Nevin Manimala

BMJ Open. 2023 Nov 2;13(11):e071253. doi: 10.1136/bmjopen-2022-071253.

ABSTRACT

OBJECTIVES: The optimal puncture technique for neuraxial anaesthesia in different populations is unclear. We sought to obtain data from randomised controlled trials comparing the impact of ultrasound-guided technology and traditional positioning technology on the success rate of neuraxial anaesthesia.

DESIGN: Systematic review and network meta-analysis using study populations, interventions, intervention comparisons, outcome measures and study types.

DATA SOURCES: PubMed, Embase, Cochrane Library and Web of science were searched until 31 September 2022.

ELIGIBILITY CRITERIA: We included randomised controlled trials comparing three types of neuraxial anaesthesia: ultrasound-assisted, ultrasound real-time guidance and conventional positioning to describe which neuraxial anaesthesia modality is best for patients and to recommend the appropriate one for different populations.

DATA EXTRACTION AND SYNTHESIS: Five independent reviewers retrieved, screened and edited included studies using standardised methods. Assess risk of bias using the Cochrane Collaboration and Evidence Project tools. Network meta-analysis was performed using STATA V.15 statistical software.

RESULTS: Twenty-two studies containing three different interventions were included. The SUCRA values of first-pass success rates for the three neuraxial anaesthesia methods were real-time guidance (82.8%), ultrasound-assisted (67.1%) and traditional positioning (0.1%). Both ultrasound techniques improved first-pass success rates compared with traditional localization, but there was no significant difference between the two. Subgroup analysis showed that the use of real-time ultrasound guidance for neuraxial anaesthesia in pregnant and patients with obesity improved first-pass success rates. Ultrasound-assisted technology can improve first-attempt success rates in older patients with abnormal lumbar spine anatomy.

CONCLUSION: Compared with conventional positioning, ultrasound guidance technology can improve the first-pass success rate of neuraxial anaesthesia, but there is no significant difference between ultrasound-assisted and real-time guidance technology. The results of subgroup analysis tell us that the most suitable neuraxial anaesthesia method is different for different groups of people.

PROSPERO REGISTRATION NUMBER: PROSPERO number: CRD42022376041.

PMID:37918920 | DOI:10.1136/bmjopen-2022-071253

Occup Environ Med. 2023 Nov 2:oemed-2023-108875. doi: 10.1136/oemed-2023-108875. Online ahead of print.

ABSTRACT

BACKGROUND: The dose-response relationship between cancers and protracted low-dose rate exposure to ionising radiation is still uncertain. This study aims to estimate quantified relationships between low-dose radiation exposures and site-specific solid cancers among Chinese medical X-ray workers.

METHODS: This cohort study included 27 011 individuals who were employed at major hospitals in 24 provinces in China from 1950 to 1980 and had been exposed to X-ray equipment, and a control group of 25 782 physicians who were not exposed to X-ray equipment. Person-years of follow-up were calculated from the year of employment to the date of the first diagnosis of cancer or the end of follow-up, whichever occurred first. All cancers were obtained from medical records during 1950-1995. This study used Poisson regression models to estimate the excess relative risk (ERR) and excess absolute risk (EAR) for incidence of site-specific solid cancers associated with cumulative dose.

RESULTS: 1643 solid cancers were developed, the most common being lung, liver and stomach cancer. Among X-ray workers, the average cumulative colon dose was 0.084 Gy. We found a positive relationship between cumulative organ-specific dose and liver (ERR/Gy=1.48; 95% CI 0.40 to 2.83), oesophagus (ERR/Gy=18.1; 95% CI 6.25 to 39.1), thyroid (ERR/Gy=2.96; 95% CI 0.44 to 8.18) and non-melanoma skin cancers (ERR/Gy=7.96; 95% CI 2.13 to 23.12). We found no significant relationship between cumulative organ-specific doses and other cancers. Moreover, the results showed a statistically significant EAR for liver, stomach, breast cancer (female), thyroid and non-melanoma skin cancers.

CONCLUSIONS: These findings provided more useful insights into the risks of site-specific cancers from protracted low-dose rate exposure to ionising radiation.

PMID:37918914 | DOI:10.1136/oemed-2023-108875

Arch Dis Child. 2023 Nov 2:archdischild-2023-325926. doi: 10.1136/archdischild-2023-325926. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate the impact of the COVID-19 pandemic experience on language development among children, we compared language development at 18 months of age, before and during the pandemic in Japan, where strict control measures continued over a long period.

METHODS: This was a repeated cross-sectional study and we included children who attended the 18-month health check-up provided by the Okayama City Public Health Center between January 2017 and December 2022 (n=33 484). We compared indicators of language development before (from January 2017 to February 2020) and during (from March 2020 to December 2022) the pandemic. Our primary outcome was the proportion of children who required follow-up for language development by the Public Health Center. The secondary outcome was the proportion of children who could not say three or more meaningful words. We estimated risk ratios (RRs) and their 95% CIs, adjusted for potential confounders.

RESULTS: The prevalence of the primary outcome was 33.5% before the pandemic and 36% during the pandemic. Compared with before the pandemic, increased RRs for the primary and secondary outcomes were observed during the pandemic, with RRs (95% CIs) of 1.09 (1.06-1.13) for the primary outcome and 1.11 (1.05-1.17) for the secondary outcome. Although the statistical interactions were not significant, the RRs were higher for children cared for at home than those in nursery schools and with ≤3 family members than those with ≥4 family members.

CONCLUSIONS: The COVID-19 pandemic was associated with an increased risk of impaired language development in children at 18 months. More extensive support is needed for higher risk families, as well as follow-up of long-term language development in children affected by the COVID-19 pandemic.

PMID:37918897 | DOI:10.1136/archdischild-2023-325926

Ann Rheum Dis. 2023 Nov 2:ard-2023-224732. doi: 10.1136/ard-2023-224732. Online ahead of print.

ABSTRACT

OBJECTIVE: Relapsing polychondritis (RP) is a systemic inflammatory disease of unknown aetiology. The objective of this study was to examine the contribution of rare genetic variations to RP.

METHODS: We performed a case-control exome-wide rare variant association analysis that included 66 unrelated European American cases with RP and 2923 healthy controls (HC). Gene-level collapsing analysis was performed using Firth’s logistics regression. Exploratory pathway analysis was performed using three different methods: Gene Set Enrichment Analysis, sequence kernel association test and higher criticism test. Plasma DCBLD2 levels were measured in patients with RP and HC using ELISA.

RESULTS: In the collapsing analysis, RP was associated with a significantly higher burden of ultra-rare damaging variants in the DCBLD2 gene (7.6% vs 0.1%, unadjusted OR=79.8, p=2.93×10^-7). Plasma DCBLD2 protein levels were significantly higher in RP than in HC (median 4.06 ng/µL vs 0.05 ng/µL, p<0.001). The pathway analysis revealed a statistically significant enrichment of genes in the tumour necrosis factor signalling pathway driven by rare damaging variants in RELB, RELA and REL using higher criticism test weighted by eigenvector centrality.

CONCLUSIONS: This study identified specific rare variants in the DCBLD2 gene as a putative genetic risk factor for RP. These findings should be validated in additional patients with RP and supported by future functional experiments.

PMID:37918895 | DOI:10.1136/ard-2023-224732

Ann Rheum Dis. 2023 Nov 2:ard-2023-224623. doi: 10.1136/ard-2023-224623. Online ahead of print.

ABSTRACT

OBJECTIVE: To compare the long-term efficacy and safety of azathioprine (AZA), 18-month fixed-schedule rituximab (RTX), 18-month tailored RTX and 36-month RTX in preventing relapses in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis who achieved a complete remission after induction therapy. Patients treated with 36-month RTX received either a fixed or a tailored regimen for the first 18 months and a fixed regimen for the last 18 months (36-month fixed/fixed RTX and 36-month tailored/fixed RTX, respectively).

METHODS: The Maintenance of Remission using Rituximab in Systemic ANCA-associated Vasculitis (MAINRITSAN) trials sequentially compared: 18-month fixed-schedule RTX versus AZA (MAINRITSAN); 18-month fixed-schedule RTX versus 18-month tailored-RTX (MAINRITSAN2); and extended therapy to 36 months with four additional RTX infusions after MAINRITSAN2 versus placebo (MAINRITSAN3). Patients were then followed prospectively through month 84 and their data were pooled to analyse relapses and adverse events. The primary endpoint was relapse-free survival at month 84.

RESULTS: 277 patients were enrolled and divided in 5 groups: AZA (n=58), 18-month fixed-schedule RTX (n=97), 18-month tailored-RTX (n=40), 36-month tailored/fixed RTX (n=42), 36-month fixed/fixed RTX (n=41). After adjustment for prognostic factors, 18-month fixed-schedule RTX was superior to AZA in preventing major relapses at month 84 (HR 0.38, 95% CI 0.20 to 0.71). The 18-month tailored-RTX regimen was associated with an increased risk of major relapse compared with fixed-schedule regimen (HR 2.92, 95% CI 1.43 to 5.96). The risk of major relapse was similar between 36-month fixed/fixed and 18-month fixed-RTX (HR 0.69, 95% CI 0.38 to 1.25).

CONCLUSIONS: According to these results, it appears that the 84-month remission rate is higher with an 18-month fixed RTX regimen compared with AZA and 18-month tailored RTX. Also, extending RTX to 36 months does not appear to reduce the long-term relapse rate compared with the 18-month fixed RTX regimen. However, as this study was underpowered to make this comparison, further prospective studies are needed to determine the potential long-term benefits of extending treatment in these patients.

PMID:37918894 | DOI:10.1136/ard-2023-224623

Ann Rheum Dis. 2023 Nov 2:ard-2023-224501. doi: 10.1136/ard-2023-224501. Online ahead of print.

ABSTRACT

OBJECTIVES: Investigating the association between different definitions of axial involvement and syndesmophytes development over 2 years in patients with psoriatic arthritis (PsA).

METHODS: Patients from a prospective multicentre cohort (Belgian Epidemiological Psoriatic Arthritis Study) involving 17 Belgian rheumatology practices were recruited between December 2012 and July 2014 and included when fulfilling the Classification Criteria for Psoriatic Arthritis. Axial involvement included six clinical and two radiographic oriented definitions.Two calibrated central readers evaluated radiographic damage by assessing the modified Stoke Ankylosing Spondylitis Spinal Score and modified New York criteria. New syndesmophytes after 2 years were described conditional on axial involvement at baseline. Logistic regression analyses were used to investigate the association between syndesmophyte development and axial involvement. All definitions of axial involvement were evaluated separately.

RESULTS: From 150 patients, a 2-year follow-up of spinal radiographs was obtained. There are 11 patients with new syndesmophytes after 2 years. For the clinical definitions of axial involvement ‘global assessment’, ‘detailed assessment’, ‘back pain (BP)’ and ‘inflammatory BP (IBP)’ the probabilities of developing syndesmophytes ranged between 0.06 and 0.08 and were similar for the presence or absence of the definition. When including elevated C reactive protein (CRP) to the definitions the probability of developing syndesmophytes over 2 years increased two times for CBP and seven times for IBP.With radiographic axial involvement a similar trend was seen; radiographic sacroiliitis as definition showed a probability three times higher. When combined with elevated CRP there would be a 14 times higher chance to develop syndesmophytes in 2 years. The ORs varied from 0.83 to 13.80, though none of them were statistically significant.

CONCLUSIONS: The likelihood of syndesmophyte formation in PsA is low. The probability of developing syndesmophytes is much higher when axial involvement is determined radiographically rather than clinically, particularly in the context of high CRP.

PMID:37918893 | DOI:10.1136/ard-2023-224501

Z Geburtshilfe Neonatol. 2023 Nov 2. doi: 10.1055/a-2180-7302. Online ahead of print.

ABSTRACT

INTRODUCTION: Pregnant women and their offspring represented a vulnerable patient collective during the Covid-19 pandemic. Beyond the direct effect of SARS-CoV-2 via vertical transmission, an indirect impact on the fetus can occur through placental lesions deteriorating placental villous function. We performed a histopathological analysis of placentas of parturients with SARS-CoV-2 compared to healthy controls.

METHODS AND MATERIALS: Between February 2022 and July 2022 we conducted a prospective case-control study analyzing placental specimens of parturients with SARS-CoV-2 infection compared to specimens of placentas of healthy controls. Patient history, Covid-19-specific symptoms, and obstetric outcomes were recorded. Statistical analysis was performed.

RESULTS: During the observation period 71 patients were included with a gestational age 37 1/7-41 5/7 weeks. Thirty-six patients presented with SARS-CoV-2 infection. The control group consisted of 35 patients and showed no placental abnormalities. Among SARS-CoV-2-positive parturients, 66.7% of placentas of the case group showed histopathological abnormalities classified as vascular or inflammatory abnormalities. 22.2% of placentas showed acute ischemic infarction areas. 8.3% of placentas showed subchorionic layered thrombi. There was one case of severe acute subchorionitis. SARS-CoV-2 increased the risk of placental lesions significantly (OR 3.000, CI 1.890-4.762, p=0.0001). Placental lesions had no significant impact on perinatal acidosis (OR 0.455, CI 0.044-4.667, p=0.498) or number of cesarean sections (OR 2.314, CI 0.717-7.473, p=0.156).

CONCLUSION: SARS-CoV-2 infection during labor and delivery increased the risk of adverse outcomes. Histopathological analysis indicated that the placenta as a maternal-fetal interface was affected by SARS-CoV-2, leading to systemic vasculopathy and inflammation.

PMID:37918832 | DOI:10.1055/a-2180-7302

Metabolism. 2023 Oct 31:155715. doi: 10.1016/j.metabol.2023.155715. Online ahead of print.

ABSTRACT

BACKGROUND: Computed tomography (CT) imaging is widely used for diagnosing and determining the severity of coronavirus disease 2019 (COVID-19). Chest CT imaging can be used to calculate the epicardial adipose tissue (EAT) and upper abdominal visceral adipose tissue (Abd-VAT) areas. The EAT is the main source of inflammatory cytokines involved in chest inflammatory diseases; thus, the EAT area might be a more useful severity predictor than the Abd-VAT area for COVID-19. However, to the best of our knowledge, there are no large-scale reports that sufficiently consider this issue. In addition, there are no reports on the characteristics of patients with normal body mass index (BMI) and high adipose tissue.

AIM: The purpose of this study was to analyze whether the EAT area, among various adipose tissues, was the most associated factor with COVID-19 severity. Using a multicenter COVID-19 patient database, we analyzed the associations of chest subcutaneous, chest visceral, abdominal subcutaneous, and Abd-VAT areas with COVID-19 outcomes. In addition, the clinical significance of central obesity, commonly disregarded by BMI, was examined.

METHODS: This retrospective cohort study evaluated patients with COVID-19 aged ≥18 years In Japan. Data including from chest CT images collected between February 2020 and October 2022 in four hospitals of the Japan COVID-19 Task Force were analyzed. Patient characteristics and COVID-19 severity were compared according to the adipose tissue areas (chest and abdominal subcutaneous adipose tissue [Chest-SAT and Abd-SAT], EAT, and Abd-VAT) calculated from chest CT images.

RESULTS: We included 1077 patients in the analysis. Patients with risk factors of severe COVID-19 such as old age, male sex, and comorbidities had significantly higher areas of EAT and Abd-VAT. High EAT area but not high Abd-VAT area was significantly associated with COVID-19 severity (adjusted odds ratio (aOR): 2.66, 95 % confidence interval [CI]: 1.19-5.93). There was no strong correlation between BMI and VAT. Patients with high VAT area accounted for 40.7 % of the non-obesity population (BMI < 25 kg/m²). High EAT area was also significantly associated with COVID-19 severity in the non-obesity population (aOR: 2.50, 95 % CI: 1.17-5.34).

CONCLUSIONS: Our study indicated that VAT is significantly associated with COVID-19 severity and that EAT is the best potential predictor for risk stratification in COVID-19 among adipose tissue areas. Body composition assessment using EAT is an appropriate marker for identifying obesity patients overlooked by BMI. Considering the next pandemic of the global health crisis, our findings open new avenues for implementing appropriate body composition assessments based on CT imaging.

PMID:37918794 | DOI:10.1016/j.metabol.2023.155715

Environ Pollut. 2023 Oct 31:122795. doi: 10.1016/j.envpol.2023.122795. Online ahead of print.

ABSTRACT

With growing concerns regarding the ecological and human risks of organic micropollutants (OMPs) in water, much effort has been devoted worldwide to establishing quality standards and compiling candidate and watch lists. Although bank filtration is recognized as an efficient natural water treatment in the removal of contaminants such as OMPs, the increase in exploitation requires continuous assessment of removal efficiency. This review aims to provide a critical overview of BF reports on more than a hundred priority substances (PSs) and compounds of emerging concern (CECs) listed in the relevant European Union regulations. Field- and lab-scale studies analyzing the removal efficiency and its variance of individual OMPs and biological indicators using BF and the main influencing factors and their interactions, shortcomings, and future challenges are discussed in this review. The removal efficiency of EU-relevant contaminants by BF has been comprehensively investigated for only a few pollutants listed in the environmental EU regulations: pharmaceutically active compounds, (e.g., the anti-inflammatory drug diclofenac, some antibiotics (e.g., sulfamethoxazole and trimethoprim)), a few pesticides (e.g., atrazine), and faecal indicators such as Escherichia coli. In many cases, the measured concentrations of PSs and CECs have not been published numerically, which hinders comprehensive statistical analysis. Although BF is one of the most cost-effective and efficient water treatments, present field and lab studies have demonstrated the diversity of site-specific factors affecting its efficiency. Even in the case of substances known to be removed by BF, the efficiency rates can vary with environmental and anthropogenic factors (e.g., hydrogeological parameters and the contamination level of infiltrating water) and abstraction well parameters (e.g., the depth, distance, and pumping volume). The published removal rate variations and influencing factors often reflect the research design (field or lab-scale), which can lead to ambiguities.

PMID:37918769 | DOI:10.1016/j.envpol.2023.122795

Sci Total Environ. 2023 Oct 31:168120. doi: 10.1016/j.scitotenv.2023.168120. Online ahead of print.

ABSTRACT

The chemical composition of river waters represents an important matter of investigation to understand environment modifications in response to climate changes and global warming. Prolonged dry periods, heavy flood events, degradation of the lands and ice thawing, modify the chemical composition of river waters influencing the drivers governing the complex dynamics of river catchments where everything comes together. In this framework, Compositional Data Analysis (CoDA) offers methods in which the complex structure of the river water composition and the interrelationships among the various components are put into the proper context for their statistical analysis. In this research, we propose a new CoDA approach combining the robust Mahalanobis distance (D) calculus of ilr-transformed chemical variables and the perturbation difference, both with respect to a pristine compositional benchmark. The aim was to trace the change in the chemical composition of the Eastern Siberian River Chemistry Database where degradation of the permafrost for global warming produces important effects on natural waters. The findings indicate complex multiplicative laws and feedback mechanisms governing solutes in Eastern Siberian rivers, with high values of D found where permafrost is more discontinuous. Perturbations clearly discriminate chemical components more resilient to stresses induced by global changes (Ca²⁺, Mg²⁺ and HCO₃^–) from those whose variability is not maintained under control (Cl^–, Na⁺, SO₄^2-). These outcomes open up a new scenario in searching for spatiotemporal resilience metrics to reveal rivers response to environmental changes.

PMID:37918739 | DOI:10.1016/j.scitotenv.2023.168120