Doctors' adherence to guidelines recommendations and glycaemic control in diabetic patients in Quetta, Pakistan: Findings from an observational study

BACKGROUND

Poor control of diabetes mellitus (DM) is partly attributed to doctors' poor adherence to guidelines.

OBJECTIVE

To evaluate doctors' adherence to pharmacotherapeutic recommendations of DM management guidelines and factors associated with guidelines adherence and glycaemic control.

METHODS

This prospective observational study included 30 doctors who were treating DM patients in their private clinics in Quetta, Pakistan. On visit 1, a total of 600 prescriptions written by 30 enrolled doctors (20 patients per doctor) were noted along with patients' sociodemographic and clinical characteristics. American Diabetes Association guidelines was used as a reference. The prescriptions noted were judged for guidelines compliance. Of 600 enrolled patients, 450 patients (15 patients per doctor) were followed for one more visit and included in final analysis. Glycated hemoglobin (HbA1c) level noted one visit 2 was related with the respective prescription on visit 1. Data were analyzed by SPSS (version 23). A p-value <0.05 was considered statistically significant.

RESULTS

Patients received a median of two antidiabetic drugs (range: 1-5). A total of 73.1% patients were on polytherapy. Metformin was the most frequently prescribed (88.4%) antidiabetic followed by gliptins (46.2%). A total of 41.6% prescriptions were judged guidelines compliant. In multivariate binary logistic regressions (MVBLR) analysis, chronic kidney disease (CKD) (OR = 0.422) and polytherapy (OR = 0.367) had statistically significant negative associations (p-value <0.05) with guidelines' compliant prescriptions. The group of doctors comprised of specialists and consultants wrote significantly (p-value = 0.004) high number of guidelines adherent prescriptions (mean rank = 20.25) than the group comprised of medical officers (mean rank = 11.34). On visit 2, only 39.5% patients were on goal glycemic levels. In MVBLR analysis, suffering from dyslipidemia (OR = 0.134) and CKD (OR = 0.111), receiving sulfonylurea (OR = 0.156) and guidelines' compliant prescription (OR = 4.195) were significantly (p-value <0 .05) associated with glycemic control.

CONCLUSION

Although guidelines compliant prescriptions produced better glycemic control, but doctors' adherence to guidelines and glycemic control were poor. Polytherapy and CKD emerged as risk factors for guidelines divergent prescriptions. Dyslipidemia, CKD and reception of sulfonylureas had negative association with glycemic control.

Frequency and Factors Associated With Adverse Events Among Multi-Drug Resistant Tuberculosis Patients in Pakistan: A Retrospective Study

Background

Treatment of multi-drug resistant tuberculosis (MDR-TB) for a prolonged period with comparatively less effective and more toxic second-line anti-TB drugs is associated with greater incidence of adverse events.

Study aim

This study aimed to evaluate the frequency and factors associated with occurrence of adverse events among patients with MDR-TB attending the Bahawal Victoria Hospital, Bahawalpur, Pakistan.

Study design

This retrospective study included all patients with MDR-TB who were registered and treated at the study site between June 2014 and December 2016 and had their treatment outcomes available at the time of data collection (i.e., November 2018).

Measures and outcomes

The Electronic Nominal Record System (ERNS) records, medical charts of patients, and laboratory reports were reviewed to obtain the data. Adverse events were reported as per the standard criteria recommended by the WHO. Multivariate binary logistic regression was used to find the independent factors associated with the occurrence of adverse events.

Results

A total of 179 patients with MDR-TB were included in the final analysis. Out of these, 114 (63.7%) patients experienced at least one adverse event during the course of their treatment. Depression was the most common adverse events (33%), followed by nausea and vomiting (27.4%) and arthralgia (27.4%). The factors associated with the occurrence of adverse events included presence of comorbidity (adjusted odds ratio [AOR] 2.951; 95% CI 1.423, 6.118) and being employed (AOR 3.445; 95% CI 1.188, 9.993).

Conclusion

Adverse events were prevalent in this cohort, however, resolved with the effective management approaches. Patients with identified factors for occurrence of adverse events need special attention and enhanced clinical management.

Positive Selection Drives the Adaptive Evolution of Mitochondrial Antiviral Signaling (MAVS) Proteins-Mediating Innate Immunity in Mammals

The regulated production of filamentous protein complexes is essential in many biological processes and provides a new paradigm in signal transmission. The mitochondrial antiviral signaling protein (MAVS) is a critical signaling hub in innate immunity that is activated when a receptor induces a shift in the globular caspase activation and recruitment domain of MAVS into helical superstructures (filaments). It is of interest whether adaptive evolution affects the proteins involved in innate immunity. Here, we explore and confer the role of selection and diversification on mitochondrial antiviral signaling protein in mammalian species. We obtined the MAVS proteins of mammalian species and examined their differences in evolutionary patterns. We discovered evidence for these proteins being subjected to substantial positive selection. We demonstrate that immune system proteins, particularly those encoding recognition proteins, develop under positive selection using codon-based probability methods. Positively chosen regions within recognition proteins cluster in domains involved in microorganism recognition, implying that molecular interactions between hosts and pathogens may promote adaptive evolution in the mammalian immune systems. These significant variations in MAVS development in mammalian species highlights the involvement of MAVS in innate immunity. Our findings highlight the significance of accounting for how non-synonymous alterations affect structure and function when employing sequence-level studies to determine and quantify positive selection.

Spectrum of Microorganisms, Antibiotic Resistance Pattern, and Treatment Outcomes Among Patients With Empyema Thoracis: A Descriptive Cross-Sectional Study From the Bahawal Victoria Hospital Bahawalpur, Punjab, Pakistan

Background: This study involves the analysis of spectrum of microorganisms, antibiotic resistance pattern, and treatment outcomes among empyema thoracis patients. This study also analyzes the factors associated with unsuccessful treatment outcome and duration of hospital stay among the patients.

Methods: This was a descriptive, cross-sectional study carried out in the Pulmonology Ward of the Bahawal Victoria hospital, Bahawalpur, Pakistan. All patients with empyema thoracis registered at the study site during the period of 1 year were included in the study. Multivariate regression analysis was used to analyze the factors associated with duration of hospital stay and unsuccessful treatment outcome among the patients.

Results: A total 110 patients were included in the study. Most of the patients (n = 73, 66.4%) were treated with piperacillin/tazobactam alone and in combination with either one or more than one antibiotics as an empiric therapy. Culture was positive in 58 (52.7%) patients and the most commonly identified organisms included, gram-negative Pseudomonas aeruginosa (n = 20; 18.8%) and Klebsiella sp. (n = 11, 10%) followed by same proportion of E. coli. The most commonly identified bacterial isolates showed high level of resistance against antibiotics used as an empiric therapy, while these showed low level of resistance against amoxicillin, clarithromycin, ertapenem, colistin, tigecycline, fosfomycin, rifampicin, and vancomycin. In this study, 82 (74.5%) patients successfully completed the treatment, while 12 (11%) showed no clinical improvement, 5 (4.5%) lost to follow up and 11 (10%) died. In multivariate binary logistic regression analysis, none of the patient attributes were significantly associated with unsuccessful treatment outcome, while in multivariate linear regression analysis, the factors which were significantly associated with duration of hospital stay included; duration of symptoms <2 weeks prior to admission (p = 0.008, beta = −0.247) and resistance to five antibiotic classes (p = 0.02, beta = 0.280).

Conclusion: Close to 25% of the patients did not complete the treatment successfully. Most of the common bacterial isolates showed high level of resistance against the broad-spectrum antibiotics used as an empiric therapy. This is alarming. However, better sensitivity of common bacterial isolates against standardized first line treatment for empyema thoracis is promising.

COVID19 Acute respiratory distress syndrome and extra-corporeal membrane oxygenation; A mere option or ultimate necessity

Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia (hypoxemia persisting despite lung-protective ventilation). One aspect of ECMO is whether there would be an application of the technology related to the Coronavirus pandemic. The number of people diagnosed with Coronavirus disease (COVID19) has crossed the five million mark on 9 August 2020, with a case fatality rate of 5.2%. Due to this exponential increase in the number of coronavirus disease (COVID19) cases particularly the ones associated with ARDS, experts are evaluating the need for ECMO in intensive care units. Herein, we chronicle a review encompassing the available evidence on ECMO and its potential role in COVID19 ARDS, as we aim for optimal patient care with appropriate resource utilization and conservation.

Mai infection simulating metastatic breast cancer

We represent a case of an asymptomatic female who was found to have a mass in the right breast which confirmed an invasive ductal carcinoma by core biopsy. After 3&emsp14;months of completion of chemo-radiotherapy, the patient remained totally asymptomatic. However, positron emission tomography scan showed four hypermetabolic lesions in the left lung thought to be consistent with metastatic disease. Standard uptake value ranged between 3.86 and 6; the results were consistent with metastatic breast cancer, so wedge resection was performed. Caseating granulomatous inflammation with necrosis was reported. Ultimately culture revealed Mycobacterium avium intracellulare infection. The lesions resolved completely after a course of antibiotics.

Updating the role of natriuretic peptide levels in cardiovascular disease

Heart disease affects 1 in 3 individuals in the United States, and the prevalence of heart failure (HF) is increasing exponentially. Although our understanding of the disease progression of congestive HF (CHF) has advanced, refining the areas of diagnosis, risk stratification, prognosis, and treatment is still needed. The natriuretic peptides, specifically B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), have shown promise in clinical practice. Brain natriuretic peptide is released from cardiac ventricular myocytes in response to volume or pressure overload. Rapid measurement of plasma BNP or NT-proBNP has been shown to increase the diagnostic accuracy of HF exacerbations. A cutoff value of 100 pg/mL has a sensitivity and specificity of 90% and 73%, respectively, according to the Breathing Not Properly Study. In addition, BNP and NT-proBNP have been considered independent predictors of adverse outcome. One study calculated a 35% increase in risk of death due to HF for every 100-pg/mL increase in BNP level. Lastly, natriuretic peptides have been known to decrease following medical therapy of HF, suggesting the role of their measurement in monitoring inpatient disease progression and outpatient medical programs. The future of natriuretic peptides lies in risk stratification in other cardiac diseases, such as acute coronary syndrome, and possibly determining severity of valvular disease. Although there is substantial work done in elucidating the power of natriuretic peptides in clinical practice, more research is necessary to reach a consensus regarding how to appropriately utilize them in treatment regimens.

Bile acids. LXXXI. Synthesis and structural assignment of E/Z isomers of substituted methyl hydroxy-5 beta-cholest-24-en-26-oates

Syntheses of the E and Z isomers of methyl 3 alpha-,3 alpha,7 alpha-,3 alpha,12 alpha-, and 3 alpha,7 alpha,12 alpha-trihydroxy-5 beta-cholest-24-en-26-oates are reported. Mass spectral studies show fragmentation patterns in support of assignment as the E or Z isomers, especially in differences in loss of the side chain. Chromatographic procedures, primarily gas chromatography and high-performance liquid chromatography, support these assignments. The E isomer predominates in either of two methods of synthesis.

Bile acids, LXXIX. Synthesis and reduction of 1,4-dien-3-ones of various bile acids

1,4-Dien-3-ones of various bile acids (IIa-d), their methyl esters (IIe-h), and their formylated derivatives (IIi-k) were synthesized and their reduction investigated by both catalytic and chemical methods as an alternative route to the synthesis of allo bile acids. Lithium-ammonia reduction proved to be the better method for the reduction of these 1,4-dien-3-ones producing the 3-keto- and 3 beta-hydroxy-allo bile acids (Vb-d) and (VIb-d) in 66-72% yields.