed.Cricket is a popular summer sport traditionally played by Commonwealth nations.4 5Currently, there is no published nationwide study reporting injury incidence across all participation levels of cricket. In NZ, the last published cricket injury surveillance study was in 2008, and was focused solely on elite cricketers.NZ residents of all age groups who claimed medical treatment and rehabilitation costs from the ACC for a cricket-related injury from 2005 to 2016 were included in this study.The NZ national cricket organisation does not capture nationwide cricket-related injury data across all levels of cricket, so data from the ACC database were obtained to describe the epidemiological extent of cricket-related injuries during the 12-year study period.NZ’s ACC scheme provides registered medical practitioner information related to the patients’ injury diagnosis and medical care provided. Compensation covers costs towards medical treatment and rehabilitation.8–13Acute personal injury claims,The injury definition for this study was ‘any injury  that had been assessed and reported by a registered health practitioner as a result of sports participation’.Injury incidence data were pooled16 18ACC data were analysed by age group, injured body area (reclassified according to the Orchard sports injury and illness classification system), type and diagnosis. Injury causes were grouped into contact, non-contact and other mechanism of injury. Only new injury claims from 2005 to 2016 were considered; all previous injury claims data were removed from the data to calculate the injury incidence rate only for each calendar year’s original injury claims and pooled to provide an overall injury incidence rate.2 test was used for comparison between reporting years for the number of claims. Injury incidence was calculated using participation data supplied by NZ cricket. Paired sampled t-tests were used to compare between male and female injury claims. Cohen’s d effect sizes were computed to complement interpretation of results, with effect sizes being interpreted as negligible/very small (d<0.20), small (d=0.20–0.49), medium (d=0.50–0.79) or large (d>0.80).All collected data entered into a Microsoft Excel spreadsheet were analysed with SPSS . Data were reported as means and 95% CIs,Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.There were 86 562 injuries  over the 12 years.Results presented were analysed by sex-specific differences in injury incidence over the years, ages, injured body site and injury type.(17)=−4.2; p=0.0006) and females (t(17)=−3.0; p=0.0073) compared with 2005 ((11)=27.5; p<0.0001) over the 12 years. There were meaningful differences in claim numbers over all years for males (t(17)=28.8; p<0.0001), females (t(17)=39.2; p<0.0001) and for all claims recorded (t(17)=29.9; p<0.0001). Although total claim numbers increased from 2005 to 2016 =−4.2; p=0.0005; d=0.31), the injury incidence decreased (59.0 (95% CI 57.5 to 60.5) vs 42.8 (95% CI 58.7 to 59.6) per 1000 participants).There were more injury claims in 2016 for males =−1.3; p=0.2118; d=0.53) and 85+ (t(11)=−1.3; p=0.2064; d=0.57) years age groups  1.23 (95% CI 1.17 to 1.29); p<0.0001; d=11.81), upper limb (RR 1.88 (95% CI 1.81 to 1.95); p<0.0001; d=8.73), lower limb (RR 1.73 (95% CI 1.67 to 1.79); p<0.0001; d=9.40) and chest/back/other (RR 2.36 (95% CI 2.23 to 2.49); p<0.0001; d=8.47) than females over the study . The upp(15)=5.0; p=0.0002), females (448.4 (95% CI 285.4 to 611.3); t(11)=5.9; p<0.0001) and total (4182.5 (2445.0 to 5920.0); t(11)=5.1; p=0.0001) injury claims recorded.There were notable differences in the number of soft tissue injuries recorded over the study for males (3734.1 (95% CI 2149.3 to 5319.0); tThere were more injuries recorded due to contact than non-contact for males (RR 2.26 (95% CI 2.23 to 2.30); p=0.0344; d=0.80), females (RR 2.76 (95% CI 2.63 to 2.89); p=0.0215; d=0.92) and total (RR 2.31 (95% CI 2.28 to 2.34); p=0.0319; d=0.82) injury claims.This study provided an epidemiological description of cricket-related injuries among the NZ resident population from the years 2005 to 2016. The key findings of this study were: (1) although injury claims increased, the incidence of injuries decreased; (2) males recorded more injuries than females in most age groups; (3) the upper limb sustained the most injuries and the hand and fingers sustained the highest injury rate and (4) there were more injuries due to contact than non-contact actions.The number of cricket-related injury claims increased by 42.6% but the injury incidence decreased from 59% to 42.8% over the 12 years. The introduction of the T20 cricket format along with the availability of streaming international cricket matches may have caused a surge in the popularity of the sport and might have led to larger participation numbers. The introduction of shorter cricket competitions across different cricket levels such as club cricket, school cricket, regional cricket and metro cricket might have caused people to play more cricket. While it is hard to discern the cause of the 42.8% increase in injury claims, there was a related increase in cricket participation across NZ with a 47% increase with 85 215 people registered to play in 2005 and 125 316 registered to play in 2016.Adolescent athletes can encounter more epiphysial and stress-related injuries due to the undergoing hormonal changes which might then predispose them to acute injuries.Reviewing the injuries by body areas across the 12 years has highlighted that the injury prone areas differ between male and female participants. A higher incidence of hand injuries has also been reported among elite cricketers.The prevalence of impact-contact injuries to the hand and wrist area  are likely due to an improper technique employed while catching the ball, or potentially due to the absence of effective protective equipment when fielding. This may be due to the requirement that the only hand protection equipment allowed in cricket are wicket-keeping and batting gloves.Contact injuries in cricket could be sustained due to impacts with balls, objects marking the boundaries or other equipment related to the game.In the upper limb, the hand and fingers may experience more contact type injuries, whereas the shoulder may sustain more non-contact type injuries. As non-contact injury type is mainly due to repetitive strenuous movement, the shoulder was most likely to have been injured due to repetitive movement in cricket.Unlike hand injuries, two-thirds of all lumbar injuries were of a non-contact nature. A commonly cited reason for elite cricketers’ lumbar injuries has been increased playing/training workload.32Participants in this study included a nationwide population with data including primary school level cricketers to elite first-class cricketers. Therefore, an acute lumbar injury could have occurred to a recreational cricketer due to improper warmup or to an elite first-class cricketer due to training/bowling workload or vice versa.While conducting injury surveillance, it is essential to record the level of the player given that elite players are likely to have access to a lot of injury prevention support, whereas recreational cricket players may not have access to or use protective equipment frequently.Elite cricketers undergo intense workload, playing frequent matches and training several times per week, increasing their predisposition to overuse injuries.Data obtained from ACC did not reveal the injury-specific medical diagnosis; if such information was available, the nature of injuries could be classified as either acute or overuse. If injury onset data were available, it would provide insight into whether bowling, batting or fielding was a predominant factor for injury, and it would highlight the most injury-prone playing positions. Some cricket injury data may not have been recorded if the injury was not severe enough to qualify for an injury entitlement claim. Some individuals might not have sought medical care, which is a limitation to the current study.This study provided evidence that as cricket participation numbers increased there was a substantial increase in cricket-related injury claims. Analysis of 12 years of ACC cricket-related injury claims showed only minimal reductions in injury incidence over the years. Injury prevention programmes for cricket need to target the prevention of hand and finger, and head injuries particularly in players aged 10–20 years.


Pelvic magnetic resonance imaging (MRI) is a key exam used for the initial assessment of loco-regional involvement of cervical cancer. In patients with locally advanced cervical cancer, MRI is used to evaluate the early response to radiochemotherapy before image-guided brachytherapy, the prognostic impact of which we aimed to study.Patients with locally advanced cervical cancer treated using concomitant radiochemotherapy followed by closure treatment between January 2010 and December 2015 were included in this study. Clinical, anatomopathological, radiological, therapeutic, and follow-up data were evaluated.After applying the inclusion and exclusion criteria to the initially chosen 310 patients, 232 were included for evaluation . The median age was 50 years , and the median tumor size was 47.5 mm . Based on the International Federation of Gynaecology and Obstetrics classification system, 9 patients were in stage IB2; 20, IB3; 2, IIA; 63, IIB; 4, IIIA; 7, IIIB; and 127, IIIC1 or higher. The re-evaluation MRI was performed at the median dose of 55.5 Gy, and median reduction in tumor size was 55.2% . There was a difference between the disease-free and overall survival rates of the patients with a tumor response greater or lesser than 50%. The risk of recurrence or death reduced by 39% in patients with a tumor size reduction >50%. The overall 5-year survival rate of patients with a response greater and lesser than 50% were 77.7% and 61.5%, respectively. The 5-year disease-free survival rate for these two groups of patients were 68.8% and 51.5%, respectively.Our study confirms the prognostic impact of tumor size reduction using MRI data obtained after radiochemotherapy in patients with locally advanced cervical cancer. Cervical cancer is the fourth cause of cancer incidence and mortality worldwide . SurvivaMagnetic resonance imaging (MRI) is important during several stages of cervical cancer treatment. Standard MRI protocols include T1- and T2-weighted imaging of the pelvis in different planes. After revision of the FIGO classification system, MRI data are being considered while assessing the tumor stage. This imaging method is superior to clinical examination alone to assess the extent of tumor infiltration  and is pTherefore, an easy, reproducible test, such as MRI, is best suited in daily clinical practice to obtain information that can help in early identification of patients at high risk of local and loco-regional recurrence so that adjuvant therapies may be administered. We performed this study to test our hypothesis that tumor response assessed by MRI after concomitant radiochemotherapy for locally advanced cervical cancer has a prognostic impact on recurrence.In this single-center, observational study, we included consecutive patients with a histologically proven diagnosis of locally advanced cervical cancer (FIGO stages IB2– IVA) who were treated with radiochemotherapy at our institution from January 2010 to December 2015. The inclusion criteria were as follows: age ≥18 years, cervix carcinoma observed on biopsy, and availability of MRI data before and after radiochemotherapy on the institution’s radiological picture archiving and communicating system at the time of the study. Patients who did not provide consent for the use of personal data according to the French national law regarding medical ethics in retrospective studies  were excluded from the study. The treatment protocol that we implemented from 2010 to 2015 has been published previously , 18.We retrospectively evaluated the initial demographic and clinical data, tumor characteristics, therapeutic data (radiation therapy and chemotherapy protocol), closure treatments , and follow-up data that we obtained from medical records.Radiological data, including maximum tumor diameter at the time of diagnosis, before image-guided brachytherapy, and after concomitant radiochemotherapy, were collected by performing MRI. MRI 1.5 T with gadolinium were performed at diagnosis and during the first week after completion of 45 Gy external beam radiotherapy prior to brachytherapy. Diffusion weighted imaging, and T1 and T2 weighted sequences with axial and sagittal planes acquired obliquely axed on the cervical canal were performed. Tumor size was defined as the largest tumor dimension measured on MRI T2 weighted sequences. All MRI examinations were evaluated by our radiologist specialized in female pelvic radiology.Historically, in the gynecologic tumor committee of our center, MRI was performed the last week of radiochemotherapy in order to adapt the following treatment according to the response: Thus, for patients that tumor volume reduction was 50% or more, (estimated as maximum tumor diameter), treatment continued with uterovaginal brachytherapy and such patients were considered as good responders; on the other hand, those patients whose tumors had reduced in size by less than 50% were considered to be radioresistant and were offered surgical treatment 6-8 weeks after the end of radiochemotherapy.Based in this argument, tumor size reduction rate of ≥50% was considered a satisfactory response and no tumor visualization was identified as a complete response.The primary endpoint was disease-free survival that was defined as the time period between the first day of radiochemotherapy and any recurrence of the tumor  or death due to any cause. Data were censored when there was no recurrence or death during the last time the patient data were evaluated. The secondary endpoint was overall survival defined as the time period between the first day of radiochemotherapy and death due to any cause. Data were censored when the patients were alive during the last time the patient data were evaluated. Times until local, loco-regional, and metastatic recurrence were calculated. Toxicities were assessed using the Common Terminology Criteria for Adverse Events, version 4.Initial demographic and clinical data, treatment methods, survival and recurrence rates, and post-therapeutic complications were summarized using descriptive statistics. Missing data were specified. Initial categorical variables were expressed as numbers and percentages, while continuous variables were expressed as median (range) or mean (standard deviation). Disease-free and overall survival rates were assessed using the Kaplan–Meier method. The cumulative impact of local, regional or loco-regional, and metastatic recurrences was evaluated by the competing risks method described by Kalbfleisch and Prentice. To compare continuous and categorical variables, we used the Student’s t-test or Mann–Whitney U test and Fisher’s exact or chi-square test, respectively. The Fine and Gray model was used to compare the MRI data at the end of radiochemotherapy between responsive and non-responsive patients. The Cox regression analysis was used to test the association between various prognostic factors and disease-free survival. A p value <0.05 was considered statistically significant. All statistical analyses were performed using Stata Statistical Software, version 15 .The flowchart showing the selection criteria based on which 232 patients were included for evaluation is shown in At diagnosis, the median age was 50 years  with a performance status of 0 for 193 patients (82.5%) and ≥1 for 41 (17.5%). Active smoking was reported by 83 patients (35%), 81 (34.9%) never smoked, 20 (8.6%) stopped before diagnosis, and data were not reported for 48 (20.7%). The main clinical symptom was metrorrhagia that was reported by 180 patients (77.5%), 22 (9.4%) had other symptoms, and 30 (12.8%) displayed no symptoms.The FIGO classification stage was IIIC1 or higher for 127 patients (54.7%), IB2 for 9 (3.8%), IB3 for 20 (8.6%), IIA for 2 (0.7%), IIB for 63 (26.9%), IIIA for 4 (1.7%), and IIIB for 7 (2.9%). Histological examination revealed tumor type as squamous carcinoma for 192 patients (82.8%), adenocarcinoma for 34 (14.5%), and other types for 6 (2.5%). The median tumor size at diagnosis was 47.5 mm  Table 1.All the patients received concomitant chemotherapy; 210 (90.5%) received cisplatin weekly; 21 (9.0%), carboplatin; and 1 (0.4%), cisplatin–5-fluorouracil. The median overall treatment time was 50 days .MRI was performed after radiochemotherapy . The median maximum tumor diameter before treatment was 47cm (0-105cm) and 21cm (0–53) after radiochemotherapy. The median tumor size reduction rate was 55.2% (−20–100%). Satisfactory response was observed in 139 patients (59.4%) and 29 (12.4%) demonstrated a complete response The risk of local recurrence after 1 and 5 years of follow-up since the beginning of treatment was 10%  and 17% (95% CI: 12.5%–22.6%), respectively. In terms of recurrence-free survival, there were 78 events, namely, 67 recurrences followed by death, 11 recurrences without death, and 0 deaths without recurrences. The median time to recurrence-free survival was not achieved in this study after 11 years of follow-up since the start of treatment. The recurrence-free survival rates after 1, 3, and 5 years of follow-up since the start of treatment were 84.3% (95% CI: 78.9%–88.4%), 69.7% (95% CI: 63.2%–75.3%), and 66% (95%CI: 59.2%–72.0%), respectively. The overall survival rates after 1, 3, and 5 years of follow-up were 97.4% (95% CI: 94.3%–98.8%), 80.0% (95% CI: 73.9%–84.6%), and 70.7% (95% CI: 64.0%–76.5%), respectively.Complete response was never obtained for 28 patients (12.1%) and 210 patients (89.7%) became disease free at one point. Recurrence was observed in 78 patients (33.3%) at a median time of 12.5 months , i.e., 25 (32.1%) with local recurrences; 17 (21.8%), regional; 14 (17.9%), loco-regional; and 54 (69.2%), metastatic. While 67 patients (28.6%) died, 167 (71.4%) were alive at the end of the study.There was a statistically significant difference in the 1- and 5-year overall survival rates between patients with a good tumor response and those with an inadequate tumor response .There was a statistically significant difference in the 1- and 5-year recurrence-free survival rates between patients with a good tumor response and those with a poor tumor response (91.1% [95% CI: 85%–94.9%) and 73.3% [95% CI: 64.6%–80. 2%] vs. (73.9% [95% CI: 63.7%– 81.7%) and 54.5% .There was a significant rise in the 1- and 5-year risks of local recurrence in patients with an inadequate tumor response (18.5% [95% CI: 11.9%–28.0%] and 26.2% [95% CI: 18.1%–36. 9%]) than those of patients with a good tumor response .The characteristics that demonstrated a statistically significant association with disease-free survival in univariate analysis are shown in Histologically, there was a statistically significant difference between patients with squamous cell carcinoma and those with adenocarcinoma both in in response (p=0.038) and overall survival rates (p=0.02). The median overall survival rate was observed after 6 years of follow-up since the start of treatment in the adenocarcinoma group, whereas patients with squamous cell carcinoma did not achieve median survival even after 10 years of follow-up. The overall survival after 5 years of follow-up in patients with squamous cell carcinoma was 72.1% (95% CI: 64.5%–78.3%) compared with 60.9% (95% CI: 42.2%–75.1%) in patients with adenocarcinoma.Multivariate analysis showed that the tumor response rate after chemoradiotherapy had a statistically significant association with disease-free survival after adjustment (p=0.008). Recurrence or death risk showed a statistically significant reduction by 46% in patients with a satisfactory response than the patients without a satisfactory response did .The other prognostic factors associated with disease-free survival observed by multivariate analysis were performance status ≥1 (p<0.001), histologic type (p=0.005) and total time of treatment (p=0.003). Recurrence or death risk was three times higher in patients with a performance score ≥1 than in patients with a performance score of 0 . Furthermore, this risk was twice as high in patients with adenocarcinoma compared with that in patients with squamous cell carcinoma  Figure 3In this study, we analyzed the MRI data of consecutive patients with locally advanced cervical cancer treated between 2010 and 2015. We found that the 1- and 5-years local control rates dropped significantly in patients with insufficient tumor response than those in patients with good. Furthermore, there was statistically significant reduction by 46% in recurrence or death risk in the patients with satisfactory response compared with that in those without a satisfactory response.MRI is the method of choice for local tumor staging at diagnosis and tumor response evaluation in cases of cervical cancer . Moreove3 was an independent factor for local control with a relative local relapse risk ratio of 2.51 (p=0.048), and in such cases, a dose of 92 Gy was required to achieve a 90% probability of local control. However, a dose of 73.9 Gy was administered in cases of volumes <30 cm3 (p =0.03) to achieve 90% local control . Reduction in gross tumor volume produces a survival impact that is greater than that by high-risk clinical target volume . EMBRACEAngeles et al. evaluated the impact of tumor volume and regression after external beam radiotherapy measured by MRI on overall survival and relapse-free survival and found that tumor reduction rate ≥60% was significantly associated with a decreased risk of relapse and death . Nam et Concerning histologic type, adenocarcinomas have been historically described as radioresistant tumors compared with epidermoid carcinomas and are associated with poor clinical outcomes mostly due to incomplete tumor regression after radiochemotherapy . Our resA question arises regarding the action required in cases of non-responding patients and those with high-volume tumors observed while performing image-guided brachytherapy. The policy at our center before 2015 was to debate whether surgery was an option. In this study, among the 15 patients who underwent surgery after radiochemotherapy, tumors were not observed in 7 patients. Moreover, surgery is associated with a high risk of urinary disorders and bowel problems. Thus, the current policy at our institution is to treat all such patients, including those responding late to treatment, with radiochemotherapy and three-dimensional image-guided brachytherapy independent of the percentage of tumor regression observed on MRI.Furthermore, concomitant/adjuvant strategies based on the addition of immunotherapy agents, such as atezolizumab (NCT03612791) or cisplatin agents (NCT04016142), are being evaluated in prospective studies. Overall, our study proves that MRI is a useful tool in the management of patients with locally advanced cervical cancer and the mandatory performance of MRI after radiochemotherapy before image-guided brachytherapy should be considered.The main strength of this study lies in the large, homogeneous study population and the long follow-up duration. Nevertheless, this study has a limitation, namely, the retrospective collection of data and emergence of late comorbidities. The current radiotherapy protocol has, therefore, been changed.Our study highlights the importance of tumor shrinkage after radiochemotherapy measured by MRI in determining prognosis, which conforms to the findings of previous studies.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.AC, BD, FT, EL, XM and AE contributed to conception and design of the study. BD and AC organized the database. MD and AM performed the statistical analysis. AC and BD wrote the first draft of the manuscript. AC, LB, EL, CM, DH and FN wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted versionWe thank all the patients for giving us their consent.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Gender-based violence (GBV) is a critical public health concern, demanding for global coordinated efforts. While nursing students form part of a healthcare team with significant roles in identifying and responding to abused victims, studies assessing their readiness to combat GBV are limited in Namibia.To assess undergraduate nursing students’ perceptions and to determine the relationship of the study variables to readiness to combat GBV during the coronavirus disease 2019 (COVID-19) pandemic in Namibia.This study was conducted at a university satellite campus in Namibia.A cross-sectional survey was used to collect data from 105 third and fourth-year undergraduate nursing students using ADKAR model. Data were analysed using Statistical Package for the Social Sciences, version 27.0, for descriptive statistics and logistic regression in determining relationships between study variables.R2 = 0.40; R2 = 0.37; p ≤ 0.05).The study results show a mean readiness of 1.65 ± 0.19. Most respondents perceived themselves ready (73.3%), whereas 26.7% were not. Readiness was common with reinforcement (89.5%) and awareness (84.8%), knowledge (81.9%) and desire (76.2%) subscales. Predictors of readiness in this study were gender and age (The results of this study highlight that age and gender were significant predictors for readiness among the undergraduate students in Namibia. The results highlight the importance of GBV education in a nursing curriculum. A qualitative design is recommended for future studies.The results of this study will support global efforts in strengthening the health system response on GBV incidences. Gender-based violence (GBV) remains a critical public health challenge, which led to United Nations (UN) calling for member countries to prioritise emergency response systems  all affiliated governments had to heed the call to implement the developed guidelines to protect the most vulnerable population  the awareness, (2) desire, (3) knowledge, (4) ability and (5) reinforcement (ADKAR) model, which has been found relevant in determining nursing students’ readiness to fight GBV  and maximum of 26 (100%), with the highest score indicating a better readiness to fight GBV. Scores were categorised as not ready (0% – 74%) and ready (75% – 100%). Data were collected between 21 and 25 September 2020 with two separate reminders sent via email.p < 0.05).Data were captured using Google Forms and were analysed using Statistical Package for the Social Sciences, version 27.0 (SPSSv27). Descriptive statistics and inferential statistics were used to analyse data. Logistic regression was performed to determine the relationship between the study variables and students’ readiness to combat GBV at 95% level of significance . The consent page was attached as a front page of the questionnaire, where the respondents had to click an ‘agree’ button on the link, after reading the objectives and additional details regarding the study. The consent page also provided information stating that participation was voluntary and that they could withdraw at any time, without any punitive measures were shared on the link. Confidentiality and anonymity were maintained by allowing respondents to complete the questionnaire in the comfort of their homes and excluding respondents’ personal details from the questionnaires.n = 75), fell into the 18–25 age group, 19% (n = 20) into the 26–33 age group, while 7.6% (n = 8) fell into the 34–41 age group and 1.9% (n = 2) were aged 42 years and above. In terms of gender, the majority of the respondents, 54.3% (n = 57), were female compared with 45.7% (n = 48) male. More than half, 59% (n = 62), of the respondents were in their fourth year of study, while third years comprised just 41% (n = 43). In terms of marital status, majority 92.4% (n = 97) were unmarried, while only a hand full number 7.6% (n = 8) were married. More than two-third, 68.2% (n = 73) of the respondent in this study had experienced GBV in the past, while 29.9% (n = 32) had not experienced GBV in the past  found ready while 26.7% (n = 28) were not ready to combat GVB. Readiness was commonly in the subdomain of reinforcement of GBV-free behaviours 89.5% . Awareness of GBV behaviour change had a readiness of 84.8% ; respondents knowledge of GBV was 81.9%  with regard to perceiving themselves having adequate knowledge and skills on GBV 80% (n = 84) and being well trained to deal with GBV 86.7% (n = 91) while desire to fight GBV had a readiness of 76.2% . Respondents were not ready in the subdomain of the ability to implement behaviour change 54.3%   .R2 = 0.40; R2 = 0.37; p ≤ 0.05). Although higher readiness was recorded among married respondents 80% (n = 8), who were in fourth years 77.4% (n = 48) and those who had no previous experience of GBV 87% (n = 67), no statistical significance was found between marital status, education level and previous experiences of GBV (p ≥ 0.05).In assessing undergraduate nursing students’ perception on their readiness to combat GBV during the COVID-19 pandemic in Namibia, the study found a mean average readiness of 1.65 ± 0.19. The majority of the respondents (73.3%) were found to be ready, whereas 26.7% were not ready to combat GVB. The results concur with a study by Natan et al. :1, whichReadiness was high in the area of being knowledgeable (81.9%). Being knowledgeable on GBV remains a critical strategy of nursing education to enable nurses to become more responsive in their approach in dealing with GBV victims  as well as the desire to fight GBV (76.2%). Maquibar et al. :1 postulR2 = 0.40; R2 = 0.37; p ≤ 0.05). In this study, male were more significantly ready  than their female counterpart . In alignment with our study findings, Berbegal-Bolsas et al. (p = 0.00).Predictors of readiness were gender and age with a statistical significance in explaining the total variance of readiness among the undergraduate nursing students in this study  in our study, it cannot be said about in respondents’ ability to implement behaviour change to combat GBV (54.3%). In agreement with our study Rituerto-González et al. :1 statesThe ADKAR model was helpful to identify both areas of strength and weakness of this study. Accordingly, as Lundin et al. :2 subscrThis study assessed undergraduate nursing students’ perceptions of their readiness and determine the relationship of the study variables to readiness to combat GBV during the COVID-19 pandemic in Namibia. The results of this study highlight that age and gender were significant predictors for readiness among the undergraduate students in Namibia. The results highlight the importance of GBV education in a nursing curriculum. However, respondents were not ready to implement behaviour change, in the fight against GBV. In support of the study results, Oliveira et al. :1 stated


Addictive behaviors on the workplace are a real public health problem because of its consequences not only on workers but also on productivity at work.To explore the relationship between addictive behaviors and productivity at work among employees of a Tunisian oil rig.A cross-sectional study was conducted in the first half of 2018. The assessment of work productivity was done using the validated WPAI-GH questionnaire. Smoking dependence was assessed via the Fagerström score and alcohol abuse by the FACE questionnaire.It was 94 employees working in an onshore oil field with an average age of 41.1 years. Average job seniority was 14.3 years. Active smoking was noted in 34.7% of cases. Alcohol consumption was noted in 19.1% of cases. In the 7 days preceding the survey, the average percentage of absenteeism was 3.64 ± 21.7% and the presenteeism was 17.66 ± 25.58%. The average decline in productivity was 14.8 ± 43.7% and the average decline in daily activities was 20.21 ± 31.45%. These parameters were not correlated with smoking and alcoholism.Addictive behaviors in the workplace still a denied reality.Increasing awareness and clarifying expectations can be a good first step in order to ameliorate employee functioning and decrease productivity problems.


However, AgNPs prepared from different parts of ginger root water or ethanol extract by ultrasound synthesis and their antioxidant activity and whether the biogenic could be used to catalyze the reduction of hazardous dye are unknown. This study concentrated on the facile green synthesis of AgNPs prepared from different parts  of ginger root water or ethanol extract by the ultrasound-assisted method. We studied their antioxidant activity and catalytic degradation of hazardous dye Direct Orange 26 (DO26) and Direct Blue 15 (DB15). The surface plasmon resonance (SPR) peak of AgNPs was at 428–443 nm. The biogenic AgNPs were approximately 2 nm in size with a regular spherical shape identified from TEM analysis. The ethanol extracts of dried unpeeled ginger and peeled ginger, fresh peeled ginger and ginger peel. The Z. officinale AgNPs synthesized by dried unpeeled ginger ethanol extract showed the best antioxidant activity. Their scavenging activities were significantly better than BHT (p <0.05). The different parts of ginger extracts showed no catalytic degradation activities of DB15 and DO26. Still, the synthesized Z. officinale AgNPs exhibited good catalytic degradation activities, while their ability to catalytic degradation to DB15 was better than DO26. In the additive ratio of 3 mL DB15, 0.1 mL NaBH4 and 0.1 mL AgNPs, the degradation rates of DB15 (or DO26) at 15 min, 30 min and 60 min were only 1.8% (0.9%), 2.8% (1.4%) and 3.5% (1.6%) in the absence of AgNPs. When adding Z. officinale AgNPs prepared from dried ginger peel ethanol extract or fresh ginger peel water extract, the degradation rates of DB15 sharply increased to 97% and 93% after 30 min, respectively. In conclusion, ginger extract has good antioxidant properties. Z. officinale AgNPs biosynthesis from ginger extract exhibit excellent catalytic degradation activities, especially for the ginger peel extract. They have application value in the treatment of textile effluents and provide a new idea and method for the comprehensive development and utilization of ginger resources.The green synthesis of silver nanoparticles (AgNPs) using a water extract of Ginger  Silver nanoparticles (AgNPs) have received widespread attention due to their excellent properties like good photoelectrochemical activity, antimicrobial activity, anti-biofilms, electrical conductivity, and enzymatic activity –5. The tGivotia moluccana  × 100. In the formula, I is the inhibition ratio, A0 is the absorbance of the sample solution, A1 is the absorbance of the ethanol-sample solution, and A2 is the absorbance of the DPPH-ethanol solution. All experiments were repeated three times.The antioxidant activity of AgNPs was determined by the DPPH radical scavenging method with minor modifications , 34. ThrZ. officinale root extract or synthesized Z. officinale AgNPs was determined based on the reductive degradation of DO26 and DB15 in the presence of NaBH4. Three milliliters of DO26 or DB15 (50 mg/L) were mixed with 0.1 mL NaBH4 (0.1 mol/L) and 0.1 mL Z. officinale root extract or synthesized Z. officinale AgNPs. The performance was monitored by recording UV-vis spectra variation over time . The control was also conducted without extract or AgNPs. The degradation rates for 15, 30, and 60 min were calculated. The degradation rate calculation formula was (1-A1/A0) *100, where A0 and A1 are the absorbance values at a wavelength of 603 nm (for DB15)/495 nm (for DO26) at 0 min, 15 min (or 30 min and 60 min), respectively. A pseudo-first-order reaction was assumed for the concentration of DO26 or DB15 to evaluate the reaction kinetics. The integrated form of first-order reaction is expressed as follows: ln At/ A0 = -kt. At is the absorbance at time t, A0 is the absorbance at time 0, and k is the rate constant. All experiments were repeated three times.The catalytic activity of AgNPs was determined by a published method with minor modifications , 32, 35.p<0.05 was used.Data are expressed as the mean values ± standard deviation (SD) and were analyzed using one-way ANOVA. Duncan’s was used to determine significant differences between treatments. All statistical procedures were conducted using SPSS 22.0 for Windows. A significance level of Z. officinale root to the colorless solution of silver nitrate, a visible color change was noticed from transparent to brownish red colloidal solution. The color of Z. officinale AgNPs prepared using ethanol extract was darker than water extract  than water extract with smaller peak width. The SPR peak absorbance of Z. officinale AgNPs synthesized using ethanol extract of dry ginger was higher (p <0.05) than ethanol extract of fresh ginger with smaller peak width. The SPR peak absorbance of Z. officinale AgNPs synthesized using water extract of fresh ginger was higher (p <0.05) than water extract of fresh ginger with a smaller peak width. TEM results show that the AgNPs synthesized using water extract of fresh ginger peel had uniform particle size distribution, which was regular and spherical, and the particle size was about 2 nm. But the AgNPs synthesized using ethanol extract of fresh unpeeled ginger, and the AgNPs synthesized using water extract of the dry unpeeled ginger show a diameter of about 20 nm with a cluster distribution . For both fresh ginger and dry ginger, the antioxidant activity of ethanol extract from different parts of ginger was better than that of water extract (p <0.05). The ethanol extracts of unpeeled dry ginger, peeled dry ginger, peeled fresh ginger, and fresh ginger peel showed the best antioxidant activity. Their scavenging activities against DPPH were 65.6%, 63.0%, 57.6% and 54.3%, respectively, which were better (p <0.05) than that of BHT (42.3%). Nevertheless, the DPPH scavenging activity of water extract of unpeeled fresh ginger and ginger peel was lower (p <0.05) than that of BHT . For both fresh ginger and dry ginger, the antioxidant activity of Z. officinale AgNPs prepared using ethanol extract was better than that prepared using water extract (p <0.05). The Z. officinale AgNPs synthesized using ethanol extract of dry peeled ginger showed the best antioxidant activity, and its scavenging activities against DPPH was 64.9%, which was better (p <0.05) than that of BHT (42.3%). Z. officinale AgNPs synthesized using ethanol extract of fresh ginger peel also showed good antioxidant activity. Its scavenging activity against DPPH was 36.2%, and there was no difference (p >0.05) compared to BHT  with the extension of time. However, the characteristic peak of DB15 decreased (p<0.05) continuously with the addition of Z. officinale AgNPs, which indicates that Z. officinale AgNPs had good catalytic abilities in the reduction of DB15 degradation. With the addition of Z. officinale AgNPs, a new peak near 430 nm appeared  than AgNPs prepared using fresh ginger extract. And AgNPs prepared using ethanol extract of ginger were better (p<0.05) than water extract  catalytic degradation of DB15 than dried ginger peel water extract  showed excellent catalytic activity of DB15 in a short time. For example, the degradation rates of DB15 could reach 86% after a reaction of 15 min Figs . Furtheract Figs .p<0.05) than unpeeled and peeled ginger extract. Among them, AgNPs prepared from water and ethanol extract of ginger peel showed the best catalytic degradation activity for DB15; the degradation rate reached 83% after 15 min, and their catalytic degradation activity did not differ (p>0.05)  . While t(p>0.05) .p<0.05) than the water extract. While the catalytic degradation activity of AgNPs prepared from three ethanol extracts of ginger all showed excellent catalytic activity in DB15 in a short time, such as 15 min, the degradation rate reached the maximum of 85%. However, no difference (p>0.05) was observed among them (p<0.05), and the catalytic activities were in order of peeled ginger, unpeeled ginger and ginger peel. The catalytic activity of AgNPs synthesized using water extract of dry ginger was lower (p<0.05) in 15 min, but the degradation rate increased with the extension of time. For example, after a reaction of 60 min, the degradation rate of DB15 for AgNPs prepared from ethanol extract of unpeeled dry ginger reached a maximum of 98% , the amount of DB15 was lower, and the amount of NaBH4 and AgNPs was higher. Thus, the catalytic degradation ability of R. rosea AgNPs and C-AgNPs was much lower than synthesized Z. officinale AgNPs in this study. Compared to the tea polyphenol AgNPs [Z. officinale AgNPs exhibited excellent catalytic activity in a much shorter time (15min VS 80min) under the same ratio. Compared to the previous report, the AgNPs synthesized from Z. officinale showed higher catalytic degradation activity of DB15.The comparisons of degradation parameters for DB15 by AgNPs synthesized from plant extracts reported in the references are listed in ol AgNPs , Z. offi4 and dye, realizing the transfer of electrons between the provider (NaBH4) and the recipient (dye). When there is no catalyst, there is an electron transfer barrier between the reducing agent (NaBH4) and the dye, so the reduction could not be effective. Based on this, in catalytic reduction, NaBH4 and dye should be adsorbed on the surface of the AgNPs catalyst as much as possible to achieve more efficient electron transfer and reduce the degradation of dye. At the same time, the surface adsorption capacity of AgNPs is closely related to their particle size distribution, and particles with small particle size distribution tend to have stronger adsorption capacity. Therefore, the excellent catalytic activity of Z. officinale AgNPs in this study may be attributed to its smaller particle size.The catalytic reduction of DB15 and DO26 was usually explained in terms of the Langmuir- Hinshelwood model , 39. EleAs shown in Figs Z. officinale AgNPs colloids were also directly used to compare the catalytic activities for the degradation of DO26 without further centrifugation. The maximum absorption of DO26 was at 494 nm, so the absorbance value at 494 nm was chosen to monitor the degradation of the azo dye. Without the addition of colloidal Z. officinale AgNPs, the characteristic peak of DO26 did not change (p>0.05) with the extension of time. However, the characteristic peak of DO26 decreased (p<0.05) continuously with the addition of Z. officinale AgNPs, which indicated that Z. officinale AgNPs had good catalytic abilities in the reduction of DO26 degradation  and AgNPs was V (DO26): V(NaBH4): V(AgNPs) = 3:0.1:0.1. In general, the catalytic degradation activity of the synthesized Z. officinale AgNPs for DO26 was lower than that for DB15 under the same conditions. The catalytic degradation activity of Z. officinale AgNPs prepared by ginger peel extract for DO26 was higher (p<0.05) than that of unpeeled ginger and peeled ginger. Among them, the catalytic degradation activity of Z. officinale AgNPs prepared from fresh ginger peel was superior to dry ginger peel, and the ethanol extract of ginger peel was better (p<0.05) than that of water extract of ginger peel , NaBHeel Figs .Z. officinale AgNPs prepared from the ethanol extract of fresh ginger peel showed the maximum catalytic degradation activity for DO26, and the degradation rate reached 72%. The Z. officinale AgNPs prepared from the ethanol extract of dry ginger peel also showed good catalytic degradation activity for DO26, but the degradation rate only reached 41% . The different parts of ginger extracts showed no catalytic degradation activities of DB15 and DO26. Still, the synthesized Z. officinale AgNPs exhibited good catalytic degradation activities, while their ability to catalytic degradation to DB15 was better than DO26. In the additive ratio of 3 mL DB15, 0.1 mL NaBH4 and 0.1 mL AgNPs, the degradation rates of DB15 (or DO26) at 15 min, 30 min and 60 min were only 1.8% (0.9%), 2.8% (1.4%) and 3.5% (1.6%) in the absence of AgNPs. When adding Z. officinale AgNPs prepared from ethanol extract of unpeeled dry ginger or water extract of fresh ginger peel, the degradation rates of DB15 sharply increased to 97% and 93% after 30 min, respectively. In conclusion, ginger extract has good antioxidant properties. Z. officinale AgNPs biosynthesis from ginger extract exhibit excellent catalytic degradation activities, especially for the ginger peel extract. They have application value in the treatment of textile effluents and provide a new idea and method for the comprehensive development and utilization of ginger resources.This study concentrated on the facile green synthesis of AgNPs using ethanol or water extracts from different parts  of the ginger root by the ultrasound-assisted method. We studied their antioxidant activity and catalytic degradation of hazardous dye DB15 and DO26. The surface plasmon resonance (SPR) peak of AgNPs was at 428–443 nm. The colloidal S1 File(ZIP)Click here for additional data file.