Pharmacokinetics and Safety Evaluation of Single-Dose Saroglitazar Magnesium in Subjects with Hepatic Impairment

Saroglitazar magnesium, a dual peroxisome proliferator-activated receptor agonist, is under evaluation for treating various liver conditions. While the pharmacokinetics (PK) of saroglitazar have been extensively studied in diverse preclinical models and healthy subjects, a comprehensive assessment of its PK behavior under conditions of hepatic impairment is lacking. In this Phase 1, open-label, parallel-group study, the PK of a single dose of 4-mg saroglitazar magnesium was investigated in subjects having varying degrees of hepatic impairment with and without portal hypertension compared with appropriately matched individuals having normal hepatic function. Treatment-emergent adverse events for safety were also evaluated. Thirty-two subjects were enrolled in the hepatic-impaired groups and 23 subjects in the normal hepatic function group. Mild and moderate hepatic impairment did not significantly affect the PK of saroglitazar, compared with normal hepatic function. Although severe hepatic impairment did not alter maximum observed plasma concentration and half-life; saroglitazar exposure (area under the plasma concentration-time curve from time 0 to infinity) increased 3-fold, while the clearance was 61% lower compared to the subjects with normal hepatic function. This may require close monitoring or dose adjustments in individuals with severe hepatic impairment. A single oral dose of saroglitazar magnesium 4 mg was found to be safe and well tolerated in subjects with varying degrees of hepatic function.

A Radiation Therapy Contouring Atlas for Delineation of the Level I-II Axilla in the Prone Position

PURPOSE/OBJECTIVE(S)

When patients are treated prone for whole breast irradiation (WBI), the axilla typically receives less dose than when patients are treated with WBI in the supine position. There are situations, however, where the axilla is a target as in a situation where the physician intends to treat with "high tangents" to provide good coverage of both the breast and level I-II axilla. In these scenarios, ideal target delineation when the patient is in the prone position is not well-defined. While different consensus guidelines exist for delineation of the nodal areas in the supine position, to our knowledge there are no contouring guidelines for the regional nodes in the prone position based on bone, skin, vascular and muscle landmarks.

MATERIALS/METHODS

Forty-three patients treated with high tangents in the prone position from 2012-2018 were identified as representative cases. The level I and II regional nodal contours from the Radiation Therapy Oncology Group (RTOG) breast cancer atlas were adapted for prone position by a radiation oncologist and a breast radiologist based on anatomic considerations and changes observed from supine to prone positioning on diagnostic imaging. The revised nodal contours were reviewed by an expanded expert multidisciplinary panel including additional breast radiation oncologists and surgical oncologists to delineate the level I and II axilla on noncontrast computed tomography (CT) scans.

RESULTS

We adapted the RTOG breast cancer atlas, supported by detailed figures, in order to create a CT based atlas of the level I and II axillary lymph node stations in the prone position. For the level I axilla, the cranial and caudal anatomic boundaries remain unchanged. With transition to the prone position from supine, tenting of the pectoralis major occurs displacing the muscle from the chest wall and shifting the axillary space anteromedial to the lateral border of the pectoralis major. Therefore, the anterior boundary is now defined by the plane of the anterior extent of the pectoralis major to skin. The medial boundary is defined by the plane of the lateral border of the pectoralis major and pectoralis minor including to ribs and intercostal muscles. The lateral boundary is defined by the skin, cropped by 5mm. The posterior boundary is defined by the plane of the anterior surface of the latissimus dorsi and subscapularis muscle to skin. For the level II axilla, the cranial, posterior, medial and lateral boundaries remain unchanged. With transition from supine to prone, the axilla exhibits an anterolateral shift, now laterally abutting the lateral border of the pectoralis minor. The anterior boundary is now defined as the posterior aspect of the pectoralis major muscle. The caudal boundary is where the pectoralis minor inserts into ribs.

CONCLUSION

The adaptations to the RTOG breast cancer atlas for prone positioning will enable radiation oncologists to more accurately target the level I and II axilla when treating patients prone in whom the axilla is a target in addition to the breast.

Saroglitazar improves nonalcoholic fatty liver disease and metabolic health in liver transplant recipients

NAFLD is common after liver transplantation (LT) and is associated with an increased metabolic burden. Currently, there is a paucity of investigations into the treatment of post-LT NAFLD. In the present study, we evaluated the safety and efficacy of saroglitazar, a novel dual peroxisome proliferator-associated receptor α/γ agonist, on the treatment of post-LT NAFLD and metabolic burden. This is a phase 2A, single-center, open-label, single-arm study in which patients with post-LT NAFLD received saroglitazar magnesium 4 mg daily for 24 weeks. NAFLD was defined by a controlled attenuation parameter ≥264 dB/m. The primary endpoint was the reduction in liver fat as measured by MRI proton density fat fraction (MRI-PDFF). Secondary MRI-based metabolic endpoints included visceral adipose tissue, abdominal subcutaneous adipose tissue volumes, muscle fat infiltration, and fat-free muscle volume. Saroglitazar treatment led to a reduction in MRI-PDFF from 10.3±10.5% at baseline to 8.1±7.6%. A relative 30% reduction from baseline MRI-PDFF value was noted in 47% of all patients and 63% of patients with baseline MRI-PDFF >5%. Reduction in serum alkaline phosphatase was an independent predictor of MRI-PDFF response. Saroglitazar did not decrease fat-free muscle volume nor increase muscle fat infiltration, but did lead to a mild increase in visceral adipose tissue and abdominal subcutaneous adipose tissue. The study drug was well tolerated and a mild nonsignificant increase in serum creatinine was noted. Saroglitazar did not affect the weight. The study provides preliminary data demonstrating the safety and metabolic benefits of saroglitazar in LT recipients and underscores the importance of future studies to establish its efficacy after LT.

Kommerell's diverticulum: an unusual cause of unilateral vocal cord palsy?

Kommerell's diverticulum is a rare congenital anomaly of the aortic arch system in which there is a left- or right-sided aortic arch with an aberrant subclavian artery on the contralateral side. Patients with this anomaly can be asymptomatic or have features of tracheal or oesophageal compression. However, there is a rising suspicion that it may be a rare cause of unilateral vocal cord palsy through its compression of the recurrent laryngeal nerve. We describe a patient who had a long history of hoarse voice and left vocal cord palsy with no other obvious cause, who was found to have a Kommerell's diverticulum on a contrast-enhanced computed tomography scan.

Utility of frozen section in pediatric and adolescent malignant ovarian nonseminomatous germ cell tumors: A report from the children's oncology group

PURPOSE

In adult women, most malignant ovarian tumors are epithelial in origin. The use of intra-operative frozen section to distinguish between benign and malignant histology is reliable in guiding operative decision-making to determine the extent of surgical staging required. Pediatric and adolescent patients with ovarian masses have a much different spectrum of pathology with most tumors arising from germ cell precursors. This review was undertaken to assess the concordance between the intra-operative frozen section and the final diagnosis as an aid to guide extent of surgical staging in a group of pediatric and adolescent patients with malignant ovarian germ cell tumors.

METHODS

Records of patients aged 0 to 20 years with malignant ovarian germ cell tumors enrolled on Children's Oncology Group study AGCT0132 were reviewed. Pathology reports from patients who had both intra-operative frozen section diagnosis and final paraffin section diagnosis were compared using descriptive statistics. By inclusion criteria for the study, all patients had a final diagnosis of malignancy with required yolk sac tumor, choriocarcinoma or embryonal carcinoma histology. Available central review of pathology final paraffin section slides were compared with final institution pathology reports.

RESULTS

Of 131 eligible patients with ovarian germ cell tumors, 60 (45.8%) had both intra-operative frozen section and final paraffin section diagnoses available. Intra-operative frozen section diagnoses were classified as: incorrect diagnosis of benign tumor (13.3%), confirmation of malignancy (61.7%), immature teratoma (16.7%), germ cell tumor not otherwise specified (5%) and no diagnosis provided (3.3%). Intra-operative frozen section was incorrect in 23 of 60 (38.3%) patients evaluated. Central pathology review was concordant with the final institution pathology diagnosis in 76.3% of patients. Central pathology review identified additional germ cell tumor components in 23.7% of patients.

CONCLUSIONS

In pediatric and adolescent patients with a confirmed final diagnosis of ovarian germ cell malignancy, intra-operative frozen section diagnosis is not reliable to inform the extent of surgical staging required. Central review by an expert germ cell tumor pathologist provides important additional information to guide therapy.

412 Knowledge and Practices for the Prevention of the Diabetic Foot in North Wales

Aim

Diabetes mellitus can result in a wide range of foot complications such as ulceration, infection, and amputation. The National Institute for Health and Care Excellence (NICE) recommend that all diabetic patients should receive verbal and written information relating to their foot care. Here we assess our compliance with the national guidelines and the levels of patient knowledge amongst the diabetic population in the North West of Wales.

Method

A questionnaire was provided to all adult diabetic patients attending the outpatient podiatry service over the course of three weeks at Ysbyty Gwynedd, North Wales. The survey included compliance and knowledge-based questions regarding foot care.

Results

A total of 65 patients were recruited and completed questionnaires. The majority of the patients were males (male:female ratio 2:1) and over 70 years and had type II diabetes.

98% of patients admitted to receiving verbal diabetic advice while only 57% received written information. Compliance with daily foot checks was 82%. Regarding patient knowledge, over 90% of patients selected the correct answer to 11 out of the 15 knowledge-based questions. Despite 95% recognising that poor footwear can contribute to diabetic foot complications, only 86% recognised that walking barefoot carries similar risks.

Conclusions

Diabetic foot knowledge is high within our studied population. Use of patient information leaflets can be further improved to help educate patients in avoiding barefoot walking and to prevent diabetic foot complications and limb loss.

Saroglitazar is non-inferior to fenofibrate in reducing triglyceride levels in hypertriglyceridemic patients in a randomized clinical trial

Saroglitazar, being a dual PPAR-α/γ agonist, has shown beneficial effect in diabetic dyslipidemia and hypertriglyceridemia. Fibrates are commonly used to treat severe hypertriglyceridemia. However, the effect of saroglitazar in patients with moderate to severe hypertriglyceridemia was not evaluated. We conducted a study to compare the efficacy and safety of saroglitazar (4 mg) with fenofibrate (160 mg) in patients with moderate to severe hypertriglyceridemia. This was a multicenter, randomized, double-blinded, double-dummy, active-control, and noninferiority trial in adult patients with fasting triglyceride (TG) levels of 500–1,500 mg/dl. The patients were randomized in a 1:1 ratio to receive daily dose of saroglitazar or fenofibrate for 12 weeks. The primary efficacy end point was the percent change in TG levels at week 12 relative to baseline. The study comprised of 41 patients in the saroglitazar group and 41 patients in the fenofibrate group. We found that the percent reduction from baseline in TG levels at week 12 was significantly higher in the saroglitazar group (least square mean = −55.3%; SE = 4.9) compared with the fenofibrate group (least square mean = −41.1%; SE = 4.9; P = 0.048). Overall, 37 treatment-emergent adverse events (AEs) were reported in 24 patients (saroglitazar: 13; fenofibrate: 11). No serious AEs were reported, and no patient discontinued the study because of AEs. We conclude that saroglitazar (4 mg) is noninferior to fenofibrate (160 mg) in reducing TG levels after 12 weeks of treatment, was safe, and well tolerated.

Proof-of-concept study to evaluate the safety and efficacy of saroglitazar in patients with primary biliary cholangitis

BACKGROUND & AIM

Saroglitazar is a novel peroxisome proliferator-activated receptor (PPAR) agonist with dual agonistic properties (α/γ). Due to a strong mechanistic rationale, we aimed to test the safety and efficacy of saroglitazar in patients with primary biliary cholangitis (PBC) who were either ursodeoxycholic acid (UDCA) resistant or intolerant.

METHODS

In this double-blind, phase II proof-of-concept trial, 37 patients with PBC were randomized to saroglitazar 4 mg (n = 13), saroglitazar 2 mg (n = 14), or placebo (n = 10) daily for 16 weeks. The primary efficacy endpoint was the reduction in alkaline phosphatase (ALP) level at Week 16.

RESULTS

A significant reduction of mean ALP levels was observed at Week 16 relative to baseline in both the saroglitazar 4 mg (least-squares [LS] mean =-163.3 U/L, SE = 25.1, p <0.001) and 2 mg (LS mean =-155.8 U/L, SE = 24.4, p <0.001) groups, compared with placebo (LS mean =-21.1 U/L, SE = 28.9). Treatment with saroglitazar resulted in a rapid reduction of ALP concentration at Week 4 that was sustained through the study duration. At least 1 treatment-emergent adverse event occurred in 11 (84.6%) patients in the saroglitazar 4 mg group, in 12 (85.7%) patients in the 2 mg group and in 8 (80%) patients in the placebo group. Study drug was discontinued in 4 patients (3 patients in the 4 mg group and 1 patient in the 2 mg group) due to aminotransferase increases that promptly returned to baseline values after drug discontinuation.

CONCLUSIONS

Saroglitazar at 2 mg and 4 mg daily was tolerated and resulted in rapid and sustained improvements in ALP. Further studies are underway at a daily dose of 2 mg and 1 mg due to the higher incidence of elevated liver enzymes observed with the 4 mg dose. CLINICALTRIALS.

GOV IDENTIFIER

NCT03112681 LAY SUMMARY: Saroglitazar resulted in a rapid and sustained improvement in alkaline phosphatase levels in patients with primary biliary cholangitis. The mean percentage reductions in alkaline phosphatase levels were 49% and 51% in the saroglitazar 4 mg and 2 mg groups compared to 3% in the placebo group.

Attentive Evaluation of Trace Elements in Patients with Breast Cancer-A Cross Sectional Study of Nawabshah, Sindh, Pakistan

Background: Breast cancer has recently become one of the most obsessing and life threatening issues in the world. Globally, females suffered mostly by breast cancer. Breast cancer is multifactorial etiological disorder. Trace elements are acts as cofactors and biological catalyst. They play a very essential role in the metabolic pathways. Methods: A cross sectional study with two hundred (200) subjects and divided into two groups. 50 females were normal healthy as a control while 150 females were patient with breast cancer. Blood was collected from all participant after taking history, clinical data, mammographic and histopathological findings. Consent and predesign porforma were filled by all participants of study. The trace elements (Na, K, Zn, Fe, Ca) were determined through atomic absorption spectrophotometer (ASS) and other biochemical analysis such as Total Protein, serum albumin and Total cholesterol were analyzed on Micro Lab.300. Data was entered on SPSS 22.0 version, and applied student t-test for continuous variables. Results were analyzed as Mean and standard deviation. Results: The results of serum Na+, K+, Ca++, Zn++, Cu++ and Fe in breast cancer patient were observed and found significantly fluctuated in breast cancer patients as compared to normal healthy subjects. Serum Total Protein significantly increased whereas serum Albumin decreased in patient with breast cancer. Conclusions: in Present study we found significantly abnormal concentration of Na+, K+, Ca++, Zn++, Cu++ and Fe in breast cancer these elements may contribute in early diagnosis of breast cancer. Increased body weight and total cholesterol are also risk factors of Ca breast.

Maternal Serum 25-Hydroxy Vitamin D Concentrations and Calcium Levels in Preeclamptic Women, Sindh, Pakistan

Objectives: To analyse the levels of serum 25-hydroxyvitamin D 25(OH) Dand calcium concentrations in patients with pre-eclampsia, Hyderabad, Sindh, Pakistan. Methodology: Cross sectional study was conducted at the Gynaecology and Obstetrics Department, LUHS, Hyderabad during the period of January 2020 to June 2020. Total 150 pregnant women were selected according to predesign Proforma and divided into two groups. 50 females were normal normotensive pregnant women as a control group, 100 were pre-eclamptic patients as case group. Obstetric history, clinical data was gathered and then 5ml of blood sample was collected from each patient. The blood samples were taken for the analysis of 25-hydroxyvitamin D or 25(OH)D and calcium levels. 25(OH)D were performed on chemiluminescence, While calcium concentration of Microlab 300. Data was analysed by using SPSS version 23. Student t-test was used for analysed of continuous variables. Results: The maternal serum vitamin D and calcium levels were significantly decreased as compared to patient with preeclampsia and normotensive healthy pregnant ladies. The blood pressure also declined in case group with P<0.001.Multinomial logistic regression showed significant odd ratio of Vitamin-D and Calcium deficiency in preeclampsia. Conclusion: The present study reveals that 25-hydroxyvitamin D, and Calcium levels declined significantly in preeclamptic women, and mighty be biomarker of this life threating disease.

Barriers and enablers in implementing an electronic incident reporting system in a teaching hospital: A case study from Saudi Arabia

BACKGROUND

Widespread recognition of the impact of healthcare adverse events has triggered incident reporting system implementation to promote patient safety. The aim was to assess the effectiveness, usability, enablers, and barriers of the Electronic Occurrence Variance Reporting System (eOVR) in addition to end user satisfaction.

METHODS

This study comprised a cross-sectional survey two years after implementation of the eOVR. Secondary data analysis evaluated the volume of incident reporting before and after implementing the eOVR.

OUTCOME MEASURES

Primary outcome measures: satisfaction and system usability, system security, workplace safety culture, training, and reporting trends. An overall satisfaction was collected. Secondary outcome: rate of reported OVRs per 1000 admissions. Furthermore, barriers and enablers to the reporting process were explored.

RESULTS

Study findings indicate that the eOVR has been successful in terms of high satisfaction according to respondents. Most of the respondents found the system easy to access, maintained patient confidentiality and reporting anonymity. Around half the respondents indicated having a non-punitive culture of reporting in their hospital. Physicians had significantly lower scores in all primary outcomes Incident reporting increased by 33.6% (p < 0.0001) after implementing the eOVR.

CONCLUSION

Successful incident reporting systems should be easy and simple to use, accessible and include features that guarantee anonymity and confidentiality. End-users should be trained prior to launching such a system. The implementation of such systems needs to be combined with promoting a just culture in the organization, timely feedback, more involvement and focus on physicians and junior staff which will improve user satisfaction and reporting rates.

The role of family factors in the association between early adulthood BMI and risk of cardiovascular disease. An intergenerational study of BMI in early adulthood and cardiovascular mortality in parents, aunts and uncles

Background

High body mass index (BMI) in childhood and adolescence is related to cardiovascular disease (CVD). Causality is not established because common genetic or early life socioeconomic factors (family factors) may explain this relationship. We aimed to study the role of family factors in the association between BMI and CVD by investigating if early adulthood BMI in conscripts and CVD mortality in their parents/aunts/uncles are related.

Methods

Data from the Armed Forces Personnel Database (including height and weight among conscripts) were linked with data from the Norwegian Population Registry, generational data from the Norwegian Family Based Life Course Study, the National Educational Registry and the Cause of Death Registry using unique personal identification numbers. The study sample (N=369 464) was Norwegian males born 1967-1993, who could be linked to both parents and at least one maternal and one paternal aunt or uncle. Subsamples were identified as conscripts whose parents/aunts/uncles had data on cardiovascular risk factors available from Norwegian health surveys. Cox proportional hazards regression models were used to estimate hazard ratios (HR) of CVD mortality in the parental generation according to BMI categories of conscripts.

Results

Parents of conscripts with obesity or overweight had a higher hazard of CVD death (fathers HR obese: 1.99 (1.79,2.21), overweight: 1.33 (1.24,1.42) mothers HR obese: 1.65 (1.32,2.07), overweight: 1.23 (1.07,1.42)) than parents of normal- or underweight conscripts. Aunts and uncles of conscripts with obesity and overweight had an elevated hazard of CVD death, but less so than parents. Adjustment for CVD risk factors attenuated the results in parents, aunts and uncles.

Conclusions

Family factors may impact the relationship between early adulthood overweight and CVD in parents. These can be genes with impact on BMI over generations and genes with a pleiotropic effect on both obesity and CVD, as well as shared environment over generations.

Effectiveness of direct oral anticoagulants in obese adults with atrial fibrillation: an overview examining the evidence from international systematic reviews and meta-analyses

Background

Obesity may influence the pharmacology of direct oral anticoagulants (DOAC) that are recommended by all international guidelines for stroke prevention in adults with atrial fibrillation (AF).

Purpose

To evaluate the safety and efficacy of DOACs in obese adults with AF.

Methods

Medline, CINAHL, Scopus, Web of Science, Cochrane Database, Johanna Briggs Institute, Embase, Psych Info and ProQuest were searched till April 2020. Only systematic reviews with meta-analyses, that were published after 2005 and were in the English language were included. Articles were screened by title and abstract, followed by full text assessment using the Covidence systematic review software. Data was extracted using a standardised extraction tool. AMSTAR-2® and ROBIS® tools were used for quality and risk of bias assessment. The entire process was undertaken by two investigators at each stage of the study selection, appraisal, and data extraction. Disagreements were resolved through consensus discussion with a third arbitrary investigator. Statistical analyses were performed using the DerSimonian and Laird method for random effects. Meta-analysis was performed using only randomised controlled trials from eligible systematic reviews at both 12 months and across the entire trial. Primary outcomes assessed was stroke (ischemic or haemorrhagic) or systemic or pulmonary embolism. Secondary outcomes assessed included all-cause mortality, transient ischemic attack, myocardial infarction, major bleed, all cause-hospitalisation, and cardiovascular mortality.

Results

Of the 8162 articles screened, a total of five systematic reviews were included in this overview. There was disagreement within the published reviews on the effect of DOAC in obesity. Four of the five reviews were of either “low” or “critically low” quality, with inconsistencies in data extraction and appropriateness of the included studies and statistical methods used in analysis. Data from only the RE-LY, AVERROES and ENGAGE AF-TIMI 48 trials, were available for the meta-analysis, which did not find any significant difference between all BMI groups for all outcomes, at both time points. However, analysis of the different weight groups versus normal weight, highlighted non-significant differences between the different DOACs.

Conclusion

There was no difference between the BMI classes in any of the outcomes assessed. However, the non-significant trends that were seen, suggests individual superiority of DOACs may exist within the obese adult populations. There is a need for prospective trials to evaluate which DOACs are safe and efficacious in the obese class III adults and at which dose.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Australian Government Research Training Program (RTP) Heart Foundation of AustraliaNational Health and Medical Research Council (NHMRC)

1476 North Wales Vascular Surgery Zoom Webinar Teaching Programme for Medical Students and Junior Doctors

Aim

Surgical Education is now more widely delivered on virtual platforms due to the COVID-19 pandemic. Due to centralisation of Vascular Surgery services in North Wales to Glan Clwyd Hospital (Central), Medical Students, Junior Doctors and General Surgical Registrars have reduced exposure to the speciality and the management of common cases in neighbouring hospitals (East and West). Subsequently, we developed a regional virtual teaching programme to help bridge gaps in knowledge and to instil confidence when providing a service.

Method

We developed a 4-part didactic webinar educational programme which covered parts of the medical undergraduate and MRCS curricula pertaining to Vascular Surgery. Under/Postgraduate educational leads from Central, East and West were contacted to promote our programme. Webinars were delivered on ZOOM video conferencing once weekly throughout December 2020. Feedback forms were collected on Google Forms™ and used 5-point Linkert scales to grade responses and analysis of data was carried out on Microsoft Excel®.

Results

186 feedback forms were collected and respondents reported significant improvements in knowledge in each of the subjects covered: [1] Abdominal Aortic Aneurysms - (2.59±1.07/5 to 4.23±0.65/5, p = <0.0001, n = 60), [2] Acute Limb Ischaemia – (2.55±1.11/5 to 4.21±0.72/5, p = <0.0001, n = 42); [3] Chronic Limb Ischaemia (2.57±1.03/5 to 4.23±0.77/5, p = <0.0001, n = 35); [4] Vascular Emergencies (2.94±1.28/5 to 4.37±0.63/5, p = <0.0001, n = 49). Overall topic interest, presentational skills and clinical usefulness was also rated highly.

Conclusions

Through this virtually delivered regional teaching programme, we successfully enhanced Vascular Surgery knowledge and addressed the educational needs of Medical Students and Junior Doctors across North Wales.

Coenzyme Q10 Supplementation Reduces Oxidative Stress in Patients with Pre-Eclampsia

Objective: To determine the effect of CoQ10 supplementation in reduction of oxidative stress by index marker, Malondialdehyde (MDA), super oxidase dismutase(SOD), catalase(CAT) and glutathione peroxidase (GPx) in patients with pre-eclampsia.  Methodology: A cross-sectional study was conducted at the Department of Biochemistry LUMHS, Jamshoro. During the period of January 2018 to June 2018. Total 200 pregnant women were recruited and divided into two groups. 50 females were normotensive pregnant women as a control group, 150 were pre-eclamptic patients as case group. Obstetric history, clinical data was gathered and then 5ml of blood sample was collected from each patient. The blood samples were taken before and after a 3 months’ supplementation to analyse Malondialdehyde (MDA). The CoQ10 was evaluated by High performance liquid chromatography (HPLC-DAD) and MDA, SOD, CAT and GPx were performed on UV- spectrophotometer. Data was analysed by using SPSS version 22. Student t­test was used for analysed of continuous variables. Results: The pre-eclamptic women treated with CoQ10 supplementation the plasma CoQ10 levels and MDA, SOD and CAT levels increased marked after 3 months(p<0.001). But the Glutathione Peroxidase was insignificant results as compared with controls (p=0.057). Conclusion: The present study reflects that supplementation of CoQ10 decreased the oxidative stress and also helpful in improving the health of mother as well of her foetus by increase antioxidant activity.

Frequency distribution and association of Fat-mass and obesity (FTO) gene SNP rs-9939609 variant with Diabetes Mellitus Type-II population of Hyderabad, Sindh, Pakistan

BACKGROUND/AIM

Diabetes Mellitus (DM) is one of the important public health issues worldwide. The Fat mass obesity (FTO) gene rs-9939609 variant identified single nucleotide polymorphism (SNP) with the T to A missense mutation, and has a strong association with T2DM. FTO gene is present on chromosome "16q12.2" comprising of nine exons. FTO gene rs-9939609 a variant is commonly found in the Pakistani Population. The purpose of the study was to alert the population about the rs-9939609 variant SNP, having a strong association with T2DM.

MATERIAL AND METHODS

Total of 190 participants were included in the present cross-sectional study. To collect the samples non-probability convenience technique was used. subjects were recruited and divided into three groups, normal healthy subjects, obese and T2DM. The patients were selected from the Medicine department Jamshoro/Hyderabad by filling the pre-designed proforma, as well as verbal and written consent taken from study participants. To analysed the data ANOVA Post hoc (Tukey-test) was applied for comparison among groups (P < 0.05) and "SNP-STAT" online software was used for frequencies.

RESULTS

The BMI, neck circumference, waist circumference and lipid profile, fasting blood sugar and HbA1c was found significant (p < 0.001) in both genders as compared to control. Homozygous and heterozygous distribution of allelic and genotyping frequency was found in study participants. 37.9 %T/A, 57.4% T/T, and A/A were 4.7%. The FTO gene rs-9939609 variant amplified and have an increased risk of developing T2DM in the Sindh population. Codominant model odd ratio of T/A showed 2.42 (CI)1.23-3.84, with significant p < 0.032.

CONCLUSION

The present study concluded that the FTO gene SNP rs-9939609 variant was found in the population of Hyderabad, Sindh and having strong association with T2DM and obese individuals. Increase BMI, neck and waist circumference are the biomarkers of obesity and causative factors of T2DM.

Assessment of the Deficiency of Vitamin D among the Tuberculosis Patients at People Medical College Hospital Nawabshah, Pakistan

Objective: The objective of this study is to assess deficiency of Vitamin D among the Tuberculosis Patients at People’s Medical College Hospital (PMCH) Nawabshah, Pakistan. Methodology: This was a case-control study in which 184 new diagnosed tuberculosis patients aged between 30 to 50 years were selected and 200 were taken as control. The study was conducted from June 2020 to May 2021. Well-structured questionnaire was administered to both case and control groups. Body mass index (BMI) was recorded as (kg/m2). Blood samples were collected for the presence of Vitamin D3 levels. Statistical Software for Social Sciences (SPSS) version 23 was used to analyze the data. Results: The mean age and standard deviation (SD) of the patients was 45.11 ± 7.99 years and gender distribution was females 94/184 (51%) and males 90/184 (49%) in patients. There was Vitamin D deficiency in 79/184 (39%) patients. Conclusion: Vitamin D deficiency was common among tuberculosis patients in contrast to control group. The female patients with low Body Mass Index (BMI) (kg/m2) were having the more deficiency of Vitamin D. Vitamin D supplementation has vital role in tuberculosis treatment and prevention. 

Role of Green Tea on Obesity and Type-II Diabetes Mellitus Male Individuals

Objective: To evaluate the effects of Green tea on obesity and hyperglycemia. Methodology: This observational study was carried out at the department of physiology, in affiliation to Medical Research Centre Liaquat University of Medical and Health Sciences Jamshoro. The sample was collected by convenient random sampling. Total 100 participants, 50 controls and 50 obese diabetics were enrolled. Informed written consent was taken from participants. The body mass index (BMI) of the participants was taken at the time of recruitment, and later at 16 weeks of consuming green tea. The serum glucose levels were assessed by fasting (FBS) and random blood sugar (RBS) levels, and HbA1C. The levels of serum Blood glucose were obtained with the glucose oxidase method. Data analysis was done on SPSS 21.0, analysis of variables was done by applying student t-test, the p-value of <0.05 was taken as statistically significant. Results:100 participants recruited out of which 50 controls and 50 obese diabetics men, it was found that the prolong consumption of green tea for 16 weeks with 20-30 minutes’ walk had statistically significant declined in FBS, RBS, HbA1c, and BMI in the obese diabetic subjects, as compared to the controls. Conclusion: This study concludes that the green tea has positive effect in reducing the total body weight and BMI and helps in maintaining the normoglycemic levels in Type 2 DM.

A Multicenter, Open-Label, Single-Arm Study to Evaluate the Efficacy and Safety of Saroglitazar in Patients With Primary Biliary Cholangitis

INTRODUCTION

Patients with primary biliary cholangitis (PBC) without biochemical response to ursodeoxycholic acid (UDCA) are at increased risk of liver-related mortality. Saroglitazar is a novel peroxisome proliferator-activated receptor (PPAR) agonist with dual PPAR agonistic properties (α/γ). There is a strong mechanistic rationale for studying saroglitazar in PBC because PPARα is a molecular target of fibrates that showed improvements in liver tests in patients with PBC.

METHODS

In this 16-week, open-label, phase 3 study, 37 patients were screened across 3 clinical centers to enroll 7 patients. All patients received daily dose of saroglitazar 4 mg for 16 weeks in addition to their ongoing treatment with UDCA. The primary efficacy endpoint was the reduction in alkaline phosphatase (ALP) level at week 16 as compared to baseline.

RESULTS

Mean age of the study population was 51.1 ± 10.0 years, all patients were female of Mexican descent, and mean body mass index was 25.5± = 4.8 kg/m2. Six (85.7%) patients reported taking ursodiol at baseline and continued throughout the study with a mean daily dosage of 417 mg. Among these, the daily dosage of UDCA 500 mg in 4 and 250 mg in 2 subjects, respectively. The mean baseline ALP level was 230 ± 103 U/L. The primary efficacy endpoint, mean change (reduction) from baseline in ALP concentration at week 16 based on the modified intent-to-treat population was -94 ± 53 U/L (P = 0.003), corresponding to a reduction of 48 ± 23%. Treatment with saroglitazar 4 mg resulted in a rapid and sustained decrease of ALP levels at week 4 (-84 ± 47 U/L, P = 0.003). Six patients who completed the study achieved mean ALP reduction of at least 40% at week 4 and all subsequent visits.

DISCUSSION

Although the study was terminated because of lack of enrollment, saroglitazar daily for 16 weeks resulted in rapid and sustained improvements in ALP with an acceptable safety profile in patients with PBC.

Assessment of the Infections and Use of Antibiotics in Pregnancy among the Pregnant Women Reported at Gynae Opd Civil Hospital Khairpur Mirs Pakistan

Introduction: Pregnancy presents uncommon issues regarding anti-infection treatment. A significant concern is the conceivable teratogenic or harmful impact on the fetus. Objectives: The objectives of this study are to assess the infections and use of antibiotics in pregnancy among the pregnant women reported at Gynae OPD Civil Hospital Khairpur Mirs Pakistan. Methodology: This was an observational cross-section study conducted at Gynae OPD Civil Hospital Khairpur Mirs Pakistan from July 2020 to January 2021. A total of 400 sample size was calculated by using Slovin’s Formula. Data were collected by purposive sampling technique. Finally, collected data were analyzed by using a statistical package for social science (SPSS) software version 24.  Results: Results reported commonly prescribed antibiotics during the pregnancy in which Phenoxymethylpenicillin was most commonly prescribed i.e. 31% and it was indicated for Maxillary sinusitis 40% and Acute tonsillitis 74%. The infections which were diagnosed during pregnancy among which vaginal candidiasis was high 117 (29.2%). Common antibiotics duration of treatment was observed in which penicillin frequency for 8-10 days was high 39 (9.7%). Common prescribed antibiotic dosages during pregnancy were observed in which the frequency of penicillin's recommended dose was high at 80 (20%). Antibiotics timing during pregnancy was observed in which Metronidazole+Tinidazole were mostly used during II trimester. Conclusion: The antibiotics use in Khairpur Mirs is very high. The dosage regiment should be properly monitored, according to the pharmacokinetic data of particular antibiotics during the pregnancy.

Assessment of the Patterns of Exercise and Diet Intake among the Pregnant and Pre-pregnant Women Reported at Gynae OPD Civil Hospital Khairpur, Sindh, Pakistan

Objectives: The objective of this study is to assess the patterns of exercise and diet intake among the pregnant and pre pregnant women visiting the Gynae OPD Civil Hospital Khairpur, Sindh, Pakistan. Methodology: This is a descriptive cross sectional study conducted at the Gynae OPD Civil Hospital Khairpur, Sindh, Pakistan, from November 2020 to January 2021. A well-structured questionnaire was introduced to collect the study data and consent was taken. Sample size was calculated by Slovin’s Formula which was 400 with 95% confidence level and 5% margin of error. Results were analyzed by using statistical package for social sciences (SPSS) software version 23. Results: Results reported that, out of 400 women, during pregnancy 304 were not having gestational diabetes, before pregnancy 348 women did not exercise. It was also found that out of 322 having normal range of Body Mass Index (BMI) during pregnancy 36 of participants performed exercise, before pregnancy 40 performed the exercise, during pregnancy 256 did the household work, during pregnancy 42 followed the special diet. Conclusion: It was concluded that women who visited the OPD do not exercise properly and do not take proper diet before and during pregnancy because of inadequate awareness of role of exercise and diet for pregnancy.

Difficult Central Venous Cannulation under Laryngeal Mask Airway Anesthesia in Adolescent

We report a case of difficult central venous cannulation under general anesthesia with laryngeal mask airway in a young female child. Our case demonstrated a difficulty in surgically finding the right internal jugular vein due to neck veins displacements by laryngeal mask airway, which caused morbidity such as prolonged surgical duration and excessive blood loss. Once the laryngeal mask airway was replaced with endotracheal tube, the internal jugular vein appeared on surface and procedure was successfully completed in a few minutes. Such difficulties warrant an alternate approach in airway management in order to prevent major adverse effects.

Thiamine Level in Type I and Type II Diabetes Mellitus Patients: A Comparative Study Focusing on Hematological and Biochemical Evaluations

Objective

Diabetes has been found to be associated with low levels of thiamine stores in the body, as thiamine directly affects carbohydrate metabolism. Amplified renal clearance of thiamine has been found in both type I and type II diabetic patients. It has been shown that high-dose thiamine therapy may have a therapeutic effect on early-stage diabetic nephropathy. The aim of this study was to evaluate various biochemical parameters and serum thiamine levels in type I and type II diabetic patients and compare them with a healthy control group.

Methods

A case-control study was carried out in the diabetic out-patient multi-centers in Karachi. A total of 90 participants were selected by using a non-probability convenient sampling technique and divided into three groups, each with 30 subjects. Group A included healthy non-diabetic subjects, while group B included subjects with type I diabetes mellitus (DM), and group C included subjects with type II DM. After receiving informed consent, blood samples were collected from all the participants for hematological and biochemical evaluation. The duration of the study was eight months.

Results

The study results revealed that the patients with type II DM had significantly higher mean fasting blood sugar (FBS), random blood sugar (RBS), and hemoglobin A1c (HbA1c) levels than those with type I DM or the control group (p<0.001 for all). Furthermore, the patients with type I or II DM had significantly higher mean levels of triglyceride (p<0.001) and total cholesterol (0.013) while significantly lower mean levels of high-density lipoprotein (HDL) (p=0.014) than controls. The study results further revealed that the patients with type I or II DM had significantly lower serum thiamine levels than controls (14.89±4.82 and 7.35±1.90 vs. 69.56±12.75, p<0.001).

Conclusion

The study results revealed that FBS, RBS, HbA1c, triglyceride, and total cholesterol levels were significantly higher in both type I and type II diabetes patients compared to controls. Furthermore, HDL and serum thiamine levels were found to be significantly lower in both type I and type II diabetic patients than in controls.

Failure Mode and Effect Analysis (FMEA) may enhance implementation of clinical practice guidelines: An experience from the Middle East

RATIONALE, AIMS, AND OBJECTIVES

Implementation of clinical practice guidelines (CPGs) has been shown to reduce variation in practice and improve health care quality and patients' safety. There is a limited experience of CPG implementation (CPGI) in the Middle East. The CPG program in our institution was launched in 2009. The Quality Management department conducted a Failure Mode and Effect Analysis (FMEA) for further improvement of CPGI.

METHODS

This is a prospective study of a qualitative/quantitative design. Our FMEA included (1) process review and recording of the steps and activities of CPGI; (2) hazard analysis by recording activity-related failure modes and their effects, identification of actions required, assigned severity, occurrence, and detection scores for each failure mode and calculated the risk priority number (RPN) by using an online interactive FMEA tool; (3) planning: RPNs were prioritized, recommendations, and further planning for new interventions were identified; and (4) monitoring: after reduction or elimination of the failure mode. The calculated RPN will be compared with subsequent analysis in post-implementation phase.

RESULTS

The data were scrutinized from a feedback of quality team members using a FMEA framework to enhance the implementation of 29 adapted CPGs. The identified potential common failure modes with the highest RPN (≥ 80) included awareness/training activities, accessibility of CPGs, fewer advocates from clinical champions, and CPGs auditing. Actions included (1) organizing regular awareness activities, (2) making CPGs printed and electronic copies accessible, (3) encouraging senior practitioners to get involved in CPGI, and (4) enhancing CPGs auditing as part of the quality sustainability plan.

CONCLUSION

In our experience, FMEA could be a useful tool to enhance CPGI. It helped us to identify potential barriers and prepare relevant solutions.

Quality of life, continence and frequency of pouchitis following laparoscopic versus open colectomy and ileal pouch-anal anastomosis: an Irish perspective

BACKGROUND

This study aims to assess quality of life outcomes, continence, rates of pouchitis and predictors of pouchitis for patients undergoing laparoscopic versus open three-stage ileal pouch-anal anastomosis (IPAA) surgery in our institution.

METHODS

Forty-two patients having had three-stage (IPAA) surgery were identified. One was excluded as they had undergone pouchectomy. A postal questionnaire followed by telephone contact was undertaken. The questionnaire was based on The Gastrointestinal Quality of Life Index (GIQLI) and Wexner/Cleveland Clinic Faecal Incontinence Symptom Severity Scoring Systems.

AIMS

Our aim was to assess morbidity, quality of life, incidence of pouchitis and continence following restorative panproctocolectomy and IPAA.

RESULTS

Thirty-five patients completed the response. The median age at colectomy of our patient population was 32 years. 57 % were male and 43 % were female. 54.3 % of cases were carried out laparoscopically. 8/19 patients who had laparoscopic surgery had pouchitis (42.1 %) versus 9/16 patients who had open surgery (56.3 %). The median Wexner score was 0. Nine patients (25.7 %) had a GIQLI score that was within or above the range reported for healthy controls. The rate of complications was 31.7 % for emergency cases and 25.7 % for elective cases. The rate of pouchitis in this group was 48.5 %. Overall pelvic sepsis rate was 12.8 %.

CONCLUSIONS

Ileal pouch-anal anastomosis is a successful and well-tolerated procedure with 94 % of patients opting to have the surgery again. Preliminary results do not show any significant difference in the incidence of pouchitis following laparoscopic surgery.