The aetiology of maxillofacial trauma in Australia: A scoping review

BACKGROUND

The oral and maxillofacial complex is subject to a range of traumas. Injuries to the region are devastating and have a great impact on social health outcomes. This review intends to investigate the aetiologies of maxillofacial trauma across Australia.

METHODS

This review was written in accordance with the PRISMA-ScR. Comprehensive searches of CINAHL, MEDLINE, Ovid, Scopus, and Web of Science databases were conducted to identify potentially relevant literature. Quantitative observational epidemiological studies were sought and were required to include at least one aetiology to the maxillofacial region in their data set. A total of 31 eligible studies were included.

RESULTS

The greatest recorded causes of maxillofacial injuries included inter-personal violence (34.98%) falls (20.87%), sports (15.62%), and motor-vehicle accidents (14.31%). These four aetiologies cumulatively accounted for more than 85% of maxillofacial injuries. From all sustained injuries (n = 7661), the orbit was the most prevalent site of fracture (31.85%), followed by the zygoma (22.01%), mandible (21%), nasal bone (12.45%), maxilla (10.04%), dentoalveolus (1.84%), antrum (<1%), and frontal bone (<1%).

CONCLUSION

Violence was an unprecedented cause of trauma-additional research is recommended to further characterize the correlation between the two variables. Research is also recommended specifically in regional/rural communities, where data was particularly limited. © 2024 Australian Dental Association.

Fractional flow reserve and instantaneous wave-free ratio in coronary artery bypass grafting: a meta-analysis and practice review

Objective

Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear.

Methods

A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice.

Results

Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment.

Conclusions

At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy.

Systematic Review Registration

ClinicalTrials.gov, identifier (CRD42023414604).

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A luminous fast radio burst that probes the Universe at redshift 1

Fast radio bursts (FRBs) are millisecond-duration pulses of radio emission originating from extragalactic distances. Radio dispersion is imparted on each burst by intervening plasma, mostly located in the intergalactic medium. In this work, we observe the burst FRB 20220610A and localize it to a morphologically complex host galaxy system at redshift 1.016 ± 0.002. The burst redshift and dispersion measure are consistent with passage through a substantial column of plasma in the intergalactic medium and extend the relationship between those quantities measured at lower redshift. The burst shows evidence for passage through additional turbulent magnetized plasma, potentially associated with the host galaxy. We use the burst energy of 2 × 1042 erg to revise the empirical maximum energy of an FRB.

The effect of a novel, digital physical activity and emotional well-being intervention on health-related quality of life in people with chronic kidney disease: trial design and baseline data from a multicentre prospective, wait-list randomised controlled trial (kidney BEAM)

BACKGROUND

Physical activity and emotional self-management has the potential to enhance health-related quality of life (HRQoL), but few people with chronic kidney disease (CKD) have access to resources and support. The Kidney BEAM trial aims to evaluate whether an evidence-based physical activity and emotional wellbeing self-management programme (Kidney BEAM) leads to improvements in HRQoL in people with CKD.

METHODS

This was a prospective, multicentre, randomised waitlist-controlled trial, with health economic analysis and nested qualitative studies. In total, three hundred and four adults with established CKD were recruited from 11 UK kidney units. Participants were randomly assigned to the intervention (Kidney BEAM) or a wait list control group (1:1). The primary outcome was the between-group difference in Kidney Disease Quality of Life (KDQoL) mental component summary score (MCS) at 12 weeks. Secondary outcomes included the KDQoL physical component summary score, kidney-specific scores, fatigue, life participation, depression and anxiety, physical function, clinical chemistry, healthcare utilisation and harms. All outcomes were measured at baseline and 12 weeks, with long-term HRQoL and adherence also collected at six months follow-up. A nested qualitative study explored experience and impact of using Kidney BEAM.

RESULTS

340 participants were randomised to Kidney BEAM (n = 173) and waiting list (n = 167) groups. There were 96 (55%) and 89 (53%) males in the intervention and waiting list groups respectively, and the mean (SD) age was 53 (14) years in both groups. Ethnicity, body mass, CKD stage, and history of diabetes and hypertension were comparable across groups. The mean (SD) of the MCS was similar in both groups, 44.7 (10.8) and 45.9 (10.6) in the intervention and waiting list groups respectively.

CONCLUSION

Results from this trial will establish whether the Kidney BEAM self management programme is a cost-effective method of enhancing mental and physical wellbeing of people with CKD.

TRIAL REGISTRATION

NCT04872933. Registered 5th May 2021.

Bedside Index of Severity in Acute Pancreatitis (BISAP) Score on Outcome of Patients Presenting with Acute Pancreatitis in a Tertiary Care Hospital

Background Acute pancreatitis is a life-threatening condition characterized by inflammation of the pancreas causing intense abdominal pain and potential harm to multiple organs. The mortality rate is 1-5% and thus requires specialized and interdisciplinary care to inhibit it. Objective To describe the bedside index of severity in acute pancreatitis score on the outcome of acute pancreatitis patients in a tertiary care hospital. Method This is a hospital based observational cross-sectional study conducted in the internal medicine inpatient department of Dhulikhel Hospital from April 2018 and March 2019. This study reviewed the medical records of the department. Result The study included 70 participants with 44 (±14) years of average age and stating common cause as gallstone (45.7%). The study showed that those with bedside index of severity in acute pancreatitis score ≥ 3 during hospital admission had significantly higher rate of organ failure (p-value < 0.05), as well as had a prolonged hospital stay (mean: 20 [±7.9] days). The mean hospital stay was 12.9 days. Conclusion Patients with bedside index of severity in acute pancreatitis score greater than three at admission were found to have an increased risk of organ failure, significantly higher chances of requiring mechanical ventilation, and a longer duration of hospital stay.

Halting COVID-19 Requires Collective, Decentralized, and Community-Led Responses

Many global health organizations are reliant on the funding provided by a few dozen high-income countries, making them fiscally insecure and fragile, especially during times of global crises. The COVID-19 pandemic could be an opportunity to move away from this status quo to a more decentralized, multipolar, and community-led approach. The global health community can take four immediate steps in response to the pandemic to start that paradigm shift now: support more regional and country-specific responses, convince national and regional business houses and philanthropies to make up for response funding shortfalls, leverage public health advocacy to improve investments in public health infrastructure, and put community leaders and members at the frontlines of mitigation efforts.

Evaluating the impact of performance status criteria on minority eligibility for oncology clinical trials

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Background: Restrictive criteria contribute to low enrollment in clinical trials. These criteria can also amplify health disparities by reducing the racial and ethnic diversity of the cohort. Many studies show that minority patients exhibit worse Eastern Cooperative Oncology Group (ECOG) performance status than white patients. Based on clinical trial data, some researchers have hypothesized that relaxing the ECOG criterion in clinical trial criteria could improve the diversity of the cohort. However, little research exists to measure ECOG’s impact on minority eligibility. Using Real-World Data (RWD), we evaluate whether relaxing the ECOG criterion monotonically increases the racial diversity of the cohort in oncology clinical trials. Methods: We used ConcertAI’s database of US oncology Electronic Medical Record (EMR) data, which includes clinical data from CancerLinQ Discovery™. We conducted sensitivity analyses for the inclusion criteria of 16 different clinical trials across multiple cancer indications. For each trial, we created five cohorts based on five different ECOG score upper limits. For example, the first cohort only included patients who had an ECOG of 0, the second cohort included patients with an ECOG of 0 or 1, etc. We then recorded the percentage of non-white patients for the resulting cohorts. We ran simple linear regressions to measure whether the change in the percentage of non-white patients was statistically significant. Results: Relaxation in ECOG status led to no uniform change in the racial diversity of patients across the 16 trials. The limited changes we did observe were not statistically significant. Conclusions: Our findings suggest that improving diversity will require more than just relaxing ECOG restrictions, and a multi-faceted approach may be needed. Future research exploring the relationship between ECOG and diversity should control for potential confounders like age, gender, and comorbidities using multivariable models. Such research needs to also account for patients with unknown race and ECOG, which represented large parts of our study population. Such research could elucidate whether the phenomenon observed in the general population—that minority patients tend to have worse performance status than whites—holds true in the sub-population of oncology patients.[Table: see text]

Impact of trial site selection on minority patient recruitment in prostate cancer trials

1558

Background: Historically, minority patients have been underrepresented in clinical cancer trials. Despite recognition of this problem, trials in the early 2000’s showed a decrease from 10.5% to 6.2% in African American trial participation when compared to trials from the early 1990’s. The drop in trial participation is also reflected in prostate cancer trials, although Black men have a 1.76 higher prostate cancer incidence rate than White men. Using prostate cancer as an example, we investigated the impact of trial site selection on potential minority patient recruitment; thus, overcoming a major system-level barrier to trial access. Methods: We created a prostate cancer cohort by filtering our real-world data sources (CancerLinQ, Electronic Medical Office Logistics) for adult male patients with ICD10 CM code C61* or ICD9 CM code 185 on 1/1/2015 or later (cohort #1). As a pre-requisite for computing site level prostate cancer patient counts, we used claims data to attribute missing site information. Finally, to identify the most promising sites for minority trial recruitment, we ranked sites by the proportion of Black patients and the overall cohort patient count. We repeated the above steps for a subset of cohort #1, which was based on the criteria for trial NCT00887198 investigating the prostate cancer drug abiraterone (cohort #2). Results: The prostate cancer cohort (#1) had 151,261 patients, of which 99,152 (65.6%) were attributed to sites. The percentage of Black patients being treated at the top ten sites ranged from 33.0% to 66.4%, with a median of 45.2% (see table). All ten sites had participated in an interventional cancer trial, and eight had participated in prostate cancer trials. Half of them were community, and half were academic sites. The abiraterone cohort (#2) had 1,267 patients, of which 1,174 (92.7%) were attributed to sites. Among the top ten sites the Black patient percentages ranged from 23.8% to 85.7%, with a median of 39.3%. Conclusions: In an analysis of 17 recent FDA drug registration trials for prostate cancer, Black trial participation ranged from only 1.4% to 6.2%, with a median of 3.0%. In contrast, Black patients being treated at the top sites in our data ranged from 33.0% to 66.4%, with a median of 45.2% (cohort #1). The percentages for the abiraterone cohort (#2) were similar, suggesting that even after applying trial criteria the Black patient percentages remain in the double-digits at top sites. Our results demonstrate that informed trial site selection could have a substantial positive impact on minority patient recruitment. [Table: see text]

Full coverage crowns for rehabilitation of MIH affected molars: 24 month randomized clinical trial

BACKGROUND

Teeth affected with severe molar incisor hypomineralization (MIH) require extensive restorations, which do not last for a long time and often require treatment in the form of onlays or full coverage restorations.

AIM

To evaluate and compare the clinical performance of zirconia, lithium disilicate, and cast metal crowns as full-coverage restorations on MIH-affected first permanent molars (FPMs).

METHODS

60 MIH affected FPMs requiring full-coverage crowns were identified in children aged 8-15 years and were randomly allocated to the three treatment groups according to the type of full coverage restoration received using block randomization technique. After an adequate removal of the MIH defect and restoration with composite resin, the tooth preparation was done followed by fabrication of crown and its cementation using resin cement. The intergroup comparison was done on the basis of USPHS criteria, gingival, plaque scores, patient and parents acceptance through a visual analog scale to decipher their clinical performance at 6, 12, 24 months.

RESULTS

After 24 months, the crowns showed similar clinical success in terms of the criterias used to compare their clinical performance. The retention, marginal adaptation, relief from hypersensitivity, proximal contact, gingival health with no statistically significant difference among the three groups.

CONCLUSION

Based on the observations, Lithium disilicate, Zirconia and full cast metal crowns showed similar clinical success in rehabilitation of First permanent molars with severe MIH over 24 months of evaluation. The clinical success is not influenced by the material of the restoration. However, prospective studies with a longer follow-up are required to reach a more definitive conclusion.

Cardiac magnetic resonance strain and mechanical dispersion assessment in patients with chronic total coronary artery occlusion

Background

Chronic total occlusions (CTO) are a frequent angiographic finding. Viability of CTO-subtended myocardium is dependent on the presence of an adequate collateral circulation. At rest, collateral supply may be sufficient to avert ischaemia and maintain normal systolic function. However, it remains unclear whether CTO-subtended myocardium may be considered truly normal, or whether subtle functional abnormalities may be present at rest.

Purpose

To determine whether, in the absence of infarction and hibernation, CTO-subtended myocardium remains functionally normal or whether abnormalities of strain and/or mechanical dispersion may be present at rest.

Methods

In a retrospective, single centre, observational study, we studied patients with ≥1 angiographically-diagnosed CTO referred for clinical stress perfusion cardiovascular magnetic resonance (CMR), and compared healthy volunteers (HVs) with a normal stress CMR scan. CMR imaging comprised functional and scar assessment with qualitative [visual] evaluation of infarction and segmental wall motion. Patients with infarction and/or wall motion score index (WMSI) ≥1 were excluded from further analysis. In remaining CTO subjects and HVs, segmental peak systolic longitudinal strain and circumferential strain were analysed (in 3 long-axis planes and 3 short-axis planes, respectively) and mechanical dispersion for both orientations was computed. Image analysis was performed using Medis (QStrain) software blinded to all clinical information.

Results

From a total of 389 patients with ≥1 angiographically-diagnosed CTO, 68 had normal WMSI and no infarction (63.0±11.7 years, 79.4% male, LVEF 62.6±4.5%). Fifty HVs (61.1±7.0 years, 74.0% males, LVEF 61.1±5.3%) were also studied. The majority of CTO patients had concomitant coronary artery disease in at least one non-CTO vessel (n=37, 54.4%). GLS was lower in CTO patients than HVs (−21.8%±1.5% versus −24.0±1.1%; p&lt;0.0001; Figure 1). By contrast, GCS was greater in CTO patients (−32.7±2.5% versus −28.8±2.1%; p&lt;0.0001). Mechanical dispersion was increased in CTO patients (Figure 2), both longitudinally (90.3±14.6 ms in CTO patients versus 68.6±11.1 ms in HVs; p&lt;0.0001) and circumferentially (66.7±9.1 ms versus 55.3±6.6 ms, respectively; p=0.02).

Conclusion

Subclinical changes in left ventricular dynamics are present at rest in CTO patients with fully viable myocardium and no evidence of resting regional wall abnormality. Further study is warranted to evaluate the potential association between mechanical dispersion and arrhythmic events in CTO.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): NIHR Clinician Scientist Award (CS-2018-18-ST2-007 to J.R.A.) and Research Professorship award (RP-2017-08-ST2-007 to G.P.M.). Figure 1. Strain analysis. CTO vs HVFigure 2. Mechanical dispersion. CTO vs HV

Seroprevalence of Scrub Typhus in Patients Attending Dhulikhel Hospital, Kavre

Background Scrub typhus is a largely ignored tropical disease and a leading cause of undifferentiated febrile illness. It is caused by Orientia tsutsugamushi. Scrub Typhus is frequently observed in South Asian countries. However, clear epidemiological information of this disease is lacking in case of Nepal. Nepal has shown steady increase in cases of Scrub Typhus since 2015. The epidemiological data related to this disease would support the decision making and surveillance design for early outbreak detection and immediate responses including prevention and treatment of scrub typhus in Nepal. Objective To understand prevalence of Scrub Typhus in subjects who had visited outpatient department at Dhulikhel Hospital. Method In this study, we have studied antibody test data (n=784) for Scrub Typhus from 2019 to 2021. The tests were performed on serum samples of patients who had visited OPD at Dhulikhel Hospital with fever lasting more than 5 days. The kit used in analysis was Scrub Typhus Detect™ IgM ELISA Kit from InBios International. Result Out of the total subjects (n=784), 133 were positive (16.9%) for IgM antibody of Scrub Typhus. The positivity in female (18.6%) was higher than the male subjects (15.3%). The positivity rate was variable among the different age groups, with highest positivity for age group 0-14 years (25%). The seasonal variation was also observed among the seropositive cases. Conclusion Scrub Typhus being a neglected tropical disease has high prevalence. It can be postulated that female subjects and subjects of age group 0-14 years are vulnerable to the infection with Scrub Typhus. There is need to increase the surveillance of Scrub Typhus to add the knowledge for diagnosis and treatment.

Evaluation of Phytochemical, Antioxidant and Antibacterial Activities of Selected Medicinal Plants

Medicinal plants are important reservoirs of bioactive compounds that need to be explored systematically. Because of their chemical diversity, natural products provide limitless possibilities for new drug discovery. This study aimed to investigate the biochemical properties of crude extracts from fifteen Nepalese medicinal plants. The total phenolic contents (TPC), total flavonoid contents (TFC), and antioxidant activity were evaluated through a colorimetric approach while the antibacterial activities were studied through the measurement of the zone of inhibition (ZoI) by agar well diffusion method along with minimum inhibitory concentrations (MIC) by broth dilution method. The methanolic extracts of Acacia catechu and Eupoterium adenophorum showed the highest TPC (55.21 ± 11.09 mg GAE/gm) and TFC (10.23 ± 1.07 mg QE/gm) among the studied plant extracts. Acacia catechu showed effective antioxidant properties with an IC50 value of 1.3 μg/mL, followed by extracts of Myrica esculenta, Syzygium cumini, and Mangifera indica. Morus australis exhibited antibacterial activity against Klebsiella pneumoniae (ZoI: 25mm, MIC: 0.012 mg/mL), Staphylococcus aureus ATCC 25923 (ZoI: 22 mm, MIC: 0.012 mg/mL), Pseudomonas aeruginosa (ZoI; 20 mm, MIC: 0.05 mg/mL), and methicillin-resistant Staphylococcus aureus (MRSA) (ZoI: 19 mm, MIC: 0.19 mg/mL). Morus australis extract showed a broad-spectrum antibacterial activity, followed by Eclipta prostrata, and Hypericum cordifolium. Future study is recommended to explore secondary metabolites of those medicinal plants to uncover further clinical efficacy.

Assessment of differences in demographic characteristics and clinical diagnoses among black and white oncology patients with COVID

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Background: Health disparities between black and white COVID-positive patients are well documented. To help address these disparities, clinicians need to understand the specific health challenges faced by black COVID patients compared to their white counterparts. These challenges are understudied in the oncologic setting. Hence, we present the demographic and clinical features of black COVID-positive cancer patients compared to whites. Methods: We used ConcertAI’s database of oncology EMR data, which includes clinical data from CancerLinQ Discovery. We conducted two-sample t-tests and chi-squared tests to measure the differences in black and white COVID-positive cancer patients across age, gender, ethnicity, state, region, ECOG, BMI, all cancer indications, stage, and Charlson comorbidities. COVID positivity was defined using claims data. Only relevant significant results are reported to save space. Results: Table summarizes the differences in 429 black and 980 white cancer patients with COVID. Black patients were younger, more likely to have an elevated BMI, and have a higher prevalence of breast cancer, congestive heart failure, diabetes, multiple myeloma, peptic ulcer disease, and renal disease. They also had less melanoma. Results were statistically significant at 0.05 level. Analyzing only black patients by COVID status shows very similar results. Conclusions: Black cancer patients suffer from multiple comorbid conditions that increase their risk of adverse outcomes when infected with COVID-19. The CDC lists eight comorbidities that put patients at a higher risk of severe COVID infection. Black patients in our cohort have a higher prevalence of four out of eight of these conditions—elevated BMI, renal disease, congestive heart failure, and diabetes. Clinicians should inspect for these comorbidities while treating this at-risk population. [Table: see text]

Phytochemical analysis of medicinal plants of Nepal and their antibacterial and antibiofilm activities against uropathogenic Escherichia coli

BACKGROUND

A biofilm is an extracellular polymeric substance (EPS) composed of polysaccharides, proteins, nucleic acids, and lipids that impede antibiotics and immune cells, thus providing a shielded environment for bacterial growth. Due to biofilm formation, some microbes can show up to 1000 fold increased resistance towards the antibiotics than the normal planktonic forms. The study was conducted to screen the crude extracts of medicinal plants used in Nepal for their in vitro antibiofilm activities.

METHODS

Total phenolic and total flavonoid contents were determined by using a Folin-Ciocalteau reagent and aluminium trichloride method, respectively. Resazurin assay was used to determine the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC). The initial antibiofilm activities and their inhibitory concentration (IC₅₀) values were determined by the microtiter based modified crystal violet staining method.

RESULTS

Out of 25 different plant extracts were used for the study, methanolic extracts of 20 plants showed a biofilm inhibition activity against five different strong biofilm producing Escherichia coli strains. Calotropis gigantea exhibited inhibition against all five different E. coli strains with IC₅₀ values ranging from 299.7 ± 20.5 to 427.4 ± 2.7 μg/mL. Apart from that, Eclipta prostrata also showed biofilm formation inhibition, followed by Eupatorium adenophorum, Moringa oleifera, Ocimum tenuifolium, Oxalis lantifolia, Prunus persica, and Urtica parviflora. The extracts of C. gigantea, E. prostrata, Mangifera indica, O. tenuifolium, P. persica, and U. parviflora exhibited a moderate to poor MIC value ranging from 625 to 2500 μg/mL. The highest amount of phenolic content (TPC) was found in Acacia catechu followed by Morus alba, which was 38.9 and 25.1 mg gallic acid equivalents, respectively. The highest amount of flavonoid content was found in A. catechu followed by M. indica, which was 27.1 and 20.8 mg quercetin equivalents, respectively.

CONCLUSION

Extracts of C. gigantea, E. prostrata, P. persica, U. parviflora, and O. tenuifolium showed antibacterial as well as antibiofilm activity against pathogenic and strong biofilm producing E. coli. Thus, extracts or the pure compound from these medicinal plants could be used as antibiotics in the future.

A multicentre prospective double blinded randomised controlled trial of intravenous iron (ferric Derisomaltose (FDI)) in Iron deficient but not anaemic patients with chronic kidney disease on functional status

BACKGROUND

Iron deficiency (ID) is common in patients with chronic kidney disease (CKD). Intravenous (IV) iron in heart failure leads to improvement in exercise capacity and improvement in quality-of-life measurements; however, data in patients with CKD are lacking.

METHODS

The Iron and the Heart Study was a prospective double blinded randomised study in non-anaemic CKD stages 3b-5 patients with ID which investigated whether 1000 mg of IV iron (ferric derisomaltose (FDI)) could improve exercise capacity in comparison to placebo measured at 1 and 3 months post infusion. Secondary objectives included effects on haematinic profiles and haemoglobin, safety analysis and quality of life questionnaires (QoL).

RESULTS

We randomly assigned 54 patients mean (SD) age for FDI (n = 26) 61.6 (10.1) years vs placebo (n = 28; 57.8 (12.9) years) and mean eGFR (33.2 (9.3) vs. 29.1 (9.6) ml/min/1.73m2) at baseline, respectively. Adjusting for baseline measurements, six-minute walk test (6MWT) showed no statistically significant difference between arms at 1 month (p = 0.736), or 3 months (p = 0.741). There were non-significant increases in 6MWT from baseline to 1 and 3 months in the FDI arm. Haemoglobin (Hb) at 1 and 3 months remained stable. There were statistically significant increases in ferritin (SF) and transferrin saturation (TSAT) at 1 and 3 months (p < 0.001). There was a modest numerical improvement in QoL parameters. There were no adverse events attributable to IV iron.

CONCLUSION

This study demonstrated a short-term beneficial effect of FDI on exercise capacity, but it was not significant despite improvements in parameters of iron status, maintenance of Hb concentration, and numerical increases in functional capacity and quality of life scores. A larger study will be required to confirm if intravenous iron is beneficial in iron deficient non-anaemic non-dialysis CKD patients without heart failure to improve the 6MWT.

TRIAL REGISTRATION

European Clinical Trials Database (EudraCT) No: 2014-004133-16 REC no: 14/YH/1209 Date First Registered: 2015-02-17 and date of end of trail 2015-05-23 Sponsor ref R1766 and Protocol No: IHI 141.

Identifying core competencies for practicing public health professionals: results from a Delphi exercise in Uttar Pradesh, India

BACKGROUND

Ensuring the current public health workforce has appropriate competencies to fulfill essential public health functions is challenging in many low- and middle-income countries. The absence of an agreed set of core competencies to provide a basis for developing and assessing knowledge, skills, abilities, and attitudes contributes to this challenge. This study aims to identify the requisite core competencies for practicing health professionals in mid-level supervisory and program management roles to effectively perform their public health responsibilities in the resource-poor setting of Uttar Pradesh (UP), India.

METHODS

We used a multi-step, interactive Delphi technique to develop an agreed set of public health competencies. A narrative review of core competency frameworks and key informant interviews with human resources for health experts in India were conducted to prepare an initial list of 40 competency statements in eight domains. We then organized a day-long workshop with 22 Indian public health experts and government officials, who added to and modified the initial list. A revised list of 54 competency statements was rated on a 5-point Likert scale. Aggregate statement scores were shared with the participants, who discussed the findings. Finally, the revised list was returned to participants for an additional round of ratings. The Wilcoxon matched-pairs signed-rank test was used to identify stability between steps, and consensus was defined using the percent agreement criterion.

RESULTS

Stability between the first and second Delphi scoring steps was reached in 46 of the 54 statements. By the end of the second Delphi scoring step, consensus was reached on 48 competency statements across eight domains: public health sciences, assessment and analysis, policy and program management, financial management and budgeting, partnerships and collaboration, social and cultural determinants, communication, and leadership.

CONCLUSIONS

This study produced a consensus set of core competencies and domains in public health that can be used to assess competencies of public health professionals and revise or develop new training programs to address desired competencies. Findings can also be used to support workforce development by informing competency-based job descriptions for recruitment and performance management in the Indian context, and potentially can be adapted for use in resource-poor settings globally.

Measuring the resilience of health systems in low- and middle-income countries: a focus on community resilience

The concept of community resilience has gained considerable attention in the global health discussions since the Ebola outbreak of West Africa in 2014–2015. However, there are no measurement models to quantify community resilience. Without measurement models, it is unclear how to test strategies for building community resilience or to describe their likely intended and unintended results and their impact on health outcomes. We propose a measurement model for community resilience with relevant constructs and indicators to measure these constructs. We conducted a scoping review, systematically searching, screening and selecting relevant articles from two bibliographic databases (PUBMED and Google Scholar) for literature using search terms such as “resilience”, “community resilience” and “health systems resilience”. We screened 500 papers, then completed a full text review of 112 identified as relevant based on their title and abstract. A total of 27 papers and reports were retained for analysis. We then aggregated and synthesised the various definitions of community resilience and the frameworks for understanding these definitions. We identified key constructs from these frameworks and organised these constructs into domains and sub-domains. We proposed indicators to capture aspects of these domains and sub-domains and operationalised these indicators as a measurement model for quantifying community resilience in health systems. We propose a model with 20 indicators to assess community resilience. These indicators tap into various constructs from different theoretical frameworks of community resilience and are useful for assessing the level of knowledge, financial resources, and human, social and physical capital that are needed (or lacking) to respond to any types of shock, including health shock at the community level. This is an initial attempt to describe a multilevel measurement model for quantifying community resilience. This model will help to guide the development and testing of strategies for strengthening community resilience and will require further work to assess its relevance, reliability and validity in different LMIC settings.

The need for COVID-19 research in low- and middle-income countries

In the early months of the pandemic, most reported cases and deaths due to COVID-19 occurred in high-income countries. However, insufficient testing could have led to an underestimation of true infections in many low- and middle-income countries. As confirmed cases increase, the ultimate impact of the pandemic on individuals and communities in low- and middle-income countries is uncertain. We therefore propose research in three broad areas as urgently needed to inform responses in low- and middle-income countries: transmission patterns of SARS-CoV-2, the clinical characteristics of the disease, and the impact of pandemic prevention and response measures. Answering these questions will require a multidisciplinary approach led by local investigators and in some cases additional resources. Targeted research activities should be done to help mitigate the potential burden of COVID-19 in low- and middle-income countries without diverting the limited human resources, funding, or medical supplies from response activities.

Vitamin D in Infant Formula and Enteral Products by Liquid Chromatography: Collaborative Study

Results from a collaborative study of a new liquid chromatographic (LC) method for determination ofvitamin D in infant formulas and enteral products are presented. Each of 15 laboratories was provided with 11 blind duplicate samples covering a range ofapproximately 200-500 International Units/quart (normal dilution), a system suitability sample, and the U.S. Pharmacopeia ergo- and cholecalciferol standards. Product types included liquid and powder forms of milk (whey and casein), soy, and hydrolyzed protein-based infant formulas and enteral products. The method includes a single liquid-liquid extraction following saponification, solid-phase extraction,and then concentration by evaporation. An isocratic, nonaqueous, chromatographic system with reversed-phase, zero end- capped C18 column, and UV detector set at 265 nm are used. Statistical evaluation ofdata from participating laboratories showthe average reproducibility and repeatability of the method across all samples to be excellent, with RSDR and RSDr values of 13.48 and 9.44, respectively, after elimination of out liers. The LC method for determination of vitamin D in infant formulas and enteral products has been adopted by AOAC INTERNATIONAL.

Determination of Ethoxyquin in Feeds by Liquid Chromatography: Collaborative Study

Ethoxyquin is a chemical antioxidant used in feeds, ingredients, fats, and oils. A liquid chromatographic (LC) method for determination of ethoxyquin was developed. The method involves acetonitrile extraction of the sample and isocratic Cis reversed-phase chromatography with ammonium acetate buffer-acetonitrile as mobile phase and fluorescence detection. A collaborative study of the determination of ethoxyquin in various meals and extruded pet foods was conducted by The lams Company Research Laboratory. Eleven laboratories analyzed 16 samples (including 2 blind duplicates) consisting of 7 meat meals and 9 extruded pet foods. Sample means ranged from 0.25 to 289 ppm. Repeatability standard deviations ranged from 0.08 to 3.2 ppm, and repeatability relative standard deviations ranged from 4.5 to 32%. Reproducibility standard deviations ranged from 0.12 to 13 ppm, and reproducibility relative standard deviations ranged from 4.5 to 55%. The LC method for determination of ethoxyquin in feeds has been adopted first action by AOAC INTERNATIONAL.