Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case-control study

Background

Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels.

Methods

The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined).

Findings

Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50).

Interpretation

There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke.

Funding

The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

Genetic programming expressions for effluent quality prediction: Towards AI-driven monitoring and management of wastewater treatment plants

Continuous effluent quality prediction in wastewater treatment processes is crucial to proactively reduce the risks to the environment and human health. However, wastewater treatment is an extremely complex process controlled by several uncertain, interdependent, and sometimes poorly characterized physico-chemical-biological process parameters. In addition, there are substantial spatiotemporal variations, uncertainties, and high non-linear interactions among the water quality parameters and process variables involved in the treatment process. Such complexities hinder efficient monitoring, operation, and management of wastewater treatment plants under normal and abnormal conditions. Typical mathematical and statistical tools most often fail to capture such complex interrelationships, and therefore data-driven techniques offer an attractive solution to effectively quantify the performance of wastewater treatment plants. Although several previous studies focused on applying regression-based data-driven models (e.g., artificial neural network) to predict some wastewater treatment effluent parameters, most of these studies employed a limited number of input variables to predict only one or two parameters characterizing the effluent quality (e.g., chemical oxygen demand (COD) and/or suspended solids (SS)). Harnessing the power of Artificial Intelligence (AI), the current study proposes multi-gene genetic programming (MGGP)-based models, using a dataset obtained from an operational wastewater treatment plant, deploying membrane aerated biofilm reactor, to predict the filtrated COD, ammonia (NH4), and SS concentrations along with the carbon-to-nitrogen ratio (C/N) within the effluent. Input features included a set of process variables characterizing the influent quality (e.g., filtered COD, NH4, and SS concentrations), water physics and chemistry parameters (e.g., temperature and pH), and operation conditions (e.g., applied air pressure). The developed MGGP-based models accurately reproduced the observations of the four output variables with correlation coefficient values that ranged between 0.98 and 0.99 during training and between 0.96 and 0.99 during testing, reflecting the power of the developed models in predicting the quality of the effluent from the treatment system. Interpretability analyses were subsequently deployed to confirm the intuitive understanding of input-output interrelations and to identify the governing parameters of the treatment process. The developed MGGP-based models can facilitate the AI-driven monitoring and management of wastewater treatment plants through devising optimal rapid operation and control schemes and assisting the plants' operators in maintaining proper performance of the plants under various normal and disruptive operational conditions.

Adherence to antihypertensives in the United States: A comparative meta-analysis of 23 million patients

Adherence to antihypertensives is crucial for control of blood pressure. This study analyzed factors and interventions that could affect adherence to antihypertensives in the US. PubMed, Scopus, Web of Science, and Embase were searched on January 21, 2022 and December 25, 2023 for studies on the adherence to antihypertensives in the US. Nineteen studies and 23 545 747 patients were included in the analysis, which showed that adherence to antihypertensives was the highest among Whites (OR: 1.47, 95% CI 1.34-1.61 compared to African Americans). Employment status and sex were associated with insignificant differences in adherence rates. In contrast, marital status yielded a significant difference where unmarried patients demonstrated low adherence rates compared to married ones (OR: 0.8, 95% CI 0.67-0.95). On analysis of comorbidities, diabetic patients reported lower adherence to antihypertensives (OR: 0.95, 95% CI 0.92-0.97); furthermore, patients who did not have Alzheimer showed higher adherence rates. Different BMIs did not significantly affect the adherence rates. Patients without insurance reported significantly lower adherence rates than insured patients (OR: 3.93, 95% CI 3.43-4.51). Polypill users had higher adherence rates compared with the free-dose combination (OR: 1.21, 95% CI 1.2-1.21), while telepharmacy did not prove to be as effective. Lower adherence rates were seen among African Americans, uninsured, or younger patients. Accordingly, interventions such as fixed-dose combinations should be targeted at susceptible groups. Obesity and overweight did not affect the adherence to antihypertensives.

Exposure to Brucella Species, Coxiella burnetii, and Trichinella Species in Recently Imported Camels from Sudan to Egypt: Possible Threats to Animal and Human Health

Brucellosis and coxiellosis/Q fever are bacterial infections caused by Brucella species and Coxiella burnetii, respectively; camels are highly susceptible to both pathogens. Trichinellosis is a parasitic infection caused by various Trichinella nematode species. Reportedly, camels are susceptible to experimental infection with Trichinella spp., but information on this potential host species is scarce. All three infections are of zoonotic nature and thus of great public health concern. The current study aimed to determine antibodies against the three pathogens in recently imported camels (n = 491) from Sudan at the two main ports for the entrance of camels into southern Egypt using commercial indirect ELISAs. Samples were collected in two sampling periods. The seropositivity rates of Brucella spp., C. burnetii, and Trichinella spp. were 3.5%, 4.3%, and 2.4%, respectively. Mixed seropositivity was found in 1% for Brucella spp. and C. burnetii. Marked differences were found between the two study sites and the two sampling periods for Brucella. A higher rate of seropositivity was recorded in the Red Sea/older samples that were collected between 2015 and 2016 (4.3%, 17/391; odds ratio = 9.4; p < 0.030) than in those collected in Aswan/recent samples that were collected between 2018 and 2021 (0/100). Concerning C. burnetii, samples collected during November and December 2015 had a significantly higher positivity rate than the other samples (13%, 13/100; OD = 4.8; p < 0.016). The same effect was observed for antibodies to Trichinella spp., with samples collected during November and December 2015 showing a higher positivity rate than the other samples (7%, 7/100; OD = 10.9; p < 0.001). This study provides valuable information on the seroprevalence of Brucella spp. and additional novel information on C. burnetii and Trichinella spp. in recently imported camels kept in quarantine before delivery to other Egyptian regions. This knowledge can be utilized to reduce health hazards and financial burdens attributable to brucellosis, Q fever, and trichinellosis in animals and humans in Egypt.

Coexistence of nephrogenic systemic fibrosis and calciphylaxis in a gadolinium-naïve, chronic haemodialysis patient

We present a case of a man in his 40s who was on haemodialysis for over 20 years presenting with rapidly progressive decline in mobility, associated with fixed flexion deformities of joints and peau d'orange appearance of skin together with areas of ulceration that was concerning for calciphylaxis. Skin biopsies were consistent with both nephrogenic systemic fibrosis and calciphylaxis. He has never had exposure to gadolinium-based contrast agent. His treatment included daily dialysis sessions, which were challenging due to vascular access issues and three times weekly sodium thiosulfate. He rapidly declined in hospital and died within 2 weeks of presentation while being treated for a hospital-acquired pneumonia.

Wall panel structure design optimization of a hexagonal satellite

Considering that it satisfies high strength and stiffness at a low weight, the grid structure is the ideal option for meeting the requirements for developing the wall panel structure for the satellite. The most attractive grid structures for the satellite wall panel industry are isogrid and honeycomb structures. The first part of this work involves studying the mechanical and dynamic performance of five designs for the satellite wall panel made of 7075-T0 Al-alloy. These designs include two isogrid structures with different rib widths, two honeycomb structures with different cell wall thicknesses, and a solid structure for comparison. The performance of these designs was evaluated through compression, bending, and vibration testing using both finite element analysis (FEA) with the Ansys workbench and experimental testing. The FEA results are consistent with the experimental ones. The results show that the isogrid structure with a lower rib thickness of 2 mm is the best candidate for manufacturing the satellite wall panel, as this design reveals the best mechanical and dynamic performance. The second part of this work involves studying the influence of the length of the sides of the best isogrid structure in the range of 12 mm-24 mm on its mechanical and dynamic performance to achieve the lowest possible mass while maintaining the structure's integrity. Then, a modified design of skinned wall panels was introduced and dynamically tested using FEA. Finally, a CAD model of a hexagonal satellite prototype using the best-attained design of the wall panel, i.e., the isogrid structure with a 2 mm rib width and 24 mm-long sides, was built and dynamically tested to ensure its safe design against vibration. Then, the satellite prototype was manufactured, assembled, and successfully assessed.

Framework for assessing bridges construction impact on work zone traffic using BrIM

This research presents a framework for visualizing bridge construction impact on work zone traffic using Bridge Information Modelling (BrIM) and Google Maps API. The framework consists of four modules. The first module contains the construction data of the bridge by reporting the construction's daily progress. The second module is designated to model traffic data of the work zone using Google Maps API, traffic Survey counting, and Google Earth Images. The third module performs a traffic simulation for the work zone, and calculating the user cost of different stages. The fourth module visualizes the bridge's construction using Bridge Information Modelling (BrIM) and virtual reality in the Twinmotion engine to demonstrate the construction stages and the corresponding traffic states. An actual case study of El-Nahas Bridge in Cairo city-Egypt is presented to demonstrate the main features of the developed framework and its practical aspects. The case study results reveal that the impact of the construction stages varies on work zone traffic throughout the project period. The impact greatly influences the traffic status at the beginning of the project associated with high user costs. Then, the impact declines in later stages depending on the type of construction activities in each stage.

Outcomes of the Q value-based nomogram in managing pediatric versus adult keratoconus: a prospective interventional study

Background

Keratoconus (KCN) is an ectatic disorder of the cornea characterized by stromal weakness and apical protrusion of the cornea, and is associated with a gradual and painless reduction in visual acuity. KCN in pediatric patients has certain important characteristics, such as a progressive and aggressive nature. We aimed to analyze the visual, refractive, and topographic outcomes of implanting a single 210° arc-length Keraring segment according to a novel, objective, Q value-based nomogram (Q-N) for the treatment of pediatric versus adult KCN.

Methods

This prospective, multicenter, non-randomized, open-label trial included 47 eyes of 47 patients who were allocated to one of two groups. The adult group included 33 eyes of patients ≥ 18 years of age, whereas the pediatric group included 14 eyes of patients aged 14 - 17 years. All patients underwent femtosecond laser-assisted implantation of a single 210° arc-length Keraring segment according to the Q-N and were followed up for 6 months. All eyes underwent visual acuity measurement, cycloplegic refraction, and corneal topography at baseline and 6 months after surgery.

Results

The study groups were comparable in terms of sex proportions and KCN grades (both P > 0.05). The adult group exhibited significant postoperative improvements in mean uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), sphere, cylinder, spherical equivalent (SE), and Kmax (all P < 0.001) with a mean change of -0.56 logarithm of the minimal angle of resolution (logMAR), - 0.40 logMAR, 3.07 diopters (D), 0.70 D, 3.42 D, and - 5.26 D, respectively. The pediatric group exhibited significant postoperative improvements in mean UDVA, CDVA, sphere, SE, and Kmax (all P < 0.05) with a mean change of - 0.62 logMAR, - 0.34 logMAR, 3.18 D, 3.67 D, and - 5.37 D, respectively. There were no significant differences between the groups in terms of the mean change in visual, refractive, and topographic variables (all P > 0.05). No postoperative complications were observed in either group.

Conclusions

Use of the objective Q-N was efficient in the treatment of pediatric KCN, with postoperative improvements in the mean visual, refractive, and topographic parameters, comparable to outcomes in adult keratoconus. Q-N achieved good corneal remodeling with subsequent improvements in visual, refractive, and topographic outcomes in both adult and pediatric patients with keratoconus. To verify our preliminary findings, we recommend further multicenter randomized clinical trials using the Q-N nomogram in a larger sample of pediatric patients with KCN as an adjunct treatment before or after CXL.

Impact of Apolipoprotein E Genotype on Neurocognitive Function in Patients With Brain Metastases: An Analysis of NRG Oncology's RTOG 0614

PURPOSE

Whole-brain radiation therapy (WBRT) is a common treatment for brain metastases and is frequently associated with decline in neurocognitive functioning (NCF). The e4 allele of the apolipoprotein E (APOE) gene is associated with increased risk of Alzheimer disease and NCF decline associated with a variety of neurologic diseases and insults. APOE carrier status has not been evaluated as a risk factor for onset time or extent of NCF impairment in patients with brain metastases treated with WBRT.

METHODS AND MATERIALS

NRG/Radiation Therapy Oncology Group 0614 treated adult patients with brain metastases with 37.5 Gy of WBRT (+/- memantine), performed longitudinal NCF testing, and included an optional blood draw for APOE analysis. NCF test results were compared at baseline and over time with mixed-effects models. A cause-specific Cox model for time to NCF failure was performed to assess the effects of treatment arm and APOE carrier status.

RESULTS

APOE results were available for 45% of patients (n = 227/508). NCF did not differ by APOE e4 carrier status at baseline. Mixed-effects modeling showed that APOE e4 carriers had worse memory after WBRT compared with APOE e4 noncarriers (Hopkins Verbal Learning Test-Revised total recall [least square mean difference, 0.63; P = .0074], delayed recognition [least square mean difference, 0.75; P = .023]). However, APOE e4 carrier status was not associated with time to NCF failure (hazard ratio, 0.86; 95% CI, 0.60-1.23; P = .40). Memantine delayed the time to NCF failure, regardless of carrier status (hazard ratio, 0.72; 95% CI, 0.52-1.01; P = .054).

CONCLUSIONS

APOE e4 carriers with brain metastases exhibited greater decline in learning and memory, executive function, and the Clinical Trial Battery Composite score after treatment with WBRT (+/- memantine), without acceleration of onset of difference in time to NCF failure.

Anthracyclines and the risk of arrhythmias: A systematic review and meta-analysis

BACKGROUND

There have been controversial findings from recent studies regarding anthracyclines use and the subsequent risk of arrhythmias. This study aimed to evaluate the existing evidence of the risk of arrhythmias in patients treated with anthracyclines.

METHODS

PubMed, Scopus, and Web of Science databases were searched up to April 2022 using keywords such as "anthracycline" and "arrhythmia." Dichotomous data were presented as relative risk (RR) and confidence interval (CI), while continuous data were presented as mean difference (MD) and CI. Revman software version 5.4 was used for the analysis.

RESULTS

Thirteen studies were included with a total of 26891 subjects. Pooled analysis showed that anthracyclines therapy was significantly associated with a higher risk of arrhythmia (RR: 1.58; 95% CI: 1.41-1.76; P < .00001), ST segment and T wave abnormalities (RR: 1.73, 95% CI: 1.18-2.55, P = .005), conduction abnormalities and AV block (RR = 1.86, 95% CI = 1.06-3.25, P = .03), and tachycardia (RR: 1.736, 95% CI: 1.11-2.69, P = .02). Further analyses of the associations between anthracyclines and atrial flutter (RR = 1.30, 95% CI = 0.29-5.89, P = .74), atrial ectopic beats (RR: 1.27, 95% CI: 0.78-2.05, P = .34), and ventricular ectopic beats (RR: 0.93, 95% CI: 0.53-1.65, P = .81) showed no statistically significant results. Higher doses of anthracycline were associated with a higher risk of arrhythmias (RR: 1.49; 95% CI: 1.08-2.05; P = .02) compared to the lower doses (RR: 1.36; 95% CI: 1.00-1.85; P = .05). Newer generations of Anthracycline maintained the arrhythmogenic properties of previous generations, such as Doxorubicin.

CONCLUSION

Anthracyclines therapy was significantly associated with an increased risk of arrhythmias. Accordingly, Patients treated with anthracyclines should be screened for ECG abnormalities and these drugs should be avoided in patients susceptible to arrhythmia. The potential benefit of the administration of prophylactic anti-fibrotic and anti-arrhythmic drugs should also be explored.

Progression of diabetic nephropathy and vitamin D serum levels: A pooled analysis of 7722 patients

BACKGROUND AND AIM

Low serum Vitamin D levels have been associated with diabetic nephropathy (DN). Our study aimed to analyse the serum levels of vitamin D in patients suffering from DN and the subsequent changes in serum vitamin D levels as the disease progresses.

METHODS

PubMed, Embase, SCOPUS and Web of Science were searched using keywords such as '25 hydroxyvitamin D' and 'diabetic nephropathy'. We included observational studies that reported the association between the serum 25 hydroxy vitamin D levels and diabetic nephropathy without restriction to age, gender, and location. R Version 4.1.2 was used to perform the meta-analysis. The continuous outcomes were represented as mean difference (MD) and standard deviation (SD) and dichotomous outcomes as risk ratios (RR) with their 95% confidence interval (CI).

RESULTS

Twenty-three studies were included in our analysis with 7722 patients. Our analysis revealed that vitamin D was significantly lower in diabetic patients with nephropathy than those without nephropathy (MD: -4.32, 95% CI: 7.91-0.74, p-value = .0228). On comparing diabetic patients suffering from normoalbuminuria, microalbuminuria, or macroalbuminuria, we found a significant difference in serum vitamin D levels across different groups. Normoalbuminuria versus microalbuminuria showed a MD of -1.69 (95% CI: -2.28 to -1.10, p-value = .0002), while microalbuminuria versus macroalbuminuria showed a MD of (3.75, 95% CI: 1.43-6.06, p-value = .0058), proving that serum vitamin D levels keep declining as the disease progresses. Notwithstanding, we detected an insignificant association between Grade 4 and Grade 5 DN (MD: 2.29, 95% CI: -2.69-7.28, p-value = .1862).

CONCLUSION

Serum Vitamin D levels are lower among DN patients and keep declining as the disease progresses, suggesting its potential benefit as a prognostic marker. However, on reaching the macroalbuminuria stage (Grades 4 and 5), vitamin D is no longer a discriminating factor.

Application of classification machine learning algorithms for characterizing nutrient transport in a clay plain agricultural watershed

Excess nutrients in surface water and groundwater can lead to water quality deterioration in available water resources. Thus, the classification of nutrient concentrations in water resources has gained significant attention during recent decades. Machine learning (ML) algorithms are considered an efficient tool to describe nutrient loss from agricultural land to surface water and groundwater. Previous studies have applied regression and classification ML algorithms to predict nutrient concentrations in surface water and/or groundwater, or to categorize an output variable using a limited number of input variables. However, there have been no studies that examined the application of different ML classification algorithms in agricultural settings to classify various output variables using a wide range of input variables. In this study, twenty-four ML classification algorithms were implemented on a dataset from three locations within the Upper Parkhill watershed, an agricultural watershed in southern Ontario, Canada. Nutrient concentrations in surface water were classified using geochemical and physical water parameters of surface water and groundwater (e.g., pH), climate and field conditions as the input variables. The performance of these algorithms was evaluated using four evaluation metrics (e.g., classification accuracy) to identify the optimal algorithm for classifying the output variables. Ensemble bagged trees was found to be the optimal ML algorithm for classifying nitrate concentration in surface water (accuracy of 90.9%), while the weighted KNN was the most appropriate algorithm for categorizing the total phosphorus concentration (accuracy of 87%). The ensemble subspace discriminant algorithm gave the highest overall classification accuracy for the concentration of soluble reactive phosphorus and total dissolved phosphorus in surface water with an accuracy of 79.2% and 77.9%, respectively. This study exemplifies that ML algorithms can be used to signify exceedance of recommended concentrations of nutrients in surface waters in agricultural watersheds. Results are useful for decision makers to develop nutrient management strategies.

A new promising approach to urodynamic stress urinary incontinence care can help menopausal women

Introduction

The goal of this study is to evaluate the effectiveness of single-incision mini-sling in the surgical treatment of postmenopausal urodynamic stress urinary incontinence (SUI) compared to the standard trans-obturator mid-urethral sling.

Material and methods

This prospective study was carried out in two tertiary centres; Al-Azhar University Maternity & Urology Hospitals. A total of 120 postmenopausal women with urodynamic SUI were randomized to undergo either single-incision mini-sling (n = 60) or standard trans-obturator mid-urethral sling procedure (n = 60) from May 2019 until Oct 2021. Main outcome measures: efficacy was evaluated utilizing objective cure rate (cough stress test) and subjective cure rate (Sandvik incontinence severity index and International Consultations on Incontinence Questionnaire - Short Form), intraoperative and postoperative complications, and postoperative pain (using a visual analogue scale).

Results

The single-incision mini-sling (SIMS) and transobturator tape (TOT) groups had no statistically significant difference in subjective and objective cure rates (p > 0.05). Compared with the transvaginal tape O group, patients in the SIMS group had significantly less postoperative pain, shorter operative duration, and less intraoperative blood loss (all p-values < 0.05). No significant difference in perioperative complications was observed between both groups.

Conclusions

Single-incision mini-sling was superior to TOT in postmenopausal as SIMS is of similar effectiveness, more safe and minimally invasive with earlier ambulance.

Role of single nucleotide polymorphism rs2383206 on coronary artery disease risk among Saudi Population: a case-control study

OBJECTIVE

We aim to investigate the relationship between genetic variation and biological function on a genomic scale, focusing on identifying genes responsible for complex diseases using single nucleotide polymorphisms. Specifically, the study explores the association between the rs2383206 gene located on chromosome 9p21.3 and the development of coronary artery disease (CAD) in a specific Saudi population.

PATIENTS AND METHODS

This case-control study was conducted between September 2013 and May 2015 at King Abdullah Medical City (KAMC) and Al-Noor Specialist Hospital targeting the Saudi Population residing in the western region of Saudi Arabia. The study enrolled 315 cases with documented CAD and 205 controls with normal coronary arteries on coronary angiography. Genomic DNA was extracted from peripheral blood samples of both groups, and genotyping of rs2383206 was performed using the tetra-primer amplification-refractory mutation system-polymerase chain reaction (ARMS-PCR) method.

RESULTS

In this study, the prevalence of the GG genotype in rs2383206 was found to be higher in patients with CAD than in controls, with an odds ratio of 1.997 [95% confidence interval (CI): 1.176-3.394, p = 0.007]. Additionally, individuals with the GG genotype who had sedentary lifestyles, hyperlipidemia, and smoked were found to be at a higher risk for developing CAD (p = 0.003, 0.009, and 0.003, respectively). The G allele also increased the risk of CAD with an odds ratio of 1.413 (95% CI: 1.099-1.817; p = 0.004).

CONCLUSIONS

In conclusion, this study demonstrated a significant association between the rs2383206 variant located on chromosome 9p21 and the development of CAD. The findings of this study provide valuable insights into the genetic susceptibility to CAD and highlight the potential of this variant as a target for future functional studies.

Safety and efficacy of direct oral anticoagulants in bioprosthetic valves: A systematic review and meta-analysis

Background

Direct oral anticoagulants are efficient alternatives to vitamin K antagonists. There is little evidence regarding their use in patients who underwent bioprosthetic valve replacement whether surgically or through a transcatheter approach and have another indication of anticoagulation. Trials have compared different members of the DOACs family to VKAs and showed that they were at least non-inferior to VKAs with regard to safety and efficacy. However, this is still controversial. Our meta-analysis aims at providing a clearer view of their future use in this subgroup of patients.

Methods

PubMed and Cochrane were searched for randomised clinical trials and observational studies. Bleeding, stroke, and all-cause mortality were the outcomes of interest.

Results

Ten papers with a total of 4,088 patients were included. Our meta-analysis revealed no significant differences between the incidence of bleeding between DOACs and warfarin (16% vs. 17%, OR = 0.94, 95% CI [0.56-1.57], p = 0.81, I 2 = 81%). No statistical difference was found in stroke between both groups (2.5% vs. 3.3%, OR = 0.75, 95% CI [0.41-1.38], p = 0.36, I 2 = 35%). All-cause mortality was not statistically significant between both groups (9.2% vs. 13.7%, OR = 0.85, 95% CI [0.68-1.07], p = 0.16, I 2 = 56%). Interestingly, subgroup analysis of randomised controlled trials and prospective studies favoured DOACs with lower risks of both bleeding and stroke.

Conclusion

Direct oral anticoagulants appear to be at least as safe and effective as VKAs in patients with bioprosthetic valves and another indication of anticoagulation. There could be potential benefit from the use of DOACs; however, further evidence is required.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021222146, identifier CRD42021222146.

Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study

PURPOSE

In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials.

METHODS

We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021.

RESULTS

2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28.

CONCLUSIONS

HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.

ADIPONECTIN LEVELS IN GRAVES' DISEASE - SYSTEMATIC REVIEW AND META-ANALYSIS

Context

Graves' disease is the most prevalent cause of hyperthyroidism worldwide. Adiponectin, the most abundant adipokine, plays a significant role in a cluster of prevalent diseases connected to metabolic disorders.

Objective

Although the association between adiponectin and Graves' disease has been studied, the existing data is inconsistent. Therefore, we conducted this systematic review and meta-analysis to evaluate the relationship between adiponectin levels and Graves' disease.

Methods

We performed a systematic electronic search on PubMed, EMBASE, Scopus and Cochrane Library using predefined keywords. We used the NHLBI quality assessment tools to assess the included studies.

Results

There were 11 studies involving 781 subjects included in our qualitative synthesis, while 6 studies were included in our quantitative synthesis. We observed significantly increased adiponectin levels in Graves' disease patients compared to controls (MD 2.983 [95% CI 0.138-5.828]) and hypothyroidism patients (MD 3.389 [95% CI 1.332-5.446]). Nevertheless, no significant MD was observed when comparing Graves' disease patients with and without Graves' ophthalmopathy (MD -27.124 [95% CI -88.893 - 34.645]).

Conclusions

Adiponectin levels were significantly higher in patients with Graves' disease compared to controls and hypothyroidism patients. However, patients with and without Graves' ophthalmopathy did not present a significant mean difference in adiponectin levels.

Total knee replacement in a transtibial amputee

We present the case of a man in his 60s with a transtibial amputation (TTA) undergoing total knee replacement (TKR) for symptomatic osteoarthritis (OA). It is unusual to develop OA in the ipsilateral knee to TTA; and while it is postulated that this is because patients preferentially load their unaffected limb to protect the TTA-sided knee, there is also the ability to offload specific knee compartments through prosthetic adjustment. When planning TKR in such patients, it is important to consider several technical challenges in order to prevent a poor outcome. The literature is sparse with evidence to guide decision-making, and this case report and literature review aims to summarise our preoperative planning and intraoperative technique, which ultimately resulted in a good outcome.

Seroprevalence of Toxoplasma gondii and Neospora caninum in camels recently imported to Egypt from Sudan and a global systematic review

INTRODUCTION

Toxoplasma gondii and Neospora caninum are closely related intracellular protozoan parasites of medical and veterinary concern by causing abortions and systemic illness. Limited or ambiguous data on the prevalence of T. gondii and N. caninum in camels triggered us to conduct this study.

METHODS

Camels (n = 460) recently imported from Sudan and destined mainly for human consumption, were tested for specific antibodies against these protozoans using commercially available ELISAs. From the two only quarantine stations for camels from Sudan, 368 camels were sampled between November 2015 and March 2016 in Shalateen, Red Sea governorate, and 92 samples were collected between September 2018 and March 2021 from Abu Simbel, Aswan governorate.

RESULTS & DISCUSSION

Overall, seropositive rates in camels were 25.7%, 3.9% and 0.8% for T. gondii, N. caninum and mixed infection, respectively. However, marked differences were found between the two study sites and/or the two sampling periods: For T. gondii, a higher rate of infection was recorded in the Red Sea samples (31.5%, 116/368; odds ratio 20.7, 5.0-85.6; P<0.0001) than in those collected in Aswan (2.2%, 2/92). The opposite was found for N. caninum with a lower rate of infection in the Red Sea samples (0.82%, 3/368; odds ratio 23.7, 6.7-83.9; P<0.0001) than in the samples from Aswan (16.3%, 15/92). Additionally, our systematic review revealed that the overall published seroprevalence of T. gondii and N. caninum was 28.6% and 14.3% in camels worldwide, respectively. To the best of our knowledge, this study provides the first record of seroprevalence of both T. gondii and N. caninum in recently imported camels kept under quarantine conditions before delivery to other Egyptian cities and regions. In addition, our review provides inclusive data on the prevalence of T. gondii and N. caninum in camel globally. This knowledge provides basic data for the implementation of strategies and control measures against neosporosis and toxoplasmosis.

Favipiravir for the treatment of coronavirus disease 2019 pneumonia; a propensity score-matched cohort study

We retrospectively investigated the clinical outcomes of favipiravir in patients with COVID-19 pneumonia. Patients who between 23 May 2020 and 18 July 2020 received ≥ 24 h of favipiravir were assigned to the favipiravir group, while those who did not formed the non-favipiravir group. The primary outcome was 28-day clinical improvement, defined as two-category improvement from baseline on an 8-point ordinal scale. Propensity scores (PS) for favipiravir therapy were used for 1:1 matching. The unmatched cohort included 1493 patients, of which 51.7% were in the favipiravir group, and 48.3% were not receiving supplemental oxygen at baseline. Significant baseline differences between the two unmatched groups existed, but not between the PS-matched groups (N = 774). After PS-matching, there were no significant differences between the two groups in the proportion with 28-day clinical improvement (93.3% versus 92.8%, P 0.780), or 28-day all-cause mortality (2.1% versus 3.1%, P 0.360). Favipiravir was associated with more viral clearance by day 28 (79.8% versus 64.1%, P < 0.001). Adverse events were common in both groups, but the 93.9% were Grades 1-3. Favipiravir therapy for COVID-19 pneumonia is well tolerated but is not associated with an increased likelihood of clinical improvement or reduced all-cause mortality by 28 days.

Model study on real-time aeration based on nitrite for effective operation of single-stage anammox

Anaerobic ammonia oxidation (Anammox) is an innovative technology for cost-efficient nitrogen removal without intensive aeration. However, effective control of the competition between nitrite oxidizing bacteria (X_NOB) and Anammox bacteria (X_ANA) for nitrite is a key challenge for broad applications of single-stage Anammox processes in real wastewater treatment. Therefore, a real-time aeration scheme was proposed to determine dissolved oxygen (DO) based on nitrite concentration for effective control of X_NOB growth while maintaining the X_ANA activity in a single-stage Anammox process. In this study, a non-steady state mathematical model was developed and calibrated using previously reported lab-scale Anammox results to investigate the efficiency of the proposed real-time aeration scheme in enhancing the Anammox process. Based on the calibrated model simulation results, DO of about 0.10 mg-O₂/L was found to be ideal for maintaining effective nitrite creation by ammonia oxidizing bacteria (X_AOB) while slowing down the growth of X_NOB. If DO is too low (e.g., 0.01 mg-O₂/L or lower), the overall rate of the ammonia removal is limited due to slow growth of X_AOB. On the other hand, high DO (e.g., 1.0 mg-O₂/L or higher) inhibits the growth of X_ANA, resulting in dominancy of X_AOB and X_NOB. According to the simulation results, nitrite concentration was found to be a rate-limiting parameter on effective nitrogen removal in single-stage Anammox processes. We also found that nitrite concentration can be used as a real-time switch for aeration in a single-stage Anammox process. A schematic aeration method based on real-time nitrite concentration was proposed and examined to control the competition between X_ANA and X_NOB. In the model simulation, the X_ANA activity was successfully maintained because the schematic aeration prevented an outgrowth of X_NOB, allowing energy-efficient nitrogen removal using single-stage Anammox processes.

Seven gene signature explores the impact of DAAs on the appearance of hepatocellular carcinoma in HCV infected patients

HCV damages the hepatocytes ending with hepatocellular carcinoma (HCC). The direct-acting antivirals (DAAs) treatment has raised hopes for reducing the incidence of HCC. However, several scientific debate regarding the impact of DAAs on the occurrence of HCC in patients with cirrhosis. We aimed to study the Cirrhosis Risk Score (CRS), several clinical factors and tumor characteristics between patients who developed HCC either with or without DAAs treatment "DAA-exposed HCC patients" and "DAA-unexposed HCC patients".

Methods

CRS was assessed via genotyping by allelic discrimination assays in HCV patients who developed de novo HCC (with DAAs (DAA-exposed HCC patients, n = 50), and without DAAs treatment (DAA-unexposed HCC patients, n = 40)). APRI, FIB-4 scores, and tumor characteristics were assessed.

Results

Around 60% and 48% of DAA-exposed HCC patients and DAA-unexposed HCC patients; respectively had high CRS scores without significant difference. DAA-exposed HCC patients showed elevated Albumin, Hemoglobin and decreased ALT, AST compared with DAA-unexposed HCC patients (P = 0.002, 0.04, <0.001 and 0.006; respectively). FIB4 and APRI didn't reach the statistical difference between the studied groups. DAA-exposed HCC patients have higher overall survival (OS) than DAA-unexposed HCC patients (median: 30 & 15 months; respectively (p = 0.019)). Moreover, no significant differences were observed between the two groups in their focal lesion characteristics.

Conclusion

All studied patients are genetically predisposed to develop HCC. Moreover, DAAs significantly improved the OS and the biochemical parameters. No differences between the two groups were detected regarding their tumor characteristics. Accordingly, the appearance of HCC after treatment is attributed to the natural course of cirrhosis.

The Influence of Ballistic Exercises on Growth, Somatomedin Hormones for Soccer Players

BACKGROUND: The sequence of exercise-induced hormonal changes demonstrates the quantification of training and competition loads and developing a sport-specific conditioning program. AIM: The present study investigates the impact of ballistic exercises on biochemical variables and the muscular ability of soccer players. METHODS: Participants were assigned randomly to two groups, including ten participants in each group, and underwent a pre- post-intervention test, including growth hormone, somatomedin hormone, triple jump, and wide jump. RESULTS: The experimental group showed a significant increase in Growth by 43.56%, somatomedin by 6.99%, Triple jumps by 18.65%, and Wide jump by 15.68% compared to the control group. CONCLUSION: In conclusion, ballistic exercises improved growth and somatomedin hormone, triple jump, and wide jump and thus enhancing biochemical variables and muscular ability.

Association of Lipids, Lipoproteins, and Apolipoproteins with Stroke Subtypes in an International Case Control Study (INTERSTROKE)

Background and Purpose The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes.Methods Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH).Results Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (<i>P</i><0.0001). Conclusions The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.

Modulatory role of garlic ( Allium sativum) extract against cisplatin- induced nephrotoxicity in female albino rats and their offspring

Background: Cisplatin (CP) is one of the chemotherapeutic drugs widely utilized in the treatment of several malignancies. However, recently; its use has been limited because of its hazardous health drawbacks. Previous researches confirmed that CP has severe deleterious side effects on pregnant mothers and their fetuses. Garlic ( Allium sativum) extract has been claimed to exhibit potent antioxidative and free radical scavenging abilities. Aim: This work is mainly designed to evaluate the potential therapeutic role of garlic extract against CP-induced nephrotoxicity in pregnant rats and their offspring. Methods: 24 pregnant rats were used in the current study. They were randomly allocated into four groups (n=6):  control, garlic, CP, and CP + garlic group. At the end of the weaning period, the mothers and the offsprings of all groups were sacrificed, the kidneys were immediately excised, and processed for histological and biochemical investigations. Also, blood samples were withdrawn and processed for estimation of the assigned biochemical parameters.   Results: The renal histological sections from CP-treated mother rats displayed pronounced histopathological lesions however, their offspring showed mild renal histopathological lesions if compared with those of their mothers. The levels of renal tissue Superoxide dismutase, catalase, and glutathione peroxidase enzymes were significantly decreased. On the contrary, the levels of malondialdehyde, serum urea, and creatinine were significantly increased in CP-treated mother rats and their offspring as compared with control. The percentage value of caspase 3 activity was markedly elevated in the renal tissues of CP-treated mother rats and their offspring compared to the control group. Supplementation of garlic extract to the CP treated rats; the overall histological lesions, as well as biochemical parameters, were restored nearly to the control ones. It is concluded that garlic ( Allium sativum) extract has a powerful ameliorative role against CP-induced nephrotoxicity in pregnant rats and their offspring.

Darunavir-cobicistat versus lopinavir-ritonavir in the treatment of COVID-19 infection (DOLCI): A multicenter observational study

Background

Coronavirus Disease 2019 (COVID-19) is an evolving pandemic that urged the need to investigate various antiviral therapies. This study was conducted to compare efficacy and safety outcomes of darunavir-cobicistat versus lopinavir-ritonavir in treating patients with COVID-19 pneumonia.

Methods and findings

This retrospective, multicenter, observational study was conducted on adult patients hospitalized in one of the COVID-19 facilities in Qatar. Patients were included if they received darunavir-cobicistat or lopinavir-ritonavir for at least three days as part of their COVID-19 treatments. Data were collected from patients’ electronic medical records. The primary outcome was a composite endpoint of time to clinical improvement and/or virological clearance. Descriptive and inferential statistics were used at alpha level of 0.05. A total of 400 patients was analyzed, of whom 100 received darunavir-cobicistat and 300 received lopinavir-ritonavir. Majority of patients were male (92.5%), with a mean (SD) time from symptoms onset to start of therapy of 7.57 days (4.89). Patients received lopinavir-ritonavir had significantly faster time to clinical improvement and/or virological clearance than patients received darunavir-cobicistat (4 days [IQR 3–7] vs. 6.5 days [IQR 4–12]; HR 1.345 [95%CI: 1.070–1.691], P = 0.011). Patients received lopinavir-ritonavir had significantly faster time to clinical improvement (5 days [IQR 3–8] vs. 8 days [IQR 4–13]; HR 1.520 (95%CI: 1.2–1.925), P = 0.000), and slower time to virological clearance than darunavir-cobicistat (25 days [IQR 15–33] vs. 21 days [IQR 12.8–30]; HR 0.772 (95%CI: 0.607–0.982), P = 0.035). No significant difference in the incidence or severity of adverse events between groups. The study was limited to its retrospective nature and the possibility of covariates, which was accounted for by multivariate analyses.

Conclusion

In patients with COVID-19 pneumonia, early treatment with lopinavir-ritonavir was associated with faster time to clinical improvement and/or virological clearance than darunavir-cobicistat. Future trials are warranted to confirm these findings.

Trial registration

ClinicalTrials.gov number, NCT04425382.

Estimation of kinetic constants in high-density polyethylene bead degradation using hydrolytic enzymes

Microplastic beads are an emerging contaminant that can cause serious environmental and public health problems. Potential bypass of microplastic beads from wastewater to sludge treatment systems is a key challenge in the conventional wastewater treatment process. Moreover, there are no systematic studies on microplastic bead degradation by hydrolytic enzymes that are rich in concentration within wastewater and sludge treatment processes (e.g., anaerobic digestion (AD)). In this study, lab-scale experiments were conducted to investigate the degradation of high-density polyethylene beads by hydrolytic enzymes (e.g., lipase) under various experimental conditions (e.g., temperature). In a 3-day batch experiment, protease was most effective in polyethylene bead degradation as 4.0% of the initial bead mass was removed at an enzyme concentration of 88 mg/L under thermophilic temperature (55 °C). It was also found that the increasing enzyme concentration and high temperature enhanced the polyethylene bead degradation. In a separate 7-day experiment with repeated doses of protease, 23.3% of the initial mass of beads was removed at thermophilic temperature, indicating that AD with a long retention time (e.g., 20 days) and heated temperature has a significant potential for polyethylene bead degradation. A mathematical model was developed and calibrated using the experimental results to estimate the kinetic constant of the high-density polyethylene bead reduction by an enzyme (k_1,i) and enzyme self-decay constant (k_2,ii). The calibrated k_1,i ranged from 5.0 to 8.1× 10^-4 L/mg/hr while k_2,ii was 0.44-1.10 L/mg/hr. Using the calibrated model, degradation of polyethylene beads using a mixture of cellulase and protease was simulated, considering an interactive-decay reaction between the two enzymes. The calibrated model was used to simulate the polyethylene bead degradation in AD where 70-95% of the initial bead mass was removed at typical retention time under mesophilic digestion (37.5 °C). Based on the experimental and simulation results, it can be concluded that hydrolytic enzymes can be an efficient technology for large-scale high-density polyethylene bead removal applications.

NEW OXPHOS REGULATING COMPOUND – AUPHOS – INCREASES MITOCHONDRIAL COMPLEXES EXPRESSION IN MURINE AND HUMAN INTESTINAL EPITHELIAL CELLS

INTRODUCTION

Mitochondrial dysfunction in intestinal epithelial cells (IEC) is a critical driver in the failure to heal chronic ulceration in IBD(1). OXPHOS is important for differentiation and cell polarity in repairing IEC(2,3). The development of new IBD drugs that improve mitochondria function would potentially accelerate mucosal repair and enhance overall clinical management of refractory patients. For this study, we tested the efficacy of a novel oral agent (AuPhos) that localized to mitochondria where it increases respiration (Wempe et al CCC, 2022) and mitochondrial energy production.

METHODS

Colonic IEC proteins from control and AuPhos-treated DSS mice were examined as described elsewhere (Wempe et al CCC, 2022). Both human biopsy and tissues from mice with reduced IEC mitochondria [VilCre/mTmG/TFAMfl/fl (IEC-TFAM-/-)](Abomhya et al CCC 2022) were incubated with AuPhos (0.2; 0.5; 1 μM for biopsies and 0.5 μM for mice) or vehicle for 3 hrs. at +4oC with rotation. N=4 mice/group.

RESULTS

In membranous IEC fractions of control mice, AuPhos increased protein expression of mitochondrial complexes (Mito-Cpx) (V – 50%, III – 52%, IV – 40%). DSS treatment decreased baseline expression dramatically (V – 62%, III – 56%, II - 69%; IV – 75%). AuPhos in DSS mice increased expression of complex V by 48%, III – 35%, II – 68%, IV – 55% {A,B}. Expression of transcriptional factors PGC1a and Nrf2, which regulate mitochondria biogenesis, were increased in nuclear IEC fractions of DSS mice by 50% and 43% respectively {C,D}. Mito-Cpx and TFAM levels increased in AuPhos-treated human biopsies in a dose dependent manner {E}. AuPhos normalized mitochondrial complex levels in tissue (3h) taken from mice with attenuated mitochondrial respiration (IEC-TFAM-/-).

CONCLUSION

AuPhos increases expression of mitochondrial complexes in human and in two different murine models. The results of biochemical signaling studies suggest increased mitochondrial respiration enhances PGC1a and Nrf2 levels which are upstream of TFAM, the major transcription factor for mitochondrial biogenesis. Our lab is currently investigating this novel compound as a means for improving mucosal metabolism and accelerating mucosal repair in IBD. (Wempe et al CCC, 2022)

1 Kugathasan, S. et al. Prediction of complicated disease course for children newly diagnosed with Crohn’s disease: a multicentre inception cohort study. Lancet389, 1710-1718, doi:10.1016/S0140-6736(1730317-3) (2017).

2 Rodriguez-Colman, M. J. et al. Interplay between metabolic identities in the intestinal crypt supports stem cell function. Nature543, 424-427, doi:10.1038/nature21673 (2017).

3 Schell, J. C. et al. Control of intestinal stem cell function and proliferation by mitochondrial pyruvate metabolism. Nat Cell Biol19, 1027-1036, doi:10.1038/ncb3593 (2017).

P-EGS01 Cholecystectomy after gall stone pancreatitis

Background

According to the UK guidelines for the management of acute pancreatitis commissioned by the British Society of Gastroenterology,

All patients presenting with gallstone pancreatitis should be considered for cholecystectomy when they are well enough to undergo surgery. In cases of mild biliary pancreatitis, cholecystectomy should ideally be performed during the index admission or within 2 weeks of discharge as interval cholecystectomy is associated with a significant risk of readmission for recurrent biliary events.

In cases of severe gallstone pancreatitis, cholecystectomy may need to be delayed until collections have improved, unless the patient is well enough for surgery and the gallbladder is some distance from the collection

Methods

Methods

Inclusion Criteria

Exclusion Criteria

Results

80 patients were collected during the study period, 96 % of them were classified as mild pancreatitis

Cholecystectomy rate

Total percentage of cholecystectomies performed for mild gall stone pancreatitis during index admission or within 2 weeks from discharge : 37%

Percentage of early cholecystectomies for eligible patients (i.e.after ruling out unfit patients, patients declining treatment, previous cholecystectomy..etc) : 54%

Re-admission rate

Re-admission rate for early cholecystectomy patients : 7.4%

Re-admission rate for delayed cholecystectomy patients : 20.7%

Conclusions

508. Title Favipiravir for the Treatment of Coronavirus Disease 2019; A Propensity Score Matched Cohort Study

Background

We investigated clinical outcomes of favipiravir in patients with COVID-19 pneumonia.

Methods

Patients who between 23 May 2020 and 18 July 2020 received ≥24 hours of favipiravir were assigned to the favipiravir group, while those who did not formed the non-favipiravir group. The primary outcome was 28-day clinical improvement, defined as two-category improvement from baseline on an 8-point ordinal scale. Propensity scores (PS) for favipiravir therapy were used for 1:1 matching. Cox regression was used to examine associations with the primary endpoint.

Results

The unmatched cohort included 1,493 patients, of which 51.7% were in the favipiravir group, and 48.3% were not receiving supplemental oxygen at baseline (table 1). Favipiravir was started within a median of 5 days from symptoms onset. Significant baseline differences between the two unmatched groups existed, but not between the PSmatched groups (N = 774) (table 1). After PS-matching, there were no significant differences between the two groups in the proportion with 28-day clinical improvement (93.3% versus 92.8%, P 0.780), or 28-day all-cause mortality (2.1% versus 3.1%, P 0.360) (Table 2). Favipiravir was associated with more viral clearance by day 28 (79.8% versus 64.1%, P < 0.001) (table 2). In the adjusted Cox proportional hazards model, favipiravir therapy was not associated 28-day clinical improvement (adjusted hazard ratio 0.978, 95% confidence interval 0.862 –1.109, P 0.726) (Table 3).

Conclusion

Favipiravir therapy for COVID-19 pneumonia is well tolerated but is not associated with an increased likelihood of clinical improvement or reduced all-cause mortality by 28 days.

Disclosures

All Authors: No reported disclosures

Flow vorticity relationships with right ventricular geometry in adult tetralogy of Fallot

Background

Repaired tetralogy of Fallot adults (rToF) undergo right ventricular (RV) remodeling, in part due to volume overload of residual pulmonary regurgitation volume (PRV). Time-resolved phase-contrast cardiac magnetic resonance imaging (4D Flow MRI) enables the qualitative and quantitative measurement of altered blood flow patterns, including vorticity. Cardiac atlases allow for complex three-dimensional heart shapes to be expressed as morphometric scores. Those scores show the extent of geometrical shift and can help explore uncharted relationships between vorticity and architecture.

Purpose

We aimed to quantify vorticity, incorporating deep learning to enhance 4D Flow data, and correlate this with global cardiac parameters and morphometric scores.

Methods

12 Adult rToF patients and 10 age-matched controls underwent 4D flow MRI and cine imaging. RV interventricular vorticity was calculated for outflow and inflow tracts. EDV, ESV and SV were computed from cines which were also used to build three-dimensional shape models.

The biventricular models were projected onto an atlas generated from 95 rToF patients, and twenty-one principal component analysis shape modes were correlated with cardiac metrics and vorticity to identify global shape variations. Association between biventricular shape and vorticity was further analysed using multivariate multiple regression models.

Results

Strong correlation was found between PRV and the right ventricular outflow tract (RVOT) vorticity. PRV and RVOT vorticity both correlated with the same 3 shape modes (r=−0.55, −0.50 and 0.6 (p&lt;0.05) respectively for PR and r=0.63, −0.82 and 0.60 (p&lt;0.05) respectively for vorticity) i.e., the RV dilates with an increase in basal bulging, apical bulging and tricuspid annulus tilting with more severe regurgitation, as well as a smaller LV, and a paradoxical movement of the septum (Figure 1). However, RV vorticity correlated with 2 modes that did not correlate with PRV, (r=−0.62, −0.69, p&lt;0.05). With higher vorticity the RV was longer, increased tilting of the tricuspid annulus and an increased basal bulge around the tricuspid area. The multivariate analysis model demonstrated that higher vorticity was associated with displacement of the pulmonary valve and change in the RVOT length and direction. A septal displacement towards the left ventricle was observed and increased apical flatness of the RV (Figure 1). Qualitatively, vorticity in rToF group was more heterogeneous than controls (Figure 2).

Conclusions

Vorticity is a novel marker based on the influence of blood motion providing new insight into early diagnosis and prognosis of cardiac disease. This is the first study to examine the relationships between vorticity and regional RV shape changes in rToF. Mode associations with vorticity were different to associations with PRV. More longitudinal studies are required for standardization of change in vorticity with the disease process.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The New Zealand heart foundation Mode variations and morphometric modelVorticity visualization and analysis

Health system and patient-level factors serving as facilitators and barriers to rheumatic heart disease care in Sudan

BACKGROUND

Rheumatic heart disease (RHD) remains a leading cause of morbidity and mortality in Sub-Saharan Africa despite widely available preventive therapies such as prophylactic benzathine penicillin G (BPG). In this study, we sought to characterize facilitators and barriers to optimal RHD treatment with BPG in Sudan.

METHODS

We conducted a mixed-methods study, collecting survey data from 397 patients who were enrolled in a national RHD registry between July and November 2017. The cross-sectional surveys included information on demographics, healthcare access, and patient perspectives on treatment barriers and facilitators. Factors associated with increased likelihood of RHD treatment adherence to prophylactic BPG were assessed by using adjusted logistic regression. These data were enhanced by focus group discussions with 20 participants, to further explore health system factors impacting RHD care.

RESULTS

Our quantitative analysis revealed that only 32% of the study cohort reported optimal prophylaxis adherence. Younger age, reduced primary RHD healthcare facility wait time, perception of adequate health facility staffing, increased treatment costs, and high patient knowledge about RHD were significantly associated with increased odds of treatment adherence. Qualitative data revealed significant barriers to RHD treatment arising from health services factors at the health system level, including lack of access due to inadequate healthcare staffing, lack of faith in local healthcare systems, poor ancillary services, and patient lack of understanding of disease. Facilitators of RHD treatment included strong interpersonal support.

CONCLUSIONS

Multiple patient and system-level barriers to RHD prophylaxis adherence were identified in Khartoum, Sudan. These included patient self-efficacy and participant perception of healthcare facility quality. Strengthening local health system infrastructure, while enhancing RHD patient education, may help to improve treatment adherence in this vulnerable population.

Unicompartmental knee arthroplasty versus High tibial osteotomy in treatment of isolated medial compartment Osteoarthritis of knee: A Systematic Review and MetaAnalysis

Background

Several surgical procedures have been mentioned to treat medial compartment osteoarthritis (OA), as total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO).

Objectives

The aim of the study is a systematic review & meta analysis conducted to compare the outcomes between UKA & HTO in different types of patients diagnosed as an isolated medial compartment OA who treated with UKA or HTO and statistically compare between their results of pain, range of motion, complications, and i ncidence of revision to TKA using studies published between 2009 to 2019 from any country.

Patients and Methods

The review will be restricted to Randomized controlled trials (RCTs), clinical trials, and comparative studies, either prospective or retrospective, which studied the outcome of HTO versus UKA of isolated medial compartment osteoarthritis patients, articles published in English &published during 2009 to 2019.

Results

About 150 articles were found using search keywords. By filtration and screening of the title and exclusion of unrelated articles, about 60 articles were found. By applications of all inclusion and exclusion criteria, only 12 articles were fit to undergo this meta-analysis.

Conclusion

In conclusion, there were no significant differences in the pain score, knee score, complication rate and revision rate to TKA between HTO and UKA, while the HTO group manifested superior ROM compared to the UKA group. So, HTO may be convenient for patients with high activity requirements. Over time, both groups exhibited increased revision rates with the deteriorated clinical outcomes. Therefore when deciding on a therapeutic plan, the ability to revise these failed choices of treatment to a total knee arthroplasty should be a major consideration. This may assist surgeons in their choice. Based on the findings of current meta-analysis, it appears that the two groups have the same efficiency and safety in the treatment of medial knee OA.

Corynebacterium Bovis: A Rare Case of Persistent Bacterial Keratitis and Corneal Perforation

We report a rare case of severe, non-contact lens-related Corynebacterium bovis corneal infection on a background of viral keratitis, resulting in corneal abscess formation with subsequent corneal perforation. An 89-year-old Caucasian lady presented with a significant epithelial defect and a dense stromal infiltrates on a background of herpes zoster keratitis, ultimately resulting in corneal perforation. Enrichment culture obtained from corneal scraping isolated the unusual organism Corynebacterium bovis. This was treated with a combination of culture-directed, targeted course of antibiotics and surgical interventions. To the best of our knowledge, this is the first reported case of profuse bacterial keratitis secondary to Corynebacterium bovis infiltration, on a background of viral keratitis, resulting in corneal abscess formation and subsequent perforation. This report highlights this rare bacterium’s characteristics including its pathogenicity in causing severe corneal disease, particularly in immunosuppressed environments such as in this case, apparent antibiotic sensitivities & resistance, and potential transmission route.

Incidence of Iatrogenic Lumbar Spinal Instability after Laminectomy, Discectomy or Facetectomy

OBJECTIVE: This thesis aim to report the incidence of iatrogenic spinal instability that occurs after laminectomy, discectomy or facetectomy in Lumbar spine surgery. METHODS: This is a prospective study of 50 cases of degenerative lumbar spondylosis complaining of various symptoms of claudication, sciatica and back pain which were surgically managed by laminectomy according to the level of stenosis in the period between October 2018 and October 2020 in the neurosurgery department at Cairo university hospitals. Mesial facetectomy was added according to the degree of stenosis if needed. Some patients needed discectomy if sciatica was an eminent symptom. RESULTS: Out of 50 patients included: 9 patients (18%) developed postoperative instability. The number of levels operated on and the degree of mesial facetectomy were found to be variables that may affect postoperative stability. CONCLUSION: Iatrogenic instability may result from large laminectomy and extensive facetectomy for lumbar stenosis in patients who do not have obvious pre-existing instability. Key words: Iatrogenic spinal instability - Laminectomy - conventional open discectomy - Mesial facetectomy.

"Put the what, where? Cut here?!" challenges to coordinating attention in robot-assisted surgery: a microanalytic pilot study

INTRODUCTION

During robot-assisted surgery (RAS), changes to the operating room configuration pose challenges to communication by limiting team members' ability to see one another or use gesture. Referencing (the act of pointing out an object or area in order to coordinate action around it), may be susceptible to miscommunication due to these constraints.

OBJECTIVES

Explore the use of microanalysis to describe and evaluate communicative efficiency in RAS through examination of referencing in surgical tasks.

METHODS

All communications during ten robot-assisted pelvic surgeries (radical cystectomies and prostatectomies) were fully transcribed. Forty-six referencing events were identified within these and subjected to a process of microanalysis. Microanalysis employs detailed transcription of speech and gesture along with their relative timing/sequencing to describe and analyse interactions. A descriptive taxonomy for referencing strategies was developed with categories including references reliant exclusively on speech (anatomic terms/directional language and context dependent words (CD)); references reliant exclusively on gesture or available aspects of the environment (point/show, camera focus/movement in the visual field and functional movement); and references reliant on the integrated use of speech and gesture/environmental support (integrated communication (IC)). Frequency of utilisation and number/percent 'miscommunication', were collated within each category when miscommunication was defined as any reference met with incorrect or no identification of the target.

RESULTS

IC and CD were the most frequently used strategies (45% and 26%, respectively, p≤0.01). Miscommunication was encountered in 22% of references. The use of IC resulted in the fewest miscommunications, while CD was associated with the most miscommunications (42%). Microanalysis provided insight into the causes and nature of successful referencing and miscommunication.

CONCLUSIONS

In RAS, surgeons complete referencing tasks in a variety of ways. IC may provide an effective means of referencing, while other strategies may not be adequately supported by the environment.

Renal Impairment and Risk of Acute Stroke: The INTERSTROKE Study

BACKGROUND

Previous studies reported an association of renal impairment with stroke, but there are uncertainties underpinning this association.

AIMS

We explored if the association is explained by shared risk factors or is independent and whether there are regional or stroke subtype variations.

METHODS

INTERSTROKE is a case-control study and the largest international study of risk factors for first acute stroke, completed in 27 countries. We included individuals with available serum creatinine values and calculated estimated glomerular filtration rate (eGFR). Renal impairment was defined as eGFR <60 mL/min/1.73 m2. Multivariable conditional logistic regression was used to determine the association of renal function with stroke.

RESULTS

Of 21,127 participants, 41.0% were female, the mean age was 62.3 ± 13.4 years, and the mean eGFR was 79.9 ± 23.5 mL/min/1.73 m2. The prevalence of renal impairment was higher in cases (22.9% vs. 17.7%, p < 0.001) and differed by region (p < 0.001). After adjustment, lower eGFR was associated with increased odds of stroke. Renal impairment was associated with increased odds of all stroke (OR 1.35; 95% CI: 1.24-1.47), with higher odds for intracerebral hemorrhage (OR 1.60; 95% CI: 1.35-1.89) than ischemic stroke (OR 1.29; 95% CI: 1.17-1.42) (pinteraction 0.12). The largest magnitudes of association were seen in younger participants and those living in Africa, South Asia, or South America (pinteraction < 0.001 for all stroke). Renal impairment was also associated with poorer clinical outcome (RRR 2.97; 95% CI: 2.50-3.54 for death within 1 month).

CONCLUSION

Renal impairment is an important risk factor for stroke, particularly in younger patients, and is associated with more severe stroke and worse outcomes.

Urinary Sodium and Potassium, and Risk of Ischemic and Hemorrhagic Stroke (INTERSTROKE): A Case-Control Study

BACKGROUND

Although low sodium intake (<2 g/day) and high potassium intake (>3.5 g/day) are proposed as public health interventions to reduce stroke risk, there is uncertainty about the benefit and feasibility of this combined recommendation on prevention of stroke.

METHODS

We obtained random urine samples from 9,275 cases of acute first stroke and 9,726 matched controls from 27 countries and estimated the 24-hour sodium and potassium excretion, a surrogate for intake, using the Tanaka formula. Using multivariable conditional logistic regression, we determined the associations of estimated 24-hour urinary sodium and potassium excretion with stroke and its subtypes.

RESULTS

Compared with an estimated urinary sodium excretion of 2.8-3.5 g/day (reference), higher (>4.26 g/day) (odds ratio [OR] 1.81; 95% confidence interval [CI], 1.65-2.00) and lower (<2.8 g/day) sodium excretion (OR 1.39; 95% CI, 1.26-1.53) were significantly associated with increased risk of stroke. The stroke risk associated with the highest quartile of sodium intake (sodium excretion >4.26 g/day) was significantly greater (P < 0.001) for intracerebral hemorrhage (ICH) (OR 2.38; 95% CI, 1.93-2.92) than for ischemic stroke (OR 1.67; 95% CI, 1.50-1.87). Urinary potassium was inversely and linearly associated with risk of stroke, and stronger for ischemic stroke than ICH (P = 0.026). In an analysis of combined sodium and potassium excretion, the combination of high potassium intake (>1.58 g/day) and moderate sodium intake (2.8-3.5 g/day) was associated with the lowest risk of stroke.

CONCLUSIONS

The association of sodium intake and stroke is J-shaped, with high sodium intake a stronger risk factor for ICH than ischemic stroke. Our data suggest that moderate sodium intake-rather than low sodium intake-combined with high potassium intake may be associated with the lowest risk of stroke and expected to be a more feasible combined dietary target.

Development of a gene signature for predicting cirrhosis risk score of chronic liver disease associated with HCV infection in Egyptians

BACKGROUND

Complex diseases such as fibrosis are likely polygenic. Lately, cirrhosis risk score (CRS) clearly discriminated Chronic HCV patients with high-risk versus those with low-risk for cirrhosis better than clinical factors.

METHODS

Herein, the CRS was assessed via genotyping by allelic discrimination assays in 243 HCV Egyptian patients categorized into 164 patients didn't develop HCC (93 mild, 71 advanced fibrosis); and 79 patients developed HCC. APRI and FIB-4 scores were calculated, compared with CRS and correlated with degree of fibrosis progression.

RESULTS

Median of the three CRS, APRI and FIB-4 scores were significantly elevated in late fibrotic and HCC patients (p < 0.001); however CRS displayed proper discrimination (mild fibrosis (0.59; 0.4-0.75), advanced fibrosis (0.75; 0.7-0.86) and HCC (0.73; 0.57-0.77); (p < 0.001)). The ROC analysis of CRS score displayed modest accuracy to discriminate between mild and advanced fibrotic patient; AUC was 0.73; p < 0.0001), while AUC was only 0.57 (p = 0.05) for the discrimination between HCC and no HCC. Moreover, the combination of CRS, APRI and FIB4 lessened the power of correlation (AUC, 0.63 (p < 0.0001)) in fibrosis prognosis. In HCC prognosis, the combination of CRS, APRI and FIB4 in HCC patients showed modest accuracy with AUC, 0.59 (p = 0.0001).

CONCLUSION

The diagnostic accuracy of FIB-4 for predicting liver fibrosis was nearly identical to that of CRS, however the strength of CRS score stemmed from that it is built on 7 SNPs host genetic factor. Our study validates non invasive algorithms for fibrosis prognosis purposes which may aid in decision making for therapeutic intervention.

Deep learning-enabled imaging flow cytometry for high-speed Cryptosporidium and Giardia detection

Imaging flow cytometry has become a popular technology for bioparticle image analysis because of its capability of capturing thousands of images per second. Nevertheless, the vast number of images generated by imaging flow cytometry imposes great challenges for data analysis especially when the species have similar morphologies. In this work, we report a deep learning-enabled high-throughput system for predicting Cryptosporidium and Giardia in drinking water. This system combines imaging flow cytometry and an efficient artificial neural network called MCellNet, which achieves a classification accuracy >99.6%. The system can detect Cryptosporidium and Giardia with a sensitivity of 97.37% and a specificity of 99.95%. The high-speed analysis reaches 346 frames per second, outperforming the state-of-the-art deep learning algorithm MobileNetV2 in speed (251 frames per second) with a comparable classification accuracy. The reported system empowers rapid, accurate, and high throughput bioparticle detection in clinical diagnostics, environmental monitoring and other potential biosensing applications.

Variations in knowledge, awareness and treatment of hypertension and stroke risk by country income level

OBJECTIVE

Hypertension is the most important modifiable risk factor for stroke globally. We hypothesised that country-income level variations in knowledge, detection and treatment of hypertension may contribute to variations in the association of blood pressure with stroke.

METHODS

We undertook a standardised case-control study in 32 countries (INTERSTROKE). Cases were patients with acute first stroke (n=13 462) who were matched by age, sex and site to controls (n=13 483). We evaluated the associations of knowledge, awareness and treatment of hypertension with risk of stroke and its subtypes and whether this varied by gross national income (GNI) of country. We estimated OR and population attributable risk (PAR) associated with treated and untreated hypertension.

RESULTS

Hypertension was associated with a graded increase in OR by reducing GNI, ranging from OR 1.92 (99% CI 1.48 to 2.49) to OR 3.27 (2.72 to 3.93) for highest to lowest country-level GNI (p-heterogeneity<0.0001). Untreated hypertension was associated with a higher OR for stroke (OR 5.25; 4.53 to 6.10) than treated hypertension (OR 2.60; 2.32 to 2.91) and younger age of first stroke (61.4 vs 65.4 years; p<0.01). Untreated hypertension was associated with a greater risk of intracerebral haemorrhage (OR 6.95; 5.61 to 8.60) than ischaemic stroke (OR 4.76; 3.99 to 5.68). The PAR associated with untreated hypertension was higher in lower-income regions, PAR 36.3%, 26.3%, 19.8% to 10.4% by increasing GNI of countries. Lifetime non-measurement of blood pressure was associated with stroke (OR 1.80; 1.32 to 2.46).

CONCLUSIONS

Deficits in knowledge, detection and treatment of hypertension contribute to higher risk of stroke, younger age of onset and larger proportion of intracerebral haemorrhage in lower-income countries.

Relation of pharmacopenile duplex ultrasonography parameters and glycated hemoglobin (HbA1c) in diabetic patients with erectile dysfunction

INTRODUCTION AND OBJECTIVES

Erectile dysfunction (ED) is one of the main threats in diabetic patients. This research aimed to assess the relationship between glycated hemoglobin (HbA1c) level and pharmacopenile duplex ultrasonography (PPDU) indices in diabetic patients with ED.

MATERIALS AND METHODS

A total of 130 males with ED were recruited (100 had diabetes mellitus (DM) and 30 did not as control). The International Index of Erectile Function (IIEF) was used to evaluate patients for ED. Measurement of HbA1c, lipid profile and assessment of erectile function using PPDU were performed. All participants were assessed to take the medical history.

RESULTS

The mean age±SD was 53.8±8.9 and 53.6±2.8 years for patients and controls, respectively. Patients had variable grades of ED: mild in 20%, mild to moderate in 32.3%, moderate in 35.3%, and severe in 12.3%. A significant association was found between the existence of DM and a deprived response to intracorporeal injection (ICI), rising end-diastolic velocity (EDV), and reducing resistance index (RI) values. Comparing all diabetic groups according to HbA1c with controls, a significant relationship was found in; severity of IIEF-5 score, poor response to ICI, decreased peak systolic velocity (PSV) at 10min, increased EDV at 10, 20min and decreased RI at 10, 20min. A significant relationship was found between smoking, dyslipidaemia, and decreased PSV at 10, 20min and decreased increment ratio. However, a non-significant relationship was observed between age, type of DM and PPDU parameters.

CONCLUSION

Poor glycaemic control of DM is associated with an increase in EDV and decrease in RI, and PSV of PPDU.