Estimation of 10-Year Fracture Risk with and without Bone Mineral Density in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis affecting 0.5-1.0% of the general population worldwide and although RA is properly considered a disease of the joints, it can cause a variety of extra-articular manifestations. This study was performed to find out any discrepancy in fracture risk estimates with and without bone mineral density (BMD) in rheumatoid arthritis (RA) patients. This observational cross-sectional study was carried out in the Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from July 2013 to July 2015. Total 65 consecutive patients with RA fulfilling ACR/EULAR criteria aged 40-90 year were recruited. Ten year fracture risk of these patients was evaluated by the FRAX score with and without BMD and differences were observed. FRAX score without BMD revealed that major fracture risk was low in 58(89.2%) patients, moderate in 7(10.8%) patients but re-estimation with BMD revealed that 55(84.6%) patients remained in low risk group, 8(12.3%) patients in moderate risk group and 2(3.1%) patients went to the high risk group. In case of hip fracture risk without BMD, risk was low in 58(89.2%) patients, high in 7(10.8%) patients; but with BMD, 50(76.9%) patients remained in low risk group but risk of 15(23.1%) patients became high. Almost all the high risk patients (93.3%) were ≥55 years of age. Increasing age, female sex, disease duration and use of steroid were positively correlated with increased FRAX score where as high BMI and high BMD were associated with low FRAX score. But in multivariate analysis it was found that only relation with age was at statistically significant level. Significant numbers of patients with rheumatoid arthritis have high risk of fracture especially hip fracture. The mean of FRAX score increased in both major & hip osteoporotic fracture risk after adding BMD. More than half of the patients above fifty five years or more had high risk of fracture. So, BMD should be done in patients aged more than fifty five.

Is There Evidence of P-Hacking in Imaging Research?

BACKGROUND

P-hacking, the tendency to run selective analyses until they become significant, is prevalent in many scientific disciplines.

PURPOSE

This study aims to assess if p-hacking exists in imaging research.

METHODS

Protocol, data, and code available here https://osf.io/xz9ku/?view_only=a9f7c2d841684cb7a3616f567db273fa. We searched imaging journals Ovid MEDLINE from 1972 to 2021. Text mining using Python script was used to collect metadata: journal, publication year, title, abstract, and P-values from abstracts. One P-value was randomly sampled per abstract. We assessed for evidence of p-hacking using a p-curve, by evaluating for a concentration of P-values just below .05. We conducted a one-tailed binomial test (α = .05 level of significance) to assess whether there were more P-values falling in the upper range (e.g., .045 < P < .05) than in the lower range (e.g., .04 < P < .045). To assess variation in results introduced by our random sampling of a single P-value per abstract, we repeated the random sampling process 1000 times and pooled results across the samples. Analysis was done (divided into 10-year periods) to determine if p-hacking practices evolved over time.

RESULTS

Our search of 136 journals identified 967,981 abstracts. Text mining identified 293,687 P-values, and a total of 4105 randomly sampled P-values were included in the p-hacking analysis. The number of journals and abstracts that were included in the analysis as a fraction and percentage of the total number was, respectively, 108/136 (80%) and 4105/967,981 (.4%). P-values did not concentrate just under .05; in fact, there were more P-values falling in the lower range (e.g., .04 < P < .045) than falling just below .05 (e.g., .045 < P < .05), indicating lack of evidence for p-hacking. Time trend analysis did not identify p-hacking in any of the five 10-year periods.

CONCLUSION

We did not identify evidence of p-hacking in abstracts published in over 100 imaging journals since 1972. These analyses cannot detect all forms of p-hacking, and other forms of bias may exist in imaging research such as publication bias and selective outcome reporting.

Accuracy of the Montreal Cognitive Assessment tool for detecting mild cognitive impairment: A systematic review and meta-analysis

INTRODUCTION

This systematic review evaluates the accuracy of the Montreal Cognitive Assessment (MoCA) for detecting mild cognitive impairment (MCI).

METHODS

We searched MEDLINE, PSYCInfo, EMBASE, and Cochrane CENTRAL (1995-2021) for studies comparing the MoCA with validated diagnostic criteria to identify MCI in general practice. Screening, data extraction, and risk of bias assessment were performed independently, in duplicate. Pooled sensitivity and specificity for MoCA cutoffs were estimated using bivariate meta-analysis.

RESULTS

Thirteen studies [2158 participants, 948(44%) with MCI] were included; 10 used Petersen criteria as the reference standard. Risk of bias of studies were high or unclear for all domains except reference standard. Sensitivity and specificity were 73.5%(95% confidence interval: 56.7-85.5) and 91.3%(84.6-95.3) at cutoff <23; 79.5%(67.1-88.0) and 83.7%(75.4-89.6) at cutoff <24; and 83.8%(75.6-89.6) and 70.8(62.1-78.3) at cutoff <25.

DISCUSSION

MoCA cutoffs <23 to <25 maximized the sum of sensitivity and specificity for detecting MCI. The risk of bias of included studies limits confidence in these findings.

How to Critically Appraise and Interpret Systematic Reviews and Meta-Analyses of Diagnostic Accuracy: A User Guide

Systematic reviews of diagnostic accuracy studies can provide the best available evidence to inform decisions regarding the use of a diagnostic test. In this guide, the authors provide a practical approach for clinicians to appraise diagnostic accuracy systematic reviews and apply their results to patient care. The first step is to identify an appropriate systematic review with a research question matching the clinical scenario. The user should evaluate the rigor of the review methods to evaluate its credibility (Did the review use clearly defined eligibility criteria, a comprehensive search strategy, structured data collection, risk of bias and applicability appraisal, and appropriate meta-analysis methods?). If the review is credible, the next step is to decide whether the diagnostic performance is adequate for clinical use (Do sensitivity and specificity estimates exceed the threshold that makes them useful in clinical practice? Are these estimates sufficiently precise? Is variability in the estimates of diagnostic accuracy across studies explained?). Diagnostic accuracy systematic reviews that are judged to be credible and provide diagnostic accuracy estimates with sufficient certainty and relevance are the most useful to inform patient care. This review discusses comparative, noncomparative, and emerging approaches to systematic reviews of diagnostic accuracy using a clinical scenario and examples based on recent publications.

Clinical Presentations of Acquired Hypothyroidism in Children: Experience in a Tertiary Care Hospital in Bangladesh

A cross sectional study was conducted in Paediatric Endocrine Outpatient Department of BIRDEM General Hospital, a tertiary care centre in Dhaka, Bangladesh among patients diagnosed with acquired hypothyroidism during the period of January 2012 to December 2016. The study was done to find out the clinical presentations and associated disorders of all patients diagnosed with acquired hypothyroidism during the study period. Data were obtained by reviewing the medical records of the patients. Total 277 children were diagnosed of having thyroid disorders. Among them 145(52.3%) had acquired hypothyroidism. The commonest clinical presentations of children with acquired hypothyroidism were short stature (35.0%), excessive weight gain (31.5%), goiter (23.1%) and poor school performance (14.0%). Autoimmune hypothyroidism was found in 34.4% of children, sub-clinical hypothyroidism in 27.5% children and positive family history was found in 15.2% children with acquired hypothyroidism. The common associated diseases were diabetes and impaired glucose tolerance (4.9%), Down syndrome (3.5%), congenital heart disease (2.1%) and primary adrenal insufficiency (1.4%).

Peri-Operative Liver Fibrosis and Native Liver Survival in Pediatric Patients with Biliary Atresia: A Systematic Review and Meta-Analysis

No systematic review to date has examined histopathological parameters in relation to native liver survival in children who undergo the Kasai operation for biliary atresia (BA). A systematic review and meta-analysis is presented, comparing the frequency of native liver survival in peri-operative severe vs. non-severe liver fibrosis cases, in addition to other reported histopathology parameters. Records were sourced from MEDLINE, Embase, and CENTRAL databases. Studies followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and compared native liver survival frequencies in pediatric patients with evidence of severe vs. non-severe liver fibrosis, bile duct proliferation, cholestasis, lobular inflammation, portal inflammation, and giant cell transformation on peri-operative biopsies. The primary outcome was the frequency of native liver survival. A random effects meta-analysis was used. Twenty-eight observational studies were included, 1,171 pediatric patients with BA of whom 631 survived with their native liver. Lower odds of native liver survival in the severe liver fibrosis vs. non-severe liver fibrosis groups were reported (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.08-0.33; I² =46%). No difference in the odds of native liver survival in the severe bile duct destruction vs. non-severe bile duct destruction groups were reported (OR, 0.17; 95% CI, 0.00-63.63; I² =96%). Lower odds of native liver survival were documented in the severe cholestasis vs. non-severe cholestasis (OR, 0.10; 95% CI, 0.01-0.73; I² =80%) and severe lobular inflammation vs. non-severe lobular inflammation groups (OR, 0.02; 95% CI, 0.00-0.62; I² =69%). There was no difference in the odds of native liver survival in the severe portal inflammation vs. non-severe portal inflammation groups (OR, 0.03; 95% CI, 0.00-3.22; I² =86%) or between the severe giant cell transformation vs. non-severe giant cell transformation groups (OR, 0.15; 95% CI, 0.00-175.21; I² =94%). The meta-analysis loosely suggests that the presence of severe liver fibrosis, cholestasis, and lobular inflammation are associated with lower odds of native liver survival in pediatric patients after Kasai.

Estimation of Serum Lipid Profile among Patients Admitted with Myocardial Infarction in a Tertiary Level Hospital of Bangladesh

Different studies worldwide showed that dyslipidaemia is involved in the pathogenesis of ischemic heart diseases (IHD). This cross sectional descriptive type of observational study was carried out at Mymensingh Medical College Hospital during the period of six months from January 2021 to September 2021 to estimate the lipid profile among patients admitted in the coronary care unit (CCU) with myocardial infarction (MI). Data were collected from purposively selected 343 patients with MI by face to face interview and laboratory investigations using a case record form. Informed written consent of participants was taken prior to interview. Data were analyzed by using SPSS version 21.0. The study results revealed that mean age of the patients with myocardial infarction was 53.16 years with a standard deviation of 11.68 years. Majority of them (284, 82.8%) were male and the remaining (59, 17.2%) were female. Proportion of risk factors for ischaemic heart disease (IHD) were estimated and found that 244(71.1%) patients were smoker; 150(43.7%) had hypertension and 110(32.2%) had family history of IHD. Ninety nine (28.9%) patents were obese with BMI ≥25kg/m². Eighty three (24.2%) patients had diabetes mellitus; 66(19.2%) lead sedentary life and 61(17.8%) patients with myocardial infarction had dyslipidaemia. Mean LDL of patients with myocardial infarction was 103.65±39.73mg/dl; mean total cholesterol (TC) was 189.44±45.41mg/dl; mean TG was 243.11±205.19mg/dl and mean HDL was 39.29±8.98mg/dl. LDL was increased in 10(2.9%) patients; total cholesterol was raised in 121 (35.3%) patients and TG was raised in 195(56.9%) patients. HDL was raised in 26(7.6%) patients and it was lowered in 57(16.6%) patients. Mean LDL, TC, TG and HDL of younger (≤45 years) and older (>45 years) patients were compared and t-test showed no significant difference (p>0.05). Similarly mean LDL, TC, TG and HDL of male and female were compared and again t-test showed no significant difference (p>0.05). Though the pattern of lipid profile was found similar in younger and older patients and in males and females, a significant number of patients (61, 17.8%) with MI had dyslipidaemia which should be address by dietary and lifestyle modification.

Clinical Presentation of Congenital Adrenal Hyperplasia in Children: Experience in a Tertiary Care Hospital of Bangladesh

This cross sectional study was conducted in Paediatric Endocrine Outpatient Department of BIRDEM General Hospital, a tertiary care centre in Dhaka, Bangladesh among patients diagnosed with congenital adrenal hyperplasia (CAH) from January 2005 to December 2018. The study was aimed to find out the clinical and laboratory profile of all patients at presentation diagnosed with CAH during the study period. Data were obtained by reviewing the medical records of the patients. Total 102 children with CAH were diagnosed during the study period. Among them 68 were female and 34 were male (female to male ratio of 2:1). Median age was 3.5 month (range 0.2-158 month) and 5.5 month (range 1-108 month) in female and male respectively (p=0.42). Family history was available in 93 patients. Consanguinity was present in 16(17.2%), history of sib death in 12(12.9%), other family members were affected in 8(8.6%). Sixty patient (58.8%) had salt-wasting (SW), 39(38.2%) had simple virilizing (SV) and 3(2.9%) had non- classic form of CAH. Median age of presentation was 2 month (range 0.2-70 month) and 42 month (range 0.8-158 month) in SW and SV group respectively (p=0.001) and 119 month (range 108-152 month) in non- classic group. Common presentations were: genital ambiguity (64.7%), vomiting (46.5%), failure to thrive (41.6%), features of early puberty (precocious pseudopuberty) (24.5%), diarrhea (12.0%). Hyperpigmentation was noted in 49.0% of patients. Among the salt-wasting type in male failure to thrive (FTT) was the most common presentation (83.3%), followed by vomiting (75.0%). In female genital ambiguity was the commonest presentation (97.2%), followed by vomiting (77.1%). Among the simple virilizing type in male early puberty was the commonest presentation (100%) and genital ambiguity was the presenting feature in all the female (100.0%).

Corona Virus Disease 2019 (COVID-19) Diagnostic Tests: A Glimpse

Mass testing for COVID-19 infection is one of the core measures in tackling the global spread of the disease. Testing is vital to diagnose and estimate cases, attack rates and case fatality rates- critical data for policy-making. As COVID-19 continues to spread globally, the demand for more extensive laboratory testing and innovative technology increases. However, countries around the world have been struggling to keep up pace with the worldwide demand to expand testing strategy. The pandemic evolves, so does our knowledge and understanding of diagnostic tests of COVID-19. Here we aim to review major challenges related to COVID-19 diagnostic tests and future development. So, the ongoing urgency and demand for tests would certainly steer the rapid uptake of novel techniques, which in turn would boost our understanding of diagnostic tests for COVID-19.

AB0546 DETERMINANTS OF VASCULITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background

Among the manifestations of SLE, vasculitic presentation is common. This study was aimed to identify the predictors of vasculitis in SLE patients.

Objectives

To identify the determinants of vasculitis in SLE patients.

Methods

The study was conducted in the Department of Rheumatology, BSMMU, Dhaka from December 2019 to January 2021. A total 168 consecutive confirmed cases of SLE patients were enrolled. The patients were evaluated for the features of vasculitic rashes, digital gangrene, mesenteric vasculitis, mononeuritis multiplex. The cutaneous vasculitis was confirmed by a dermatologist. Study subjects were grouped into vasculitic and no vasculitic groups. The disease activity and damage were assessed using SLEDAI and SLICC/ACR DI. The rate of vasculitis was expressed in percentage. The multivariate logistic regression analysis was done to determine the independent predictors of vasculitis in SLE. P value <0.05 was considered significant.

Results

Rate of lupus vasculitis was 14.3%. The features shown significant difference between vasculitic and no vasculitic groups were: ACLE (79.2% vs. 18.8%, p<0.001), oral ulcer (70.8% vs. 13.2%, p<0.001), alopecia (83.3% vs. 27.1%, p<0.001), Raynaud’s phenomenon (20.8% vs. 5.6%, p=0.011), fever (54.2% vs. 25.0%, p=0.002), arthritis (70.8% vs. 29.9%, p<0.001), pregnancy loss (68.8% vs. 32.7%, p=0.003), lupus nephritis (25.0% vs. 45.1%, p=0.032), seizure (8.3% vs. 0.7%, p=0.027), pleurisy (8.3% vs. 0.7%, p=0.027), leucopenia (8.3% vs. 1.4%, p=0.049), anti ds-DNA positivity (87.5% vs. 62.5%, p=0.008), hypocomplementemia (87.5% vs. 59%, p=0.003), higher mean SLEDAI (p<0.001) and SLICC/ACR damage index score (p<0.001). Though not significant the rate of antiphospholipid antibody positivity was high (69.2% vs. 42.9%, p=0.052) in vasculitis group. In multivariate logistic regression analysis, higher SLEDAI score (OR = 1.296, 95% CI =1.114-1.508) was positively and lupus nephritis (OR= 0.055, 95% CI =0.007-0.413) was negatively associated with lupus vasculitis.

Conclusion

In SLE, vasculitic presentation is common. Higher the SLEDAI score greater the chance of lupus vasculitis.

References

[1]Aringer, M., Costenbader, K., Daikh, D., Brinks, R., Mosca, M., Ramsey-Goldman, R., et al., (2019). 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis & Rheumatology, 71(9), pp.1400-1412.

[2]Drenkard, C., Villa, A., Reyes, E., Abello, M. and Alarcón-Segovia, D. (1997). Vasculitis in systemic lupus erythematosus. Lupus, 6(3), pp.235-242.

[3]Ramos-Casals, M., Nardi, N., Lagrutta, M., Brito-Zerón, P., Bové, A., Delgado, et al., (2006). Vasculitis in Systemic Lupus Erythematosus. Medicine, 85(2), pp.95-104.

Table 1.

Comparison of clinical features of Lupus vasculitis and without vasculitis (n=168)

Clinical featuresLupus vasculitis (n=24) n (%)Without vasculitis (n=144) n (%)p-valueFever13 (54.2)36 (25.0)0.002γSLE specific skin lesionsACLE19 (79.2)27(18.8)<0.001γSCLE1 (4.2)6(4.2)0.500*SLE non-specific skin lesionsOral ulcer17 (70.8)19 (13.2)<0.001γAlopecia20 (83.3)39 (27.1)<0.001γ   Raynaud’s5 (20.8)8 (5.6)0.011*Arthritis17 (70.8)43 29.9)<0.001γLupus nephritisa6 (25.0)65 (45.1)0.032γNeuro psychiatricSeizure2 (8.3)1 (0.7)0.027*Psychosis1 (4.2)2 (1.4)0.186*SerositisPleurisyPericarditis2 (8.3)1 (4.2)1 (0.7)3 (2.1)0.027*0.231*Pregnancy loss11/16 (68.8)32/98 (32.7)0.003γDVT1 (4.2)6 (4.2)0.500*APS3 (12.5)11 (7.6)0.213*AVN1 (4.2)2 (1.4)0.186*Pulmonary HTN2 (8.3)3 (2.1)0.074*

* Fisherʼs eхact test; γ chi-Square test, p < 0.05 is considered statistically significant, n: Number, %: Percent.

ACLE: Acute Cutaneous Lupus Erythematosus, SCLE: Sub-acute Cutaneous Lupus Erythematosus, DVT: Deep Vein Thrombosis, APS: Anti Phospholipid Antibody Syndrome, AVN: Avascular necrosis, HTN: Hypertension,

a: all diagnosed cases of lupus nephritis, presented with or without flare

Acknowledgements

We acknowledge all of our patients for their kind participation in this study. We also acknowledge Prof. Syed Atiqul Haq, Prof. Minhaj Rahim Choudhury, Prof. Abu Shahin, Dr. Md. Masudul Hasaan, Dr. Shamim Ahmed, Dr. Abul Kalam Azad, Department of rheumatology, BSMMU for their support and kind help during the work. At the end we acknowledge BSMMU authority for their support in conducting the study.

Disclosure of Interests

None declared

Diagnostic Accuracy of Cardiac MRI versus FDG PET for Cardiac Sarcoidosis: A Systematic Review and Meta-Analysis

Background There is limited consensus regarding the relative diagnostic performance of cardiac MRI and fluorodeoxyglucose (FDG) PET for cardiac sarcoidosis. Purpose To perform a systematic review and meta-analysis to compare the diagnostic accuracy of cardiac MRI and FDG PET for cardiac sarcoidosis. Materials and Methods Medline, Ovid Epub, Cochrane Central Register of Controlled Trials, Embase, Emcare, and Scopus were searched from inception until January 2022. Inclusion criteria included studies that evaluated the diagnostic accuracy of cardiac MRI or FDG PET for cardiac sarcoidosis in adults. Data were independently extracted by two investigators. Summary accuracy metrics were obtained by using bivariate random-effects meta-analysis. Meta-regression was used to assess the effect of different covariates. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies-2 tool. The study protocol was registered a priori in the International Prospective Register of Systematic Reviews (Prospero protocol CRD42021214776). Results Thirty-three studies were included (1997 patients, 687 with cardiac sarcoidosis); 17 studies evaluated cardiac MRI (1031 patients) and 26 evaluated FDG PET (1363 patients). Six studies directly compared cardiac MRI and PET in the same patients (303 patients). Cardiac MRI had higher sensitivity than FDG PET (95% vs 84%; P = .002), with no difference in specificity (85% vs 82%; P = .85). In a sensitivity analysis restricted to studies with direct comparison, point estimates were similar to those from the overall analysis: cardiac MRI and FDG PET had sensitivities of 92% and 81% and specificities of 72% and 82%, respectively. Covariate analysis demonstrated that sensitivity for FDG PET was highest with quantitative versus qualitative evaluation (93% vs 76%; P = .01), whereas sensitivity for MRI was highest with inclusion of T2 imaging (99% vs 88%; P = .001). Thirty studies were at risk of bias. Conclusion Cardiac MRI had higher sensitivity than fluorodeoxyglucose PET for diagnosis of cardiac sarcoidosis but similar specificity. Limitations, including risk of bias and few studies with direct comparison, necessitate additional study. © RSNA, 2022 Online supplemental material is available for this article.

Thoracic imaging tests for the diagnosis of COVID-19

BACKGROUND

Our March 2021 edition of this review showed thoracic imaging computed tomography (CT) to be sensitive and moderately specific in diagnosing COVID-19 pneumonia. This new edition is an update of the review.

OBJECTIVES

Our objectives were to evaluate the diagnostic accuracy of thoracic imaging in people with suspected COVID-19; assess the rate of positive imaging in people who had an initial reverse transcriptase polymerase chain reaction (RT-PCR) negative result and a positive RT-PCR result on follow-up; and evaluate the accuracy of thoracic imaging for screening COVID-19 in asymptomatic individuals. The secondary objective was to assess threshold effects of index test positivity on accuracy.

SEARCH METHODS

We searched the COVID-19 Living Evidence Database from the University of Bern, the Cochrane COVID-19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID-19 publications through to 17 February 2021. We did not apply any language restrictions.

SELECTION CRITERIA

We included diagnostic accuracy studies of all designs, except for case-control, that recruited participants of any age group suspected to have COVID-19. Studies had to assess chest CT, chest X-ray, or ultrasound of the lungs for the diagnosis of COVID-19, use a reference standard that included RT-PCR, and report estimates of test accuracy or provide data from which we could compute estimates. We excluded studies that used imaging as part of the reference standard and studies that excluded participants with normal index test results.

DATA COLLECTION AND ANALYSIS

The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using QUADAS-2. We presented sensitivity and specificity per study on paired forest plots, and summarized pooled estimates in tables. We used a bivariate meta-analysis model where appropriate.

MAIN RESULTS

We included 98 studies in this review. Of these, 94 were included for evaluating the diagnostic accuracy of thoracic imaging in the evaluation of people with suspected COVID-19. Eight studies were included for assessing the rate of positive imaging in individuals with initial RT-PCR negative results and positive RT-PCR results on follow-up, and 10 studies were included for evaluating the accuracy of thoracic imaging for imagining asymptomatic individuals. For all 98 included studies, risk of bias was high or unclear in 52 (53%) studies with respect to participant selection, in 64 (65%) studies with respect to reference standard, in 46 (47%) studies with respect to index test, and in 48 (49%) studies with respect to flow and timing. Concerns about the applicability of the evidence to: participants were high or unclear in eight (8%) studies; index test were high or unclear in seven (7%) studies; and reference standard were high or unclear in seven (7%) studies. Imaging in people with suspected COVID-19 We included 94 studies. Eighty-seven studies evaluated one imaging modality, and seven studies evaluated two imaging modalities. All studies used RT-PCR alone or in combination with other criteria (for example, clinical signs and symptoms, positive contacts) as the reference standard for the diagnosis of COVID-19. For chest CT (69 studies, 28285 participants, 14,342 (51%) cases), sensitivities ranged from 45% to 100%, and specificities from 10% to 99%. The pooled sensitivity of chest CT was 86.9% (95% confidence interval (CI) 83.6 to 89.6), and pooled specificity was 78.3% (95% CI 73.7 to 82.3). Definition for index test positivity was a source of heterogeneity for sensitivity, but not specificity. Reference standard was not a source of heterogeneity. For chest X-ray (17 studies, 8529 participants, 5303 (62%) cases), the sensitivity ranged from 44% to 94% and specificity from 24 to 93%. The pooled sensitivity of chest X-ray was 73.1% (95% CI 64. to -80.5), and pooled specificity was 73.3% (95% CI 61.9 to 82.2). Definition for index test positivity was not found to be a source of heterogeneity. Definition for index test positivity and reference standard were not found to be sources of heterogeneity. For ultrasound of the lungs (15 studies, 2410 participants, 1158 (48%) cases), the sensitivity ranged from 73% to 94% and the specificity ranged from 21% to 98%. The pooled sensitivity of ultrasound was 88.9% (95% CI 84.9 to 92.0), and the pooled specificity was 72.2% (95% CI 58.8 to 82.5). Definition for index test positivity and reference standard were not found to be sources of heterogeneity. Indirect comparisons of modalities evaluated across all 94 studies indicated that chest CT and ultrasound gave higher sensitivity estimates than X-ray (P = 0.0003 and P = 0.001, respectively). Chest CT and ultrasound gave similar sensitivities (P=0.42). All modalities had similar specificities (CT versus X-ray P = 0.36; CT versus ultrasound P = 0.32; X-ray versus ultrasound P = 0.89). Imaging in PCR-negative people who subsequently became positive For rate of positive imaging in individuals with initial RT-PCR negative results, we included 8 studies (7 CT, 1 ultrasound) with a total of 198 participants suspected of having COVID-19, all of whom had a final diagnosis of COVID-19. Most studies (7/8) evaluated CT. Of 177 participants with initially negative RT-PCR who had positive RT-PCR results on follow-up testing, 75.8% (95% CI 45.3 to 92.2) had positive CT findings. Imaging in asymptomatic PCR-positive people For imaging asymptomatic individuals, we included 10 studies (7 CT, 1 X-ray, 2 ultrasound) with a total of 3548 asymptomatic participants, of whom 364 (10%) had a final diagnosis of COVID-19. For chest CT (7 studies, 3134 participants, 315 (10%) cases), the pooled sensitivity was 55.7% (95% CI 35.4 to 74.3) and the pooled specificity was 91.1% (95% CI 82.6 to 95.7).

AUTHORS' CONCLUSIONS

Chest CT and ultrasound of the lungs are sensitive and moderately specific in diagnosing COVID-19. Chest X-ray is moderately sensitive and moderately specific in diagnosing COVID-19. Thus, chest CT and ultrasound may have more utility for ruling out COVID-19 than for differentiating SARS-CoV-2 infection from other causes of respiratory illness. The uncertainty resulting from high or unclear risk of bias and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results.

Diagnostic accuracy of thoracic imaging modalities for the detection of COVID-19

The ongoing coronavirus disease 2019 (COVID-19) pandemic continues to present diagnostic challenges. The use of thoracic radiography has been studied as a method to improve the diagnostic accuracy of COVID-19. The ‘Living’ Cochrane Systematic Review on the diagnostic accuracy of imaging tests for COVID-19 is continuously updated as new information becomes available for study. In the most recent version, published in March 2021, a meta-analysis was done to determine the pooled sensitivity and specificity of chest X-ray (CXR) and lung ultrasound (LUS) for the diagnosis of COVID-19. CXR gave a sensitivity of 80.6% (95%CI: 69.1-88.6) and a specificity of 71.5% (95%CI: 59.8-80.8). LUS gave a sensitivity rate of 86.4% (95%CI: 72.7-93.9) and specificity of 54.6% (95%CI: 35.3-72.6). These results differed from the findings reported in the recent article in this journal where they cited the previous versions of the study in which a meta-analysis for CXR and LUS could not be performed. Additionally, the article states that COVID-19 could not be distinguished, using chest computed tomography (CT), from other respiratory diseases. However, the latest review version identifies chest CT as having a specificity of 80.0% (95%CI: 74.9-84.3), which is much higher than the previous version which indicated a specificity of 61.1% (95%CI: 42.3-77.1). Therefore, CXR, chest CT and LUS have the potential to be used in conjunction with other methods in the diagnosis of COVID-19.

TB prevalence among patients with diabetes in Bangladesh

OBJECTIVE: 1) To assess the prevalence of TB among patients with diabetes mellitus (DM) attending diabetic care centres in Bangladesh, and 2) to compare TB- and DM-related sociodemographic and other factors in diabetic patients who had TB and those who did not.METHODS: This cross-sectional study was conducted from 1 June 2019 to 31 March 2020 in 108 centres of the Diabetic Association of Bangladesh (BADAS), with a sample size of 3,649 patients with DM. Data were collected by face-to-face interview using semi-structured questionnaire from each patient/guardian. Other ethical issues were also maintained.RESULTS: Out of 3,649 patients with DM, 676 presumptive TB cases were identified and tested; from them, 85 patients were detected as TB cases. Another 39 patients were already diagnosed and on anti-TB medication. Prevalence of TB among patients with DM attending diabetic care centres was 3.4%. Prevalence was higher in female than male (4.0% vs 2.6%). Underweight (9.0%) patients and patients having diabetes for more than 10 years (7.1%) had a higher prevalence of TB.CONCLUSION: TB prevalence was over 3% among study population with DM. Periodic screening and active case finding among DM patients should be strengthened to reduce the risk of TB infection among DM patients.

Association of Accuracy, Conclusions, and Reporting Completeness With Acceptance by Radiology Conferences and Journals

BACKGROUND

Preferential publication of studies with positive findings can lead to overestimation of diagnostic test accuracy (i.e. publication bias). Understanding the contribution of the editorial process to publication bias could inform interventions to optimize the evidence guiding clinical decisions.

PURPOSE/HYPOTHESIS

To evaluate whether accuracy estimates, abstract conclusion positivity, and completeness of abstract reporting are associated with acceptance to radiology conferences and journals.

STUDY TYPE

Meta-research.

POPULATION

Abstracts submitted to radiology conferences (European Society of Gastrointestinal and Abdominal Radiology (ESGAR) and International Society for Magnetic Resonance in Medicine (ISMRM)) from 2008 to 2018 and manuscripts submitted to radiology journals (Radiology, Journal of Magnetic Resonance Imaging [JMRI]) from 2017 to 2018. Primary clinical studies evaluating sensitivity and specificity of a diagnostic imaging test in humans with available editorial decisions were included.

ASSESSMENT

Primary variables (Youden's index [YI > 0.8 vs. <0.8], abstract conclusion positivity [positive vs. neutral/negative], number of reported items on the Standards for Reporting of Diagnostic Accuracy Studies [STARD] for Abstract guideline) and confounding variables (prospective vs. retrospective/unreported, sample size, study duration, interobserver agreement assessment, subspecialty, modality) were extracted.

STATISTICAL TESTS

Multivariable logistic regression to obtain adjusted odds ratio (OR) as a measure of the association between the primary variables and acceptance by radiology conferences and journals; 95% confidence intervals (CIs) and P-values were obtained; the threshold for statistical significance was P < 0.05.

RESULTS

A total of 1000 conference abstracts (500 ESGAR and 500 ISMRM) and 1000 journal manuscripts (505 Radiology and 495 JMRI) were included. Conference abstract acceptance was not significantly associated with YI (adjusted OR = 0.97 for YI > 0.8; CI = 0.70-1.35), conclusion positivity (OR = 1.21 for positive conclusions; CI = 0.75-1.90) or STARD for Abstracts adherence (OR = 0.96 per unit increase in reported items; CI = 0.82-1.18). Manuscripts with positive abstract conclusions were less likely to be accepted by radiology journals (OR = 0.45; CI = 0.24-0.86), while YI (OR = 0.85; CI = 0.56-1.29) and STARD for Abstracts adherence (OR = 1.06; CI = 0.87-1.30) showed no significant association. Positive conclusions were present in 86.7% of submitted conference abstracts and 90.2% of journal manuscripts.

DATA CONCLUSION

Diagnostic test accuracy studies with positive findings were not preferentially accepted by the evaluated radiology conferences or journals.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Change of Hemoglobin Level among Exclusively Breastfed Term and Preterm Babies up to Six Months of Age

There is progressive increase of Hb levels is observed during course of intrauterine development of fetus but high concentrations found at birth. In preterm neonate normal Hb is characteristically deviated from term neonate. Breast milk is the only natural ideal food for both term and preterm babies from birth up to 6 months. Preterm milk was found to contain significantly higher concentrations nutrients particularly iron than term milk. Preterm human milk is more suitable for the premature infant than term human milk. As Hb concentration varies in term and preterm babies in different counties in different feeding practices. The purpose of this longitudinal descriptive study is to find out the pattern of changes in the Hb level among exclusively breastfed preterm and term infants during the first six months of life. This study was carried in the Neonatal Intensive Care Unit (NICU), Mymensingh Medical College Hospital (MMCH), Mymensingh from September 2016 to February 2018. One hundred fifty (150) neonates both term and preterm were included in this study and followed up to 6 months of age. After admission informed written consent was taken from parents, thorough history taking and clinical examination were done. Data were collected in a pre-designed case record form. All the babies of Group A provided 2mg/kg iron supplementation from 6 weeks for 2 months for universal recommendation. Hb level was measured of all exclusively breast feed babies at admission after birth then next follow-up at 6 weeks, 3 months and 6 months. All information regarding history, anthropometrics measurement, Hb level was recorded in structural questionnaire. Data analysis was done by SPSS version 20.0. Male were predominant in both groups. Most of the preterm (72.0%) and term babies (65.3%) were delivered by vaginal route. Mean Hb level was found significantly higher among preterm babies than term babies after birth were 16.55g/dl and 15.98g/dl respectively. Sharp fall of Hb concentration was observed after birth up to 6 weeks in both preterm and term babies but Hb level was found significantly lower in preterm in comparison to term babies (9.27gm/dl vs. 9.58gm/dl). In term babies, even after 6 weeks fall of Hb level continued to 3 months of age followed by gradual increase up to 6 months without iron supplementation. Hb level of in preterm babies gradually increased from 6 weeks up to 6 months with universal iron supplementation. Hb level fall sharply up to 6 weeks in both exclusively breastfed term and preterm babies but even after 6 weeks term babies experienced gradual fall of Hb levels up to 3 months. Hb level increases in exclusively breast-fed term babies without iron supplementation from 3 months of age. Hb level in exclusively breastfed preterm babies increase from 6 weeks onward might be effect of universal iron supplementation.

Factors Influencing Trainees' Interest in Breast Imaging

Purpose: To gauge the level of interest in breast imaging (BI) and determine factors impacting trainees' decision to pursue this subspecialty. Methods: Canadian radiology residents and medical students were surveyed from November 2020 to February 2021. Training level, actual vs preferred timing of breast rotations, fellowship choices, perceptions of BI, and how artificial intelligence (AI) will impact BI were collected. Chi-square, Fisher's exact tests and univariate logistic regression were performed to determine the impact of trainees' perceptions on interest in pursuing BI/women's imaging (WI) fellowships. Results: 157 responses from 80 radiology residents and 77 medical students were collected. The top 3 fellowship subspecialties desired by residents were BI/WI (36%), abdominal imaging (35%), and interventional radiology (25%). Twenty-five percent of the medical students were unsure due to lack of exposure. The most common reason that trainees found BI unappealing was repetitiveness (20%), which was associated with lack of interest in BI/WI fellowships (OR = 3.9, 95% CI: 1.6-9.5, P = .002). The most common reason residents found BI appealing was procedures (59%), which was associated with interest in BI/WI fellowships (OR, 3.2, 95% CI, 1.2-8.6, P = .02). Forty percent of residents reported an earlier start of their first breast rotation (PGY1-2) would affect their fellowship choice. Conclusion: This study assessed the current level of Canadian trainees' interest in BI and identified factors that influenced their decisions to pursue BI. Solutions for increased interest include earlier exposure to breast radiology and addressing inadequacies in residency training.

Overweight and Obesity among Children of Primary Schools of Mymensingh Municipal Area

Obesity is now recognized as a major cause of morbidity and mortality throughout the world. The relative percentage of change is higher in developing countries. Childhood obesity has become a serious public health emerging problem because of its strong association with adulthood obesity and related adverse health consequences. The main objective of the study was to find out the status of overweight and obesity among primary school children of Mymensingh municipal area. This cross sectional descriptive study was carried out among primary school children of Mymensingh municipal area from September 2016 to February 2018. Total 1450 students were enrolled from 6 schools. Schools were selected by random lottery method. Data was collected in predesigned case record forms by investigator with the help of students, teachers and parents. Anthropometry was measured by principal investigator. Body mass index (BMI) was calculated and plotted by using Center for disease control (CDC) BMI growth charts for age and sex. Children were categorized as obese, overweight, normal and underweight. Data analysis was done by computer software SPSS version 20.0. Mean age of children was 9.0±1.124 years. There was 47.4% male and 52.6% female. Among the 1450 children 18.6% obese, 17.5% overweight, 53.5% normal and 10.4% underweight. So, total 36.1% children had BMI above normal limit. Obesity was found more common among male children (p<0.001). Obesity and overweight was significantly associated with fast food consumption (p<0.001), playing computer and mobile games (p<0.001), watching TV (p<0.001), higher parent's education (p<0.001), higher parent's income (p<0.001), service holder father (p<0.001), family history of overweight or obesity (p<0.001), single child in family (p<0.001) and increased birth weight (p<0.001). A large number of primary school children in Mymensingh municipal area were overweight and obese. Childhood obesity and overweight varies from school to school. Childhood obesity and overweight is an emerging and growing health issue in municipal area.

Association of working shifts, inside and outside of healthcare, with severe COVID-19: an observational study

BACKGROUND

Health and key workers have elevated odds of developing severe COVID-19; it is not known, however, if this is exacerbated in those with irregular work patterns. We aimed to investigate the odds of developing severe COVID-19 in health and shift workers.

METHODS

We included UK Biobank participants in employment or self-employed at baseline (2006-2010) and with linked COVID-19 data to 31st August 2020. Participants were grouped as neither a health worker nor shift worker (reference category) at baseline, health worker only, shift worker only, or both, and associations with severe COVID-19 investigated in logistic regressions.

RESULTS

Of 235,685 participants (81·5% neither health nor shift worker, 1·4% health worker only, 16·9% shift worker only, and 0·3% both), there were 580 (0·25%) cases of severe COVID-19. The odds of severe COVID-19 was higher in health workers (adjusted odds ratio: 2·32 [95% CI: 1·33, 4·05]; shift workers (2·06 [1·72, 2·47]); and in health workers who worked shifts (7·56 [3·86, 14·79]). Being both a health worker and a shift worker had a possible greater impact on the odds of severe COVID-19 in South Asian and Black and African Caribbean ethnicities compared to White individuals.

CONCLUSIONS

Both health and shift work (measured at baseline, 2006-2010) were independently associated with over twice the odds of severe COVID-19 in 2020; the odds were over seven times higher in health workers who work shifts. Vaccinations, therapeutic and preventative options should take into consideration not only health and key worker status but also shift worker status.

Serum Iron Profile and Red Cell Indices in Children with Severe Acute Malnutrition in A Tertiary Level Hospital

This cross-sectional analytical study was conducted in the department of Paediatrics, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from March 2017 to August 2018 to assess the pattern of serum iron profile and red cell indices in children with severe acute malnutrition. Seventy children having severe acute malnutrition were compared with 70 age matched children those had normal growth. Age range of the studied children was 6 months to 59 completed months. Male was found predominant (54.3%) in both study group and comparison group. Mean serum iron, serum ferritin, serum total iron binding capacity and transferrin saturation in severely malnourished children were 45.3±19.3μg/dl, 26.5±20.0ng/ml, 246.3±47.5μg/dl and 16.4±2.0% respectively which were significantly lower than that of healthy children (p<0.05). Mean Hb level in children with severe acute malnutrition was found 8.3±1.6gm/dl which was also found significantly lower than that of normal children (p<0.05). Anaemia was found in all (100%) severely malnourished children compared to 25.7% of children in comparison group. Mean MCV, MCH and MCHC in children with severe acute malnutrition was found 71.7±13.5fl, 24.0±5.8pg and 31.4±4.0gm/dl respectively which were significantly lower than that of comparison group (p<0.05). Serum iron profile and red cell indices should be routinely done in severely malnourished children for early intervention and management of iron deficiency anaemia.

Pandemic Now and Then: A Historical Perspective of Non-Pharmaceutical Interventions Adopted In Covid-19

The coronavirus disease 2019 (COVID-19), first reported in Wuhan, China is now a major global health threat - a pandemic. Public health control measures are the cornerstones in the fight against COVID-19 in the absence of an effective vaccine or proven treatment. The aim of this review was to explore the historical use case of various public health measures adopted today to tackle COVID-19 spread. Although our knowledge about this novel coronavirus transmission is evolving over time, the fundamental non-pharmaceutical interventions e.g., handwashing, wearing a mask, physical distancing, isolation, quarantine and border control which are adopted globally at present are not new. This review highlighted that historically and religiously similar approaches were practised in the medieval past for controlling disease outbreaks. The successful implementation of the public health control measures largely depends on health systems resilience, community engagement and changes in population behaviour. Combined global efforts are essential to strengthen health systems, improve the capability of research and transparent information sharing with both public and international bodies to combat the pandemic.

Thoracic imaging tests for the diagnosis of COVID-19

BACKGROUND

The respiratory illness caused by SARS-CoV-2 infection continues to present diagnostic challenges. Our 2020 edition of this review showed thoracic (chest) imaging to be sensitive and moderately specific in the diagnosis of coronavirus disease 2019 (COVID-19). In this update, we include new relevant studies, and have removed studies with case-control designs, and those not intended to be diagnostic test accuracy studies.

OBJECTIVES

To evaluate the diagnostic accuracy of thoracic imaging (computed tomography (CT), X-ray and ultrasound) in people with suspected COVID-19.

SEARCH METHODS

We searched the COVID-19 Living Evidence Database from the University of Bern, the Cochrane COVID-19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID-19 publications through to 30 September 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We included studies of all designs, except for case-control, that recruited participants of any age group suspected to have COVID-19 and that reported estimates of test accuracy or provided data from which we could compute estimates.

DATA COLLECTION AND ANALYSIS

The review authors independently and in duplicate screened articles, extracted data and assessed risk of bias and applicability concerns using the QUADAS-2 domain-list. We presented the results of estimated sensitivity and specificity using paired forest plots, and we summarised pooled estimates in tables. We used a bivariate meta-analysis model where appropriate. We presented the uncertainty of accuracy estimates using 95% confidence intervals (CIs).

MAIN RESULTS

We included 51 studies with 19,775 participants suspected of having COVID-19, of whom 10,155 (51%) had a final diagnosis of COVID-19. Forty-seven studies evaluated one imaging modality each, and four studies evaluated two imaging modalities each. All studies used RT-PCR as the reference standard for the diagnosis of COVID-19, with 47 studies using only RT-PCR and four studies using a combination of RT-PCR and other criteria (such as clinical signs, imaging tests, positive contacts, and follow-up phone calls) as the reference standard. Studies were conducted in Europe (33), Asia (13), North America (3) and South America (2); including only adults (26), all ages (21), children only (1), adults over 70 years (1), and unclear (2); in inpatients (2), outpatients (32), and setting unclear (17). Risk of bias was high or unclear in thirty-two (63%) studies with respect to participant selection, 40 (78%) studies with respect to reference standard, 30 (59%) studies with respect to index test, and 24 (47%) studies with respect to participant flow. For chest CT (41 studies, 16,133 participants, 8110 (50%) cases), the sensitivity ranged from 56.3% to 100%, and specificity ranged from 25.4% to 97.4%. The pooled sensitivity of chest CT was 87.9% (95% CI 84.6 to 90.6) and the pooled specificity was 80.0% (95% CI 74.9 to 84.3). There was no statistical evidence indicating that reference standard conduct and definition for index test positivity were sources of heterogeneity for CT studies. Nine chest CT studies (2807 participants, 1139 (41%) cases) used the COVID-19 Reporting and Data System (CO-RADS) scoring system, which has five thresholds to define index test positivity. At a CO-RADS threshold of 5 (7 studies), the sensitivity ranged from 41.5% to 77.9% and the pooled sensitivity was 67.0% (95% CI 56.4 to 76.2); the specificity ranged from 83.5% to 96.2%; and the pooled specificity was 91.3% (95% CI 87.6 to 94.0). At a CO-RADS threshold of 4 (7 studies), the sensitivity ranged from 56.3% to 92.9% and the pooled sensitivity was 83.5% (95% CI 74.4 to 89.7); the specificity ranged from 77.2% to 90.4% and the pooled specificity was 83.6% (95% CI 80.5 to 86.4). For chest X-ray (9 studies, 3694 participants, 2111 (57%) cases) the sensitivity ranged from 51.9% to 94.4% and specificity ranged from 40.4% to 88.9%. The pooled sensitivity of chest X-ray was 80.6% (95% CI 69.1 to 88.6) and the pooled specificity was 71.5% (95% CI 59.8 to 80.8). For ultrasound of the lungs (5 studies, 446 participants, 211 (47%) cases) the sensitivity ranged from 68.2% to 96.8% and specificity ranged from 21.3% to 78.9%. The pooled sensitivity of ultrasound was 86.4% (95% CI 72.7 to 93.9) and the pooled specificity was 54.6% (95% CI 35.3 to 72.6). Based on an indirect comparison using all included studies, chest CT had a higher specificity than ultrasound. For indirect comparisons of chest CT and chest X-ray, or chest X-ray and ultrasound, the data did not show differences in specificity or sensitivity.

AUTHORS' CONCLUSIONS

Our findings indicate that chest CT is sensitive and moderately specific for the diagnosis of COVID-19. Chest X-ray is moderately sensitive and moderately specific for the diagnosis of COVID-19. Ultrasound is sensitive but not specific for the diagnosis of COVID-19. Thus, chest CT and ultrasound may have more utility for excluding COVID-19 than for differentiating SARS-CoV-2 infection from other causes of respiratory illness. Future diagnostic accuracy studies should pre-define positive imaging findings, include direct comparisons of the various modalities of interest in the same participant population, and implement improved reporting practices.

Prophylactic antibiotics for preventing genital tract infection in women undergoing surgical procedures for incomplete abortion: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Findings about the effect of prophylactic antibiotics in preventing genital tract infection (GTI) associated with surgical procedures used for incomplete abortions are conflicting. Some reported a decrease in infection associated with the use of antibiotic prophylaxis, whereas others found no significant reduction in GTI.

OBJECTIVE

To synthesise systematically the evidence on the effect of prophylactic antibiotics compared with placebo in women undergoing surgical procedures for incomplete abortion.

SEARCH STRATEGY

In February 2020, PubMed, Embase and Cochrane Central for Register of Controlled Trials were searched for relevant published randomised controlled trials.

SELECTION CRITERIA

Randomised controlled trials reporting GTI following surgical procedures for incomplete abortion and comparing antibiotic prophylaxis with placebo.

DATA COLLECTION AND ANALYSIS

Meta-analysis using inverse variance heterogeneity model included subgroup and sensitivity analyses determined a priori were conducted. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

MAIN RESULTS

A total of 16 178 women who participated in 24 eligible randomised controlled trials published between 1975 and 2019 were included. Pooled estimates showed the risk of GTI following surgical procedures after incomplete abortion was significantly lower among those who had prophylactic antibiotics (relative risk [RR] = 0.72; 95% CI 0.58-0.90; I²  = 49%). There was no significant effect of antibiotics in women in low- and middle-income countries (three studies, 3579 participants, RR = 0.90; 95% CI 0.50-1.62; I²  = 63%), but it was clinically and statistically significant among women high-income countries (21 studies, 12 599 participants, RR = 0.67; 95% CI 0.53-0.84; I²  = 44%), with a strong level of evidence as assessed by GRADE.

CONCLUSION

This study provides evidence that antibiotic prophylaxis is beneficial in reducing post-abortion GTI among women undergoing surgical procedures for incomplete abortion. More studies are needed from low- and middle-income countries.

TWEETABLE ABSTRACT

Prophylactic antibiotics after incomplete abortion are effective in reducing GTI. More studies are needed from low- and middle-income countries.

Thoracic imaging tests for the diagnosis of COVID-19

BACKGROUND

The respiratory illness caused by SARS-CoV-2 infection continues to present diagnostic challenges. Early research showed thoracic (chest) imaging to be sensitive but not specific in the diagnosis of coronavirus disease 2019 (COVID-19). However, this is a rapidly developing field and these findings need to be re-evaluated in the light of new research. This is the first update of this 'living systematic review'. This update focuses on people suspected of having COVID-19 and excludes studies with only confirmed COVID-19 participants.

OBJECTIVES

To evaluate the diagnostic accuracy of thoracic imaging (computed tomography (CT), X-ray and ultrasound) in people with suspected COVID-19.

SEARCH METHODS

We searched the COVID-19 Living Evidence Database from the University of Bern, the Cochrane COVID-19 Study Register, The Stephen B. Thacker CDC Library, and repositories of COVID-19 publications through to 22 June 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We included studies of all designs that recruited participants of any age group suspected to have COVID-19, and which reported estimates of test accuracy, or provided data from which estimates could be computed. When studies used a variety of reference standards, we retained the classification of participants as COVID-19 positive or negative as used in the study.

DATA COLLECTION AND ANALYSIS

We screened studies, extracted data, and assessed the risk of bias and applicability concerns using the QUADAS-2 domain-list independently, in duplicate. We categorised included studies into three groups based on classification of index test results: studies that reported specific criteria for index test positivity (group 1); studies that did not report specific criteria, but had the test reader(s) explicitly classify the imaging test result as either COVID-19 positive or negative (group 2); and studies that reported an overview of index test findings, without explicitly classifying the imaging test as either COVID-19 positive or negative (group 3). We presented the results of estimated sensitivity and specificity using paired forest plots, and summarised in tables. We used a bivariate meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs).

MAIN RESULTS

We included 34 studies: 30 were cross-sectional studies with 8491 participants suspected of COVID-19, of which 4575 (54%) had a final diagnosis of COVID-19; four were case-control studies with 848 cases and controls in total, of which 464 (55%) had a final diagnosis of COVID-19. Chest CT was evaluated in 31 studies (8014 participants, 4224 (53%) cases), chest X-ray in three studies (1243 participants, 784 (63%) cases), and ultrasound of the lungs in one study (100 participants, 31 (31%) cases). Twenty-six per cent (9/34) of all studies were available only as preprints. Nineteen studies were conducted in Asia, 10 in Europe, four in North America and one in Australia. Sixteen studies included only adults, 15 studies included both adults and children and one included only children. Two studies did not report the ages of participants. Twenty-four studies included inpatients, four studies included outpatients, while the remaining six studies were conducted in unclear settings. The majority of included studies had a high or unclear risk of bias with respect to participant selection, index test, reference standard, and participant flow. For chest CT in suspected COVID-19 participants (31 studies, 8014 participants, 4224 (53%) cases) the sensitivity ranged from 57.4% to 100%, and specificity ranged from 0% to 96.0%. The pooled sensitivity of chest CT in suspected COVID-19 participants was 89.9% (95% CI 85.7 to 92.9) and the pooled specificity was 61.1% (95% CI 42.3 to 77.1). Sensitivity analyses showed that when the studies from China were excluded, the studies from other countries demonstrated higher specificity compared to the overall included studies. When studies that did not classify index tests as positive or negative for COVID-19 (group 3) were excluded, the remaining studies (groups 1 and 2) demonstrated higher specificity compared to the overall included studies. Sensitivity analyses limited to cross-sectional studies, or studies where at least two reverse transcriptase polymerase chain reaction (RT-PCR) tests were conducted if the first was negative, did not substantively alter the accuracy estimates. We did not identify publication status as a source of heterogeneity. For chest X-ray in suspected COVID-19 participants (3 studies, 1243 participants, 784 (63%) cases) the sensitivity ranged from 56.9% to 89.0% and specificity from 11.1% to 88.9%. The sensitivity and specificity of ultrasound of the lungs in suspected COVID-19 participants (1 study, 100 participants, 31 (31%) cases) were 96.8% and 62.3%, respectively. We could not perform a meta-analysis for chest X-ray or ultrasound due to the limited number of included studies.

AUTHORS' CONCLUSIONS

Our findings indicate that chest CT is sensitive and moderately specific for the diagnosis of COVID-19 in suspected patients, meaning that CT may have limited capability in differentiating SARS-CoV-2 infection from other causes of respiratory illness. However, we are limited in our confidence in these results due to the poor study quality and the heterogeneity of included studies. Because of limited data, accuracy estimates of chest X-ray and ultrasound of the lungs for the diagnosis of suspected COVID-19 cases should be carefully interpreted. Future diagnostic accuracy studies should pre-define positive imaging findings, include direct comparisons of the various modalities of interest on the same participant population, and implement improved reporting practices. Planned updates of this review will aim to: increase precision around the accuracy estimates for chest CT (ideally with low risk of bias studies); obtain further data to inform accuracy of chest X-rays and ultrasound; and obtain data to further fulfil secondary objectives (e.g. 'threshold' effects, comparing accuracy estimates across different imaging modalities) to inform the utility of imaging along different diagnostic pathways.

Diagnostic Radiology Residency Application Trends: Canadian Match Results From 2010-2020

INTRODUCTION

Rapid advancements in artificial intelligence (AI) have generated uncertainty about the future of radiology among medical students. However, it is unclear whether this has affected radiology residency applications. The purpose of this study was to evaluate recent trends in the Canadian radiology residency match.

METHODS

Canadian Resident Matching Service annual data reports from 2010-2020 were collected. Statistics were extracted for Canadian medical graduates applying to radiology in the R-1 main residency match and analyzed using linear regression.

RESULTS

The number of available radiology residency positions decreased (P = .01); declining from 84 in 2010 to 81 in 2020 (mean = 83.1). The overall number of applicants did not change (P = .08, mean = 131.8). The proportion of applicants with radiology as their first choice decreased (P = .001); declining from 4.5% in 2010 to 3.1% in 2020 (mean = 3.4%). The number of applicants applying exclusively to radiology also decreased (P = .02); declining from 39 in 2010 to 16 in 2020 (mean = 23). Positions per applicant (P = 0.24, mean = 0.64), and positions per applicant with radiology as their first choice did not change (P = 0.07, mean = 0.91).

CONCLUSION

While the overall number of students applying to radiology did not change, the number of applicants ranking radiology as their first or only choice decreased sharply. This analysis corroborates recent reports of increased workload, burnout, and declining reimbursement as well as uncertainty about the future of radiology due to advances in AI.

The effect of oestrogen withdrawal on cardiac Ca2+ regulation and the influence of GPER1

Background

Post-menopausal women have an enhanced risk of developing heart failure, attributed to declining oestrogen levels during menopause. However, the signalling mechanisms remain undetermined.

Purpose

We aim to determine the role of G-protein coupled oestrogenic receptor 1 (GPER1) in intracellular Ca2+ regulation and the consequences of hormonal changes that may exacerbate the pathophysiology of heart failure.

Methods

Ovariectomy (OVx) (mimics menopausal hormone changes) or sham surgeries were conducted on female guinea pigs. Left ventricular cardiomyocytes were isolated 150-days post-operatively for experimental use. Cellular t-tubule network and structural integrity was measured using fluorescent di-8-ANEPPs staining and scanning ion conductance microscopy. GPER1 expression and localisation was measured by Western blot and immunostaining. The role of GPER1 activation was measured using selective agonist G-1 in electrophysiological and Ca2+-sensitive dye fluorescence experiments.

Results

Following oestrogen withdrawal, the t-tubule network density decreased by 13% and z-groove index reduced by 15%. GPER1 predominantly localised to the peri-nuclear endoplasmic reticulum and its expression increased by 32% in OVx. Action potential duration (APD) prolonged in OVx and following GPER1 activation, APD90 shortened by 11% and 25% in sham and OVx respectively. OVx cells had larger peak inward Ca2+ current (ICaL) (by 22%) and sarcoplasmic reticulum (SR) Ca2+ content (by 13%), compared with sham. While GPER1 activation had little effect on peak ICaL or SR content, it reduced Ca2+ transient amplitude (by 20%), SR fractional release (by 11%) in OVx cells. The frequency of occurrence of spontaneous Ca2+ waves evoked by periods of rapid stimulation reduced by 40% and wave-free survival time prolonged in OVx cells following GPER1 activation.

Conclusions

In the hearts of an animal species whose electrophysiology and intracellular Ca2+ regulation is akin to humans, we show that following oestrogen deficiency, the t-tubule network is down-regulated and becomes disorganised, GPER1 expression is increased and its activation induces negative inotropic responses in cardiomyocytes. This may limit the adverse changes to Ca2+ signalling reported in OVx that could be pro-arrhythmic and exacerbate the progression to heart failure.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Antimicrobial Sensitivity Pattern in Neonatal Sepsis in Neonatal Intensive Care Unit of Mymensingh Medical College Hospital

This cross-sectional descriptive study was conducted at the neonatal intensive care unit (NICU) in the department of Neonatology, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from July 2017 to December 2017 to determine antimicrobial sensitivity pattern in neonatal sepsis. Ninety four neonates (0-28 days) who were admitted in NICU with suspected sepsis were included in this study by purposive sampling technique. After admission written informed consent from parents or guardians obtained and then septic screening along with blood culture and antimicrobial sensitivity was done. All data were compiled, tabulated and then analyzed by SPSS version 21.0. Among 94 cases, 68(72.3%) were preterm and 26(23.4%) were term. There was male predominance and male female ratio was 1.9:1. Most of the patient admitted within 72 hours of birth. Most (84%) had low birth weight (<2500gm). Pre-mature onset of labour, pre-mature rupture of membrane >18 hours, vaginal route of delivery, instrumental resuscitation, pre-lacteal feeding, bottle feeding were the major perinatal risk factors in this study. Early onset sepsis (76.6%) was most prevalent in this study. Blood culture yielded positive growth in 20(21.3%) cases. Among them, Klebsiella was found in 7(35%). E. coli in 6(30%), Acinetobacter was in 3(15%), Staphylococcus aureus in 2(10%) cases. Pseudomonas and Enterobacter were found in rest 2(10%) of the cases. Gram negative bacteria were found in 18(90%) cases. Klebsiella was sensitive to Imipenem (85.7%), Colistin (85.7%) and Ciprofloxacin (77.5%). Sensitivity of E. coli was Imipenem (100%), Colistin (100%), Amikacin (66.7%), Ciprofloxacin (66.7%), Netilmicin (66.7%) and Gentamicin (50%). Acinatobecter had sensitivity to Netilmicin, Colistin, Imipenem (100%). Staphylococcus was 100% sensitive to Imipenem, Netilmicin and Vancomycin. Pseudomonas was found sensitive to Imipenem (100%), Amikacin (100%), Netilmicin (100%) and Colistin (100%). Enterobacter was found highly sensitive to Ciprofloxacin, Colistin and Imipenem. Almost all organisms were resistant to Ampicillin, Gentamicin, Cefotaxime and Ceftazidime. Based on result it is concluded that Klebsiella pneumoniae and Escherichia coli are the leading cause of neonatal sepsis in this study and most of them resistant to multiple antibiotics. Organisms found more sensitive to Imipenem, Colistin, Ciprofloxacin and Netilmicin.

Thoracic imaging tests for the diagnosis of COVID-19

BACKGROUND

The diagnosis of infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents major challenges. Reverse transcriptase polymerase chain reaction (RT-PCR) testing is used to diagnose a current infection, but its utility as a reference standard is constrained by sampling errors, limited sensitivity (71% to 98%), and dependence on the timing of specimen collection. Chest imaging tests are being used in the diagnosis of COVID-19 disease, or when RT-PCR testing is unavailable.

OBJECTIVES

To determine the diagnostic accuracy of chest imaging (computed tomography (CT), X-ray and ultrasound) in people with suspected or confirmed COVID-19.

SEARCH METHODS

We searched the COVID-19 Living Evidence Database from the University of Bern, the Cochrane COVID-19 Study Register, and The Stephen B. Thacker CDC Library. In addition, we checked repositories of COVID-19 publications. We did not apply any language restrictions. We conducted searches for this review iteration up to 5 May 2020.

SELECTION CRITERIA

We included studies of all designs that produce estimates of test accuracy or provide data from which estimates can be computed. We included two types of cross-sectional designs: a) where all patients suspected of the target condition enter the study through the same route and b) where it is not clear up front who has and who does not have the target condition, or where the patients with the target condition are recruited in a different way or from a different population from the patients without the target condition. When studies used a variety of reference standards, we included all of them.

DATA COLLECTION AND ANALYSIS

We screened studies and extracted data independently, in duplicate. We also assessed the risk of bias and applicability concerns independently, in duplicate, using the QUADAS-2 checklist and presented the results of estimated sensitivity and specificity, using paired forest plots, and summarised in tables. We used a hierarchical meta-analysis model where appropriate. We presented uncertainty of the accuracy estimates using 95% confidence intervals (CIs).

MAIN RESULTS

We included 84 studies, falling into two categories: studies with participants with confirmed diagnoses of COVID-19 at the time of recruitment (71 studies with 6331 participants) and studies with participants suspected of COVID-19 (13 studies with 1948 participants, including three case-control studies with 549 cases and controls). Chest CT was evaluated in 78 studies (8105 participants), chest X-ray in nine studies (682 COVID-19 cases), and chest ultrasound in two studies (32 COVID-19 cases). All evaluations of chest X-ray and ultrasound were conducted in studies with confirmed diagnoses only. Twenty-five per cent (21/84) of all studies were available only as preprints, 15/71 studies in the confirmed cases group and 6/13 of the studies in the suspected group. Among 71 studies that included confirmed cases, 41 studies had included symptomatic cases only, 25 studies had included cases regardless of their symptoms, five studies had included asymptomatic cases only, three of which included a combination of confirmed and suspected cases. Seventy studies were conducted in Asia, 2 in Europe, 2 in North America and one in South America. Fifty-one studies included inpatients while the remaining 24 studies were conducted in mixed or unclear settings. Risk of bias was high in most studies, mainly due to concerns about selection of participants and applicability. Among the 13 studies that included suspected cases, nine studies were conducted in Asia, and one in Europe. Seven studies included inpatients while the remaining three studies were conducted in mixed or unclear settings. In studies that included confirmed cases the pooled sensitivity of chest CT was 93.1% (95%CI: 90.2 - 95.0 (65 studies, 5759 cases); and for X-ray 82.1% (95%CI: 62.5 to 92.7 (9 studies, 682 cases). Heterogeneity judged by visual assessment of the ROC plots was considerable. Two studies evaluated the diagnostic accuracy of point-of-care ultrasound and both reported zero false negatives (with 10 and 22 participants having undergone ultrasound, respectively). These studies only reported True Positive and False Negative data, therefore it was not possible to pool and derive estimates of specificity. In studies that included suspected cases, the pooled sensitivity of CT was 86.2% (95%CI: 71.9 to 93.8 (13 studies, 2346 participants) and specificity was 18.1% (95%CI: 3.71 to 55.8). Heterogeneity judged by visual assessment of the forest plots was high. Chest CT may give approximately the same proportion of positive results for patients with and without a SARS-CoV-2 infection: the chances of getting a positive CT result are 86% (95% CI: 72 to 94) in patient with a SARS-CoV-2 infection and 82% (95% CI: 44 to 96) in patients without.

AUTHORS' CONCLUSIONS

The uncertainty resulting from the poor study quality and the heterogeneity of included studies limit our ability to confidently draw conclusions based on our results. Our findings indicate that chest CT is sensitive but not specific for the diagnosis of COVID-19 in suspected patients, meaning that CT may not be capable of differentiating SARS-CoV-2 infection from other causes of respiratory illness. This low specificity could also be the result of the poor sensitivity of the reference standard (RT-PCR), as CT could potentially be more sensitive than RT-PCR in some cases. Because of limited data, accuracy estimates of chest X-ray and ultrasound of the lungs for the diagnosis of COVID-19 should be carefully interpreted. Future diagnostic accuracy studies should avoid cases-only studies and pre-define positive imaging findings. Planned updates of this review will aim to: increase precision around the accuracy estimates for CT (ideally with low risk of bias studies); obtain further data to inform accuracy of chest X rays and ultrasound; and continue to search for studies that fulfil secondary objectives to inform the utility of imaging along different diagnostic pathways.

Comparison of feeding behavior problems of hostel and non-hostel living children with ASD in Dhaka

Backgrounds

The purpose of this study was to determine the distribution and differences of nutritional status and feeding behavior problems between the school going children with autism spectrum disorder (ASD) who are living either at school hostel or at home with parents of the urban lower-middle-class population in Dhaka city, Bangladesh.

Methods

This is a cross-sectional study where the children with ASD were randomly selected from 4 schools for children with special needs in Dhaka, Bangladesh. Written consent was taken from the parents of the children. Anthropometric and other nutrition referral data were taken directly from the children during school time. Demographic, parity and behavioral pediatrics feeding assessment scale (BPFAS) module have been interviewed through structured questionnaires from the parents. The referral scores have been applied to measure and compare the mean BPFAS scores.

Results

93 children have participated in this study (mean age 10.21 years). It was observed that BPFAS scores for &gt;10 years of age are higher in overall both groups of children (p = &lt;0.05). Parents from joint or bigger families reported higher feeding problems of their child living at home (p = &lt;0.05). Significant difference found in BPFAS score according to the number of siblings in the homegroup (52.0 vs. 81.8; p = &lt;0.01). Mean BPFAS score was higher in the hostel group if the children's parents were highly educated (p = &lt;0.05). No association found in feeding assessment and socio-economic status as we found the SES were quite similar in both groups.

Conclusions

In this preliminary data, we found that feeding behavior problems reported by parents are less in the hostel living children and also lower in comparatively higher aged children. This study is important for researchers and policymakers as it opens windows to think and do more research about the importance and impact of hostel disciplines and in-home family bonding for the healthy growth of children with ASD.

Key messages

Higher aged children are have less feeding problem in general. Keeping children with ASD at home in touch of family members have positive impact on their feeding problems and overall nutrition.

Complete mitochondrial genome sequence of Catla catla (Hamilton, 1822) from the Halda river of Bangladesh

Catla (Catla catla) is one of the fastest-growing major carp found in South Asia as well as Bangladesh. Catla catla is the second most popular indigenous carp species in the freshwater aquaculture industry of Bangladesh due to its relatively good taste and high market price. In this study, we disclosed the complete mitochondrial genome sequence of Bangladeshi Catla fish from Halda river located in Chittagong. The circular mitogenome of Catla catla is 16,597 bp in length and nucleotide composition is AT-based (72%), contains 37 genes including 13 protein-coding genes, 22 tRNA genes, 2 rRNA genes and a D-loop (control region).

An Overview of Unsafe Abortion: Patterns and Outcomes in a Tertiary Level Hospital

Unsafe abortion is one of the most critical global public health concerns and human rights challenges of the current time. The complications arising from unsafe abortion account for the death of almost 192 women each day; that is one woman every eight minutes and nearly all of them in developing countries. It is a descriptive type of observational study where all abortion related admissions from July 2017 to June 2018 in Obstetrics & Gynaecology department of Mymensingh Medical College Hospital were analyzed. Cases of unsafe abortion were identified as missed abortion, incomplete abortion and septic abortion. Total 2396 abortion related cases were admitted in one year. Among them 2173 cases were unsafe abortion (90.69%). The commonest mode of unsafe abortion was by taking improper regimen of different types of oral abortifacients either by self-administration or by improper prescriptions of local medical dispensers in 90% women. The commonest clinical presentation was per vaginal moderate to heavy bleeding in 88.5% women. After evaluation, the commonest diagnosis made was incomplete abortion in 92.87% women. The first line of intervention taken was recommended dose of medications like Misoprostol alone or Misoprostol followed by Mifepristone in 96.3% women to avoid unnecessary endometrial injury by surgical procedure. Further 44.2% women underwent Manual Vacuum Aspiration and thus reducing hospital stay to around 3.0±0.25 days. Almost all the patients (94%) were given post abortion contraceptives along with long acting family planning services to 20% patients. The miserable complication was septic abortion in 1.29% women and they were mainly done by insertion of foreign bodies which contribute to total 4.4% of maternal death. The impact of unsafe abortion on the woman and her family is intimidating. Timely and proper management of unsafe abortions and their complications with adequate provision for post abortion care may reduce the morbidity and mortality related to it. Moreover, use of long acting contraceptives to prevent unintended pregnancy and access to safe abortion may reduce the burden of unsafe abortions on public health system.

P943The effects of ovariectomy on guinea pig cardiomyocyte intracellular calcium regulation and phosphorylation

Background

Differences in cardiovascular disease risk between men and women have been partly attributed to the cardioprotective effects of oestrogen. Long-term oestrogen deficiency has been shown to alter cardiomyocyte intracellular calcium handling, but little is known about the mechanisms by which these changes occur. Oestrogen is thought to induce both genomic and non-genomic effects on cardiomyocytes, the latter including phosphorylation of calcium handling proteins.

Purpose

This study addresses the hypothesis that long-term oestrogen deficiency increases protein kinase A (PKA) and calcium/calmodulin-dependent kinase II (CaMKII) phosphorylation in cardiomyocytes, resulting in altered intracellular calcium regulation.

Methods

Female guinea pigs underwent sham (n = 7) or ovariectomy (OVx) (n = 8) operations and 150 days later, left ventricular myocytes were enzymatically isolated and loaded with fluo-4AM to monitor intracellular calcium. Calcium transients (CaT) were recorded using confocal microscopy. PKA and CaMKII phosphorylation were inhibited by superfusing cells with specific inhibitors, PKI and AIP, respectively. Experiments were carried out both in the presence and absence of β-agonist, isoprenaline (ISO), and relative changes to CaT parameters compared between OVx and sham cells.

Results

CaT amplitude was greater (p &lt; 0.05) in the OVx group (ΔF/Fo= 2.51 ± 0.57) compared with sham (ΔF/Fo = 2.16 ± 0.57). Inhibition of CaMKII phosphorylation increased CaT amplitude in the sham but not OVx group, both in the presence (by 22%, p &lt; 0.01) and absence of ISO (by 19%, p &lt; 0.01). Time to peak of the CaT increased to a greater extent following inhibition of PKA and CaMKII phosphorylation in the OVx group compared with sham, both in the presence (by 69%, p &lt; 0.0001) and absence (by 162%, p &lt; 0.0001) of ISO respectively. CaT decay time significantly increased (by 21%, p &lt; 0.01) in the sham group following inhibition of PKA and CaMKII together, whilst decay times in the OVx group remained unchanged in the presence and absence of ISO. At higher pacing rates, time to peak of the CaT decreased significantly (by 48%, p &lt; 0.01) in the OVx group but not sham with inhibition of phosphorylation.

Conclusion

Our findings suggest ovariectomy alters intracellular calcium regulation and some of these effects appear to be mediated by alterations in phosphorylation of calcium handling proteins and/or changes to sites of phosphorylation.

Short Term Outcome of Cardiac Resynchronization Therapy on Functional Recovery of Patients with Congestive Heart Failure in Bangladeshi Population

Cardiac resynchronization therapy (CRT) reduces symptoms and improves left ventricular function in patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. We analyzed the clinical and echocardiographic outcome of CRT in heart failure patients. Thirty five (35) heart failure patients were included in this prospective observational study, conducted from February 2015 to February 2016 in the Department of cardiology, National Institute of Cardiology & Vascular Disease (NICVD) hospital, Dhaka, Bangladesh. Patients underwent CRT-P (BiV pacemaker) or CRT-D (defibrillator) implantation and were followed up. Clinical, electrocardiographic and echocardiographic study were performed before and 3 months after CRT implantation. After 3 months of BiV pacing, New York Heart Association functional class has improved from 3.3±0.44 to 1.7±0.60; (p<0.001). Left ventricular end diastolic diameter was reduced from 67.9±5.20 to 61.9±5.90mm; (p<0.001) and left ventricular end systolic diameter was reduced from 56.4±6.50 to 50.5±7.20mm; (p<0.001). Ejection fraction was significantly increased from 27.5±4.3% to 38.8±6.7%; (p<0.001). The average grade of mitral regurgitation was decreased from 1.49±0.65 to 0.43±0.61; (p<0.001). The number of hospitalization was also significantly reduced from 2.51±1.44 to 0.11±0.32; (p<0.001). Among the study patients, 71.4% patient was responders, 17.1% super responders and 11.4% non-responders. Although the study was performed on a small number of patients, it can be considered that CRT had favorable hemodynamic and clinical results and reduced the need for hospitalization in our heart failure patients.

Evaluation of Preoperative Ultrasonography in Gall Stone Disease to Predict Technical Difficulties during Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is the gold standard in the treatment of gallstones. This study was carried out to determine the technical difficulties that can be encountered during laparoscopic cholecystectomy and to evaluate the role of ultrasonography in identifying patients at risk of conversion returning to open surgery. The objective of this study was to evaluate the efficacy of preoperative ultrasonography in assessing technical difficulty faced during laparoscopic cholecystectomy in gallstone disease. This was an observational comparative study which was conducted in the Department of Surgery of Shaheed Suhrawardy Medical College & Hospital, Dhaka, Bangladesh from January 2016 to January 2017. A purposive sampling method was applied to select the study sample. A total of 160 patients were included this study. Data processing and analysis were done using SPSS (statistical package for social sciences), version 20. The summarized data were presented in the form of figures and tables with due statistical interpretation. In this study, there was a total of 160 cases, among which 90(56.25%) turned out to have undergone normal laparoscopic cholecystectomies. Seventy (43.75%) were difficult, among which 6(3.75%) were converted to open cholecystectomies. Among 160 patients, 120(75%) were female and 40(25%) were male. There is a total of 136/160 (85%) patients with gallbladder wall thickness <3mm and 24/160 (15%) patients >3mm. Among the 136 patients with gallbladder wall thickness <3mm, there was difficulty in holding the gallbladder in 28(25%) cases, 28(20.6%) had undergone gallbladder perforation, 32(23.5%) had undergone moderate bleeding and only 2(1.5%) had undergone severe bleeding. Among the 24 patients with gallbladder wall thickness >3mm, there was difficulty in holding the gallbladder in 22(91.7%) cases, 18(75%) had undergone gallbladder perforation, 18(75%) had undergone moderate bleeding and only 2(8.33%) had undergone severe bleeding. It shows a total of 124/160 (77.5%) patients with normal gall bladder, 26/160 (16.25%) patients with contracted gallbladder and 10/160 (6.25%) patients with distended gallbladder. Among the 124 patients with normal gallbladder, 16(12.9%) had undergone difficult Calot's dissection, 26(21%) had undergone difficult gallbladder bed dissection, 26(21%) had undergone moderate bleeding and none had undergone severe bleeding. Among 26 patients with contracted gallbladder, 20(76.9%) underwent difficult Calot's dissection, 24(92.3%) had undergone difficult gallbladder bed dissection, 18(69.2%) had undergone moderate bleeding and 4(15.4%) had undergone severe bleeding. Among 10 patients with distended gallbladder, 4(40%) underwent difficult Calot's dissection, 6(60%) underwent difficult gallbladder bed dissection, 6(60%) had undergone moderate bleeding and none had undergone severe bleeding. From this study, we conclude that preoperative ultrasonography is a good predictor of difficulty in laparoscopic cholecystectomy in the majority of cases and should be used as a screening procedure.