Reward: Cube all three shards below level 60 to create the Sunstone of the Twin Seas.Sunstone of the Twin SeasRequired Level: 50Keep in Inventory to Gain Bonus+2 to All Skills10% Combat Speeds-5% to Enemy Fire Resistance-5% to Enemy Lightning Resistance-5% to Enemy Cold Resistance10% to All AttributesElemental Resists +10%+5% to Experience GainedAlthough the level can be accessed at level 45, you cannot cube the shards together until at least level 50.If you are past level 59, you can still do the challenge, but with the added penalty of 2 Arcane Crystals per 10 levels.
All this would be for nothing without the monster AI modifications and new abilities, elite and heroic monsters with even more powerful skills, and for advanced players there are 30 new uberquests based on Diablo lore and the challenges, which reward you for killing bosses at a low level or two of them at once.
These are special dungeons, levels or player-summoned bosses that should only be attempted by the skilled and powerful. Median XL offers 17+1 uberbosses, 8 uberlevels and 4 separate bosses, most based on Diablo lore. The uberquests range from the invasion of Toraja by the edyrem to the cursed city of Ureh (from the Diablo novel 'Kingdom of Shadow') and an uberquest that recreates the capture of Baal by Tal Rasha and the Horadrim... with you as Baal.
Completing difficult tasks and encounters at a low level or performing tricks like dodging witches or shattering stained glass windows may earn you big rewards... from powerful charms to additional new skills.
New skill trees with 210 new skills, new base items, gems, runes, uniques, runewords, sets, crafting improved monster AI and new monster types, elite and heroic monsters, 28 uberquests for advanced characters, 5 challenges. Compatible with Diablo II Lord of Destruction 1.10/1.11/1.12/1.13 (PC/Mac).
With intense deficiency of medical resources during COVID-19 pandemic, risk stratification is of strategic importance. Blood glucose level is an important risk factor for the prognosis of infection and critically ill patients. We aimed to investigate the prognostic value of blood glucose level in patients with COVID-19.
We collected clinical and survival information of 2041 consecutive hospitalized patients with COVID-19 from two medical centers in Wuhan. Patients without available blood glucose level were excluded. We performed multivariable Cox regression to calculate HRs of blood glucose-associated indexes for the risk of progression to critical cases/mortality among non-critical cases, as well as in-hospital mortality in critical cases. Sensitivity analysis were conducted in patient without diabetes.
Elevation of blood glucose level predicted worse outcomes in hospitalized patients with COVID-19. Our findings may provide a simple and practical way to risk stratify COVID-19 inpatients for hierarchical management, particularly where medical resources are in severe shortage during the pandemic.
Previously published articles found that age, gender, comorbidities, lymphocyte counts, C reactive protein, procalcitonin, D-Dimer and other cytokines were associated with prognosis of patients with COVID-19. However, the effect of blood glucose level on prognosis was never reported.
However, there was still no universally feasible laboratory index to predict the prognosis of patients with COVID-19, particularly during such a large-scale infectious disease outbreak setting. Blood glucose level is a routine test that can be carried out in virtually all clinical settings. Among patients with COVID-19, 45.2% had anomalies in blood glucose levels.3 Previous studies showed that stress hyperglycemia was an independent risk factor associated with worse outcomes among critically ill patients.6 In addition, hypoglycemia may lead to cardiovascular events, also conferring a harmful effect on prognosis.7 We therefore speculated that blood glucose levels may have predictive value on COVID-19 prognosis.
In our current study, we reviewed 2041 patients with COVID-19 from two medical centers in Wuhan City and explored the effects of blood glucose levels on the outcomes of progression to critical cases and in-hospital mortality. We sought to identify an instant and simple approach for risk stratification and hierarchical management of COVID-19 in all clinical settings.
All continuous variables were tested for normality. Data were expressed as mean and SD if normally distributed or as median and IQR otherwise. The categorical variables were presented as frequencies and percentages. Cox proportional hazard regression models were applied to evaluate the association between the multiple blood glucose indexes and prognosis. This multivariable analysis was adjusted for all factors included in the univariable analysis. The HRs and 95% CIs of Cox regression models were reported. Because patients with diabetes generally had higher glucose levels and poor outcomes than that of patients without diabetes, which may result in bias in evaluating the relationship of glucose levels with the rate of progression to critical cases/death or in-hospital mortality. Therefore, in the present study, sensitivity analysis was conducted to evaluate the association of admission blood glucose level with the risk of critical cases/death among non-critical patient without diabetes at admission. Similar analyses were also performed to evaluate the association of initial blood glucose level of critical diagnosis with in-hospital mortality among critical patients without diabetes. We used Stata/MP V.14.0 and R software (V.3.6.1) to conduct data analyses, and two-sided p values less than 0.05 were considered significant.
For 1690 non-critical cases at admission, 382 (22.6%) patients developed into critical cases/death. The 30-day rate of progression to critical cases/death among non-critical cases at admission is 28.9%. Results of univariable regression model showed that age, gender, hypertension, diabetes, chronic kidney disease, admission white cell counts, lymphocyte counts, D-Dimer, aspartate aminotransferase, alanine aminotransferase, insulin treatment, corticosteroid use, admission blood glucose, glucose coefficient of variation (CV), median blood glucose, median in-hospital glucose level, maximum blood glucose and minimum blood glucose were significantly associated with progression from non-critical cases to critical cases/death (p
As for the 697 critical cases, the time of critical diagnosis was available in 556 patients who were enrolled into the univariable and multivariable analysis. One hundred and fifty-one out of 556 patients died. The 30-day in-hospital mortality for critical cases is 30.9%. Univariable analysis revealed that age, gender, smoking history, admission white cell counts, lymphocyte counts, D-Dimer, creatinine, insulin treatment, corticosteroid use, initial blood glucose level of critical diagnosis, median blood glucose, median glucose level after critical diagnosis, maximum blood glucose and minimum blood glucose were significantly associated with in-hospital mortality (p
Based on the data from 2041 consecutive patients with COVID-19, we found that admission blood glucose level was an independent risk factor for predicting the progression to critical cases/death from non-critical cases, and initial blood glucose level of critical diagnosis was an independent risk factor for in-hospital mortality in critical cases. In addition, patients with higher median glucose level during hospital stay or after critical diagnosis had significantly poorer clinical outcomes. The above results were also confirmed in COVID-19 patients without a history of diabetes.
Interestingly, while 47.2% of the patients had admission hyperglycemia, only 13.4% of the patients had diabetes. Diabetes has been previously reported to affect the outcomes of COVID-19 cases.3 However, the predictive value of blood glucose level in patients without diabetes are more concerning in clinical practice. Elevation of the blood glucose level may represent relative hyperglycemia. Infection might trigger an inflammatory storm, which leads to insulin resistance. Infection could also induce stress and sympathetic stimulation. The SARS-CoV-2 virus might also directly attack the pancreas. All these factors may render infected COVID-19 patients more prone to hyperglycemia.14 15 Therefore, we performed analysis in patients without diabetes. Results are consistent with the overall findings. These results further illustrated that blood glucose could reliably predict the risk of hospitalized patients with COVID-19.
In summary, our study found that blood glucose level was an independent risk factor to predict the progression to critical cases/death in non-critical cases and in-hospital mortality in critical cases, whereas patients with higher median glucose level during hospital stay or after critical diagnosis had significantly poorer clinical outcomes. Our results provided a simple and practical way to risk stratify COVID-19 inpatients for hierarchical management, particularly where medical resources are in severe shortage during the pandemic.
We computed differences using unadjusted and adjusted quantile regression with the median (ie, 0.5 quantile) specified, as DAH distributions were expected to be skewed.17 18 Three adjusted models were created. The first included terms for patient-level factors. The second combined patient-level, clinician-level, intervention-level, admission-level and hospital-level factors listed above with a random intercept for the index hospital. The third added surgeon and anaesthesiologist random intercepts to the second model but was limited to individuals who had surgical fixation (this allowed us to calculate intraclass correlation coefficients (ICC) for these random intercepts).
The forest plot depicts the median adjusted difference in days alive at home after hip fracture admission and the associated 95% credible intervals based on the highes