Morphometric and gut microbial evaluation of Tilapia (Oreochromis niloticus) fed on different levels of Moringa oleifera

Abstract In current study, different feeding levels of Moringa oleifera formulated diet was compared to analyze the growth performance, feed conversion ratio, feed conversion efficiency and gut microbiology of Oreochromis niloticus. The study was comprised of four treatment groups including 4%, 8% and 12% Moringa oleifera and one control group which was devoid of Moringa leaves. The experimental trial was conducted at the Zoology laboratory of Pakistan Institute of Applied and Social Sciences, (PIASS) Kasur. The physicochemical parameters of water such as temperature, dissolve oxygen, pH, total dissolved solids and salinity in all aquaria were found non-significantly different from each other. In control condition T1, the average weight gain was 14.89±16.90a grams, while average length gain was 11.52±7.444a cm. However, the total viable count on Eosin methylene blue was 7.4×107, 5.8×107 on Tryptic soy agar and 5.8×107on Nutrient agar. In T2, the average weight gain was 16.22±16.09b grams and average length gain was 12.97±7.79b cm. The total viable count on Eosin methylene blue was 7×107, 5.5×107 on Tryptic soy agar and 5.8×107on Nutrient agar. In T3, the average weight gain was 37.88±27.43c grams, while the average length gain was recorded as 16.48±12.56c cm. However, the total viable count for treatment 3 was 6.4×10 on Eosin methylene blue, 4.8×107 on Tryptic soy agar and 5.2×107on Nutrient agar. In T4, the average weight gain was 44.22±31.67d grams, while the average length gain was 15.25±10.49d cm. The total viable count was 4.3×107on Eosin methylene blue, 3.1×107 on Tryptic soy agar and 3.8×107 on Nutrient agar. The effect of Moringa oleifera on the growth of Oreochromis niloticus was found to be significant and 12% Moringa extract showed maximum length and weight gain and minimum feed conversion ratio with the least microbial count in fish intestine.

Effects of replacement of dietary fish oil with plant oil on growth performance and fatty acid composition of spinefoot rabbitfish, Siganus rivulatus

Abstract A 95-day feeding study was carried out to evaluate the impact of complete replacement of fish oil by plant oils in the growth performance, feed consumption fatty acid and body composition of juvenile rabbitfish, Siganus rivulatus. There were four treatments i.e., A (fish oil diet), (linseed oil diet), C (soybean meal oil diet) and D (sunflower oil diet). The experimental trial was conducted in twelve 1.5-m3 fiber glass tanks (n=3). Spinefoot rabbitfish juveniles had an average initial weight of 0.948 g ± 0.124 g and they were stocked at 50 fish per tank. Fish fed diet A showed significantly better growth rate, final body weight, and total body weight than fish fed on the other diets. Moreover, the best FCR was observed for diet A followed by diet C and diets B and D had the worst FCR. Fish body composition for crude protein, dry matter, ashes and gross energy at the end of the trial had not differed between the treatments. The highest polyunsaturated fatty acids (PUFA) was found in fish fed diet A followed in decreasing order by diets D, B, and C. Fish oil is a better dietary lipid source for Spinefoot rabbitfish juveniles, Siganus rivulatus, than plant oils. Among plant oils, soybean oil was better than linseed oil and sunflower oil as the main dietary fat source.

Size at sexual maturity estimation for 36 species captured by bottom and mid-water trawls from the marine habitat of Balochistan and Sindh in the Arabian Sea, Pakistan, using maximum length (Lmax) and logistic (L50) models

Abstract The aim of this study was to estimate the size at first sexual maturity (Lm) for 36 species belonging to 24 families from the marine habitat of Balochistan and Sindh in Arabian Sea, Pakistan through maximum length based an empirical and logistic model using commercial catch during June 2020 to May 2021. Individual total length (TL) was noted up to 0.1 cm using measuring broad. The Lm was calculated using two formulae; (i) log (Lm) = - 0.1246 + 0.9924 * log (Lmax) for Elasmobranchs and (ii) log (Lm) = -0.1189 + 0.9157* log (Lmax) for ray-finned fishes. The minimum Lm was recorded as 10.27 cm TL for Caranx malabaricus and 108.38 cm TL for Isurus oxyrinchus, respectively. Around Lm with 58.33% species were ranges from 19.00 cm to 25.00 cm TL. This study was estimated 16 newly Lm which is globally absent and rest 20 Lm are absent in the Arabian Sea (Pakistan coastal habitats). Therefore, the results will be helpful for the sustainable management and conservation of these marine fishes through the establishment of mesh size of trawl nets based on the size at sexual maturity (Lm).

Antibiotic Guidelines for Critically Ill Patients in Nigeria

BACKGROUND

It is well documented that inappropriate use of antimicrobials is the major driver of antimicrobial resistance. To combat this, antibiotic stewardship has been demonstrated to reduce antibiotic usage, decrease the prevalence of resistance, lead to significant economic gains and better patients' outcomes. In Nigeria, antimicrobial guidelines for critically ill patients in intensive care units (ICUs), with infections are scarce. We set out to develop antimicrobial guidelines for this category of patients.

METHODS

A committee of 12 experts, consisting of Clinical Microbiologists, Intensivists, Infectious Disease Physicians, Surgeons, and Anesthesiologists, collaborated to develop guidelines for managing infections in critically ill patients in Nigerian ICUs. The guidelines were based on evidence from published data and local prospective antibiograms from three ICUs in Lagos, Nigeria. The committee considered the availability of appropriate antimicrobial drugs in hospital formularies. Proposed recommendations were approved by consensus agreement among committee members.

RESULTS

Candida albicans and Pseudomonas aeruginosa were the most common microorganisms isolated from the 3 ICUs, followed by Klebsiella pneumoniae, Acinetobacter baumannii, and Escherichia coli. Targeted therapy is recognized as the best approach in patient management. Based on various antibiograms and publications from different hospitals across the country, amikacin is recommended as the most effective empiric antibiotic against Enterobacterales and A. baumannii, while colistin and polymixin B showed high efficacy against all bacteria. Amoxicillin-clavulanate or ceftriaxone was recommended as the first-choice drug for community-acquired (CA) CA-pneumonia while piperacillin-tazobactam + amikacin was recommended as first choice for the treatment of healthcare-associated (HA) HA-pneumonia. For ventilatorassociated pneumonia (VAP), the consensus for the drug of first choice was agreed as meropenem. Amoxycillin-clavulanate +clindamycin was the consensus choice for CAskin and soft tissue infection (SSIS) and piperacillin-tazobactam + metronidazole ±vancomycin for HA-SSIS. Ceftriaxone-tazobactam or piperacillin-tazobactam + gentamicin was consensus for CA-blood stream infections (BSI) with first choice+regimen for HA-BSI being meropenem/piperacillin-tazobactam +amikacin +fluconazole. For community-acquired urinary tract infection (UTI), first choice antibiotic was ciprofloxacin or ceftriaxone with a catheter-associated UTI (CAUTI) regimen of first choice being meropenem + fluconazole.

CONCLUSION

Data from a multicenter three ICU surveillance and antibiograms and publications from different hospitals in the country was used to produce this evidence-based Nigerian-specific antimicrobial treatment guidelines of critically ill patients in ICUs by a group of experts from different specialties in Nigeria. The implementation of this guideline will facilitate learning, continuous improvement of stewardship activities and provide a baseline for updating of guidelines to reflect evolving antibiotic needs.

Efficacy of surgeon-performed, intra-operative ultrasound scan for localisation of parathyroid adenomas in patients with primary hyperparathyroidism

BACKGROUND

In the UK, guidance recommends ultrasound scanning alone or in combination with sestamibi scintigraphy to guide surgery in patients with primary hyperparathyroidism. If an adenoma is localised on imaging, this can facilitate targeted or minimally invasive surgery. Surgeon-performed ultrasound scan on the operating table benefits from being performed on an anaesthetised patient with optimal positioning. The aim of this study was to investigate the efficacy of intra-operative, blinded, surgeon-performed ultrasound scan in localisation of parathyroid adenomas.

METHODS

Prospective data were collected on consecutive patients undergoing surgery for primary hyperparathyroidism at a single tertiary centre from November 2019 to June 2021. Patients underwent blinded, surgeon-performed ultrasound scan under general anaesthesia immediately prior to surgery. Localisation results from pre-operative imaging and surgeon-performed ultrasound scan were then compared with the intra-operative findings.

RESULTS

Forty-nine patients underwent surgery and were found to have single-gland disease. Sestamibi scintigraphy, radiologist-performed ultrasound scan and surgeon-performed ultrasound scan had sensitivities of 59.4, 43.75 and 73.8 per cent, respectively. Surgeon-performed ultrasound scan had a statistically significantly increased sensitivity compared with radiologist-performed ultrasound (p < 0.05).

CONCLUSION

Intra-operative, surgeon-performed ultrasound scan is effective in localising parathyroid adenomas and may be a useful adjunct to facilitate minimally invasive parathyroid surgery.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Feasibility of an artificially intelligent vaccines chatbot in Pakistan: A mixed methods evaluation

Background

Despite free vaccination services, gaps in information access impede immunization uptake in low and middle-income countries (LMICs), including Pakistan. We developed Bablibot (Babybot), a local-language, text-based chatbot to connect caregivers with immunization-related information in real-time, and evaluated its feasibility and acceptability in resolving immunization-related queries among Karachi's low-income communities.

Methods

We developed Bablibot using Natural Language Processing (NLP), Machine Learning, and Human in the Loop features. We conducted a sequential mixed-methods pilot in Karachi where caregivers were recruited when visiting selected immunization centers for any childhood vaccine except Measles 2 (last vaccine visit) or were informed through targeted text messages. We assessed Bablibot's feasibility and acceptability through user-engagement metrics and thematic analysis of qualitative interviews conducted with 20 pilot participants.

Results

Between March 9, 2020 and April 15, 2021, Bablibot accrued 677 users and participated in 874 conversations. Of 2,202 pilot-enrolled caregivers, 210 (10%) interacted with the bot; other 467 users were not pilot participants. Most queries were about due dates (25%; 221/874), delaying vaccination (17%; 146/874), or side-effect management (16%;137/874). The conversations now constitute a valuable training database for future local-language bots. Over 90% (277/307) of responses to text-based exit surveys indicated user satisfaction. Qualitative analysis showed caregivers appreciate Bablibot's convenience, reliability, and responsiveness.

Conclusions

Our results demonstrate the feasibility and acceptability of local-language NLP chatbots in providing immunization information. Text-based chatbots can minimize workload on helpline operators, in addition to quickly resolving queries that otherwise lead to delay or default. Bablibot's conversation data provides learning infrastructure for future health-related bots.

Key messages

An AI-based NLP chatbot is a feasible and acceptable intervention for providing immunization-related information to large number of caregivers 24/7 in limited resource setting. By serving as a remote, low-cost and confidential bi-directional channel, chatbots can address gaps in information access, especially for women, and have long term impact on immunization uptake.

Role of Intraperitoneal Normal Saline Instillation in Relieving Post-operative Pain Following Laparoscopic Cholecystectomy: A Quasi Experimental Study

Laparoscopic cholecystectomy has rapidly become the procedure of choice for the treatment of calculus cholecystitis for having clear advantage over open method in reducing surgical morbidity, postoperative pain and complication. But still patients undergoing laparoscopic cholecystectomy complain of considerable pain especially on first post-operative day necessitating use of better methods for postoperative analgesia. This quasi experimental study was done in Surgery Unit III, Mymensingh Medical College Hospital from July 2016 to June 2017 to assess the role of intraperitoneal normal saline instillation following laparoscopic cholecystectomy in relieving postoperative pain. In this study total 200 patients of calculus cholecystitis were enrolled according to inclusion and exclusion criteria and assigned equally into two groups by non-equivalent control group design. Both the control group and experimental group were managed according to the standard protocol and operated in routine operation theater. The experimental group (n=100) was additionally instilled with 25-30ml/kg body weight of normal saline at 37°C at the gallbladder bed and subdiaphragmatic space at the end of surgery and all the data were recorded in individual case record form. Among the sample most of the patients were between 25-60 years of ages with the peak age being between 43-51 years. Eighty one percent (81%) of the total patients were female with male female ratio being 1:5.25 in Control group and 1:3.54 in Experimental group. The VAS scores for visceral pain in experimental group were significantly less than that of control group at 6 hours (p<0.001), 12 hours (p<0.001), 24 hours (p<0.001) and 48 hours (p=0.026). The VAS scores for shoulder tip pain in experimental group were also significantly less than that of control group at 6 hours (p<0.001), 12 hours (p<0.018) and 24 hours (p=0.004). The administration of analgesics was also significantly less in the experimental group than in control group at 6 hours (p<0.001), 12 hours (p<0.001), 24 hours (p=0.313) and 48 hours (p=0.297) with no significant differences at 72 hours. The mean hospital stay in this study was 2.2±0.7 days in the control group and 2.1±0.8 days in the experimental group showing no significant difference (p>0.05). Intraperitoneal normal saline instillation following laparoscopic cholecystectomy may be an eminent choice for reducing postoperative pain improving patient's experience.

Fluid mechanics of facial masks as personal protection equipment (PPE) of COVID-19 virus

A fluid mechanics model of inhaled air gases, nitrogen (N₂) and oxygen (O₂) gases, and exhaled gas components (CO₂ and water vapor particles) through a facial mask (membrane) to shield the COVID-19 virus is established. The model was developed based on several gas flux contributions that normally take place through membranes. Semiempirical solutions of the mathematical model were predicted for the N95 facial mask accounting on several parameters, such as a range of porosity size (i.e., 1-30 nm), void fraction (i.e., 10^-3%-0.3%), and thickness of the membrane (i.e., 10-40 µm) in comparison to the size of the COVID-19 virus. A unitless number (Nr) was introduced for the first time to describe semiempirical solutions of O₂, N₂, and CO₂ gases through the porous membrane. An optimum Nr of expressing the flow of the inhaled air gases, O₂ and N₂, through the porous membrane was determined (NO₂ = NN₂ = -4.4) when an N95 facial mask of specifications of a = 20 nm, l = 30 µm, and ε = 30% was used as a personal protection equipment (PPE). The concept of the optimum number Nr can be standardized not only for testing commercially available facial masks as PPEs but also for designing new masks for protecting humans from the COVID-19 virus.

Cryopreservation Studies on Silver Carp (Hypophthalmichthys molitrix) Embryos

BACKGROUND

Cryopreservation is an effective tool for the preservation of live biological materials.

OBJECTIVE

This study examined the suitability of cryopreservation protocols and the effectiveness of ultrasound for silver carp embryos.

MATERIALS AND METHODS

Embryos at three developmental stages were exposed to 10, 15, 20, and 25% of five cryoprotectants (CPAs), namely propylene glycol (PG), dimethylformamide (DFA), DMSO, MeOH, and ethylene glycol (EG) for 20 min. Embryos were exposed to twelve vitrification solutions (VSs) for 10 (five steps of 2 min), 15 (five steps of 3 min), 20 (five steps of 4 min) min. Embryos were also exposed to ultrasound in VSs prior to cooling for cryopreservation.

RESULTS

Hatching rates decreased with increasing CPA concentrations while toxicity varied in the order of PG < DMSO < EG < MeOH < DFA. Tail elongation stage was more tolerant to CPA than 6-somites and morula stages. The survival of embryos exposed to ultrasound in VS was remarkably lower than in water. Embryos exposed to ultrasound in VSs under the best conditions did not response well after attempted vitrification.

CONCLUSION

Ultrasound-mediated CPA impregnation could be effective but other innovative methods may be needed to attain successful cryopreservation.

Endoscopic management of acute oesophageal variceal bleeding within 12 hours of admission is superior to 12-24 hours

Background: Acute oesophageal variceal haemorrhage (AOVH) is a medical emergency. The American Association for the Study of Liver Diseases recommends endoscopy management as soon as possible and not more than 12 hours after presentation. The United Kingdom guidelines recommended endoscopy for unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation and within 24 hours of admission. We aimed to evaluate the outcome of endoscopic management of AOVH in less than 12 hours compared to 12-24 hours post admission.Methods: 297 patients with AOVH were divided into groups depending on the timing of the endoscopic management: 180 within 12 h of admission and 117 patients at 12-24 hours of admission. Routine clinical and laboratory data were collected.Results: Compared to patients with endoscopic management at 12-24 hours (mean 16 hours), patients with endoscopic management within 12 hours (mean 8.3 hours) of admission had fewer hospital stay days (P = 0.001), significant reduction of ammonia levels (P < 0.0001) and significant improvement in associated hepatic encephalopathy grade 25 (p = 0.048). There were no major clinical events in the 12-hour group, but 8 events in the 12-24 hour group (p < 0.01).Conclusion: Endoscopic management of acute variceal bleeding within 12 hours of admission is superior to endoscopic management at 12-24 hours of admission regarding reduction of hospital stay, ammonia levels, correction of hepatic encephalopathy, re-bleeding and mortality rate, hence, reducing the cost of treatment benefiting patient satisfaction and improving hospital bed availability.

Damage localization in piezo-ceramic using ultrasonic waves excited by dual point contact excitation and detection scheme

A novel experimental technique based on point contact and Coulomb coupling is devised and optimized for ultrasonic imaging of bulk and guided waves propagation in piezo-ceramics. The Coulomb coupling technique exploits the coupling and transfer of electric field to mechanical vibrations by excitation of phonons. The point contact excitation and detection technique facilitates the spatial-temporal imaging of ultrasonic waves. The motivation of this research is the diagnosis and localization of surface cracks in the piezoelectric sensors and actuators. The underlying principle of the detection scheme is that any discontinuity on the surface causes high localization of electric gradient. The localized electric field at the defect boundaries enables then to behave as secondary passive ultrasonic sources resulting in strong back reflections. However, due to the interference between transmitted and reflected wave components from rigid boundaries and defect, the resolution on the localization of the damage is challenging. Therefore, an algorithm based on the two-dimensional spectral decomposition is utilized for selective suppression of the transmitted wave. The algorithm includes data transformation and vectorization in polar coordinates for efficient spectral decomposition. In the spectral domain, the complex wave component (phase and amplitude) are suppressed for the transmitted wave field. The reflected wave component in the spectral domain is retained and retrieved back using inverse spectral transformation. The algorithm is successful in retaining and exemplifying only the reflected wave sources arising from the strong scattering of ultrasonic waves from the surface and sub-surface defects. In summary, a novel experimental technique based on Coulomb coupling and spectral decomposition technique has been implemented for localization of surface defect in piezo-ceramic structures.

Feasibility of implementing Integrated Management of Childhood Illnesses through Mobile Technology

Background

The Integrated Management of Childhood Illnesses (IMCI) strategy was launched by WHO and partners in 1995 to reduce child mortality by enhancing frontline health workers' (FHWs) ability to diagnose and manage childhood illnesses, and strengthen overall health systems. However, although IMCI is associated with decreased child mortality, numerous studies have shown its impact has been limited due to persistent barriers to implementation.

Methods

We developed a digitized version of IMCI (eIMCI) using Android technology to overcome implementation problems, including poor protocol compliance, lengthy trainings, paper-based data collection, and gaps in the referral system. The feasibility and efficacy of eIMCI was assessed through a mixed-methods pilot study encompassing baseline and end-line surveys, interviews, and Focus Group Discussions, in a low-resource rural district of Punjab, Pakistan. During the 8 weeks of deployment, a total of 1,978 children were enrolled in the eIMCI application by 10 participating FHWs, and 47 electronic referrals were generated.

Results

Preliminary outcomes showed reduced disease occurrence (for example, diarrhea decreased from 48% at baseline to 29% at endline), increased adherence to IMCI protocol, and strengthened health system linkages (facility referrals increased from 5% at baseline to 45% at endline). FHWs reported enhanced performance, as well as an improved community response to their services.

Discussion

Indicating the feasibility and efficacy of eIMCI deployment in a low-resource setting, evidence from the pilot demonstrates the benefit of digitizing the IMCI protocol. eIMCI is a digital health solution with the potential to significantly reduce child mortality and improve service delivery and performance of FHWs.

Key messages

eIMCI is a feasible solution for the implementation of IMCI strategy in developing countries and demonstrates increased compliance and enhanced performance by the frontline health workers. Implementation of eIMCI can result in a significant reduction in child morbidity and mortality via timely referrals of patients and reduced disease occurrence.

Real-time immunization trends in under-2 children in Pakistan: insights from big data analysis

Background

Despite the provision of free-of-cost vaccines in Pakistan, fully immunized child (FIC) coverage in Sindh province remains low at 49%. In 2012, we developed and piloted the Zindagi Mehfooz (Safe Life; ZM) Digital Immunization Registry, an Android-based platform that enables vaccinators to enroll and track child level immunization data of children in the catchment population. In 2017, ZM was scaled-up across Sindh province and is currently being used by 2,284 vaccinators across 1,526 facilities serving &gt;48 million (m) population.

Methods

All children under-2 years of age visiting EPI centers are enrolled. At enrollment, caregiver and child bio-data and child immunization history are recorded, and the child is provided with a unique Quick Response (QR) code for identification. For follow-up immunization visits, 3 SMS reminders are sent to caregivers, and upon immunization, child history is retrieved by scanning the QR code and vaccination record updated. ZM allows real-time access to data and generation of monitoring reports. Data from ZM was used to calculate coverage rates, timeliness, and trends for immunization coverage in Sindh.

Results

From Oct'17 to Dec'19, more than 2.4m children and 0.8m women were enrolled in the Registry, while &gt;17m immunizations were administered. The FIC coverage in 12-23 months old children has increased from 49% (at baseline) to 57% for children enrolled in ZM. Additionally, pentavalent-3 coverage increased from 59% to 68%.

Discussion

ZM demonstrates the potential of DIRs to improve immunization outcomes within low-resource settings by enabling better child tracking and a higher retention rate. Additionally, the big dataset provides the opportunity to identify real-time trends and provides actionable data for evidence-based decision making.

Key messages

ZM Immunization Registry has strengthened the current EPI program through increased FIC coverage and timeliness through better tracking of children and increased retention. Big Data from ZM can be used to analyze immunization trends of global relevance, and guide strategic policy decisions for improving immunization coverage and equity, based on actionable data insights.

Guideline-based flexible cystoscopy safely improves capacity, avoiding unnecessary intervention with cost savings

Introduction:

Flexible cystoscopy (FC) is a common and useful diagnostic tool. Because of its broader applications, availability and simplicity, there has been criticism of its overuse with accompanying financial burden to the health system and unnecessary invasive intervention to the patient. Therefore, we reviewed our local practice against current guidelines to evaluate compliance, enhance patient safety and capacity utilisation.

Patients and methodology:

Data were collected retrospectively on all patients having FC over two months. The indications and findings of FC were gathered from the hospital electronic patient record system.

Results:

A total of 413 FCs were carried out over the study period. The most common indications were cancer surveillance 116 (28%) and visible haematuria 76 (18.4%). A total of 152 (37%) FCs were performed for non-recommended indications. The most common conditions that deviated from guidelines were lower urinary tract symptoms (LUTS) (72, 17.4%), urinary tract infection (UTI) (41, 9.9%) and asymptomatic non-visible haematuria (35, 8.5%). In all non-visible haematuria cases, 65 (90%) of LUTS and 39 (95%) of UTI patients, FC was non-contributory. Adherence to guidelines would have yielded 37% of FC slots. Based on current UK National Tariffs, cost savings would have been £352,032 annually in this trust.

Conclusions:

FC is a frequent investigation within urology departments for which referral guidelines exist. Protocol-driven practice enables appropriate use, ensures patient safety and leads to efficient utilisation of capacity with substantial cost savings.

Level of evidence:

Not applicable for this multicentre audit.

Effectiveness of Pressurized Normal Saline Irrigation of Subcutaneous Tissue Following Appendicectomy in Decreasing Wound Infection: A Quasi Experimental Study

Acute appendicitis is the commonest cause of acute abdomen necessitating surgical intervention and wound infection is the most frequently encountered complication following appendicectomy. To assess the effectiveness of pressurized normal saline irrigation of subcutaneous tissue following appendicectomy in decreasing wound infection this quasi experimental study was done in Surgery Unit III, Mymensingh Medical College Hospital from January 2018 to December 2018. In this study total 200 patients of acute appendicitis were enrolled according to inclusion and exclusion criteria and assigned equally into two groups by non-equivalent control group design. In control group all the standard protocol of wound closure following appendicectomy was followed and in experimental group along with the standard protocol the subcutaneous tissue was irrigated by pressure with normal saline and all the data were recorded in individual case record form. Among the sample most of the patients were between 10-19 years of ages and the male female ratio was 1.38:1. In control group 30% patients developed wound infection while 12% patients developed wound infection in experimental group with a P value of 0.027. Mean hospital stay of experimental group was less than the control group (P value less than 0.05). Overall postoperative outcome in context of wound infection and hospital stay is better following pressurized normal saline irrigation of subcutaneous tissue during closure.

Efficacy of Intra-peritoneal Tramadol Instillation for Postoperative Pain Management after Laparoscopic Cholecystectomy

Gall stone disease is one of the most common conditions encountered in general surgical practices in adult population. The gold standard treatment for symptomatic gall stone disease is laparoscopic cholecystectomy. It results in less post-operative pain as compared to open cholecystectomy but post-operative pain may be mild, moderate or even severe in some patients. This Randomized control trail was conducted to In-patient department of Surgery, Mymensingh Medical College & Hospital (MMCH), Mymensingh, Bangladesh from April 2018 to September 2018. It was undertaken to evaluate the analgesic effect of intra-peritoneal tramadol instillation in patients undergoing laparoscopic cholecystectomy. Total 70 patients with symptomatic gallstone disease undergoing laparoscopic cholecystectomy were randomized equally in two groups. Then patients were selected in according to the inclusion and exclusion criteria. In first group (Group A), patients were received intra-peritoneal tramadol 100mg (diluted in 20.0ml distilled water). Sprayed 10.0ml diluted tramadol into the sub diaphragmatic area, 5.0ml into the area of gall bladder bed and 5.0ml into the space between the liver and kidney under direct vision just before removal of trocars. In second group (Group B) the conventional operative procedure was followed. Postoperatively, patient was extubated and shifted to recovery room. Data recorded and analyzed, such as post-operative pain score at 1, 4, 8, and 24 hour; cumulative 1, 8 and 24 hour analgesic consumption. In addition that postoperative hospital period monitoring of heart rate, blood pressure, respiratory rate, temperature at 0, 4, 8, 24 hours was also analyzed. Intensity of pain was assessed by Visual Analogue Scale (VAS) scoring system. Patients showed a VAS ≥3 or patients who requested for analgesia was administrated a supplemental dose of analgesic. In the present study the mean pain scores in Group A were found to be low at1hourpost-operative was 0.60±0.56 and there was a gradual increase in score in respect of time interval with peak of 2.07±0.91 at 24 hours. Whereas, in Group B the mean pain scores immediate post-operative period were at its peak was, 2.50±0.82 which decreased to 1.30±0.84 at 1 hour and further there was rise at 4 hours (2.10±0.71) and 24 hours (2.33±0.0.71). But at any point of time the mean VAS remained significantly low (p<0.050) in patients with Group A compared to Group B except at 1st 24 hours (p=0.210). Intra-peritoneal instillation of tramadol for postoperative pain control in laparoscopic cholecystectomy has beneficial effect in terms of postoperative pain relief following laparoscopic cholecystectomy.

[Hookworm-related folliculitis in a woman performing skin bleaching in Benin]

Hookworm-related cutaneous larva migrans is caused by the subcutaneous migration of hookworm larvae. The characteristic sign is a serpiginous cutaneous track. Folliculitis is an uncommon clinical manifestation. We report a case of hookworm-related folliculitis in a woman performing skin bleaching. A 33-year-old woman presented with a widespread cutaneous eruption made of erythematous and itchy follicular papulo-nodules, with erythematous serpiginous tracks, about 5-10cm long and numerous streaks of scratching, located on the limbs, buttocks and trunk. The cutaneous lesions occurred two days after contact with the floor of a warehouse contamined by faeces of cats. The lesions have been evolving for a week and have been treated with antibiotics without success. Clinical examination found cutaneous atrophy, purple stretch marks and hyperpigmentation of dorsal parts of fingers joints. The patient reported having been using bleaching cosmetics containing topical steroids and hydroquinone for twelve years. She was cured within 4 weeks with oral albendazole 400mg per day during 7 consecutive days.

Post-traumatic growth in (ex-) military personnel: review and qualitative synthesis

BACKGROUND

Military service can be a traumatic experience and cause mental health problems in a minority of personnel, such as post-traumatic stress disorder (PTSD), which is linked to negative long-term outcomes. As a result, PTSD has received significant research attention. However, post-traumatic growth (PTG) is a newer construct, with comparatively little known about its presentation and development.

AIMS

To qualitatively examine the experience of (PTG) in military and ex-military personnel.

METHODS

A qualitative systematic search of electronic databases was conducted, with studies assessed for methodological quality and data analysed using thematic analysis. Nine qualitative studies, carried out between 2011 and 2016, met the inclusion criteria with 195 participants in total, including both military and ex-military personnel.

RESULTS

Six themes were identified: appreciation for life, re-evaluating sense of purpose, improvement of personal human traits, bonding and connecting with others, integrating into society, and being proud of heritage and feeling valuable to society.

CONCLUSIONS

The results of this review illustrate that military personnel may experience PTG due to deployment-related trauma exposure, and the presentation of PTG in this population is not dissimilar to that of civilians. This study highlights the need for additional research to quantify the long-term psychological impact of PTG and whether a focus on PTG may be helpful in psychological treatment for (ex-) military personnel.

Connectivity of diagnostic technologies: improving surveillance and accelerating tuberculosis elimination

In regard to tuberculosis (TB) and other major global epidemics, the use of new diagnostic tests is increasing dramatically, including in resource-limited countries. Although there has never been as much digital information generated, this data source has not been exploited to its full potential. In this opinion paper, we discuss lessons learned from the global scale-up of these laboratory devices and the pathway to tapping the potential of laboratory-generated information in the field of TB by using connectivity. Responding to the demand for connectivity, innovative third-party players have proposed solutions that have been widely adopted by field users of the Xpert(®) MTB/RIF assay. The experience associated with the utilisation of these systems, which facilitate the monitoring of wide laboratory networks, stressed the need for a more global and comprehensive approach to diagnostic connectivity. In addition to facilitating the reporting of test results, the mobility of digital information allows the sharing of information generated in programme settings. When they become easily accessible, these data can be used to improve patient care, disease surveillance and drug discovery. They should therefore be considered as a public health good. We list several examples of concrete initiatives that should allow data sources to be combined to improve the understanding of the epidemic, support the operational response and, finally, accelerate TB elimination. With the many opportunities that the pooling of data associated with the TB epidemic can provide, pooling of this information at an international level has become an absolute priority.

Biochemical and molecular characteristics of Malaysian patients with lysinuric protein intolerance

Lysinuric protein intolerance (LPI) is an inborn error of dibasic amino acid transport due to a defect in the dibasic amino acid transporter in the renal and intestine and has a heterogenous presentation. Three Malaysian patients with LPI were studied and their biochemical and molecular findings compared. There were differences and similarities in the biochemical and molecular findings. Molecular analysis of SLC7A7 gene revealed a novel mutation c.235G>A; p.(Gly79Arg) in exon three in Patient 1 and a mutation c.1417C>T; p.(Arg473*) in exon 10 in patient 2 and 3. The degree of concentration of dibasic amino acids may determine the type of disease of the cell membrane transport, however, a positive molecular confirmation will secure the diagnosis.

Serum Fragments of Tau for the Differential Diagnosis of Alzheimer's Disease

Differential diagnosis of AD is still a challenge due to overlapping features with other types of dementia. Biomarkers for the differential diagnosis of AD can improve the diagnostic value of the disease and ensure an appropriate treatment of patients. The aim of this study was to evaluate the potential of two neo-epitope fragments of Tau as serum biomarkers for differential diagnosis of AD. The neo-epitope fragments of Tau were assessed in a cross-sectional cohort of subjects with AD, MCI, other dementias or subjects with non-dementia related memory complaints. The two Tau neo-epitope fragments were an ADAM10-generated fragment (Tau-A) and a caspase-3-generated fragment (Tau-C). The serum levels of the fragments were measured by two competitive ELISAs detecting Tau-A and Tau-C, respectively. Tau-A and Tau-C were able to separate subjects with AD and MCI from those with other dementias (p<0.0042 and p<0.05), and Tau-A could also discriminate between AD and MCI patients and subjects with non-dementia related memory complaints (p<0.05). Tau-A showed a significantly greater discrimination between AD and MCI subjects and patients with other dementias when compared to CSF biomarkers t-Tau and p-Tau. The ability of Tau-A to differentiate between AD and MCI from other dementias was comparable with CSF Aβ1-42, t-Tau/Aβ1-42 and p-Tau/Aβ1-42. The separation between the diagnostic groups was significantly improved when the CSF biomarkers as well as age and BMI were used in combination with Tau-A (AUC=0.87, 95% CI: 0.75-0.94) (p<0.0001). In conclusion, this study shows that a neoepitope fragment of Tau detected in serum can provide guidance on the differential diagnosis of AD.

Urban and rural comparison of vitamin D status in Pakistani pregnant women and neonates

We undertook a cross-sectional study in rural Jehlum and urban Karachi to evaluate the prevalence of vitamin D deficiency in Pakistani pregnant women and neonates and to assess any association of serum 25(OH) vitamin D [25(OH)D] concentration with vitamin D binding protein (Gc) genotypes. Altogether, 390 women and 266 neonates were recruited from urban and rural sites, respectively. Serum 25(OH)D was measured by an immunoassay, while Gc genotypes were identified using polymerase chain reaction followed by restriction fragment length polymorphism or PCR-RFLP. One-way analysis of variance or ANOVA and linear regression were used for statistical analysis. In urban Karachi, 99.5% of women and 97.3% of neonates were vitamin D deficient (< 50 nmol/L), while 89% of women and 82% of neonates were deficient in rural Jehlum. Gc genotypes were not associated with serum 25(OH)D concentrations in both women and their neonates. We conclude that vitamin D deficiency is highly prevalent in Pakistani women and their neonates, and Gc genotypes are not associated with serum 25(OH)D concentrations.

Comparative Study of Clinical and Sonographic Estimation of Foetal Weight at Term

A cross sectional comparative study was conducted at Dhaka National Medical College, Dhaka from January to June 2012, to observe the accuracy of clinical and ultrasonographic estimation of foetal weight at term in our environment. Seventy five pregnant women who fulfilled the inclusion criteria had their foetal weight estimated independently using clinical and ultrasonographic methods. Accuracy was determined by percentage error, absolute percentage error and proportion of estimates within 10% of actual birth weight (birth weight fetus of +10%). Statistical analysis was done using the paired t-test, the Wilcoxon signed-rank test, and the chi-square test. The study sample had an actual average birth weight of 2989.60 ± 408.76 (range 2310-4000 gm). Overall, the clinical method overestimated birth-weight, while ultrasound underestimated it. The mean absolute percentage error of the clinical method was more than that of the sonographic method, and the number of estimates within 10% of actual birth weight for the clinical method (41.3%) was less than for the sonographic method (57.3%); the difference was not statistically significant. In the low birth-weight (<2,500 gm) group, the mean absolute percentage error of sonographic estimates were significantly smaller. Significantly more sonographic estimates (75%) were within 10% of actual birth-weight than those of the clinical method (0%). No statistically significant difference was observed in all the measures of accuracy for the normal birth-weight range of 2,500-<4,000 gm and in the macrosomic group (≥ 4,000 gm). Clinical estimation of birth-weight is as accurate as routine ultrasonographic estimation, except in low-birth-weight babies.

Advanced 3D-Sonographic Imaging as a Precise Technique to Evaluate Tumor Volume

Determination of tumor volume in subcutaneously inoculated xenograft models is a standard procedure for clinical and preclinical evaluation of tumor response to treatment. Practitioners frequently use a hands-on caliper method in conjunction with a simplified formula to assess tumor volume. Non-invasive and more precise techniques as investigation by MR or (μ)CT exist but come with various adverse effects in terms of radiation, complex setup or elevated cost of investigations. Therefore, we propose an advanced three-dimensional sonographic imaging technique to determine small tumor volumes in xenografts with high precision and minimized observer variability. We present a study on xenograft carcinoma tumors from which volumes and shapes were calculated with the standard caliper method as well as with a clinically available three-dimensional ultrasound scanner and subsequent processing software. Statistical analysis reveals the suitability of this non-invasive approach for the purpose of a quick and precise calculation of tumor volume in small rodents.