Objective: Clinical research has shown that local injections for carpal tunnel syndrome reduce the symptoms of patients and enhance their quality of life considerably. However, there are several therapy options, and the optimal choice of regimen remains uncertain. Therefore, we comprehensively evaluated the variations in clinical efficacy and safety of several medications for treating carpal tunnel syndrome.Methods: Computer searches of Embase, PubMed, Cochrane Library, and Web of Science databases were used to collect articles of randomized controlled trials on local injections for treating carpal tunnel syndrome from database creation till 10 June 2023. Two researchers independently screened the literature, extracted information, evaluated the risk of bias in the included studies, and performed network Meta-analysis using Stata 17.0 software. Drug efficacy was assessed using symptom severity/function and pain intensity. Surface under the cumulative ranking curve (SUCRA) ranking was used to determine the advantage of each therapy.Results: We included 26 randomized controlled trials with 1896 wrists involving 12 interventions, such as local injections of corticosteroids, platelet-rich plasma, 5% dextrose, progesterone, and hyaluronidase. The results of the network meta-analysis showed the following: (i) symptom severity: at the 3-month follow-up, D5W combined with splinting (SUCRA = 95%) ranked first, and hyaluronidase (SUCRA = 89.6%) at 6 months; (ii) functional severity: either at the 3-month follow-up (SUCRA = 89.5%) or 6 months (SUCRA = 83.6%), iii) pain intensity: 5% dextrose in water combined with splinting was the most effective at the 3-month (SUCRA = 85%) and 6-month (SUCRA = 87.6%) follow-up.Conclusion: Considering the combination of symptoms/function and pain intensity, combining 5% dextrose in water with splinting is probably the treatment of choice for patients with carpal tunnel syndrome. It is more effective than glucocorticoids and no adverse effects have been observed.Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022370525. Carpal tunnel syndrome (CTS) is a commonly observed nerve entrapment disorder characterized by numbness and pain in the area of median nerve innervation, which may radiate in all directions and involve the shoulder and elbow . The preThe current management of CTS is mainly conservative and surgical release . ConventThe use of several emerging topical, injectable agents as options for treating CTS has been attempted. Of them, platelet-rich plasma (PRP) and 5% dextrose in water (D5W) are the most critical potential treatments . Ozone OThis systematic review and meta-analysis were conducted in accordance with A Measurement Tool to Assess Systematic Reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines . Go to tComputer searches of the PubMed, Embase, The Cochrane Library, and Web of Science databases were performed to collect randomized controlled trials on local injections of corticosteroids, PRP, 5% dextrose in water, progesterone, ozone, hyaluronic acid, and splints for the treatment of CTS. The search period was from the creation of the database until 10 June 2023. The search was conducted using a combination of MeSH and free terms adapted to the characteristics of each database. References to relevant subject meta-analyses and gray literature were also searched to supplement access to pertinent information. The keywords used in the search were carpal tunnel syndromes, steroids, hyaluronidase, 5% dextrose in water, PRP, splints, ozone, progesterone, and randomized controlled trial. The specific search formula is presented in 1) Participants were patients older than 18 years who fulfilled the criteria for the CTS clinical and electrophysiological diagnosis.2) Interventions were local steroids, PRP, glucose, progesterone, hyaluronic acid, or ozone for the experimental group and corticosteroids, saline, local anesthetics, and splints for the control group.3) The Boston Carpal Tunnel Questionnaire (BCTQ), Symptom Severity Scale (SSS), Functional Severity Scale (FSS), and visual analog score (VAS) were the end measures , and all4) Randomized controlled trial5) English languageInclusion criteria were the following.Exclusion criteria were animal studies, observational studies, conference abstracts, case reports, reviews, systematic reviews, or literature with incomplete data.The downloaded literature data were searched for duplicate title information, using EndNote X9 software. Two researchers (Zhou/Wu) independently screened the literature, extracted information, and cross-checked it. Disagreements were resolved through discussion or negotiation with a third party. The literature was screened by first reading the article’s title, and after eliminating irrelevant documents, the abstract and full text was further read to determine whether the articles could be included. Contact the original study authors by email or telephone to obtain missing data.Two researchers (Zhou/Wu) independently extracted and cross-checked the following information: 1) basic information on the included studies: first author, time of publication, diagnostic criteria, positioning method, and study type; 2) baseline characteristics  and interventions of the study population; 3) key elements of risk of bias evaluation; and 4) outcome indicators and outcome measures of interest . All the continuous variables were combined for different dose subgroups according to the Cochrane Handbook; the means and standard deviations of change were calculated by means and standard deviations at baseline and endpoints . All extThe quality of each study was assessed independently by two investigators (Zhou/Wu). The quality of the randomized controlled trials was evaluated using the Cochrane Risk-Of Bias tool 2.0. The tool included six domains used for methodological assessment: 1) random sequence generation, 2) allocation concealment, 3) blinding of participants and personnel, 4) blinding of outcome assessment, 5) incomplete outcome data, and 6) selective reporting . Each stp > 0.05), the inconsistency did not exist. The local inconsistency test then used the “node splitting method.” If the difference between the split points was not statistically significant (p > 0.05), the consistency model was used for analysis. If the relationship graph contained a closed loop, the loop inconsistency (LF) factor was used to determine whether there was an inconsistency. If the lower 95% CI limit for the inconsistency factors’ (IFs’) value was 0 or nearly 0, the direct and indirect evidence were considered consistent. If there was a closed loop in the relationship diagram, its inconsistency was judged by the loop inconsistency factor. If the lower limit of 95% CI IFs’ value was 0 or close to 0, the direct and indirect evidence was consistent  and 95% confidence interval (CI) were used as effect measures. The NMA was conducted using the “network” package of Stata 17.0 software, and the network relationships were mapped out. An inconsistency model was used to test the overall inconsistency. If the difference was not statistically significant . Of the remaining 728 articles, after reading the title and abstract, 668 articles were excluded for not fulfilling the inclusion criteria. The remaining 60 articles were used in the full-text re-screening. The final sample had 26 articles, with a total of 1896 wrists. The process is shown in Six studies did not describe specific randomization methods . ThirteeThe network relationship between various treatment measures is presented in Figure 33: the letters represent the corresponding intervention, the circle size denotes the number of individuals using this intervention, and the thickness of the lines between the different letters represents the number of studies.p = 0.88, there was no overall inconsistency, and the nodal split method showed p > 0.05 between all nodes, suggesting no local inconsistency. The results of the loop inconsistency (LI) test’s inconsistency factor (IF) values ranged from 0.03 to 0.46, and the lower limit of 95% CI  was 0, indicating no significant inconsistency among the closed loops. Network relationships were centered on CS and NSS, forming seven trilateral closed loops . Therefore, publication bias may exist .CS has been commonly used as a treatment for CTS and has shown short-term efficacy. According to a systematic review that included 1,028 subjects from 10 publications, there was no significant difference in symptom severity, functional status, or pain indices between surgical treatment and topical CS injections at 3 and 12 months post-treatment . AlthougIn this study, NMA was used to compare the effects of local injections of different drugs on the symptom severity, functional status, and pain index in patients with CTS. The results of NMA showed that regarding improving SSS scores, D5W + S was the most effective at the 3-month follow-up, followed by CS + S, with HA being most effective at the 6-month follow-up, followed by PRP. Regarding improvement of FSS scores, HA ranked first among the eight interventions at 3 and 6 months, followed by PRP at 3 months and D5W at 6 months. The ranked results excluded the treatment of local injection combined with splinting because no follow-up data were available for BCTQ scores at 6 months. In improving VAS scores, D5W + S was more effective than the other treatments at both 3 and 6 months, followed by PRP at 3 months and CS + S at 6 months. However, the clinical efficacy difference was nonsignificant compared with each drug.Our findings are consistent with those of other systematic reviews, with some differences. In a systematic review, Jiang et al. included 8 RCTs with 220 subjects. They showed that local PRP injections were superior to other conservative treatments in medium-term efficacy in relieving pain, improving wrist function and symptoms, reducing median nerve swelling, and partially improving electrophysiological indices . A similBy contrast, ultrasound localization was mostly not used for CS injections, possibly resulting in high effect sizes for PRP, D5W, and HA. Babaei-Ghazani et al. found that the improvement in symptom severity, functional impairment, and pain index scores of CS for CTS was at its largest effect size at the 6-week follow-up . TherefoThe pathophysiological mechanism of CTS remains unclear. The increased pressure in the carpal tunnel may be one of the mechanisms due to the fibrosis of the connective tissue of the median nerve and the sub-synovial region, increased carpal tunnel contents, and adhesions of the synovial connective tissue of the flexor tendons surrounding the median nerve . The expStudies have found that PRP is rich in growth factors that promote nerve repair and regeneration, namely, platelet-derived growth factor, transforming growth factor-beta, insulin-like growth factor, and vascular endothelial growth factor, these cytokines promote wound healing, reduce inflammation to repair the damaged median nerve, and increase the production of alpha-2 collagen and type III collagen in flexor support band cells, reducing the pressure in the carpal tunnel . HoweverHA is an enzyme that catalyzes the hydrolysis of hyaluronic acid and promotes the rebuilding of the nerve myelin sheath by degrading the accumulated hyaluronic acid. HA also reduces the inflammatory response, reduces viscoelasticity, increases tissue permeability, and allows local anesthetic to diffuse through the surrounding tissue . In a raThe D5W is often used for microinjection because it has an osmotic pressure similar to that of saline and can inhibit the activation of capsaicin-sensitive receptors , blocking the release of substance P and calcitonin gene-related peptide and relieving neurogenic inflammatory pain . SeveralProgesterone has anti-inflammatory effects and is essential in local inflammatory healing, myelin repair, and axonal regeneration . In two 1.Fewer studies were included. There was only one study involving PRP combined with splinting, and the sample size was small; thus, bias may have occurred.2.Raeissadat et al. did not use ultrasound localization and the PRP dose was 1 mL, which was lower than other experiments in which PRP was injected alone, resulting in inadequate efficacy. .3.The follow-up time was only 10 weeks , which iThe neutral splint is the first-line treatment option for CTS and is widely used in clinical practice . ConsideAnd in a related study, which confirms our speculation, compared to the study of Raeissadat et al., Gado et al. used ultrasound-guided injection using an in-plane ulnar approach; the puncture needle was passed from the ulnar side of the wrist joint to the MN, and 2 mL of PRP was injected, and the flexor supporting band of nerves was stripped with water, and the remaining 1 mL of PRP was injected underneath the MN, and evaluated the results of the treatment in 40 patients (PRP + S group 20 patients and splint group 20 patients) at 3-month follow-up, and their results showed that the differences in VAS, SSS, FSS and CSA between the two groups at 1 month after treatment were not statistically significant; however, patients in the PRP combined with brace group showed better improvement in all of the above indexes than those in the brace-only group at 3 months after treatment , indicatAdditionally, the volume of injection used for PRP in the literature mostly ranged from 1 to 3.5. We found that the optimal volume of injection for PRP may be approximately 2 mL by comparing the change in BCTQ and VAS scores for different volumes of PRP; the optimal volume of NSS for aqueous autopsy ranged from 2.5 to 3.5 mL using the same method. Lin et al. found that 4 mL 5% D5W was superior to 1 mL and 2 mL D5W in symptom relief and functional improvement in CTS at weeks 1, 4, and 12 post-injection by comparing the efficacy of ultrasound-guided injections of different doses of D5W in CTS . By contThis study has limitations. The water separators applied are mainly lidocaine and saline; thus, the use of lidocaine or saline in the various studies may also affect the experimental results. High-quality evidence has not been found on whether ultrasound localization is superior to landmark localization. Different types of corticosteroids may have different efficacy, and three types of corticosteroids were used in the included studies. However, they are treated as the same intervention in this paper. In addition, despite some advantages of PRP in the treatment of CTS, there are currently no uniform standards for the preparation of PRP, resulting in different studies using different PRP components. For example, both platelet concentration and leukocyte content can be affected by different preparation methods as well as the patient’s own body composition. These can all have an impact on the efficacy of PRP. However, no sub-group analysis was performed owing to the small number of studies reviewed in this meta-analysis.In summary, the current SUCRA ranking, which considers all indicators, shows that D5W + S is the best treatment option, followed by PRP, HA, CS + S, D5W, P, 0 + S, CS, S, LA, PRP + S, and NSS. The PRP, HA, and D5W + S treatments were more effective than corticosteroids in improving function, symptoms, and pain in the short term (3 months) and the long term (6 months). No severe complications were reported in the included literature, and the safety profile was good. It is hoped that future studies will further determine the optimal dose of different local injection treatments, reach a consensus regarding the method of PRP preparation, and conduct longer (>6 months) follow-ups.


After the initial 72 h, most of the SSD patients (30.8%) improved and no longer had SSD; 19.2% continued to experience SSD and one patient (3.8%) progressed to delirium. The post-hospital discharge survival rate for the SSD patients was 100% at 3 months and 87.5% at 6 months. At admission, 96.2% of the SSD patients were fully independent in daily living activities, 66.7% at 3-month follow-up, and 100% at 6-month follow-up. Most SSD patients demonstrated a cognitive decline from admission to 3-month follow-up and improved at 6 months . We concluded that early SSD is associated with worse outcomes, mainly a transitory cognitive decline after hospital discharge at 3 months, with an improvement at 6 months. This highlights the need to prevent and identify this condition during ICU stays.Subsyndromal delirium (SSD) in the Intensive Care Unit (ICU) is associated with an increased morbidity with unknown post-discharge functional and cognitive outcomes. We performed a prospective multicenter study to analyze the mental status of patients during their first 72 h after ICU admission and its trajectory, with follow-ups at 3 and 6 months after hospital discharge. Amongst the 106 included patients, SSD occurred in 24.5% (n = 26) and was associated with the duration of mechanical ventilation ( Subsyndromal delirium (SSD) is commonly considered as an intermediate stage of severity between delirium and non-delirium ,2. Therep = 0.031) [The management of delirium and SSD in ICUs remains a challenge. The authors of the Guidelines for the Prevention and Management of Pain, Agitation, Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) recommend a multicomponent, nonpharmacological approach to reducing the risk factors for delirium, enhancing cognitive function, and improving sleep, mobility, and patient reorientation . Innovat= 0.031) .Delirium studies on critically ill adults have consistently found an association with cognitive impairment at 3 and 12 months after ICU discharge, but its association with depression, functionality/dependence, or mortality has not been consistently established ,12,13.The functional and cognitive outcomes of SSD are not as well understood as those of delirium. The existing literature on SSD has primarily focused on non-critically ill patients, where it has a combined prevalence of 23%   and outcIn the ICU, studies on SSD outcomes are limited. SSD is associated with longer ICU stays, lower cognitive scores, and an increased likelihood of institutionalization ,18. It dThe present study aims to evaluate the prevalence of early SSD in critically ill patients and cognitive and functional follow-ups at 3 and 6 months after hospital discharge.ClinicalTrials.gov Identifier: NCT0381345. We conducted a prospective, observational, multicenter clinical study (SubSynd study) in four medical and surgical Portuguese ICUs, between 1 August 2018 and 31 March 2020, with the All adult patients admitted to the ICU were screened for the exclusion criteria. The exclusion criteria included the following: acute neurologic injury as the primary reason for ICU admission  of <14 at admission or in the days prior); a history of severe cognitive dysfunction or severe dementia; impaired hearing or visual acuity; speech difficulties or an inability to speak or understand Portuguese; patients expected to die within 24 h after admission; a limitation of therapeutic effort; refusal to participate; an inability to provide informed consent; and patients who were readmitted to the ICU. Patients with an RASS score below three and patients with missing evaluations (ICDSC assessment) within the first 72 h after admission were also excluded.We used the ICDSC scale for the diagnosis of SDD and applied it until ICU discharge or death, for a maximum duration of 14 days. Patients who obtained a score of 0 on each examination were categorized as non-delirious, those scoring between 1 and 3 were classified as having SSD, and a score of 4 or higher was indicative of delirium. The ICDSC, in conjunction with the Richmond Agitation and Sedation Scale (RASS), was applied once daily, with an initial assessment by a clinician occurring in the morning. If the patient was deeply sedated (RASS < −3), the assessment could not be conducted. All the clinicians involved in the screening for SSD and delirium underwent systematic training by a senior instructor to ensure the proper utilization of the ICDSC. For the specific analysis conducted in this study, our focus was on the early occurrence of SSD. We assessed the patients within the first 72 h following their ICU admission and analyzed the progression of each patient group over the subsequent three days . The patients were categorized in the first 72 h, based on the highest score of the ICDSC, as having (1) delirium; (2) SSD; or (3) no-delirium/no-SSD. This means that patients with at least one classification of delirium in the first 72 h were classified as having delirium. Patients without delirium, but with at least one classification of subsyndromal delirium, were classified as having SSD. Patients without delirium or subsyndromal delirium were classified as no-delirium/no-SSD. We selected this period (72 h) since SSD and delirium occurrence is higher in the first days after ICU admission ,22. At enrollment, we collected the following baseline demographic variables: age, gender, pre-illness cognitive status (via IQCODE), pre-illness disability status (via the Katz index), medical comorbidities (Charlson comorbidity index), admission type (urgent or elective), admission characterization, pre-ICU location, admission diagnosis, E-PRE-DELIRIC Score , APACHE The primary outcome of the study was the prevalence of early-onset SSD (within the first 72 h). The secondary outcomes included the duration of mechanical ventilation, the length of the stay in the ICU and hospital, ICU and hospital mortality rates, and cognitive and functional outcomes at 3 and 6 months after hospital discharge.We assessed the functional and cognitive outcomes at 3 and 6 months post-hospital discharge. The functional evaluation was conducted using the modified Katz index of independence in activities of daily living ,25, whilThe IQCODE was originally described as a 26-item informant questionnaire that retrospectively assesses changes in cognitive performance over a 10-year time period and allows a screen for potential dementia. Later, a shorter version was created, the IQCODE-Short form (IQCODE-SF), measuring a range of cognitive declines using a 16-item score. This short form is common in clinical practice and has been recommended as the preferred IQCODE format, being repeatedly shown to be effective in identifying the presence of significant cognitive impairments in medical populations and elderly populations . For eacIn the original IQCODE development and validation work, an average score higher than 3.31 was indicative of cognitive impairment , but theThe Katz Index of Independence in Activities of Daily Living (Katz ADL Index) evaluates the adequacy of performance in six functions: bathing, dressing, toileting, transferring, continence, and feeding. Each function is scored as either independent (yes) or dependent (no). Based on their total score, the patients were categorized as follows: total dependency = 0; severe dependence = 1–2; moderate dependence = 3–4; mild dependence = 5; and total independence = 6.The study received ethical approval from the Research and Ethics Committee of Centro Hospitalar de Lisboa Ocidental  and from the National Data Protection Commission .Each participating hospital obtained approval from their respective Institutional Review Boards. Written informed consent was obtained from the participants or their proxies and no incentives were provided to encourage participation. The study was conducted in accordance with the approved ethical guidelines. There were no interventions in the regular management of the patients. Data were collected and entered into a dedicated electronic database that was specifically created for this study. The authors ensured the confidentiality of the data, and the patients were assigned unique code numbers to maintain their anonymity. Standard descriptive statistics were used as appropriate. Continuous variables were expressed as mean ± standard deviation or median and interquartile range, depending on the normality assumption. Categorial variables were expressed as absolute (n) and relative (%) frequencies.p < 0.25 in a univariable analysis). The significance level used was 0.05. All the statistical analyses were performed with the IBM SPSS Statistics software, version 26.0 .The chi-square test was used to evaluate the associations between the categorical variables, while, for continuous variables and group comparisons , the t-Student and Kruskal–Wallis tests were used. The variables were compared between the three groups using the Bonferroni test. We used a multivariable regression to evaluate the association between early SSD, invasive mechanical ventilation, and the length of the ICU stay. Covaried APACHE II, E-PRE-DELIRIC score, age, SOFA score, and admission characterization were used , 34 patients with delirium (32.1%), and 43 patients without delirium or SSD (34%) .p = 0.003). The type of admission was mainly urgent (p = 0.17), with a predominance of medical admissions (p = 0.09) with infections/sepsis being the most prevalent diagnosis. The severity of the illness expressed by the median APACHE II score and median admission SOFA score showed an increase through the three groups (no-delirium/no-SSD < SSD < delirium), higher in delirium patients, with a significative association with both scores (p < 0.001) (p < 0.001). Their demographic characteristics are presented in < 0.001) . The medp = 0.003). The median length of ICU stay was longer in the delirium group compared to that in the SSD group and no-delirium/no-SSD group (8 (4–10) days, 4.5 (3–6) days, and 4 (2–6) days, respectively; p = 0.002). The length of hospital stay was similar in the three groups . No significant differences were observed among the three groups concerning either hospital or ICU mortality (p = 0.41 and p = 0.68) (The median (IQR) of the number of days of mechanical ventilation was significantly associated with cognitive dysfunction (no-delirium/no-SSD group 0 (0–1)); SSD, 0.5 (0–1); and delirium, 1.5  . The cognitive trajectory during days 4, 5, and 6 after admission is presented in p = 0.43). Concerning readmissions, only two patients (13.3%) from the SSD group required hospital re-admission, and there were also no statistically significant differences among the groups   .p = 0.35). The rate of hospital re-admission at 6 months was higher in the delirium group . In terms of the risk of institutionalization, most patients were still able to reside at home  , while only 1 patient (6.7%) went to a nursing home. Similarly, in the other groups, most patients were able to return home . Only three delirium patients were still in the hospital at the time of the evaluation. At 6 months post-discharge, the mortality rate among the SSD patients was 12.5% (two patients), among no-delirium/no-SSD was 5.9% (two patients), and no deaths occurred among the delirium patients ( > 0.99) .At ICU admission, most patients in all three groups were fully independent . The patients that were more dependent at hospital admission were those who developed delirium .At 3 and 6 months after discharge, the SSD patients exhibited the best functional outcomes, followed by the no-SSD/no-delirium patients. At 3-month follow-up, 10 SSD patients (66.7%) were fully independent, 2 patients (13.3%) had severe dependence, and 3 patients (20%) were completely dependent. However, upon reevaluation at 6 months, all the SSD patients had regained their full independence.Regarding cognitive outcomes, the SSD patients exhibited a decline in their cognitive function from admission to the 3-month follow-up . At admiThe no-delirium/no-SSD patients did not show significant changes in their cognitive function at admission, but experienced worsening at the 3-month follow-up, with an IQCODE-SF score of 3.2, indicating cognitive decline. At 6 months, this group showed improvement and returned to the cognitive score reported before admission. The delirium patients had the highest scores from admission to the 3- and 6-month follow-ups, indicating more severe cognitive dysfunction .Our study evaluated the trajectories of early SSD and its impact on clinical outcomes and post-discharge follow-ups in critically ill patients. We found that 24.5% of these patients had early SSD, which was associated with significantly worse clinical outcomes during their ICU stay and at 3-month follow-up. Most of the studies on SSD in ICUs have focused on patients who have undergone on-pump cardiac surgery, with reported incidence rates ranging from 34% to 57.1% ,19,31, wWe used the ICDSC scale; however, neither this scale nor any other has been validated specifically for the clinical identification of SSD in ICUs. Evidence has suggested that the use of quantitative tools such as the ICDSC could aid with SSD assessment, as part of a presentation in a graduation of cognitive dysfunction. With the ICDSC, SSD is identified when the total score falls between 1 and 3 points. This means that, between 0 points (no symptoms) and 4 points (indicative of delirium), there is a range of presentations that are minor in number (as compared to delirium), but could be very relevant as clinical presentations and related to worsening outcomes. The Confusion Assessment Method for the ICU (CAM-ICU) is a dichotomous scale, primarily designed for delirium assessment (present/absent) . In someIn our study, we did not assess the use of sedative medications on a daily basis see . HoweverThe relevance of an RASS score of −3 in delirium diagnosis has been approached differently in various studies. In some instances, researchers have chosen to apply delirium scales only to patients with an RASS score of ≥−2, as they believe that reliable results cannot be obtained for patients with an RASS score of −3 using any of the validated diagnostic tools . In the et al., studying the impact of SSD occurrence and its trajectory during ICU stays, reported that patients with delirium or coma had a higher baseline severity of illness (expressed by a higher APACHE II score), and an APACHE score of >23 points was one of the main factors associated with the progression from SSD to delirium or coma [The patients with SSD were older and had greater critical illness (assessed using the APACHE II and SOFA scores) than the no delirium/SSD patients. In the study by Ouimet et al., the patients with no delirium/SSD were younger, and also had the lowest APACHE II scores at admission when compared to the SSD and delirium patients, respectively . These p or coma . Additio or coma . Early SSD was found to be associated with a prolonged ICU length of stay (LOS) and an increased duration of mechanical ventilation. These outcomes were more similar to the group without delirium/SSD, although these results are limited by our small sample size. The number of days on mechanical ventilation in both the no-delirium/SSD and SSD groups showed a median interquartile range (IQR) between 0 and 1 day. However, a significant percentage of patients in both groups received invasive mechanical ventilation, with 28.3% in the no-delirium/SSD group and 50% in the SSD group. While we did not conduct a specific analysis on the ventilated patients, we can hypothesize some reasons for the short duration of mechanical ventilation in these groups: these patients were younger, including more admissions from the operating room and elective surgeries, and exhibited a better performance status compared to the patients with full delirium.p = 0.025), but this did not lead to an increased mortality [The trajectory of SSD in ICUs has been analyzed in various studies and documented as follows: (1) SSD patients can revert to a normal cognitive state or (2) deteriorate into delirium or coma. Furthermore, SSD can either (1) be the initial presentation of brain dysfunction or (2) exist along a continuum with delirium (delirium improving into SSD or SSD worsening into delirium). The trajectory involving delirium or coma tends to be associated with poorer outcomes. In our study, we were unable to establish a clear cognitive pathway from SSD to delirium, as only 1 SSD patient (3.8%) progressed to delirium, while 12 patients with delirium (35.3%) progressed to SSD. The rapid resolution of SSD on the 3rd, 4th, and 5th days was more similar to the patterns of patients without delirium/SSD. Serafim R. et al. proposed that the trajectory of SSD should influence outcomes, and their study revealed that SSD often represents a transitional phase that rapidly evolves towards either normalization or deterioration into delirium or coma . SSD patortality . The keyWe documented that early SSD was not found to be associated with hospital and ICU mortality, which aligns with the findings of previous studies . HoweverRegarding functional outcomes, most SSD patients maintained their independence in the successive evaluations, with a slight reduction at the 3-month follow-up, without statistical significance. In contrast, the patients with delirium consistently showed higher levels of dependency. This functional presentation of the SSD patients was also more similar to that of the no-delirium/no-SSD group rather than that of the delirium group. Concerning cognitive outcomes, at admission, the SSD patients exhibited an IQCODE-SF score of 3.13, which already indicated cognitive decline. This was in initial IQCODE testing, and further testing with a more specific tool is necessary for cognition and dementia assessments. This score was more similar to the patients without delirium/SSD, who had a score of 3.05. During the post-discharge follow-up at 3 and 6 months, it was observed that the SSD patients experienced cognitive impairment that persisted for at least 6 months, with greater impairment reported at 3 months. In a study conducted by Li et al., similar findings were reported in patients undergoing elective coronary artery bypass graft surgery . They obDuring critical illness, alterations in cognition can be recognized and manifest in various patterns. Some patients may experience a worsening of pre-existing cognitive dysfunction, while others may develop new cognitive impairments or not exhibit cognitive dysfunction at all. The recognized risk factors for cognitive dysfunction during critical illness include: advancing age, pre-existing cognitive disorders, severe sepsis, and a longer duration of mechanical ventilation and longer duration of delirium . Delirium is the most common manifestation/ marker of acute brain dysfunction during critical illness, and the longer a patient suffers from delirium, the greater the chance of long-term cognitive impairment . Like dep = 0.001 and p = 0.04, respectively) and worse executive function at 3 and 12 months  [In our study, the delirium patients presented higher cognitive dysfunction scores, with the highest score seen at 3 months. Pandharipande et al. demonstrated an association between duration of delirium and cognitive dysfunction at 3 and 12 months post-discharge (ctively) . The facComparing studies on cognitive dysfunction is hindered by the lack of consensus on a definition of cognitive dysfunction and the scales used. Another limitation in various studies is the limited information on overall health and pre-hospitalization cognitive statuses for follow-ups and defining the course of progression.To the best of our knowledge, this is the first study to evaluate the outcomes of early SSD, including functional and cognitive impairments, after hospital discharge during a 3–6-month follow-up period. The decline in cognition and functional capacities is higher at 3-month follow up, but seems reversible, with an improvement or even resolution at 6-month follow-up. Therefore, concerning the higher risk during the first 3 months after discharge, rehabilitation efforts are of particular interest and benefit as soon as the patient is discharged, and should be prepared before patients are discharged. The limitations of our study must also be acknowledged. The primary limitation is its small sample size. Due to the scarcity of studies specifically focusing on SSD in mixed ICUs, it was challenging to estimate an adequate sample size, and our sample may have been insufficient for detecting significant differences between the groups. Therefore, larger studies specifically designed to evaluate SSD are necessary to validate our findings.Secondly, we chose to include patients with early SSD as their initial presentation to minimize the influence of multiple factors associated with prolonged ICU stays. However, it should be noted that some patients may have continued to experience SSD beyond this period or developed SSD after a period of delirium. Furthermore, post-operative delirium is known to occur within the first two days after surgery, but our study only had a 27.4% representation of surgical patients, limiting our ability to address this aspect . A thirdThe early occurrence of SSD is a prevalent condition, with intermediate outcomes when compared to delirium and patients without SSD or delirium. It is associated with an increased use of resources , but not with ICU or hospital mortality. In the long-term follow-up, despite findings of a worsening functionality and cognition at 3 months, most of the patients improved within 6 months. This shows that this condition is relatively “benign” in the medium term, with transitory worsening outcomes at 3-month follow-up. These findings emphasize the importance of regular assessments for SSD, the optimization of patient care during ICU stays, and preparation for patient discharging with an early rehabilitation plan. Given the limited studies on interventions aimed at reducing SSD, it is advisable to implement the same non-pharmacological interventions that are well-documented for minimizing the occurrence of delirium.


Drosophila melanogaster, but provides greater specification of the individual hydrocarbon chains on particular lipids than has been previously reported in insects. A level of complexity in the configuration of the hydrocarbon chains not previously described in insects is revealed. Genomic analysis reveals a diversity of genes encoding lipid biosynthesis and remodelling enzymes comparable to that seen in mammals, which could account for the complexity of chain configurations observed.This paper reports the first lipidomic analysis of a tephritid fruit fly. It shows broadly similar lipid profiles to those reported for another dipteran, Drosophila melanogaster. Here, we present the lipidome of adult males of another higher dipteran frugivore, Bactrocera tryoni. We describe 421 lipids across 15 classes of ester neutral lipids and phospholipids and ether neutral lipids and phospholipids. Most of the lipids are specified in terms of the carbon and double bond contents of each constituent hydrocarbon chain, and more ether lipids are specified to this degree than in any previous insect lipidomic analyses. Class-specific profiles of chain length and (un)saturation are broadly similar to those reported in D. melanogaster, although we found fewer medium-length chains in ether lipids. The high level of chain specification in our dataset also revealed widespread non-random combinations of different chain types in several ester lipid classes, including deficits of combinations involving chains of the same carbon and double bond contents among four phospholipid classes and excesses of combinations of dissimilar chains in several classes. Large differences were also found in the length and double bond profiles of the acyl vs. alkyl or alkenyl chains of the ether lipids. Work on other organisms suggests some of the differences observed will be functionally consequential and mediated, at least in part, by differences in substrate specificity among enzymes in lipid synthesis and remodelling pathways. Interrogation of the B. tryoni genome showed it has comparable levels of diversity overall in these enzymes but with some gene gain/loss differences and considerable sequence divergence from D. melanogaster. Modern lipidomics has the power and sensitivity to elucidate the role of insects’ lipidomes in their adaptations to the environment at a mechanistic molecular level. However, few lipidomic studies have yet been conducted on insects beyond model species such as  Recent lipidomic analyses of model mammal, yeast and plant species have revealed highly nuanced usage of different acyl/alkyl chains in various classes of lipids ,4,5,6,7 Historically, much of the work associating insect lipids with phenotypic and fitness traits was based on total lipid contents or major neutral lipid, phospholipid or fatty acid fractions using a variety of colorimetric, chromatography and mass spectrometry methods. The traits implicated by these analyses have included developmental rates, longevity, quiescence and diapause, flight and long-distance migration, and tolerances to climatic and dietary stresses ,26,27,28Drosophila melanogaster [Aedes species [Bombyx mori [Recent developments in lipidomics have allowed more detailed dissection of differences in insect lipid profiles due to the various physiological, environmental or genetic factors. Much of the work has focussed on the model dipteran nogaster ,52,53,54nogaster , mosquit species ,57,58,59byx mori ,61. Diffbyx mori ,52,53,54byx mori ,53,54,62byx mori ,57 or dibyx mori ,50,51,58byx mori ,57. EtheBactrocera tryoni. Like D. melanogaster, the Qfly is a highly polyphagous dipteran frugivore. The two species share many host species, although the larvae of D. melanogaster feed on rotting fruit, whereas Qfly attacks fresh fruit and, as a consequence, is a major horticultural pest [D. melanogaster [Here, we present the first comprehensive lipidomic analysis of any tephritid fruit fly, the Queensland fruit fly (Qfly), ral pest ,64,65,66ral pest . Howevernogaster .D. melanogaster homologs. Our findings will facilitate more detailed analyses of lipidomic contributions to important phenotypes, and phenotypic differences, than has previously been possible in insects.In this study, we have resolved a total of 421 individual lipids across 15 different classes, including 6 classes of ether lipids, and specified the carbon and double bond contents of individual chains within most of the neutral lipids and phospholipids, and more ether lipids than any previous insect study. This, in turn, has enabled us to examine the frequency distributions of acyl and, in the ether lipids, alkyl and alkenyl chains across most of the lipids in the different classes and to test for non-random combinations of the chains attached to the different headgroups. As in the mammal and plant precedents, our results reveal a highly nuanced usage of different sorts of chains in the different classes. Annotation of the relevant gene–enzyme systems in the Qfly genome shows a comparable capacity to encode these complex patterns, although we also find evidence of some copy number and significant sequence divergence from their All chemicals used for lipid extraction and analysis were LC-MS-grade compounds from Sigma-Aldrich .3) or ~250 in medium-sized cages (32.5 × 32.5 × 32.5 cm3) . All life stages were maintained at a temperature of 25 ± 1 °C, relative humidity of 65 ± 5% and a 13:11 h light:dark cycle in which the light hours included an hour of stimulated dusk and dawn using 40 W LED lights .The S06 stock  used wasLipids were extracted from freshly emerged  and sexually mature  males. Flies were provided water but no food for the first 24 h after eclosion and a normal adult diet after the Day 1 collection. Sixteen replicate males were selected at random for assay from a total of six different cages (at a maximum of three from any one cage) for each day, and the Day 1 and Day 19 flies were drawn from the same six cages. Following Zhou et al. , males sg for 60 s, and 100 µL of cold methanol: water solution  was added, with vortexing  for 10 s. Then, 600 µL of chloroform: methanol solution  was added with vortexing for another 10 s. Samples were then sonicated  at 40 kHz and 4 °C for 5 min. Following centrifugation at 18,110× g for 15 min, the supernatant was pipetted into a new 2 mL Eppendorf tube and 200 µL of chloroform and 300 µL of distilled H2O were added. The mixture was vortexed for 10 s and centrifuged at 18,110× g for 5 min. The organic phase  was carefully withdrawn with a pipette and transferred to a clean 2 mL standard amber LC-MS vial . Lipids were then re-extracted from the remainder with 400 µL of chloroform and the organic phase (~90% volume) combined with the first extract, which was then completely dried under nitrogen at 30 °C for 10–15 min and stored at −80 °C. All sample manipulations during the extraction procedure were carried out on ice.Following Guan et al. , the frev/v) solution at a ratio of 50 µL per mg of dry tissue. Then, 1 µL of this solution was injected into a Vanquish Horizon ultra-high pressure liquid chromatography (UHPLC) system coupled to an Orbitrap FusionTM TribridTM Mass Spectrometer  equipped with polarity switching and controlled using Xcalibur software . Conditions for the LC-MS were broadly based on those of Rampler et al. [v/v, 0.1% formic acid, 10 mM ammonium formate, 500 µM phosphoric acid) and solvent B was isopropanol: acetonitrile . The flow rate was 0.26 µL min−1 and elution was achieved with a gradient of solvent B starting at 30% B, with increments to 43% at 2 min, 55% at 2.1 min, 65% at 12 min, 85% at 18 min and, finally, 100% at 20 min, where it was held until 25 min. H-ESI (heated electrospray ionisation) settings were sheath gas, 35 arb units; sweep gas, 5 arb units; auxiliary gas, 1 arb unit; vaporiser temperature, 300 °C. The spray voltage was 3500 V in positive ion mode and 2400 V in negative ion mode and the ion transfer tube temperature was 300 °C. MS spectra were recorded in the scan range 250–1500 m/z at 120,000 resolution (at 200 m/z) using the Orbitrap mass analyser with an automated gain control of 4.0 × 105 ions. Data-dependent MS/MS spectra were recorded using the ion trap mass analyser following mass isolation at 0.7 m/z, with HCD  collision energy stepped between 25, 30 and 35 eV in positive ion mode and held at 30 eV in negative ion mode. In positive ion mode, the PC headgroup daughter ion at 184 m/z triggered CID (collision-induced dissociation) fragmentation of the parent ion at 32 eV and the neutral loss of fatty acids triggered MS3 of TG species at CID 35 eV. The dried extracts were resuspended in butanol:methanol  was used to annotate the mass spectra. The product ion search feature was used to identify lipid species using the Orbitrap database with a precursor mass tolerance of 5.0 ppm and product ion tolerance of 0.5 Da. Both positive and negative ionisation data were used to create the compound lists, which were then manually verified. Quantitative analysis was then carried out on all those compounds using online and in-house spectral libraries and annotation tools in the Compound Discoverer software . These data were then converted to concentrations (ng/µL) with reference to the results for a range of concentrations of several standards that had been included in every run .Statistical analysis was conducted in R version 4.1.2  using tht-tests to compare the observed and expected frequencies of each combination, with Bonferroni corrections of p-values to account for multiple testing.In order to test for non-random associations among different acyl chains in each of the nine ester lipid classes that we analysed, we first derived expected frequencies for each combination of chain types in each relevant class under the assumption of random association. Broadly following an approach used by Li et al. , we achiWe identified and quantified 370–380 lipids at each of the two ages of adult males sampled, 332 of them in both ages, 43 just at Day 1 and 46 just at Day 19 . Most ofD. melanogaster adults, whereas numbers for the other classes were closer to the low end of the D. melanogaster range [D. melanogaster studies, and only about a third were chain-specified, many more ether lipids were chain-specified in Qfly than in the D. melanogaster precedents.About half the lipids we identified were TGs, with three classes of phospholipids, namely cardiolipins (CLs), PCs and PEs, accounting for about half of the remainder. The other eleven classes analysed comprised DGs, four additional phospholipid classes, namely phosphatidylglycerols, phosphatidylinositols, phosphatidylserines and lysophosphatidylcholines  and, generally least numerous, six ether lipid classes  and, to a lesser extent, PCs , and relatively high values in CLs  . Generalnogaster ,53,54,89nogaster ,51,53,54C. elegans and mammalian studies [Double bond numbers in both the acyl and alkyl chains of the chain-specified Qfly TGes (~0.4–1.0) were comparable to those in the acyl chains of TGs (~0.6–0.8) but, as with the carbon content data, there were large differences in those numbers in the acyl vs. alkyl or alkenyl chains of the chain-specified PCe, PEes and PEps . Unlike  studies ,86,87,88D. melanogaster males [Although generally not significant in individual phospholipid classes, there was a consistent trend across all the classes of phospholipids, but not the other lipid classes, for there to be slightly fewer double bonds in Day 19 males than Day 1 males . This coer males .To test for any relationship between the average carbon and double bond contents of the chains in each class, we classified each chain in each fully specified lipid both as short, medium or long  and as saturated, monounsaturated or polyunsaturated  . This reExcept in the solitary PCe, whose acyl chain was short and monosaturated, a similar trend was evident in the acyl chains of the chain-specified ether lipids. Once again, monounsaturation was largely confined to the medium acyl chains, with most of the short and long acyl chains again being either saturated or polyunsaturated.The patterns were more variable across the alkyl/alkenyl chains of the four ether lipid classes analysed. Consistent with the pattern in the acyl chains above, monounsaturation was largely confined to medium alkyl chains in the PEes but it was also seen in some short alkyl chains in the TGes. Polyunsaturated alkyl/alkenyl chains were only seen in the TGes, with most alkyl/alkenyl chains in all four classes being saturated, and with medium alkyl/alkenyl chains of any double bond category generally being rare.The Qfly dataset contained 18 individually common chains, which we defined as constituting at least 5% of all the chains in at least 1 of the 13 classes for which we had chain-specified members in at least one of the Day 1 or Day 19 datasets . These 1As found in most other insects , and indBactrocera oleae and Mediterranean fruit fly Ceratitis capitata [B. oleae and C. capitata  also contributed the majority of the acyl chains in the chain-specified TGes. However, the alkyl chains of the TGes and both the acyl and alkyl or alkenyl chains of the chain-specified PCe, PEes and PEps were generally short or long, with considerable variation between them as to the specific acyl and alkyl/alkenyl chains that predominated. The most abundant chain was 20:0 among the alkyl chains of the TGes, while 12:0, 14:1, 20:0, 24:0 and 24:2 were each the most abundant acyl or alkyl/alkenyl chain in one or other of the three ether phospholipid classes in question.Moreover, the frequencies of the specific chains in each of the four ether lipid classes differed radically between their respective acyl and alkyl/alkenyl complements. Despite significant differences in the particular chains involved, the common theme across all four classes was for an essentially complete dichotomy between the acyl and alkyl/alkenyl chain complements of each of them .D. melanogaster males [B. mori [D. melanogaster. However, our data agree with the limited data available for other insects and the more extensive data for other organisms in finding minimal overlap between the compositions of the acyl vs. alkyl/alkenyl chains of the four ether lipid classes for which we had chain-specified data.We are unaware of any previous reports of the acyl/alkyl chain complements of ether neutral lipids in insects, but in other organisms, the great majority of the alkyl chains of DGes at least are 16:0, 18:0 and 18:1 ,96. Two er males  and one [B. mori , produce[B. mori ,82. ThusGiven we had found lower proportions of  medium chains in Qfly ether phospholipids than have been reported for other species, we investigated the possibility that ours was an unrepresentative sample of those lipids in the Qfly lipidome . Such a D. melanogaster, even though those in the latter were seldom chain-specified [The scope for detection bias was significant, given that the total number of ether lipids we recovered, 38, was only about a third as many as have so far been reported in pecified ,52. The The scope for bias in chain resolution was significant in the case of the TGes, because the two TGes that were not chain-specified, 32:1e and 34:2e, were also by far the most common . However, the relatively small aggregate carbon numbers across their three chains (32 and 34) indicated that both included at least one and possibly two short chains. None of the six DGes were chain-specified, but five of them each had aggregate carbon numbers of 32–36 that could be explained by individual C16 and C18 chains. However, the sixth, 22:3e, which was also the most common, clearly involved at least one short chain. Three of the five unresolved PEes  had aggregate carbon numbers implying at least one long chain but the combined frequency of these five PEes was very low anyway (~0.1% on each day). Two of the eight chain-specified PEes each had two medium chains, and the combined frequency of those two was higher (~0.1% at Day 1 and ~0.3% at Day 19). However, the other six each had at least one short or (mainly) long chain, and their combined frequencies were higher still (~1.6% at Day 1 and ~0.9% at Day 19). All seven of the PEps detected were resolved; all the chains in four  were medium chains, while none of the other three  had any of these chains and each included both a C10 or C12 alkenyl and a C24 acyl chain. The combined frequencies of the first four were lower than those of the last three, although both groups were relatively frequent compared to the other ether phospholipids. Thus, relatively low proportions of the six medium chains were recurring features of the TGes, DGes and PEes whether or not they were chain-specified. The situation with the PEps was more complex, with the limited data available suggesting one group only contained such chains and the other only contained short and long combinations. The single PCe detected  was chain-specified and had no medium chains, whereas the single PSe  was not resolved and both of its chains could have been medium chains. In sum, we cannot discount the possibility that the relatively low frequency of medium chains in some of our ether lipid classes was due to biases in their detection. However, for some classes at least, it seems unlikely to be due to the subset that could be chain-specified being a biased sample of those detected.Given the indications in About 89% of the comparisons for the nine possible combinations of the three carbon and three double bond categories across the two days showed significant differences between the frequencies observed and those expected under the assumption of random associations . Both thTo screen for the major patterns in the differences, we focussed on 29 large biases in the nine joint carbon and double bond categories . For theD. melanogaster, there were still some classes where our values were at or beyond the extremes of those already quite large ranges. The significance of these differences is unclear, however, given the potentially large contributions of differences between studies in research focus and methodology. While the diversities and abundances of the different Qfly lipid classes were generally within the ranges reported for D. melanogaster precedents. This might be expected, given the strong structural constraints associated with their functions in various lipoproteins, lipid droplets and lipid bilayers in membranes [On the other hand, with a few notable exceptions, the compositional profiles of the different Qfly classes generally fell within the relatively tight ranges of the embranes ,29,79,99D. melanogaster, as were the relatively high double bond contents of the cardiolipins and the relatively low carbon, albeit not double bond, contents in the PC chains [Most of the differences in the ester neutral lipids and phospholipids involved differences in saturation states. Slightly shorter chains were found in PCs than other phospholipids but proportionately larger differences were seen in average levels of unsaturation, which were relatively low in the TGs and PCs, relatively high in the cardiolipins and, among the phospholipids, consistently higher on Day 1 than Day 19. The relatively low double bond contents of the TG chains were consistent with the findings for C chains ,53,54,89D. melanogaster [The higher double bond contents of the phospholipids in the Day 1 compared to Day 19 flies also agreed with differences seen between newly emerged and sexually mature nogaster  and woulnogaster ,42,78,79nogaster ,42,78,79D. melanogaster, have shown that organisms adjust their membrane phospholipid compositions according to the temperature of their environments , there is also a growing body of evidence linking such non-random associations to positional differences on the headgroups of ester lipids in other organisms. For example, Manni et al. [sn1 vs. saturated, monounsaturated or polyunsaturated at sn2, where they ranged from 14:0 to 22:6. Our statistical analyses showed that combinations of dissimilar chains were also more frequent than expected simply from their individual frequencies in several classes of ester lipid. Significantly, Li et al. , on whosi et al.  found meD. melanogaster, where there are also largely medium polyunsaturated chains [In contrast to the situation in most other classes analysed, Qfly cardiolipins showed an excess of a combination of chains that were all similar in both carbon and double bond contents. In this case, all four of the CL acyl chains were medium in length and polyunsaturated. This concurs with findings in other organisms, including d chains ,107,109.d chains ,123,124.d chains ,110,111.sn position on the different lipid headgroups depend in a large part on the substrate specificities of key enzymes in the Kennedy and acyl DHAP lipid biosynthetic pathways for ester and ether phospholipids, respectively, and the Lands’ cycle responsible for remodelling both ester and ether phospholipids [Homo sapiens, several of these steps can be catalysed by multiple enzymes with varying substrate specificities and expression profiles [D. melanogaster and Qfly genomes  genes in Qfly but more in D. melanogaster, fewer acylglycerolphosphate acyltransferase (AGPAT/AAGPAT) genes in both species, and more diacylglycerol acyltransferase (DGAT) genes in D. melanogaster, in the biosynthetic pathways. The two insect species also have more phospholipase A2 (PLA2) but fewer lysophospholipid acyl transferase (LPLAT) genes than H. sapiens in the Lands’ cycle. These differences, together with considerable amino acid sequence divergence in all orthologous comparisons, even between the two fruit fly species (>20% in each case; However, the two fruit fly species also show some presence/absence differences, both from pathways . CompareD. melanogaster and, often also, in more distantly related taxa. On the other hand, some environmentally sensitive functions might be expected to vary between species of metamorphic poikilotherms, in particular. Our comparisons provide some evidence for this, although methodological differences—including, in some cases, potential sampling biases—could also explain much of the variation. However, together with the D. melanogaster precedents, our study provides a foundation for future comparative and population lipidomic work, using standardised methodologies and including more life stages and both sexes, to investigate the role which many studies in the pre- and early lipidomic era indicate lipids play in phenotypic variation in ecologically sensitive traits [In conclusion, our analyses have revealed levels of complexity in an insect lipidome comparable to that seen in more intensively studied mammals. Functional data from model systems suggest this complexity could be important for tuning various classes of lipids to suit their diverse functions. Many basic cellular functions will require tight conservation of certain aspects of lipid profiles across species and many aspects of our compositional data indeed closely resemble those reported in e traits ,26,27,28e traits ,137,138,


We repo Hypereosinophilic syndrome (HES) is a spectrum of myeloproliferative disorders, which is characterized by persistent and marked blood eosinophilia and damage to multiple organs due to eosinophilic infiltration. The criteria for HS consist of (1) persistent eosinophilia of >1500 eosinophils/mm3; (2) exclusion of other conditions causing eosinophilia; (3) signs and symptoms of organ system dysfunction . Eosinophilic myocarditis is a rare and potentially lethal disease characterized by eosinophil infiltration of the myocardium. Paediatric myocarditis remains challenging from the perspectives of diagnosis and management [ 9/L (+5), obstructive airway disease (+3), nasal polyps (+3), a cytoplasmic antineutrophil cytoplasmic antibody (ANCA) or anti-proteinase 3-ANCA positivity (−3), extravascular eosinophilic predominant inflammation (+2), mononeuritis multiplex/motor neuropathy not due to radiculopathy (+1) and haematuria (−1) [ agement  . Multiplia (−1)  . Paediatia (−1)  .3 uL, eosinophilia 24.9%, absolute eosinophilia 25.53x103/uL, thrombocytopenia 72x103/ uL, erythrocytes 4.32x106/ µL, CRP 87 mg/L, LDH 994 U/L, ferritin 1306 ng/mL, total IgE > 2000 U/mL, EGA 48 mm/h, pANCA and cANCA negative, ANA positive 1:1280, EBV IgM positive, troponin I 1880.4 pg/ml  and ProBNP 6786 pg/ml. While at the emergency department, the child complained about generalized pain in her body and was not able to move her right hand or her right leg. The computed tomography (CT) of the head without contrast showed no signs of haemorrhages but thickened mucous membranes in all paranasal sinuses. Magnetic resonance imaging (MRI) of the head was performed and revealed: acute cerebral infarcts of various sizes, localized in the cerebellum, in all lobes of the large hemispheres in the anterior, posterior, and inferior border basins. The finding might be consistent with hypereosinophilia syndrome.An 8-year-old patient presented to the Emergency Department of the Children’s Clinical University Hospital (CCUH) in the late evening in August 2021, complaining of an acute febrile illness for 3 weeks with an intermittent febrile body temperature above 38 ˚C, accompanied by submandibular oedema, abdominal pain, loose stools, joint pain, and pain and tightness in her chest. The general practitioner had previously diagnosed an Epstein–Barr virus infection clinically, but the EBV IgM was negative, while the EBV IgG was positive. The patient was treated with amoxicillin/clavulanate for a week and has since then developed persistent diarrhoea. The patient had a diagnosis of bronchial asthma for 1 year with a need for the intermittent use of inhalation with salbutamol and fluticasone propionate due to a dry cough, but with no severe asthmatic episodes. On admission, her body temperature was 37.7˚C, tachycardia 165 beats/minute, normal arterial pressure 110/50 mmHg, no cardiac murmurs or pulmonary rales audible, a respiratory rate 40 times per minute, SpO2 96%, no hepatomegaly and negative meningeal symptoms. The patient’s blood tests showed HES, fulfilling the criteria: severe leucocytosis WBC 102.34 x10To exclude the diseases of the hematopoietic system, blood tests for flow cytometry and cytogenetics of peripheral blood were sent to the laboratory at Vilnius Hospital and excluded the myeloproliferative process. No significant findings related to HES were found by flow cytometry in the peripheral blood and bone marrow. No signs of clonality in TCRB, TCRG or TCRD genes were detected. In the bone marrow biopsy, hypercellularity was found with a predominance of eosinophils, but no atypical eosinophils, platelets or increased blast count were found, corresponding to secondary HES.toxoplasma, toxocara, taenia solium, trichinella or echinococcus), and cryptococcus antigens in the blood were excluded. Other probable causes such as tuberculosis, entero and coxacki, and HIV viruses were excluded. The patient had positive Toxocara canis IgA and a subsequent positive Western blot test. She, therefore, also received treatment with albendazole to treat the possible cause of hypereosinophilic syndrome.Serology of the blood was performed to exclude parasitic diseases , hypertrophy of the right ventricle (RV) , normal functioning of the left ventricle, but mild hypertrophy of the ventricular septum.Her cardiac MRI was consistent with a presentation of acute myocarditis: late gadolinium enhancement, subendocardially diffuse in the right ventricle, and also in the inferior and lateral wall of the left ventricle, ejection fraction (EF) of the left ventricle of 41%, hypokinesia in the apex and posterior wall of the left ventricle, hypertrophy of the free wall of the right ventricle and severe hypertrophy of the apex of the right ventricle, diffuse oedema of the right ventricle and local oedema in the anterior and posterior walls of the left ventricle.Image 1.A thoracic CT showed right-sided pleural effusion up to 1.5 cm, small infiltrates in the right lower lobe segments S8 and S9. No evident hyperplasia of the intrathoracic lymph nodes.Abdominal ultrasound and ophthalmological examinations were without pathology.The patient’s treatment was discussed in a multidisciplinary consilium together with paediatric haematologists, paediatric rheumatologists, pneumonologists, cardiologists, neurologists, and immunologists. The diagnosis was hypereosinophilic syndrome with ischemic stroke and suspected eosinophilic myocarditis , but EGPA was considered as a possible differential diagnosis, as was the possibility of development of a myeloproliferative disorder.2, but her weight increased afterwards to 74 kg . With this acute episode, the patient was treated in the CCUH for 41 days. She received a low molecular weight heparin (enoxaparin) therapeutic dose for 7 days, then a prophylactic dose which was changed to oral rivaroxaban for 6 months. Due to initial persistent tachycardia, myocardial hypertrophy, and inflammation, she received carvedilol 3.125 mg twice a day in the long term. The patient underwent rehabilitation and the paresis of the right leg already disappeared during the hospital stay, and after discharge, her right hand function improved fully within the next 3 months (the patient regained her right handwriting skills).Based on the “Guidelines for the Investigation and Treatment of Eosinophilia” : the pat3/uL.The patient’s progress was followed up by a cardiologist, haematologist, pneumonologist and neurologist. In the echocardiography, hypertrophy of the right ventricle had decreased. Two months after her discharge from the hospital, her blood count showed eosinophilia 0% and absolute numbers of eosinophilia 0x10The follow-up MRI of the heart performed on February 2022, 6 months after the first MRI, showed significant improvement in both ventricular functions, with left and right ventricular volumes within normal limits and without enlargement. Myocardial hypertrophy was still visualized in the right ventricle and was more pronounced in the distal segment of the apical region, where the residual abnormal myocardial gadolinium enhancement with a subendocardial oedema had markedly decreased but was still persistent. The myocardial morphological lesion had markedly regressed.3, erythrocytes 5×106 µ/L, thrombocytes 460 × 103 µ/L and CRP 1.61 mg/L. The ophthalmologist noted that the right eye was sensitive to the left and left downward view, and that there was restriction of movement to the upward view, but the left eye was mobile to a lesser extent. The left eye had a full range of movement. A conclusion of right sided pre-septal and post-septal cellulitis was made. The otolaryngologist detected that the mucous membrane was pink and slightly oedematous.At the end of May 2022, the patient developed an oedema of the right upper eye lid. Tobradex (eye drops containing tobramycin and dexamethasone) were prescribed, but the oedema spread over the right side of the face and especially the right orbita during the next five days. The patient was hospitalized at the CCUH. Blood analyses showed eosinophilia 16.7%, leukocytes 10.74 × 10To clarify the inpatient diagnosis, the patient underwent a biopsy of the inflammatory foci: in the ethmoid tissue there was constant lymphohistiocytic and eosinophilic inflammation with 30–50% eosinophilic ipsilateral infiltrate cells; granulomatous and chronic perivascular inflammation with eosinophils was found in the striated muscle tissue, which might be consistent with EGPA. Based on scientific articles, the early use of steroids (this patient received Medrol therapy) for a brief period could help to shorten hospitalization and prevent the progress of the inflammation . As the eosinophilia is associated with a variety of conditions: allergic, infectious, and neoplastic disorders with a wide diagnostic differential and limited data on hypereosinophilia in paediatric patients. EGPA is a type of ANCA-associated small-to-medium-sized vasculitis associated with asthma and eosinophilia. The most common manifestations in children are seen in the respiratory tract (69%), cutaneous tissue (61–62%), the gastrointestinal tract (46%), the cardiovascular system (46%), in paranasal sinus abnormality (38%), arthritis/arthralgia (38%), and the peripheral nerves (15%) [vs ANCA-negative EGPA [Paediatric es 15%) ,10,12. H% ,10,12.es (15%) ,10,11. Tive EGPA .Central nervous system (CNS) involvement in paediatric EGPA is rare with the main neurological manifestations being ischemic cerebrovascular lesions in 46 (52%) of the 88 described adult EGPA cases. Whereas among the 81 patients with assessable neurological responses, 43% had complete responses without sequalae . Ocular The prevalence and incidence of HES is unknown, but it is considered a rare disease in children and affected adults between 20 and 50 years old, with a 9:1 male-female ratio  and EGPAPaediatric eosinophilic granulomatosis with polyangiitis (EGPA) and hypereosinophilic syndrome are multisystemic disorders with the possibility of overlapping and a wide range of life-threatening manifestations and a broad range of differential diagnostics with a need for multidisciplinary collaboration, urgent diagnostics and treatment and long term follow up to avoid a poor outcome. Mepolizumab might be safe and effective for controlling disease activity in relapsing EGPA and reducing and weaning off corticosteroids.


Research on the impact of the COVID-19 pandemic among college students around the world has primarily focused on their mental health symptoms and COVID-specific worry. However, contextually specific understanding of outbreak impacts is key to inform directed public health messaging and programming to improve wellbeing and coping. The current study aimed to identify the main psychosocial problems college students experienced during the first 6 months of the COVID-19 pandemic in Monterrey, Mexico. Participants were 606 college students  enrolled in a private university. Participants described COVID-related problems in an open-ended prompt as part of a longitudinal online survey: initially in May 2020, and then every 2 weeks for 3 months. Thematic analyses were conducted within a longitudinal inductive qualitative approach to rank responses by frequency across themes. Five major categories emerged. At baseline, over 75% of participants noted the outbreak negatively impacted their daily activities and responsibilities, 73% their mental health, 50% their physical health, 35% their interpersonal relationships, and 22% their economic situation. Concerns remained relatively stable throughout the follow-up period, with interpersonal and economic concerns becoming more prevalent as the pandemic progressed. Problems identified in this study can inform preventative measures for future health crises, including tailoring public health messaging and expanding access to contextually sensitive mental and behavioral health programming. InternaCollege students, specifically, show concerningly high levels of mental health problems across the globe , 8, withemic framework  informing directed and culturally sensitive public health messaging and directives, 2) identifying new or exacerbated psychosocial concerns that may persist over time, and 3) designing interventions that target a broad variety of pandemic-related psychosocial problems. The current study aims to explore COVID-related symptoms and problems among college students in Monterrey, Mexico between May and August 2020. We used free-list qualitative interviewing to elicit problems related to COVID-19 and the associated public health guidelines. We asked students to report the problems they experienced as a result of the pandemic every 2 weeks to assess potential changes in the types and perceived importance of difficulties. This study provides a contextually specific understanding of psychosocial concerns resulting from COVID-19 to contribute to the global literature in public mental health response. In addition, this study contributes a unique longitudinal qualitative methodological approach to measuring distress over time, as multiple quantitative studies have reported longitudinal changes in COVID-related symptomatology . Results2.2.1.All procedures for this study were approved by the Institutional Review Board at Universidad de Monterrey. Participants were 606 college students enrolled in a private University in Monterrey, Mexico. Monterrey has over 5.13 million habitants  and is oStudents included 434 females (71.6%), 167 males, and 5 non-binary students, ages 18 to 33 . A range of monthly family-level income was reported, with 25.7% reporting less than 30,000 pesos , 44% between 30,000 and 80,000 , and 30.3% a family income greater than 80,000 ; less than 10% of the sample reported a monthly household income under the poverty line . ParticiAll students in the University were invited to participate in the study via an email sent by their Program Director and the social media networks of the College of Education and Humanities. Some instructors and student groups also shared information about the study in their courses or through social media. Interested students accessed a Qualtrics survey to confirm they met the recruitment criteria, completed informed consent, and then completed a 30-min survey about their demographics, mental health, adverse childhood experiences, social supports, and reactions to the COVID-19 pandemic and stay-at-home measures.The study took place between May and August 2020. After the first case of COVID-19 was reported in Mexico on February 27th, 2020, cases steadily climbed, leading to a state of national emergency, declared on March 30th, that mandated the suspension of all non-essential economic, government, and social activities, including face-to-face classes. Despite continued increases in infection rates and mortality, the state of national emergency was lifted on June 1st 2020, and states developed guidelines for safely reopening governmental and economic activities, including mandatory face coverings, required social distancing, limited hours of operation and reduced capacity. However, all schools continued exclusively relying on online and distance programming. Despite these measures, cases continued to increase exponentially during the summer, with 606,036 infections and 65,241 deaths reported in the country by September 1st, 2020 .The baseline survey was available from May 13 to May 27, 2020. Then, all participating students were invited via email every 2 weeks to complete brief surveys for the following 14 weeks (June to August); 520 students completed at least one of the summer surveys, and completion rates were as follows: T2 = 478, T3 = 399, T4 = 386, T5 = 352, T6 = 310, T7 = 296, T8 = 279. All recruitment and data collection procedures were completed online as all in-person activities in the University were suspended since March 2020.2.2.An inductive approach was used to collect and analyze the data . InductiWhat are the three main problems you have faced due to COVID-19 and the stay-at-home measures? You can include problems related to your health , mental health , interpersonal , academic , work-related , financial , or other situations you are experiencing. Describe each one concretely (in 1 to 5 words).Survey questions were administered in Spanish, the primary language spoken by participants. Participants were prompted to provide three COVID-related problems in open free text response boxes. Students answered the initial survey between May 13 and May 27, 2020, about 8 weeks after the initial suspension of in-person classes and non-essential activities took place in Mexico, in March. Then, they received an invitation to answer the same question in regards to the most significant problems experienced during the past 2 weeks throughout June, July and August (T2 to T8).The full research team included eight Mexican research staff and one American global mental health researcher. The American investigator worked closely with the Mexican research team throughout project development, implementation, and dissemination.2.3.M = 91.69%) and with each other (M = 93.31%) and above.90 Kappa with the master coder (M = 0.91) and with each other (M = 0.93). These steps were taken to support reliability and validity  and five undergraduate research assistants underwent the following procedures to create the final codebook: (1) Coders independently reviewed responses to the initial survey from 100 participants, (2) One hundred participant’s responses  were consensus coded, (3) coders met to review codes, reconcile discrepancies, and create a preliminary codebook, (4) 50 additional participant responses were consensus coded according to the preliminary codebook, (5) coders met to reconcile discrepancies and create a final codebook, and (6) 75 participant responses were consensus coded using the final codebook, from which percent agreement and Kappa were calculated with the master coder (CMT) and with each other. All five coders had above 90% agreement with the master coder . In the case of a participant listing 2 or more distinct responses in a single text box, responses were split and analyzed as separate entries. Responses were aggregated for each code and within categories, both by a proportion of total responses and by total number of participants.3.n = 456) noted the outbreak and restrictions negatively impacted their daily activities and responsibilities (actividades y responsabilidades diarias), and about 73% (n = 443) reported impact on their mental health . Over 50% (n = 312) of participants noted COVID negatively impacted their physical health , 35% (n = 215) their interpersonal relationships , and 22% (n = 133) their economic (económico) situation. Please see Only 4% of the sample reported having contracted COVID-19 at some point during the study, but 60% had a loved one who tested positive. Participants reported a wide range of domains impacted by the COVID-19 outbreak and associated restrictions/guidelines. In the initial survey, over 75% of participants . The most frequently reported areas impacted by the outbreak and associated restrictions at T1 were stress , academic problems , problems with sleep , anxiety or worry , and mental health problems generally  or their mental health functioning. Over half reported an increase in physical health problems due to the outbreak and restrictions. In addition, about one-third reported problems with interpersonal relationships and one-quarter faced economic problems due to COVID-19. This is consistent with findings of challenges associated with COVID-19 and related public health guidelines and restrictions, including stress, worry, economic challenges, and disrupted academic, occupational, and interpersonal functioning , 29, 30.As the pandemic progressed, students continued reporting mental health difficulties, disruptions to daily activities and responsibilities, and physical health problems as their most common concerns. However, we observed slight longitudinal changes in the most salient problems identified. Over time, students expressed less frequent difficulties with their daily activities and responsibilities. This may reflect resilience and adaptation to a “new normal,” which is consistent with frameworks of individual and community adaptation to crisis and disaster . For exaOn the other hand, physical health problems became more prevalent over time. Somatization symptoms during the COVID-19 pandemic have similarly been reported among University students internationally , 35. TheAmong subtheme level responses, stress, academic problems, sleep problems, mental health difficulties, and anxiety/worry were among the most frequently reported concerns at baseline. Notably, the most frequently reported problems align with a cluster of symptoms that are characteristic of a fear and anxiety-based response, including worry, disrupted sleep, difficulty concentrating, and stress. This response may help characterize the initial reactions to the COVID-19 outbreak, as the initial data collection was relatively shortly after the outbreak (about 2 months following the first cases in Monterrey). Our results are similar to a handful of other studies examining initial responses to the COVID-19 outbreak in Mexico and Latin America. For example, an online survey of a community sample in Mexico found 21% of participants reported severe symptoms of anxiety and 28% reported severe symptoms of depression in the early stages of the pandemic . In addiAs students continued reporting on their concerns throughout the summer, economic difficulties emerged as a highly pressing concern among students in our sample. This is noteworthy, considering only about 10% of the sample fell below the federal poverty line at T1. The economic impacts of the pandemic are well-documented. Research in the US reports almost half of all students in their sample lost their employment or their hours were reduced . EconomiOur findings can also be interpreted in light of previous research of Mexican college students’ responses to previous health emergencies, such as the 2009 A/H1N1 Influenza. Similar to our findings, Infante et al.  identifi4.1.To our knowledge, this is one of the first longitudinal studies of the psychosocial impact of COVID-19 among college students in Mexico. By using an open-ended longitudinal qualitative design, this study captures participant-generated problems over time that are not bound by items on existing measures, reducing risk of researcher bias, “category truncation,” and eliminating the need to implement multiple measures specific to areas of functioning. Findings further support the use of open-ended symptom assessments to capture salient problems not captured by existing measurement tools , 19. ThiCurrent findings indicate university students in this sample associate a range of psychosocial, academic, health functioning, and economic problems with the COVID-19 outbreak and associated restrictions. Problems described here should inform future pandemic response in this region and elsewhere, including public health messaging, community-level preventative programming and psychosocial assessment as a part of infectious disease-related assessment and care. It is clear from the current data and other emerging findings that a focus on mental health, physical health, and social connections and resources are a critical for facilitating cross-domain recovery from pandemic-related impacts.Despite its longitudinal design, the current study assessed Mexican college students during the first few months of the pandemic, during a period where Universities were closed and vaccines were not available. Additional qualitative research is needed to better understand the evolving concerns and needs of university students, as they navigate the return to in-person classes. In addition, men and commonly marginalized populations  were under-represented in our sample; future studies may benefit from exploring unique concerns of these populations.5.The COVID-19 outbreak and the accompanying guidelines, restrictions, and closures impact a wide range of psychosocial, physical health, academic, and economic domains. In this sample of university students in Monterrey, Mexico, a majority noted problems with mental health, physical health, and daily activities and responsibilities due to COVID-19. Stress, mental health symptoms, anxiety, worry, and challenges with academics, sleep, and concentration were among the most frequently reported problems in this sample. It is critical to screen for problems and symptoms specific to the context and population to accurately and effectively assess, treat, and monitor the impact of public health emergencies and improve wellbeing and resilience. In addition, problems identified in this study can inform preventative measures for future public health crises, including tailoring guidelines and other messaging, disseminating information, and expanding access to mental health care early in the outbreak response.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comité de Ética en Investigación – Escuela de Medicina de la Universidad de Monterrey. The patients/participants provided their written informed consent to participate in this study.CM-T, CF, LRH, and BT-d contributed to the preparation of this manuscript. CM-T, CF, and LRH contributed to conceptualization and study design, CF and CM-T contributed to data coding, analyses, and manuscript writing. BT-d contributed to data collection and manuscript writing. All authors contributed to the article and approved the submitted version.This research was supported by a grant from Universidad de Monterrey (UIN #20538).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.