Finding gaps in routine TB surveillance activities in Bangladesh

BACKGROUND :

TB was the leading cause of death from a single infectious pathogen globally between 2014 and 2019. Fine-scale estimates of TB prevalence and case notifications can be combined to guide priority-setting for strengthening routine surveillance activities in high-burden countries. We produce policy-relevant estimates of the TB epidemic at the second administrative unit in Bangladesh.

METHODS :

We used a Bayesian spatial framework and the cross-sectional National TB Prevalence Survey from 2015–2016 in Bangladesh to estimate prevalence by district. We used case notifications to calculate prevalence-to-notification ratio, a key metric of under-diagnosis and under-reporting.

RESULTS :

TB prevalence rates were highest in the north-eastern districts and ranged from 160 cases per 100,000 (95% uncertainty interval [UI] 80–310) in Jashore to 840 (UI 690–1020) in Sunamganj. Despite moderate prevalence rates, the Rajshahi and Dhaka Divisions presented the highest prevalence-to-notification ratios due to low case notifications. Resolving subnational disparities in case detection could lead to 26,500 additional TB cases (UI 8,500–79,400) notified every year.

CONCLUSION :

This study is the first to produce and map subnational estimates of TB prevalence and prevalence-to-notification ratios, which are essential to target prevention and treatment efforts in high-burden settings. Reaching TB cases currently missing from care will be key to ending the TB epidemic.

Concurrent Infection of Orientia Tsutsugamushi with Rickettsia spp. Including Rickettsia felis in North Central Bangladesh

Rickettsial diseases are one of the leading causes of treatable acute febrile illness in Asia pacific region. This cross-sectional descriptive study was conducted at Department of Microbiology, Mymensingh Medical College to diagnose scrub typhus by rapid Immunochromatographic Test (ICT) and Nested PCR followed by molecular identification of possible Rickettsial coinfection among suspected febrile patients in Mymensingh, Bangladesh from March 2019 to February 2020. Among the enrolled 402 patients, 89 samples (22.13%) were seropositive by Immunochromatographic Test (ICT) and 65 samples (16.16%) were positive for O. tsutsugamushi DNA by Nested PCR, targeting 47KDa gene. Therefore, 113/402 (28.10%) samples were positive for scrub typhus by PCR and/or ICT. All the scrub typhus positive samples were further subjected to Nested PCR targeting 17 KDa gene for identification of Rickettsial co-infection and 13/113 (11.50%) were documented as positive. Then 13 Rickettsial co-infected samples were undertaken to automate sequencing and all were genetically confirmed as Rickettsia felis. Findings of the study may help clinicians to expand their list of differential diagnoses for undifferentiated fever and detection of Rickettsial co-infection may guide them to prescribe effective antimicrobials.

Effect of COVID-19 Pandemic on Food Systems and Determinants of Resilience in Indigenous Communities of Jharkhand State, India: A Serial Cross-Sectional Study

The COVID-19 pandemic has globally jeopardized food security, with heightened threats for the most vulnerable including smallholder farmers as well as rural, indigenous populations. A serial cross-sectional study was conducted to document effect of COVID-19 pandemic on food environment, agricultural practices, diets and food security, along with potential determinants of food systems resilience, among vulnerable smallholder farmer households in indigenous communities of Santhal, Munda, and Sauria Paharia of Jharkhand state, India. Telephonic household surveys were conducted in two phases i.e., lockdown and unlock phase to assess the impact of the pandemic on their food systems and agricultural practices. Market surveys were conducted during the unlock phase, to understand the impact on local informal markets. Secondary data on state and district level food production and Government food security programs were also reviewed. For data analysis purpose, a conceptual framework was developed which delineated possible pathways of impact of COVID-19 pandemic on food environment, food security and food consumption patterns along with factors that may offer resilience. Our findings revealed adverse effects on food production and access among all three communities, due to restrictions in movement of farm labor and supplies, along with disruptions in food supply chains and other food-related logistics and services associated with the pandemic and mitigation measures. The pandemic significantly impacted the livelihoods and incomes among all three indigenous communities during both lockdown and unlock phases, which were attributed to a reduction in sale of agricultural produce, distress selling at lower prices and reduced opportunity for daily wage laboring. A significant proportion of respondents also experienced changes in dietary intake patterns. Key determinants of resilience were identified; these included accessibility to agricultural inputs like indigenous seeds, labor available at household level due to back migration and access to diverse food environments, specifically the wild food environment. There is a need for programs and interventions to conserve and revitalize the bio-cultural resources available within these vulnerable indigenous communities and build resilient food systems that depend on shorter food supply chains and utilize indigenous knowledge systems and associated resources, thereby supporting healthy, equitable and sustainable food systems for all.

An antimicrobial activity of oil extracted from Saara hardwickii

Present research work represents antiviral and antibacterial value of body fat of Saara hardwickii commonly called as spiny tailed lizard. Oil was extracted from body fats located in the ventral region of this animal using hydrocarbons e.g., n-hexane, methanol, butanol and ethyl acetate as a solvent. The antibacterial activity of lizard oil was tested against standard as well as multi-resistant lines ofEscherichia coli, Styphalococcus aureus, Pseudomonas aeruginosa and Proteus vulgaris alone and with antibiotic ampicillin. For antibacterial potential, Ethyl acetate and Butanol solvent extract showed best zone of inhibition (7mm) with P. aeruginosa and S. aureus respectively. For antiviral potential, Butanol and Methanol extract showed best HA (Hemagglutination) titer of 04 with NDV and IBV viral strain respectively. It is concluded that lizard oil has antimicrobial potential against different pathogens strains (virus, bacteria).

Measurement of the Cross Section for e^{+}e^{-}→Hadrons at Energies from 2.2324 to 3.6710 GeV

Based on electron-positron collision data collected with the BESIII detector operating at the Beijing Electron-Positron Collider II storage rings, the value of R≡σ(e^{+}e^{-}→hadrons)/σ(e^{+}e^{-}→μ^{+}μ^{-}) is measured at 14 center-of-mass energies from 2.2324 to 3.6710 GeV. The resulting uncertainties are less than 3.0% and are dominated by systematic uncertainties.

Perceptions and Responses of Diversified Farm Producers in the Northern Great Plains to the Early Stage of the COVID-19 Pandemic

The initial months of the COVID-19 pandemic revealed unique vulnerabilities of the global food system with notable societal consequences, calling for the need to implement resilience strategies to support food security for all. The objective of this study was to elicit perceptions, experiences, and responses of producers of diversified farms in the Northern Great Plains of the United States to the early stage of the COVID-19 pandemic toward identifying factors for strengthening the resilience of agricultural production for supporting livelihoods and food security. Between May and August 2020, a cross-sectional online survey was administered to the emerging community of diversified farm managers in two rural U.S. states, Montana and South Dakota (n = 53), where monocropping and extensive livestock production are prevalent. About two-thirds of surveyed producers (68%) reported that they did not change their farming practices in response to the pandemic up until the survey period in Summer 2020. Almost three-quarters of producers (73%) indicated that access to commodities, farm inputs, and farm labor was not a concern for them during the early stage of the pandemic. Most surveyed producers (88%) were not concerned about their household food security and expressed confidence regarding a long-term increase in the demand for local food. However, almost half of surveyed producers (47%) reported that their anxiety increased because of the pandemic. Findings further highlight that small farms implemented a greater number of practices for enhancing ecological self-regulation while depending strongly on off-farm income compared to larger farms that were economically more autonomous. This study points to the promise of farm system diversification in strengthening the resilience of agricultural systems. We conclude by outlining pathways for increasing diversity on farms toward supporting food security during extreme food system shocks.

A cost analysis of local anaesthetic nose and sinus surgery for the treatment of chronic rhinosinusitis

Background: People with chronic rhinosinusitis may be referred for endoscopic sinus surgery (ESS), a procedure commonly performed under general anaesthesia, once maximal medical therapy has failed. A new pathway of care is emerging: Local Anaesthetic Nose & Sinus Surgery (LANSS). With LANSS the patient is not placed under general anaesthesia, but instead the procedure is performed under a local anaesthetic. Methodology: A decision analytic model was developed from the perspective of the UK National Health Service (NHS) to assess the potential cost impact of LANSS versus current standard care pathway for ESS. Results: Modelling indicated that the introduction of LANSS would generate substantial savings of around £84,500 per year if introduced to a typical NHS trust with a large otolaryngology department undertaking 300 ESS procedures per year. These savings are generated as a proportion of the ESS procedures no longer need to be completed in an operating theatre, which reduces operational costs (saving around £64,500 per year), plus the use of local anaesthetic instead of general anaesthetic and a reduction in the time a patient spends as an inpatient. Conclusions: The uptake of LANSS could generate cost-savings of around £84,500 per year to a typical NHS trust in the UK.

First Measurement of Polarizations in the Decay D^{0}→ωφ

Using a data sample corresponding to an integrated luminosity of 2.93  fb^{-1} collected at a center-of-mass energy sqrt[s]=3.773  GeV by the BESIII detector, the decay D^{0}→ωϕ is observed for the first time. The branching fraction is measured to be (6.48±0.96±0.40)×10^{-4} with a significance of 6.3σ, where the first and second uncertainties are statistical and systematic, respectively. An angular analysis reveals that the ϕ and ω mesons from the D^{0}→ωϕ decay are transversely polarized. The 95% confidence level upper limit on longitudinal polarization fraction is set to be less than 0.24, which is inconsistent with current theoretical expectations and challenges our understanding of the underlying dynamics in charm meson decays.

Socio-demographic and Clinico-epidemiological Study of Scrub Typhus in A Tertiary Care Hospital of Mymensingh, Bangladesh

Scrub typhus is one of the leading causes of undifferentiated treatable febrile illness in Asia pacific region. It is grossly under diagnosed in many tropical countries of South Asia including Bangladesh, due to wide range of non-specific clinical presentations, low index of suspicion among clinicians, limited awareness and lack of accurate diagnostic facilities. This cross sectional observational study was conducted at department of Microbiology, Mymensingh Medical College, Mymensingh, Bangladesh from March 2019 to February 2020 enrolling 113 diagnosed cases of scrub typhus by Immunochromatographic test (ICT) and / or Nested PCR to characterize the socio-demographic and clinico-epidemiological features of scrub typhus in Mymensingh area. Majority of the scrub typhus cases came from rural areas (63.83%) and there was a slight female predominance (52.21%). The young (32.74%) and the young-adult age group (28.31%) were mostly affected. Most of the scrub typhus cases were housewives (30.98%), followed by farmers (23.89%) and students (21.23%). All the enrolled cases presented with fever. Other findings were myalgia (76.10%), headache (56.63%), cough (30.97%), vomiting (12.38%) and Respiratory distress (9.73%). Typical eschar of scrub typhus was present only in 9(7.96%) cases and 4(3.53%) patients had rashes on their skin. Few cases (3.53%) had jaundice and 15.96% cases were anaemic. Oliguria (7.96%) and neck rigidity (1.76%) were also documented. Most of the Nested PCR positive scrub typhus cases were documented during late rainy season and beginning of winter months. Findings of the study may offer increased awareness about high burden of scrub typhus as well as heightened suspicion among clinicians for early diagnosis, timely treatment and prevention of complications.

Coexistence of ESBL and MBL-mediated resistance in Acinetobacter baumannii in a Tertiary Care Hospital, Bangladesh

Antimicrobial resistance mediated by extended-spectrum beta-lactamases (ESBL), AmpC beta-lactamase and metallo-beta-lactamase (MBL) producing Acinetobacter species is an emerging problem worldwide. In this cross-sectional study total 341 specimens were collected over a period of one year from January 2017 to January 2018. Specimens were collected from ICU and Surgery unit of Mymensingh Medical College Hospital, Mymensingh, Bangladesh. Specimens were collected from ICU and Surgery Unit of Mymensingh Medical College Hospital, Mymensingh, Bangladesh. Samples were processed for culture by standard conventional methods and susceptibility testing and determined by Kirby Bauer disc diffusion method. Antibiotic discs and their strength were according to the CLSI 2017 guideline. Molecular study was done to detect the species by OXA-51 gene and drug resistance genes (IMP, VIM, NDM, TEM, SHV, CTX, SPM, SIM and GIM). Species identification was done by OXA-51 gene which is intrinsic to Acinetobacter baumannii. Among the 46 isolates, 36(78.26%) were positive for Oxa-51 gene, 16(34.8%) for TEM gene, 9(19.6%) for VIM gene, 3(6.5%) for NDM gene and 1(2.2%) for IMP gene. This study gives an alarming sign towards high prevalence of cephalosporin and carbapenem resistance due to production of extended spectrum beta-lactamases and metallo-betalactamases, respectively. Early detection, proper antibiotic policies, and compliance towards infection control practices are the best defenses against these organisms.

Detection of Quinolone Resistance Pattern and Presence of qnr Genes in Human Salmonella Isolates at Mymensingh, Bangladesh

Among the quinolones, fluoroquinolones are broad spectrum antimicrobial agents used for treating many clinical infections including Salmonellosis. Although high level of resistance to fluoroquinolones remains low in Salmonella but reduced susceptibility is increasing worldwide. Plasmid-mediated quinolone resistance (PMQR) of qnr type (qnrA, B and S) has been identified now a day in several enterobacterial species including Salmonella spp. This cross-sectional study was held at department of Microbiology, Mymensingh Medical College, Mymensingh, Bangladesh from March 2019 to February 2020. This study was conducted to determine the current quinolone resistance pattern and to detect the presence of qnrA, qnrB and qnrS genes among Salmonella isolates. Antimicrobial susceptibility test of 36 Salmonella isolates were done by disc diffusion method. MIC of ciprofloxacin was detected by agar dilution method. Then amplification with specific primers of qnrA, qnrB and qnrS genes were performed for all Salmonella isolates. The present study observed 80.5% resistance to nalidixic acid, 33.3% to ciprofloxacin and 19.4% to ofloxacin by disc diffusion method. qnr A gene was detected in 2(5.5%) isolates, where as qnrS was detected in 5 (13.8%) isolates. None of the isolates was positive for qnrB gene. All the qnrA positive isolates showed resistance to Ciprofloxacin (MIC=128μg/ml) and Ofloxacin. In conclusion, presence of qnr genes in the study isolates is alarming, because, rapid dissemination might occur due to conjugative plasmid mediated horizontal transfer.

Case-Control Study to Evaluate Zinc Deficiency as a Risk Factor for Oxygen Requirement in Patients with COVID-19

Zinc is one of the important trace elements of blood. It helps in maturation of immune system in our body. In the past studies originate the relationship between viral disease and serum zinc deficiency. This was a multicenter case-control study to measure the serum zinc level of COVID-19 patients with different respiratory supports and to evaluate the Odds Ratio (OR) and Relative risk (RR) of zinc deficiency for oxygen requirement for COVID-19 patients. Study places were COVID-19 unit of three tertiary hospitals of Sylhet, a Northern district of Bangladesh. There were 30 controls and 90 cases in this study. The mean zinc level of cases (53-38mcg/dl) was significantly (p=0.000072) lower than the level of controls (73-23mcg/dl). The mean zinc level of the COVID-19 patients required oxygen (49-33mcg/dl) was significantly (p=0.0054) lower than the patients were not treated by oxygen therapy (64-51mcg/dl). The RR of getting affected by COVID-19 was 1-91 for the low zinc level people. Among the COVID-19 affected participants the lower zinc level people had a RR of 1-93 to receive oxygen supplementation. Lower zinc level people are more likely to be affected by COVID-19 in comparison to the normal zinc level people. Among the COVID-19 patients the lower zinc level people had nearly double (RR 1-93) risk of becoming hypoxic and eventually prone for oxygen support.

Procalcitonin as a predictor of severity and mortality in a cohort of patients hospitalised with COVID-19

INTRODUCTION

To evaluate the association of Procalcitonin (PCT) with severity in Coronavirus disease 2019 (COVID-19), hospitalised patients and to test the hypothesis that it is an independent predictor of mortality.

MATERIALS AND METHODS

This study was conducted at Chemical Pathology, Department of Pathology and Laboratory Medicine and Department of Medicine, Aga Khan University (AKU), Karachi Pakistan. Electronic medical records of all in-patients including both genders and all age groups with documented COVID-19 from March to August 2020 were reviewed and recorded on a pre-structured performa. The subjects were divided into two categories severe and non-severe COVID-19; and survivors and non-survivors. Between-group differences were tested using the Chi-square and Mann-Whitney's U-test. The receiver operating characteristic curve was plotted for serum PCT with severity and mortality. A binary logistic regression was used to identify variables independently associated with mortality. The data was analysed using SPSS.

RESULTS

336 patients were reviewed as declared COVID-19 positive during the study duration, and 136 were included in the final analysis including 101 males and 35 females. A statistically significant difference in PCT was found between severe and non-severe COVID-19 (p value=0.01); and survivors and nonsurvivors (p value<0.0001). PCT, older age and increased duration of hospital stay were revealed as variables independently associated with mortality. On ROC analysis, an AUC of 0.76 for mortality prediction was generated for PCT.

CONCLUSION

Baseline serum PCT concentration is a promising predictor of mortality and severity in COVID-19 cases when considered in combination with clinical details and other laboratory tests.

An updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Introduction

The most common cancers in the UK are keratinocyte cancers (KCs): the combined term for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Registration of KC is challenging due to high numbers and multiplicity of tumours per person.

Methods

We provide an updated report on the descriptive epidemiology of trends in KC incidence for the resident populations of UK countries (England, Northern Ireland, Scotland and Wales) using population-based cancer registry and pathology report data, 2013-18.

Results

Substantial increases in cSCC incidence in England, Scotland and Northern Ireland can be detected for the period of 2013-18, and the incidence of cSCC also increased in Wales from 2016 to 2018. In contrast, however, the pattern of annual change in the incidence of BCC across the nations differs. In England, the incidence of BCC declined slightly from 2016 to 2018, however, the overall trend across 2013-18 is not statistically significant. In Scotland, the incidence of BCC shows some variability, declining in 2017 before increasing in 2018, and the overall trend across 2013-18 was also not statistically significant. In Northern Ireland, the incidence of BCC increased significantly over the study period, and in Wales, the incidence of BCC increased from 2016 to 2018. One in five people will develop non-melanoma skin cancers (NMSC) in their lifetime in England. This estimate is much higher than the lifetime risk of melanoma (1 in 36 males and 1 in 47 females born after 1960 in the UK), which further highlights the burden of the disease and importance of early prevention strategies.

Conclusions

We highlight how common these tumours are by publishing the first ever lifetime incidence of NMSC. Additionally, the first time reporting of the age standardised incidence of KC in Wales further confirms the scale of the disease burden posed by these cancers in the UK. With approximately one in five people developing NMSC in their lifetime, optimisation of skin cancer prevention, management and research are essential.

Sagittal sinus thrombosis in a patient with familial Protein C deficiency: Highlighting the impact of thrombophilia testing

Plasma protein-C is a natural anticoagulant that inactivates factors Va and VIIIa. Familial protein C deficiency is inherited as an autosomal dominant disorder. The homozygous or compound heterozygous type may present early as purpura fulminant, while the heterozygous type can present as thromboembolism later in life. Presented in this report is a case of a 21-year-old female patient with protein-C deficiency, confirmed by thrombophilia investigations. She experienced recurrent deep vein thrombosis and cerebral sinus thrombosis due to thrombotic occlusion. She had a family history of deep vein thrombosis. Hence, high-risk cases should be seriously considered for long term anticoagulation therapy. The utility versus futility of thrombophilia testing in a particular situation is discussed to address and ensure safe practice among patients with thromboembolism.

105 COVID-19 IN OLDER ADULTS: INPATIENT OUTCOMES IN A LEVEL 3 IRISH HOSPITAL

Background

COVID-19 has proved devastating in older persons. Previous studies reveal a mortality rate of 31% for hospitalised patients over 70.1 We examine outcomes for older COVID patients in our hospital.

Methods

We conducted a Hospital In Patient Enquiry Scheme review for patients coded as COVID-19 between 19/03/2020–19/02/2021 (n = 674). Older adults were defined as those aged over 65 years at time of admission. Age, sex, length of stay and survival were collected. Data was collated by ‘wave’: (Wave 1 n = 294, 2 n = 105, 3 n = 275). We reviewed whether patients had a CT pulmonary angiogram (CTPA) on the National Integrated Medical Imaging System.

Results

42.3% of COVID patients in our hospital were older persons (n = 285). This remained stable throughout the pandemic (Wave 1 44.2%, Wave 2 44.7%, Wave 3 39.3%). Mean length of stay was 19.7 days for older adults vs 7.4 for those under 65. Older persons had a higher mortality rate at 30.9% vs 3.6%. Overall incidence of PE was low at 1.9% (1.1% in older persons). However, the likelihood of a CTPA being positive for those over 65 was much higher at 42.9% vs 17.9%. While there was improvement in mortality rates in older persons from Wave 1 (31.5%) to 2 (19.1%), our data showed a significant rise in mortality in Wave 3 (35.2%). This compares to a different pattern in younger people, with mortality rates by wave at 6.7%, 0% and 1.7%.

Conclusion

In a large Irish cohort of patients hospitalised with COVID-19, 42.3% were older adults. Length of hospital stay was 3 times longer and mortality was 10 times higher than patients under 65. Older adults were also more likely to have a positive CTPA. Further study is needed to evaluate the long term effects of COVID-19 in our older population.

Reference

Zerah et al, Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2021 Feb 25; 76 (3): e4–e12.

Suitability of Data-Collection Methods, Tools, and Metrics for Evaluating Market Food Environments in Low- and Middle-Income Countries

Globalization is transforming food environments in low- and middle-income countries (LMICs) with implications for diets and nutrition. However, most food-environment assessments were developed for use in high-income countries. We evaluated the suitability of 113 data-collection assessments (i.e., methods, tools, and metrics) for eight dimensions of informal and formal market food environments for diverse contexts of LMICs. We used a scoring exercise and a survey of experts (n = 27). According to the scoring exercise, 10 assessments (8 methods, 1 tool, and 1 metric) were suitable without modification for informal markets. Suitability for formal markets was markedly higher, with 41 assessments (21 methods, 14 tools, and 6 metrics) found suitable without modification. Experts considered availability, accessibility, price, and affordability the most important dimensions of market food environments to evaluate in LMICs. Market-basket analysis and vendor audits (which include inventories) were ranked as the most suitable methods to assess multiple dimensions of market food environments, including availability, price, affordability, vendor and product characteristics, marketing, and regulation. Gaps in relevant assessments were found for convenience and desirability. Results demonstrate the need for the development, adaptation, and validation of assessments relevant for informal markets in a diverse range of LMIC contexts to support diets, nutrition, and health globally.

Centering Equity in Sustainable Food Systems Education

Sustainable food systems education (SFSE) is rapidly advancing to meet the need for developing future professionals who are capable of effective decision-making regarding agriculture, food, nutrition, consumption, and waste in a complex world. Equity, particularly racial equity and its intersectional links with other inequities, should play a central role in efforts to advance SFSE given the harmful social and environmental externalities of food systems and ongoing oppression and systemic inequities such as lack of food access faced by racialized and/or marginalized populations. However, few institutional and intra-disciplinary resources exist on how to engage students in discussion about equity and related topics in SFSE. We present perspectives based on our multi-institutional collaborations to develop and apply pedagogical materials that center equity while building students' skills in systems thinking, critical reflection, and affective engagement. Examples are provided of how to develop undergraduate and graduate sustainable food systems curricula that embrace complexity and recognize the affective layers, or underlying experiences of feelings and emotions, when engaging with topics of equity, justice, oppression, and privilege.

Measurement of the Absolute Branching Fraction of D_{s}^{+}→τ^{+}ν_{τ} via τ^{+}→e^{+}ν_{e}ν[over ¯]_{τ}

Using a dataset of 6.32  fb^{-1} of e^{+}e^{-} annihilation data collected with the BESIII detector at center-of-mass energies between 4178 and 4226 MeV, we have measured the absolute branching fraction of the leptonic decay D_{s}^{+}→τ^{+}ν_{τ} via τ^{+}→e^{+}ν_{e}ν[over ¯]_{τ}, and find B_{D_{s}^{+}→τ^{+}ν_{τ}}=(5.27±0.10±0.12)×10^{-2}, where the first uncertainty is statistical and the second is systematic. The precision is improved by a factor of 2 compared to the previous best measurement. Combining with f_{D_{s}^{+}} from lattice quantum chromodynamics calculations or the |V_{cs}| from the CKMfitter group, we extract |V_{cs}|=0.978±0.009±0.012 and f_{D_{s}^{+}}=(251.1±2.4±3.0)  MeV, respectively. Combining our result with the world averages of B_{D_{s}^{+}→τ^{+}ν_{τ}} and B_{D_{s}^{+}→μ^{+}ν_{μ}}, we obtain the ratio of the branching fractions B_{D_{s}^{+}→τ^{+}ν_{τ}}/B_{D_{s}^{+}→μ^{+}ν_{μ}}=9.72±0.37, which is consistent with the standard model prediction of lepton flavor universality.

Educator Practices and Perceptions of Integrating Sustainability and Food Systems Concepts Into Elementary Education: Comparative Case Study in Two Northwestern States in the United States

Elementary education can equip future consumers and leaders with the systems thinking skills, real-world experiences, and knowledge to make decisions and lead progress toward sustainability transitions. The implementation of learning standards that focus on sustainability is one approach for integrating sustainability and food systems content into elementary education. The purpose of this study was to administer a survey with elementary-level educators to: (1) identify practices and perceptions of integrating sustainability and food systems concepts into the classroom; and (2) determine if practices and perceptions vary based on the presence of state learning standards focused on sustainability. A total of 171 educators completed the majority of the survey from two northwestern states in the United States: Washington (which has state learning standards focused on sustainability) and Montana (which does not have sustainability learning standards). Findings that 30% or less of the surveyed educators integrate sustainability and food systems content in their classroom highlights the urgent need for reforming elementary school curriculum to integrate sustainability as a central unifying framework to support societal and planetary health. Given the similarities in survey responses between educators in Washington and Montana, findings emphasize that state learning standards focused on sustainability are not adequate on their own to foster teacher adoption of sustainability content. There is thus a need for larger curriculum reformation to integrate sustainability as a framework, development of place-based teacher resources, and open access professional development to ensure that elementary-school students cultivate the systems thinking skills, real world experience, and knowledge that will allow them to develop the competencies to ultimately guide society toward meeting the Sustainable Development Goals of the United Nations.

Prevalence of cestodes infection among school children of urban parts of Lower Dir district, Pakistan

Tapeworms of zoonotic importance have been described as a leading public health problem. Current research was aim to assess the prevalence of tapeworms among 5-12years school children residing in district Lower Dir, Pakistan from January 2019-December 2019. The wet mount preparation in saline/iodine/methods were used for stool examination. Data was analyzed using appropriate descriptive, static methods. Of the 400 children studied 71.7% were infected with one or more species of intestinal parasites. Single infection of cestode species was found in 69 individuals with 17.2% prevalence and multiple parasitic infections were identified in 19.7% (n=79/400) individuals. The multiple infection were comprised as 10% (n=40) double, 6.75% (n=27) triple and 3% (n=12) quadruple. A total of 9 species of helminths and one species of protozoan infection. Among the helminths Ascaris lumbricoides was the most prevalent 33.1% (n=95), Taenia saginata 22.6% (n=65), hookworm 19.8% (n=57), Hymenolepis nana 18.8% (n=54), Enterobius vermicularis and Hymenolepis diminuta 1.39% (n=4each), Trichuris trichura 1.04% (n=3), Toxocara spp 0.69% (n=2) and Schistosoma japonicum 0.34% (n=1) were reported. One protozoan species was Cryptosporidium spp 0.69% (n=2) in current study. In case of A.lumbricoides, hookworm, E.vermicularis, T.trichura, T.saginata, H.nana and H.diminuta the male children of below 8 years of age were highly infected. Other infections are reported in the same prevalence with slight difference if any. We conclude that there is a need for mass scale campaigns to create awareness regarding health and hygiene in children and the need for development of effective poverty control programs because deworming alone is not adequate to control parasitic infections.

The impact of psychiatric diagnoses on two-year outcomes in patients with ventricular assist devices

Background

A multi-specialty approach is required during patient selection for left ventricular assist device (LVAD) implantation. In addition to a comprehensive medical evaluation, patients undergo an extensive psychiatric work up to ensure their candidacy when pursuing durable support devices. We aim to analyze the impact of psychiatric illnesses on 2-year outcomes after VAD implantation.

Methods

This study was a single center, retrospective analysis of 263 patients who underwent durable LVAD implantation between 2015 and 2017. All patients were evaluated by a single specialist during their work up for LVAD implantation. Patients who had a pre-existing diagnosis defined by criteria outlined in Diagnostic and Statistical Manual of Mental Disorders (DSM-5) were assigned to the History of Psychiatric Diagnosis group. Statistical analysis was performed using Chi-Square and Student's t-tests, wherein p&lt;0.05 was considered statistically significant.

Results

Of the 263 patients, 68 patients were found to have a history of psychiatric illness compared to 195 who had no previous diagnosis. Of those with a psychiatric history, 30.8% had Depression, 1.5% had Bipolar disorder, 22.1% had Anxiety, 1.5% had PTSD, and 16.2% had more than one diagnosis. 19.5% of patients with no history went on to be transplanted compared to 22.1% of patients with a psychiatric history (p=0.65). No significant difference was found between length of stay, days to readmission, 30-day survival, and 2-year survival. Patients without a psychiatric history were found to have fewer number of readmissions over 2 years (p&lt;0.01) (See Table). No significant difference was seen in complications including driveline infections, bacteremia, cerebrovascular accidents, pump thromboses, pump hemolysis, or major bleeding events (See Table).

Conclusion

Psychosocial characteristics play a significant role in determining a patient's candidacy for LVAD implantation. Although patients with a history of psychiatric illness were found to have a greater number of readmissions, this did not correlate to poorer outcomes or increased morbidity and mortality over 2 years. This study highlights the importance of taking a multi-faceted approach when determining patient eligibility for mechanical support devices. Future studies with larger population models should be conducted.

Funding Acknowledgement

Type of funding sources: None.

41 Low Flow Priapism as A Complication of Covid-19 Infection

On 12 March 2020 the World Health Organisation (WHO) declared a pandemic of SARS-COV-2(Covid 19). We report a case of a 58-year-old man who presented with dyspnoea, pyrexia and a dry cough. Upon admission he was noted to be in a severe Type 1 Respiratory Failure with Bi-lateral pulmonary infiltrates suggestive of Covid 19 infection. Rapid transfer to ITU ensued with Intubation, Ventilation and Inotropic support. Priapism was noted a day into admission which was subsequently aspirated by the Urology team, achieving detumescence. Priapism is a state of persistent penile erection that continues for 4 hours beyond sexual stimulation. We describe the role of thrombosis, dysregulation of the clotting cascade and acute disseminated intravascular coagulation (DIC) as shared pathologies in priapism and Covid 19 infection. We highlight the importance of vigilance for extra-pulmonary manifestations of Covid-19 and feel that the pro-thrombotic phenomena exhibited by Covid-19 infection affects distal vasculature in the same manner as Low Flow Priapism and hence explains why our patient suffered from this particular urological complication

111 The Systemic Effects of Intra-Articular Steroid Injections- Should COVID-19 Change Our Practice?

Aim

The COVID-19 pandemic prompted us to review and often suspend services, while patients continue to suffer with painful musculoskeletal conditions. The diagnostic and therapeutic value of intra-articular corticosteroid injections (IACSI) cannot be denied. Current BOA guidelines advise giving the lowest effective dose for inflammatory arthritis and limit use in osteoarthritis to patients with high levels of pain and disability. We aimed to evaluate the literature pertaining to the use of IACSI and the potential systemic immunosuppressive effects.

Method

We searched Medline, using the terms “systemic effects of intra-articular steroid” and “clinical course of Coronavirus infection in patients with steroid use”, between 1997 and 2020.

Results

No studies specifically looked at the systemic effects of intra-articular steroids in the presence of COVID-19 infection; however, four studies were identified which concluded that intra-articular steroid injections resulted in sufficient systemic absorption to cause suppression of the hypothalamic-pituitary-adrenal axis and endogenous cortisol production. These effects are dose dependent and are more common in patients with inflammatory joint diseases. A further four RCT’s, including one systematic review, showed that suppressed cortisol concentration was associated with a significant increase in mortality.

Conclusions

There is a lack of evidence in relation to the use of intra-articular steroids in COVID-19. However, evidence suggests that intra-articular steroids can result in systemic absorption and suppression of endogenous cortisol production thus increasing the potential risk of complications of COVID-19. We therefore support cautious use of low dose steroid injections in patients with inflammatory arthritis, where no alternative treatment is available.

835 Evaluation of an International Virtual Teaching Series for UK Academic Foundation Programme Applications and Interviews: A Cross-Sectional Study

Background

UK academic foundation programme (AFP) is an important steppingstone into academic surgical training, but there is paucity in undergraduate preparedness. We aimed to evaluate the effectiveness of a virtual webinar series to prepare students for applications and interviews.

Method

A cross-sectional study was conducted between 18/10/2020 – 19/12/2020. Ethical approval was not required as this was an evaluation of teaching interventions. Medical students interested in AFP were included. Three 1-hour presentations, delivered by two AFP doctors, focused on evidence-based frameworks to approach AFP applications, critical appraisal, personal and clinical interviews. Pre- and post-webinar electronic surveys compared preparedness in self-reported knowledge (SRK) and confidence (SRC) on a Likert scale (1: not knowledgeable/confident – 5: very knowledgeable/confident). SPSS v27.0 was used to perform Wilcoxon Signed-rank test; P-value&lt;0.05 was considered statistically significant.

Results

Mean attendance per presentation was 136, with 93(68.4%) pre-webinar responses and 62(45.6%) post-webinar responses. Both SRK and SRC regarding AFP applications improved by the same value (median 3 versus 4; p &lt; 0.0001). Both SRK and SRC in critical appraisal also improved by the same value (median 2 versus 4; p &lt; 0.0001). SRK and SRC in using interview answer frameworks (SPIES, STARR and CAMP) improved from median 2 versus 4 (p &lt; 0.0001) and median 1 versus 4 (p &lt; 0.0001), respectively. Across all pre-surveys, 129(46.4%) had no preference regarding teaching platforms, 115(41.3%) preferred webinars and 34(12.2%) preferred face-to-face teaching.

Conclusions

Webinars, teaching evidence-based frameworks can improve preparedness for AFP applications and interviews. Medical schools should address students’ perceived lack of knowledge and confidence in critical appraisal.

1577 Using CTS5 Calculator to Predict The 5-10-Year Risk of Late Distant Recurrence for Women With ER-Positive Breast Cancer Who Are Recurrence-Free 5 Years After Endocrine Therapy and To Reduce the Number of Patients Needing Discussion for The Extended Endocrine Therapy in The Breast MDTs: A Quality Improvement Project

Introduction

The increasing number of patients has created a pressure on the services provided that aim to ensure the maximum level of care, particularly MDT meetings. Using the CTS5 calculator can readily reduce the number of patients needing discussion for EET. This is will prevent delays in decisions made for patients and more importantly, an evidence-based tool will be used for more accurate results.

Method

A retrospective data collection was undertaken from the Breast MDT records, initially dating from January to December 2018. Then when the optional use of CTS5 was established, data were retrieved from August to October 2019. As per guidance for the use of the CTS5 calculator; Women were deemed low risk if their 5–10-year risk is less than 5%, intermediate if between 5–10%, and high risk if their 5–10-year risk is more than 10%. Finally, a prospective data collected from January to March 2020 where an agreement was made for all involved Surgeons to use the CTS5 calculator.

Results

Before Introducing the CTS5 Calculator, in 2018, the number of patients was 1523 from which 66 were for EET 4.3%. When CTS5 Calculator was first introduced, 1st of August - 31st October 2019, the percentage reduced to 4.1% and from January to March 2020, a further reduction 3.9% was noticed.

Conclusions

The CTS5 calculator is an effective evidence-based tool used to predict the risk of 5-10 years recurrence in breast cancer patients. Implementing it will reduce the number of patients needing discussion in Breast MDTs, sparing meetings’ and patients’ time.

1560 Unusual Sites of Colorectal Cancer Metastases – A Complete Systematic Review

Background

While colorectal cancer (CRC) usually metastasizes to liver, lungs, and central nervous system, spread to more unusual sites is rarely reported in literature. We aimed to investigate unusual colorectal metastases (UCRM), their clinical course and disease progression.

Method

MEDLINE, EMBASE and Cochrane Library were searched by independent reviewers to identify clinical studies to date that reported UCRM and relevant demographic/clinical data were extracted.

Results

We identified 349 patients, involving 28 sites (bone, musculo-skeletal, skin, brain/spinal cord, head, eye, oral mucosa, thyroid, mediastinum, heart, bronchus, breast, biliary/GI tract, stomach, pancreas, spleen, adrenal, urinary tract, inguinal canal, ovaries, vagina, vulva, testes, spermatic cord, prostate, penis) with male preponderance and median age of 59 years (IQR=54.5-65). These were diagnosed at a median interval of 18 months (IQR=6-36)) after a median follow-up of 12 months (IQR=6-22.5). More were metachronous (n = 210) with recurrence rate of 15.75%. Primary CRC staging revealed T3 in 61% (28%-T4), equal distribution of N0/N1 (38%/37%) and M0 in 85%. 74% of primaries were surgically resected (96%=adenocarcinomas) and 54% underwent adjuvant therapy. UCRM were resected in 45% of cases and showed same histology as primary. 30% had chemotherapy. Only 8% were palliated. Overall morality was 35.24%.

Conclusions

This is the first comprehensive review looking at clinical course and outcomes of patients with UCRM. Most of these developed in patients with primary T3/N0 staging. Outlook of these patients is comparable to those with usual metastatic disease. Judicious and rigorous surveillance is the key to early detection and timely management.

Climate Change and Coffee Quality: Systematic Review on the Effects of Environmental and Management Variation on Secondary Metabolites and Sensory Attributes of Coffea arabica and Coffea canephora

Climate change is impacting crop performance and agricultural systems around the world with implications for farmers and consumers. We carried out a systematic review to synthesize evidence regarding the effects of environmental factors associated with climate change and management conditions associated with climate adaptation on the crop quality of a culturally-relevant perennial crop, coffee (Coffea arabica and Coffea canephora). Seventy-three articles were identified that addressed the study's research question including 42 articles on environmental factors, 20 articles on management conditions, and 11 articles on both. While variation was found between studies, findings highlight that coffee quality is vulnerable to changes in light exposure, altitude, water stress, temperature, carbon dioxide, and nutrient management. Both increases as well as decreases were found in secondary metabolites and sensory attributes that determine coffee quality in response to shifts in environmental and management conditions. The most consistent evidence identified through this systematic review includes the following two trends: (1) increased altitude is associated with improved sensory attributes of coffee and; (2) increased light exposure is associated with decreased sensory attributes of coffee. Research gaps were found regarding the effects of shifts in carbon dioxide, water stress, and temperature on the directionality (increase, decrease, or non-linear) of coffee quality and how this varies with location, elevation, and management conditions. This systematic review further identified the following research needs: (1) long-term studies that examine the interactive effects of multiple environmental factors and management conditions on coffee quality; (2) studies that examine the interaction between sensory attributes and secondary metabolites that determine coffee quality and; (3) studies on the feasibility of various climate-adaptation strategies for mitigating the effects of climate change on coffee quality. Evidence-based innovations are needed to mitigate climate impacts on coffee quality toward enhanced sustainability and resilience of the coffee sector from farm to cup.

The Influence of the COVID-19 Pandemic on the Food Supply in the Emergency Food System: A Case Study at 2 Food Pantries

BACKGROUND

The onset of the coronavirus disease 2019 (COVID-19) pandemic increased demand for emergency food assistance and has caused operational shifts in the emergency food system.

OBJECTIVE

This research explored how the initial phase of the COVID-19 pandemic influenced the food supply of 2 food pantries.

METHODS

A case study approach was applied to collect data during the initial phase of the COVID-19 pandemic. Food supply data were collected weekly at 2 food pantries in southwest Montana for 17 wk in 2020. Surveys and interviews were conducted with food pantry clients and staff, respectively. Descriptive statistics and inferential statistics were applied to analyze quantitative data. Food supply data were analyzed using the Healthy Eating Index (HEI)-2015, NOVA system, and Unprocessed Pantry Project (UP3) Framework. Thematic analysis was applied to qualitative data.

RESULTS

The food boxes collected between the 2 food pantries (n = 43) had a mean (± SD) total HEI-2015 score of 76.41 ± 7.37 out of a possible score of 100. According to both the NOVA and the UP3 Framework, 23.4% of the total food distributed was ultra-processed food. Of the food distributed, 50.0% and 48.3% was fresh, unprocessed food according to NOVA and UP3 Frameworks, respectively. From staff interviews, 3 themes arose that describe the food pantry operations that experienced change during the COVID-19 pandemic, including food procurement, distribution preparation, and food distribution. Nine supporting subthemes describing the causes and consequences of the operational themes were identified. Staff perceived that the nutrient quality of the food boxes increased from food distributed previously to the COVID-19 pandemic, whereas over one-third (39.4%) of food pantry clients who responded to surveys preferred the food box model.

CONCLUSIONS

The COVID-19 pandemic has caused enormous operational challenges within food pantries. Food pantries overcame these challenges by swiftly and effectively altering operations so as to continue to distribute nutritious food boxes to pantry clients.

Rapid Serologic and Molecular Diagnosis of Scrub Typhus among Suspected Febrile Patients Visiting Mymensingh Medical College Hospital

Scrub typhus, caused by the bacterium- Orientia tsutsugamushi is one of the leading causes of undifferentiated treatable febrile illness in Asia pacific region. It is grossly under diagnosed in many tropical countries of South Asia including Bangladesh, due to wide range of non-specific clinical presentations, low index of suspicion among clinicians, limited awareness and lack of accurate diagnostic facilities. This cross-sectional descriptive study was conducted at Department of Microbiology, Mymensingh Medical College to diagnose scrub typhus by rapid Immunochromatographic test (ICT) as well as molecular detection of O. tsutsugamushi by Nested PCR and automated nucleotide sequencing among suspected febrile patients in Mymensingh, Bangladesh during 2019-20. Blood samples were collected from 402 febrile patients of suspected Rickettsial illness, referred from inpatient and outpatient departments of Medicine and Pediatrics, Mymensingh Medical College Hospital (MMCH). Among the enrolled 402 patients, 89 samples (22.13%) were seropositive by Immunochromatographic test (ICT) and 65 samples (16.16%) were positive for O. tsutsugamushi DNA by Nested PCR, targeting 47KDa gene. Therefore, 113/402 (28.10%) samples were positive for scrub typhus by PCR and/ or ICT. Highest number of patients was detected positive by nested PCR during the first 5-10 days of fever but only 2 cases were positive after 20 days. In case of ICT, highest positivity for only IgM (8.13%) and both antibodies (2.43%) were documented in first 5-10 days of fever, but IgG positivity was highest (41.66) in >20 days of fever. From 65 PCR positive samples, automated nucleotide sequencing was performed on 20 randomly selected samples and all were genetically confirmed to be O. tsutsugamushi.

Seropositivity of Human Brucellosis among Patients with Pyrexia of Unknown Origin on Both Risk and Non-Risk Group of Individuals and Molecular Detection by Real-time PCR

Brucellosis is a zoonotic disease that is one of the important infectious causes of Pyrexia of Unknown Origin (PUO). The objective of the present study was to determine the seropositivity and molecular detection of human brucellosis among the patients with pyrexia of unknown origin on both risk and non-risk group of individuals in greater Mymensingh. A total of 400 blood samples were randomly collected from pyretic patients started from September 2018 to August 2019. Questionnaires were used to collect data on both risk and non-risk group of individuals. All samples were initially screened for anti-Brucella antibodies using the Brucella-specific latex agglutination test. For accurate investigation, seropositive as well as seronegative serum samples were tested by BCSP31 Brucella genus-specific TaqMan real-time PCR. Overall 32(8%) cases were positive out of 400 samples by Brucella-specific latex agglutination test and/or BCSP31 Brucella genus-specific real-time PCR. Brucella-specific latex agglutination test documented 7% (28/400) positivity for brucellosis. 22(5.5%) samples found Brucella genus-specific real-time PCR positive out of 400 samples. Most real-time PCR positive cases were found from sero-positive samples of risk group population (15/32). Sero-negative but real-time PCR positive cases also found only from risk group population (4/32). There were 10 seropositive cases where real-time PCR was negative. In addition to Brucella-specific latex agglutination test as a screening test, Brucella genus-specific real-time PCR was performed for confirmation and also to avoid unjustified costs, drug toxicity, and masking of other potentially dangerous diseases.

Early and Rapid Detection of Typhoid Fever by Nested PCR in Blood

Typhoid fever caused by Salmonella typhi is one of the major health problems in developing countries including Bangladesh. Still now blood culture is gold standard method for diagnosing typhoid fever, but this method is laborious, requires several days and detection rate is low. Failure of early laboratory diagnosis often leads to increased morbidity and mortality. This study was intended to apply a nested PCR in blood for early diagnosis of typhoid fever. In this cross sectional study blood samples were collected from 200 suspected typhoid fever patients attending Mymensingh Medical College Hospital, Bangladesh. Nested Polymerase Chain Reaction (n PCR) of flagellin gene was done in all the blood samples. At the same time all blood samples were subjected to culture by lytic centrifugation method. Culture positive isolates were identified as S. typhi by biochemical tests. Among the 200 blood samples, 57 (28.5%) were positive for S. typhi on nested PCR where as blood culture was positive for S. typhi in 16 (8%) samples. Among the 57 PCR positive samples, only 15 (26.3%) samples were culture positive for S. typhi and rest 42 (73.7%) were culture negative. So, in culture negative cases PCR can be used as a rapid diagnostic test for diagnosing typhoid fever. Considering time requirement, PCR takes one day, whereas blood culture takes 3 or more days to confirm diagnosis.

Effectiveness of GenoType MTBDRsl in excluding TB drug resistance in a clinical trial

OBJECTIVES: To assess the performance of the GenoType MTBDRsl v1, a line-probe assay (LPA), to exclude baseline resistance to fluoroquinolones (FQs) and second-line injectables (SLIs) in the Standard Treatment Regimen of Anti-tuberculosis Drugs for Patients With MDR-TB 1 (STREAM 1) trial.METHODS: Direct sputum MTBDRsl results in the site laboratories were compared to indirect phenotypic drug susceptibility testing (pDST) results in the central laboratory, with DNA sequencing as a reference standard.RESULTS: Of 413 multidrug-resistant TB (MDR-TB) patients tested using MTBDRsl and pDST, 389 (94.2%) were FQ-susceptible and 7 (1.7%) FQ-resistant, while 17 (4.1%) had an inconclusive MTBDRsl result. For SLI, 372 (90.1%) were susceptible, 5 (1.2%) resistant and 36 (8.7%) inconclusive. There were 9 (2.3%) FQ discordant pDST/MTBDRsl results, of which 3 revealed a mutation and 5 (1.3%) SLI discordant pDST/MTBDRsl results, none of which were mutants on sequencing. Among the 17 FQ- and SLI MTBDRsl-inconclusive samples, sequencing showed 1 FQ- and zero SLI-resistant results, similar to frequencies among the conclusive MTBDRsl. The majority of inconclusive MTBDRsl results were associated with low bacillary load samples (acid-fast bacilli smear-negative or scantily positive) compared to conclusive results (P < 0.001).CONCLUSION: MTBDRsl can facilitate the rapid exclusion of FQ and SLI resistances for enrolment in clinical trials.

Detection of Biocide Resistance Genes (qacE and qacΔE1) in Pseudomonas spp Isolated from Patients with CSOM at Mymensingh Medical College Hospital, Bangladesh

Biocides, including disinfectants and antiseptics, are used for a variety of topical and hard surface applications in health care facilities. Biocides play a significant role for preventing and controlling nosocomial infections. However, failures in the antimicrobial activities of biocides have been reported. The resistance mechanism to disinfectants is usually determined by genes which are related to resistance to quaternary ammonium compounds, namely, qacE, qacΔE1 that are found in Gram-negative bacteria. The aim of this study is to detect the prevalence of Biocides resistance genes, qacE and qacΔE1, in clinical isolates of Pseudomonas spp. It was carried out from March 2017 to July 2018 in the department of Microbiology, Mymensingh Medical College, Mymensingh, Bangladesh. Samples were collected from Outpatient of ENT department, MMCH. In this study, 300 clinical samples of CSOM cases were tested by the PCR method. The present study shows detection of biocide resistance genes (qacE, qacΔE1) among 87 isolated Pseudomonas spp by uniplex PCR. Among 72 clinical isolates of Pseudomonas aeruginosa 67(93.05%) had the gene qacEΔ1 and 25(34.72%) had the gene qacE. In addition other 15 Pseudomonas spp 3(20%) isolates had the qacEΔ1 gene and 2(13.33%) isolates had the qacE gene. In this study there is a marked difference in detection of the qacEΔ1 gene between the MDR and non MDR P. aeruginosa isolates. The qacEΔ1 was identified in 50 of 54(92.59%) MDR isolates and 7 of 18(38.89%) non MDR strains respectively. While gene qacE was detect 25(46.29%) MDR isolates and did not show any qacEΔ1gene in non MDR isolates. This study shows that the genes, qacE, qacΔE1 are widespread among Pseudomonas aeruginosa, they are higher in MDR strains than non MDR strains.