Simulation of bempedoic acid in the lipid-lowering treatment pathway using the European contemporary SANTORINI cohort of high- and very high-risk patients

Background

Lowering LDL-C treatment goals in the 2019 ESC/EAS guidelines necessitates greater use of combination therapies (1). Cost of PCSK9 inhibitors (PCSK9i) and efficacy of ezetimibe alone as add on therapies limit population level achievement of LDL-C goals.

Purpose

This simulation study assessed the addition of oral bempedoic acid (BA) to ezetimibe in the treatment pathway in a real-world cohort of patients in order to assess the proportion of patients who might reach goal.

Methods

SANTORINI is a cohort study of European patients at high or very-high CV risk. Patients who were receiving any known LLT regimen with available data on LDL-C at baseline were eligible for this analysis. For patients not at risk-based LDL-C goals, the following treatment algorithm was applied (Figure 1), first the addition of ezetimibe and subsequently BA for those on statins, or addition of BA for those on ezetimibe and not at goal. Patients on PCSK9i remained in the cohort but no simulation was done. LDL-C reductions associated with ezetimibe and BA treatment were based on probabilistic distributions sourced from clinical trial efficacies based on prior studies (2–3). The effect of treatment on LDL-C levels was simulated through a Monte Carlo simulation run 10,000 times. No statin intensification was simulated as we assumed statin therapy was at maximum tolerated dose.

Results

At baseline (N=6252), mean age was 66 years and mean baseline LDL-C was 80.6 mg/dL with 1444 patients (23%) at goal; 93% (n=5797) were very high risk and 7% (n=455) high risk, of whom 84% (n=5227) were on statins, 23% (n=1447) on ezetimibe and 9% (n=546) on PCSK9i. Out of 4486 patients entering the simulation, 3419 received ezetimibe add-on with a third of those predicted to be achieving their risk-based goal (32%, n=1078/3419). Of those on ezetimibe and not at goal, the addition of BA would be predicted to result in another 36% goal achievement (n=1218/3408). Overall, the number of patients at goal would be expected to increase from 1444 (23%) at baseline to 2522 (40%) and 3740 (60%) after addition of ezetimibe and BA, sequentially. The mean LDL-C for the whole cohort would be expected to fall through this pathway from 80.6 mg/dL at baseline to 69.2 mg/dL and 61.1 mg/dL, respectively.

Conclusion

Few patients in the SANTORINI cohort were at goal at baseline and few would have LDL-C eligible for PCSK9i use. Optimising use of ezetimibe and BA after statins in the ESC/EAS 2019 LLT pathway could result in significantly more patients attaining lipid goals with likely additional health benefits.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH

407 Surgical Site Infection of Renal Transplant Patients Stratified by BMI

Aim

Surgical site infection increases with BMI with values ranging from 20% to greater than 40%. There are increasing numbers of obese patients (BMI >30) undergoing transplants and this audit aims to review the incidence and grade of surgical site infection (SSI) of renal transplant recipients stratified by BMI.

Method

65 renal transplants were performed between April 2020-March 2021 with 58 kidneys from deceased donors and 7 kidneys from live donors. A retrospective review of clinical attendances, GP letters, prescriptions, imaging, and re-admissions was completed. Nearly one-third of the patients had pre-transplant diabetes (32%), and their median BMI was 28 (range 19–40.7). The incidence of SSI was reported after 3 months follow up and graded using the Clavien-Dindo Classification.

Results

The overall rate of SSI was 15%. SSI was 12.8% in patients with BMI<30, 15.8% in BMI 30–34.9, 33.3% in BMI 35–35.9, and 0 in BMI>40 (only one recipient). There was no significant correlation between diabetes and SSI, with 19% of SSI reported in diabetic patients versus 14% in patients without diabetes (p-value=0.7). Two patients had a Clavien-Dindo grade I infection, 1 grade II, and 7 Grade III, with no grade IV or V SSI. No patients required operative management of SSI.

Conclusions

The overall rates of SSI stratified by BMI were within expected limits. Diabetes was not an independent predictor of SSI. No complication required general anesthesia or surgical treatment. When SSI did occur in obese patients it did cause considerable morbidity through number of attendances for dressing changes over 3 months.

663 Potential for Prophylactic Antibiotics in Renal Transplantation: A Retrospective Study of Kidney Perfusion Fluid Cultures and Kidney Cold Ischaemic Time

Aim

Infection is a significant cause of morbidity in kidney transplantation, and it is believed that an increased cold ischemic time is an independent risk factor. Identification of common pathogens in perfusion fluids, as well as the safe limit of cold ischaemic time can be used to reduce the risk of postoperative complications. There are currently no guidelines for prophylactic antibiotics.

Method

This is a retrospective review of the microbiological analysis of kidney perfusion fluids samples for a recipient transplant between 2017–2020. 100 patients were identified in this time period and this data was compared against the cold ischaemic time of the donor kidney.

Results

23% (22/96) samples were positive for bacteria with the majority being gram positive cocci. The most common bacteria grown was Coagulase Negative Staphylococcus (44% - 11/25). However, a broad spectrum of bacteria was grown including Hafnia, Pseudomonas, Klebsiella, Kocuria and E-coli. 3% (3/96) of samples grew two different species of bacteria.

The mean cold ischemic time for all transplants was 799 minutes with a range of 281–1618 minutes. The mean for infected samples was 935 mins with a range of 645–1410. Samples that grew 2 bacteria had a range of 913–941 mins.

Conclusions

There is potential to reduce the risk of infection with the use of broad-spectrum induction antibiotics and it is important that potential bacterial species and common resistance profiles are covered. There is a possible correlation between increased cold ischaemic time and bacterial growth in perfusion fluid however further research is warranted.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Rapid deployment technology versus conventional sutured bioprostheses in aortic valve replacement

Objectives

Despite the benefits of rapid deployment aortic valve prostheses (RDAVR), conventional sutured valves (cAVR) are more commonly used in the treatment for aortic stenosis. Given the paucity of randomized studies, this study aimed to synthesize available data to compare both treatment options.

Methods

A systematic search of Pubmed, OVID, and MEDLINE was conducted to retrieve comparative studies for RDAVR versus cAVR in the treatment of aortic stenosis. Out of 1773 returned titles, 35 papers were used in the final analysis, including 1 randomized study, 1 registry study, 6 propensity‐matched studies, and 28 observational studies, incorporating a total of 10,381 participants (RDAVR n = 3686; cAVR n = 6310).

Results

Random‐effects meta‐analysis found no difference between the two treatment groups in terms of operative mortality, stroke, or bleeding (p > .05). The RDAVR group had reduced cardiopulmonary bypass (standardized mean difference [SMD]: −1.28, 95% confidence interval [CI]: [−1.35, −1.20], p < .001) and cross‐clamp times (SMD: −1.05, 95% CI: [−1.12, −0.98], p < .001). Length of stay in the intensive care unit was also shorter in the RDAVR group (SMD: −0.385, 95% CI: [−0.679, −0.092], p = .010). The risk of pacemaker insertion was higher for RDAVR (odds ratio [OR]: 2.41, 95% CI: [1.92, 3.01], p < .001) as was the risk of paravalvular leak (PVL) at midterm follow‐up (OR: 2.52, 95% CI: [1.32, 4.79], p = .005). Effective orifice area and transvalvular gradient were more favorable in RDAVR patients (p > .05).

Conclusions

Despite the benefits of RDAVR in terms of reduced operative time and enhanced recovery, the risk of pacemaker insertion and midterm PVL remains a significant cause for concern.

Phytochemical and biological attributes of Bauhinia variegata L. (Caesalpiniaceae)

Abstract Bauhinia variegata plant is a very popular and traditionally potent ethnomedicine. Therefore, it is need of hour to study ameliorative characteristics of B. variegata for novel secondary metabolites. The current study was designed to explore antiproliferative potential of B. variegata due to scant reports on this aspect. Extracts of various parts (flowers, leaves, bark, stem, and roots) were prepared by successive maceration using organic solvents in increasing order of polarity (n-hexane, ethyl acetate, methanol, and water). The determination of polyphenolic contents was done by using colorimetric methods while antioxidant potential was measured using reducing power assay. Brine shrimp lethality assay was performed for determining preliminary cytotoxicity and antiproliferative activity against breast cancer MCF-7 cell line using MTT protocols. Moreover, antimicrobial activities were detected by using disc diffusion assay. The alpha-amylase assay was performed to monitor the antidiabetic potential of the plant. In case of phytochemical analysis methanolic extract of leaves and bark showed highest phenolic and flavonoids contents. n-Hexane and ethyl acetate extracts of stem and roots exhibited more than 90% mortality with LD50 ranges between 1-25 µg/mL when studied by brine shrimp lethality assay. n-Hexane and ethyl acetate extracts of roots and stem also showed antiproliferative activity against human breast cancer MCF-7 cell line with IC50 values ranges between 12.10-14.20 µg/mL. Most of the extracts displayed moderately high antibacterial and antifungal activities. The n-hexane extract of roots showed antidiabetic activity with 60.80 ± 0.20% inhibition of alpha-amylase. In sum, these preliminary results will be useful for further compound isolation from selected plant parts for the discovery of antibacterial, antidiabetic, and anticancer lead candidates.

Treatment of high- and very high-risk patients for the prevention of cardiovascular events in Europe: baseline demographics from the multinational observational SANTORINI study

Background

The ESC/EAS 2019 guidelines recommend ambitious lower goals for low-density lipoprotein cholesterol (LDL-C), especially for patients with high and very high cardiovascular (CV) risk which could necessitate more intensive lipid-lowering therapy (LLT) regimens. Multiple real-world studies in Europe have demonstrated suboptimal achievement of older 2016 LDL-C goals, with combination therapy with ezetimibe or proprotein convertase subtilisin kexin 9 inhibitors (PCSK9i) used in 9% and 1% of patients, respectively. SANTORINI is the first European observational study since the 2019 guidelines to assess whether management of high- and very high-risk patients has improved.

Purpose

To describe patient characteristics and treatment patterns of LLT in real-world practice for the management of LDL-C levels in high- and very high-risk patients.

Methods

Baseline data were assessed from SANTORINI, which recruited patients aged ≥18 years with high and very high CV risk requiring LLT. Risk was defined as per a commonly available assessment system, e.g. the Systematic Coronary Risk Estimation (SCORE) system, for which ESC/EAS guidelines classify high-risk and very high-risk as a calculated 10-year risk of fatal CV disease of ≥5–&lt;10% and ≥10%, respectively. Patients were recruited from 14 European countries across primary and secondary care settings, with patient characteristics, medical history, current LLT and other co-medications documented at baseline.

Results

Of 9606 patients recruited from March 2020 to February 2021 (55.0% from secondary care), cleaned data on 4308 were available through to February 2021. In this interim report, mean (standard deviation [SD]) age was 64.8 (10.8) years and 27.8% were female. Mean (SD) LDL-C was 2.45 (1.21) mmol/L. The majority of patients were classified as very high risk (69.3%), with 30.6% high risk. ESC/EAS guidelines were the most common basis for risk classification (51.3%), then clinical experience (33.5%) and national guidelines (10.4%). Concomitant CV risk factors included being a current or former smoker (16.5% and 41.8%, respectively), hypertension (70.9%), diabetes (35.4%) and familial hypercholesterolemia (10.1%). At baseline, 18.6% of patients were not receiving any LLT. 54.1% of patients were receiving LLT monotherapy, including 51.1% on statins, 1.4% ezetimibe, 1.2% a PCSK9i, and 0.5% other oral LLT. Combination therapy was used in 27.3% of patients, including 17.1% receiving statin plus ezetimibe, 4.1% PCSK9i plus oral LLT, and 6.1% any other oral combination therapy.

Conclusions

This large study in patients at high and very high CV risk from 14 European countries suggests that, although the ESC/EAS guidelines are the most frequently used basis for risk classification, LDL-C levels remain substantially higher than recommended goals, with combination therapies underutilised. An expanded data cut from SANTORINI will be reported in 2021.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH, Munich, Germany

Global epidemiology of Equine Influenza viruses; "A possible emerging zoonotic threat in future" an extensive systematic review with evidence

There are different opinions around the World regarding the zoonotic capability of H3N8 equine influenza viruses. In this report, we have tried to summarize the findings of different research and review articles from Chinese, English, and Mongolian Scientific Literature reporting the evidence for equine influenza virus infections in human beings. Different search engines i.e. CNKI, PubMed, ProQuest, Chongqing Database, Mongol Med, and Web of Knowledge yielded 926 articles, of which 32 articles met the inclusion criteria for this review. Analyzing the epidemiological and Phylogenetic data from these articles, we found a considerable experimental and observational evidence of H3N8 equine influenza viruses infecting human being in different parts of the World in the past. Recently published articles from Pakistan and China have highlighted the emerging threat and capability of equine influenza viruses for an epidemic in human beings in future. In this review article we have summarized the salient scientific reports published on the epidemiology of equine influenza viruses and their zoonotic aspect. Additionally, several recent developments in the start of 21st century, including the transmission and establishment of equine influenza viruses in different animal species i.e. camels and dogs, and presumed encephalopathy associated to influenza viruses in horses, have documented the unpredictable nature of equine influenza viruses. In sum up, several reports has highlighted the unpredictable nature of H3N8 EIVs highlighting the need of continuous surveillance for H3N8 in equines and humans in contact with them for novel and threatening mutations.

Artificial intelligence in personalized cardiovascular medicine and cardiovascular imaging

The collection of large, heterogeneous electronic datasets and imaging from patients with cardiovascular disease (CVD) has lent itself to the use of sophisticated analysis using artificial intelligence (AI). AI techniques such as machine learning (ML) are able to identify relationships between data points by linking input to output variables using a combination of different functions, such as neural networks. In cardiovascular medicine, this is especially pertinent for classification, diagnosis, risk prediction and treatment guidance. Common cardiovascular data sources from patients include genomic data, cardiovascular imaging, wearable sensors and electronic health records (EHR). Leveraging AI in analysing such data points: (I) for clinicians: more accurate and streamlined image interpretation and diagnosis; (II) for health systems: improved workflow and reductions in medical errors; (III) for patients: promoting health with further education and promoting primary and secondary cardiovascular health prevention. This review addresses the need for AI in cardiovascular medicine by reviewing recent literature in different cardiovascular imaging modalities: electrocardiography, echocardiography, cardiac computed tomography, cardiac nuclear imaging, and cardiac magnetic resonance (CMR) imaging as well as the role of EHR. This review aims to conceptulise these studies in relation to their clinical applications, potential limitations and future opportunities and directions.

308 A Qualitative Study Evaluating the Uses, Benefits and Barriers of Tele-Consultations in The Pre-Operative Pathway for Elective Orthopaedic Surgery at A Major London Teaching Hospital

Introduction

Digital healthcare technology is becoming a prodigious tool in healthcare management, supporting efforts for effective demand management and personalised, user-centred care. One example is tele-consultations, clinical consultations conducted remotely using technology such as telephones or videos. However, there is slow adoption of such technology and lack of literature supporting its use, particularly within the pre-operative surgical pathway, where communication, patient education and planning is vital to post-surgical outcomes. This study aimed to evaluate the uses, benefits and barriers of tele-consultations in the pre-operative pathway for elective hip and knee arthroplasty, at Imperial College Healthcare NHS Trust, from the perspective of key clinical stakeholders.

Method

16 Semi Structured Interviews were conducted with Healthcare professionals (HCPs) along the preoperative pathway before conducting a thematic analysis.

Ethical approval was received from Imperial College Research Ethics Committee on 05/02/2019.

Results

HCPs suggested use-cases for tele-consultation use in pre-assessment consultations with lower risk patients, information delivery, physiotherapy, and occupational therapy pre-assessment. Benefits cited were reduced overall costs and time, increased workflow efficiency with barriers noted as accessibility challenges, lack of holistic examination of patient and digital illiteracy.

Conclusions

Future studies should be conducted in other NHS trusts to identify greater uses within the entire surgical pathway.

Older people and technology: Time to smarten up our act

The NHS faces challenges today that it was not designed to tackle at its conception in 1948. The UK demographic has changed considerably with higher life expectancy and 'an ageing population'. Keeping this demographic healthy through prevention and management of age-related degeneration is crucial to their independence and improving resource utilisation. The Department of Health and Social Care's agenda for digital transformation of the NHS is facilitating a move towards preventative healthcare and greater community care, which will likely be supported by virtual healthcare delivery models. Despite views on digital illiteracy in the older population, this demographic may stand to benefit the most. Research has shown that the older demographic adopts technology in line with the technology acceptance model if their needs are carefully considered. Executed successfully, the deployment of virtual healthcare could save transformational costs to the NHS and support better quality of life for the senior members of society. This is particularly relevant in the current COVID-19 pandemic with patients facing challenges in accessing outpatient appointments. With many hospitals kickstarting virtual outpatient clinics to ensure continuity of care during a time of social isolation; we await to see the ingenuities that arise from the current pandemic.

Imaging to evaluate suspected infective endocarditis

Although echocardiography is fundamental in diagnosing infective endocarditis, sometimes it reveals no evidence of endocarditis while clinical indicators remain consistent with the diagnosis. In such cases, repeat imaging is necessary, and the appropriate timeline for it and whether it should be done with transthoracic echocardiography (TTE), trans esophageal echocardiography (TEE), or an advanced imaging method are important.

Can technology optimise the pre-operative pathway for elective hip and knee replacement surgery: a qualitative study

BACKGROUND

An ageing population has resulted in a rise in the number of hip and knee replacement surgeries in the UK. The pre-operative pathway is plagued with issues causing long delays and cancellations. Virtual healthcare technologies have a growing evidence base to help solve these issues. One problem of implementing these technologies is the resistance to change mentality from healthcare professionals. By getting their opinions on the place of these technologies within the pre-operative pathway, a united front can be formed to help deliver change.

METHODS

Sixteen semi-structured interviews were conducted with key stakeholders within the orthopaedic pre-operative pathway at Imperial College Healthcare NHS Trust. General topics included the different technologies that could be used within the pathway, their uses and associated benefits and problems. Interviews were audio-recorded, before being manually transcribed and then analysed to form categories and themes.

RESULTS

Various uses, benefits and problems were identified by healthcare professionals for each modality of technology. E-forms were seen as a high reward, low-risk intervention. Remote patient monitoring and teleconsultations had their bonuses, but feasibility was a primary concern. Web-based interventions were seen as an intervention of the past, whereas virtual reality was seen as perhaps being ahead of its time. M-health was very positively viewed due to its all-encompassing nature. Digital illiteracy emerged as a consistent problem for most technologies.

CONCLUSIONS

Current literature, the results from this study and technology trends within society highlight both M-health and E-forms as the 2 most promising virtual healthcare technologies for use in the pre-operative pathway for orthopaedics. Areas such as pre-operative assessment, triaging and prehabilitation are prime candidates for virtual intervention. Future research should also consider including patient opinions on any proposed interventions, as well as taking into account barriers to implementation.

Unrecognized HIV infection in asymptomatic volunteer blood donors at district Peshawar, Khyber Pakhtunkhwa, Pakistan

Acquired immunodeficiency syndrome (AIDS) is a global epidemic that impacts the lives of many individuals each year. Human immunodeficiency virus (HIV) is a retrovirus that infects human CD4⁺ T helper cells and macrophages thereby causing severe immune disease. The current study aimed to examine the prevalence of HIV among the blood donors of Khyber Pakhtunkhwa at Peshawar. In this study, a total of 8634 volunteers who donated blood were carefully screened for HIV using ELISA and RT-PCR techniques. Among the volunteers (n = 8634), 63 were positive by both ELISA and RT-PCR; which shows a prevalence of 0.73%. Both diagnostic techniques exhibited similar results. All the positive individuals were informed immediately and advised to start treatment to control the progression of the infection. It was concluded that HIV is on the rise in Peshawar, and routine screening and preventive measures are immediately required to address the urgent situation of HIV infection.

59 A Qualitative Study Evaluating Patient Education in the Pre-Operative Pathway for Elective Hip and Knee Arthroplasty at A Major London Teaching Hospital

Introduction

Rising demands for hip and knee arthroplasty have been met with incremental advancements in both implant design and surgical technique. Despite these advancements in the intraoperative setting, the preoperative pathway has remained largely unchanged. The resulting ineffective demand management and improper patient optimisation through education and engagement, has contributed to long waiting times and increasing surgical cancellations. This has in turn lead to both patient distress and the disruption of clinical workflow.

Aims

This study aimed to investigate the effectiveness of patient education in the pre-operative pathway for elective hip and knee arthroplasty, at Imperial College Healthcare NHS Trust, from the perspective of key clinical stakeholders.

Methods

16 Semi Structured Interviews were conducted with Healthcare professionals (HCPs) along the preoperative pathway. These included GPs, Orthopaedic Surgeons, Nurses, Anaesthetists, Orthogeriatricians, Occupational Therapists and Physiotherapists. Interviews were recorded, transcribed and thematically analysed. Sampling continued until information redundancy was reached.

Results

HCPs stressed that patient education lacked engagement & effectiveness. Whilst joint school (an MDT run seminar) is in place for patients before surgery, it was resource intensive meaning sessions were infrequent and often overcrowded.

Furthermore, not all patients were invited/attended joint school as a result of problems with scheduling and transport. Of those whom did, information retention was identified as a problem, highlighted by patients not bringing in medication, and failing to follow fasting instructions, leading to cancellations on the day of surgery. A significant proportion of elderly patients also needed additional and continued support in understanding and interpreting information, a key issue that was not addressed by traditional joint school.

Conclusions

This study has provided a more in-depth analysis of patient education in the pre-operative pathway revealing inadequate tailoring, and delivery of education material particularly for the older patient. Both timing, content and frequency of patient education could be improved in order to improve quality of care and reduce cancellations in turn improving the management of demand for orthopaedic services. Future studies may want to evaluate the use of digital technology in this area of the pathway in efforts to overcome these issues.

UK medical students' perspectives on practical prescribing teaching and learning provisions: a cross-sectional survey

PURPOSE

To determine medical students' perspectives on the provision for the teaching and learning of processes that lead to and include the writing of a clear, safe and legal prescription (practical prescribing) in UK medical schools.

METHODS

We designed a cross-sectional survey of UK medical students in years three, four and five. Students were asked about their experiences and views of practical prescribing teaching and learning they had encountered on their medical course.

RESULTS

A total of 1023 medical students responded (7% response rate), from 25 UK medical schools: 22%, 37% and 41% in the third, fourth and final years, respectively. Teaching of practical prescribing was widespread, with 94.3% of final year (n = 396, 95% confidence interval [CI] = 92-97%), 86.8% of fourth year (n = 328, CI = 83-90%) and 73.8% of third year (n = 166, CI = 67-80%) students reporting they had received it. Availability of this teaching appeared to vary by medical school. Self-directed learning was the most frequently reported mode of delivery (90.9%, n = 809). Validated pre-prescribing and simulation were perceived by students in each year group as the most effective methods. Clinical pharmacologists, clinical pharmacists and junior doctors were perceived by the students as being the most effective professional groups at teaching practical prescribing.

CONCLUSIONS

UK medical students reported a variety of methods utilised in the teaching and learning of practical prescribing. However, methods they perceived to be very effective (simulation and pre-prescribing) do not appear to be widely available or are only reserved for the final year of study. Combining such methods with involvement of professional groups perceived to be most effective should be explored.

Cross-sectional studies published in Indian journal of community medicine: evaluation of adherence to strengthening the reporting of observational studies in epidemiology statement

Background:

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement is a set of recommendations about what should be included in a more accurate and complete description of observational studies.

Aim:

The aim was to assess the quality of reporting of cross-sectional studies by evaluating the extent to which they adhere to the STROBE statement.

Materials and Methods:

This study has a cross-sectional design. All the articles published as original articles in Indian Journal of Community Medicine from January 2010 to September 2011 were downloaded from the journal website. A total of 96 articles were downloaded out of which 80 were found to have a cross-sectional design. Variables were: (1) Percentage of STROBE items included in a report and (2) percentage of articles reporting each item in the STROBE checklist. Data analysis was done by descriptive statistics using frequencies and percentages.

Results:

A total of 80 articles were evaluated. About 46% (37/80) articles reported 12–15 items of the STROBE checklist. Bias, nonparticipants and reasons for nonparticipation, other analyses done, generalizability, and source of funding were reported by < 25% of studies. The most frequently reported items of the checklist were summary of what was done and what was found in the abstract, background/rationale, objectives, setting, outcome data, key results in discussion, interpretation of results. None of the articles reported all items of the STROBE checklist.

Conclusion:

This study reveals that the quality of reporting cross-sectional studies in Indian Journal of Community Medicine is not satisfactory and there is room for improvement.

'Toy' laser macular burns in children

PURPOSE

Laser 'toys' can be purchased online and imported with relative ease; the variety of such devices is a potential public safety concern. We describe five children with maculopathy following exposure to laser 'toys'.

METHODS

Case series of maculopathy following exposure to laser 'toys'.

RESULTS

Five children were seen in our Ophthalmic Unit with macular injuries following exposure to laser 'toys'. Clinically, three children had an acute vitelliform-like maculopathy which resolved to leave sub-foveal retinal pigment epithelium changes with reduced vision. One case was complicated by a choroidal neovascular membrane.

CONCLUSION

Laser 'toys', which resemble laser pointers, are increasingly available over the internet. Such 'toys' may not meet safety standards. Retinal injury in childhood following exposure to laser 'toys' is a public safety concern.

[Comparative assessment of Cladophora, Spirogyra and Oedogonium biomass for the production of fatty acid methyl esters]

The use of alternative fuels for the mitigation of ecological impacts by use of diesel has been focus of intensive research. In the present work, algal oils extracted from cultivated biomass of Cladophora sp., Spirogyra sp. and Oedogonium sp. were evaluated for the lipase-mediated synthesis of fatty acid monoalkyl esters (FAME, biodiesel). To optimize the transesterification of these oils, different parameters such as the alkyl group donor, reaction temperature, stirring time and oil to alcohol ratio were investigated. Four different alcohols i.e. methanol, ethanol, n-propanol and n-butanol were tested as alkyl group donor for the biosynthesis FAME and methanol was found to be the best. Similarly, temperature 50 C and stirring time of 6 h were optimized for the transesterification of oils with methanol. The maximum biodiesel conversions from Cladophora (75.0%), Spirogyra (87.5%) and Oedogonium (92.0%) were obtained when oil to alcohol ratio was 1 : 8.

Serum-ascites albumin gradient in differential diagnosis of ascites

The present study was aimed to find out causes of ascites based on serum-ascites albumin gradient (SAAG) and to compare the diagnostic accuracy of the serum-ascites albumin gradient, proposed as a new biochemical criterion for the differential diagnosis of ascites and to evaluate the value of serum-ascites albumin gradient in differential diagnosis of ascites. This study includes 50 patients with ascites admitted in Medicine wards of Comilla Medical College Hospital, Comilla during the period of July 2010 to June 2011. Blood was drawn from the antecubital vein and ascetic fluid was obtained by paracentesis at the same time. Determination of the concentrations of albumin in both the serum and the ascitic fluid was carried out simultaneously. Considering SAAG value of ≥1.1g/dl is high SAAG and a SAAG value <1.1g/dl is low SAAG. Out of 50 patients, male patients were 36 and female patients were 14. Male and female ratio was 2.5:1. Age range was 21 years to 70 years. Most of the patients fall in age group of 41-50(28%).Among the 50 patients with ascites, cirrhosis of liver accounted for 68%, followed by tubercular peritonitis 12%, nephrotic syndrome 8%, congestive cardiac failure 6%, hepatocellular carcinoma 4% and malignancy related 2%. In this study serum ascites albumin gradient accurately identified the cause of ascites in 97% cases. In contrast the exudate-transudate concept identified only 83% correctly. Serum ascites albumin gradient was found superior to the exudate-transudate concept. So, differential diagnosis of ascites should be based on the serum ascites albumin gradient which is a better distinguishing marker.

Prevalence and genetic variation of salivary gland hypertrophy virus in wild populations of the tsetse fly Glossina pallidipes from southern and eastern Africa

The Glossina pallidipes salivary gland hypertrophy virus (GpSGHV) is a rod-shaped, non-occluded double-stranded DNA virus that causes salivary gland hypertrophy (SGH) and reduced fecundity in the tsetse fly G. pallidipes. High GpSGHV prevalence (up to 80%) makes it impossible to mass-rear G. pallidipes colonies for the sterile insect technique (SIT). To evaluate the feasibility of molecular-based GpSGHV management strategies, we investigated the prevalence and genetic diversity of GpSGHV in wild populations of G. pallidipes collected from ten geographical locations in eastern and southern Africa. Virus diversity was examined using a total sequence of 1497 nucleotides (≈ 1% of the GpSGHV genome) from five putative conserved ORFs, p74, pif1, pif2, pif3 and dnapol. Overall, 34.08% of the analyzed flies (n=1972) tested positive by nested PCR. GpSGHV prevalence varied from 2% to 100% from one location to another but phylogenetic and gene genealogy analyses using concatenated sequences of the five putative ORFs revealed low virus diversity. Although no correlation of the virus diversity to geographical locations was detected, the GpSGHV haplotypes could be assigned to one of two distinct clades. The reference (Tororo) haplotype was the most widely distributed, and was shared by 47 individuals in seven of the 11 locations. The Ethiopian haplotypes were restricted to one clade, and showed the highest divergence (with 14-16 single nucleotide mutation steps) from the reference haplotype. The current study suggests that the proposed molecular-based virus management strategies have a good prospect of working throughout eastern and southern Africa due to the low diversity of the GpSGHV strains.

Determination of some significant batch culture conditions affecting acetyl-xylan esterase production by Penicillium notatum NRRL-1249

Background

Acetyl-xylan esterase (AXE, EC 3.1.1.72) hydrolyses acetate group from the linear chain of xylopyranose residues bound by β-1,4-linkage. The enzyme finds commercial applications in bio-bleaching of wood pulp, treating animal feed to increase digestibility, processing food to increase clarification and converting lignocellulosics to feedstock and fuel. In the present study, we report on the production of an extracellular AXE from Penicillium notatum NRRL-1249 by solid state fermentation (SSF).

Results

Wheat bran at a level of 10 g (with 4 cm bed height) was optimized as the basal substrate for AXE production. An increase in enzyme activity was observed when 7.5 ml of mineral salt solution (MSS) containing 0.1% KH₂PO₄, 0.05% KCl, 0.05% MgSO₄.7H₂O, 0.3% NaNO₃, 0.001% FeSO₄.2H₂O and 0.1% (v/w) Tween-80 as an initial moisture content was used. Various nitrogen sources including ammonium sulphate, urea, peptone and yeast extract were compared for enzyme production. Maximal enzyme activity of 760 U/g was accomplished which was found to be highly significant (p ≤ 0.05). A noticeable enhancement in enzyme activity was observed when the process parameters including incubation period (48 h), initial pH (5), 0.2% (w/w) urea as nitrogen source and 0.5% (v/w) Tween-80 as a stimulator were further optimized using a 2-factorial Plackett-Burman design.

Conclusion

From the results it is clear that an overall improvement of more than 35% in terms of net enzyme activity was achieved compared to previously reported studies. This is perhaps the first report dealing with the use of P. notatum for AXE production under batch culture SSF. The Plackett-Burman model terms were found highly significant (HS), suggesting the potential commercial utility of the culture used (df = 3, LSD = 0.126).

Production of 3,4-dihydroxy L-phenylalanine by a newly isolated Aspergillus niger and parameter significance analysis by Plackett-Burman design

BACKGROUND

The amino acid derivative 3,4-dihydroxy L-phenylalanine (L-dopa) is gaining interest as a drug of choice for Parkinson's disease. Aspergillus oryzae is commonly used for L-dopa production; however, a slower growth rate and relatively lower tyrosinase activity of mycelia have led to an increasing interest in exploiting alternative fungal cultures. In the present investigation, we report on the microbiological transformation of L-tyrosine to L-dopa accomplished by a newly isolated filamentous fungus Aspergillus niger.

RESULTS

The culture A. niger (isolate GCBT-8) was propagated in 500 ml Erlenmeyer flasks and the pre-grown mycelia (48 h old) were used in the reaction mixture as a source of enzyme tyrosinase. Grinded mycelia gave 1.26 fold higher L-dopa production compared to the intact at 6% glucose (pH 5.5). The rate of L-tyrosine consumption was improved from 0.198 to 0.281 mg/ml. Among the various nitrogen sources, 1.5% peptone, 1% yeast extract and 0.2% ammonium chloride were optimized. The maximal L-dopa was produced (0.365 mg/ml) at 0.3% potassium dihydrogen phosphate with L-tyrosine consumption of 0.403 mg/ml.

CONCLUSION

Over ~73% yield was achieved (degree of freedom 3) when the process parameters were identified using 2k-Plackett-Burman experimental design. The results are highly significant (p ≤ 0.05) and mark the commercial utility (LSD 0.016) of the mould culture which is perhaps the first ever report on L-dopa production from A. niger.

Validity of Weech's formulae in detecting undernutrition in children

Primary care physicians in developing countries frequently use Weech's formulae to estimate the expected weight and height of children using age as a variable. The present study was undertaken to assess the validity of Weech's formulae in diagnosing undernutrition. We collected anthropometric information from 294 consecutive children, aged 12-59 months, who visited a health centre. Age was calculated from birth records and was recorded in completed months as well as completed years. Weight and height/length were measured using standard methods. Weight-for-age and height-for-age Z scores were calculated using WHO Anthro. Weech's formulae were used to calculate weight-for-age (%) and height-for-age (%). A cut off of < or =80.0% weight-forage and < or = 95.0% height-for-age were used to evaluate the validity of underweight and stunting respectively; a cut off of < or = 60.0% weight-for-age and <85.0% height-for-age were used for severe underweight and severe stunting respectively. Weech's formulae were found to be 100% sensitive in detecting underweight (weight-for-age Z score<-2) and stunting (height-for-age Z score<-2). When evaluating severe underweight (weight-for-age Z scorc<-3) and severe stunting (height-for-age Z scorc<-3), Weech's formulae were found to be 100% specific but the sensitivity was very low, 25.0% and 15.4% respectively. Based on the findings of our study Weech's formulae appear to be a sensitive tool to detect underweight and stunting in children between 12-59 months of age. Such formulae should however be used with caution when evaluating severe forms of undernutrition.

Application of 2-factorial design on the enhanced production of calcium gluconate by a mutant strain of Aspergillus niger

Sixty-eight isolates of the filamentous fungus Aspergillus niger were examined for calcium gluconate production under submerged culture conditions in 500-ml Erlenmeyer flasks. The isolate Chem-15 was selected for improvement through ultraviolet (UV) light-induced mutagenesis. Among viable mutants, strain 32 exhibited the best gluconate productivity, and it was subjected to N-methyl N-nitro N-nitroso guanidine (NG) treatment. Mutant strain NG-7 gave the highest gluconate production (86.48g/L) which varied significantly (p0.05) from that of the wild type. The mutant was cultured overnight and plated on 5-fluorocytosine-PDA medium. Gluconate productivity was increased by 35% when the process parameters, incubation period (72h), initial pH (6.5), glucose as carbon source (15%), inoculum size (1.875x10(6)CFU/ml) and corn steep liquor (CSL) as nitrogen source (0.5%) were optimized using a 2-factorial Plackett-Burman design. Maximal glucose oxidase activity (28U/ml/min) was achieved at the optimal fermentation conditions with 26.5g/L DCM. The model terms were highly significant thus suggesting the potential commercial utility of the mutant (HS, df=3 approximately 0.0182).

Turning off artistic ability: the influence of left DBS in art production

BACKGROUND

The influence of Parkinson's disease (PD) as well as deep brain stimulation (DBS) on visual-artistic production of people who have been artists is unclear. We systematically assessed the artistic-creative productions of a patient with PD who was referred to us for management of a left subthalamic region (STN) DBS. The patient was an artist before her disease started, permitting us to analyze changes in her artistic-creative production over the course of the illness and during her treatment with DBS.

METHODS

We collected her paintings from four time periods: Time 1 (Early Pre-Presymptomatic), Time 2 (Later Presymptomatic), Time 3 (Symptomatic), and Time 4 (DBS Symptomatic). A total of 59 paintings were submitted to a panel of judges, who rated the paintings on 6 different artistic qualities including: aesthetics, closure, evocative impact, novelty, representation, technique.

RESULTS

Aesthetics and evocative impact significantly declined from Time 2 to Time 4. Representation and technique indicated a curvilinear relationship, with initial improvement from Time 1 to Time 2 followed by a decline from Time 2 to Time 4.

CONCLUSIONS

These results suggest that left STN/SNR-DBS impacted artistic performances in our patient. The reason for these alterations is not known, but it might be that alterations of left hemisphere functions induce a hemispheric bias reducing the influence the right hemisphere which is important for artistic creativity. The left hemisphere itself plays a critical role in artistic creativity and DBS might have altered left hemisphere functions or altered the mesolimbic system which might have also influenced creativity. Future studies will be required to learn how PD and DBS influence creativity.

Cardiovascular risks of COX inhibition: current perspectives

BACKGROUND

NSAIDs are among the most commonly used pharmacotherapeutic agents worldwide. As the long-term use of these drugs is associated with serious gastrointestinal side effects, a new subgroup of COX-2 selective NSAIDs was developed. It was thought that the therapeutic strategy underlying the development of these newer compounds would enable them to provide the same analgesic and anti-inflammatory benefits as those of their traditional counterparts but perhaps offer a much safer gastrointestinal profile. Much scientific data has accumulated over the last few years, however, raising concerns regarding the increased cardiovascular complications associated with the use of COX-2 selective NSAIDs, and perhaps of the traditional NSAIDs as well.

OBJECTIVE

To review current and emerging evidence related to the cardiovascular effects of COX inhibitors and examine the clinical implications.

METHOD

We studied data from basic clinical research, non-randomized analyses, and randomized trials of COX inhibitors that investigated their cardiovascular effects.

CONCLUSION

Both COX-2 selective and traditional NSAIDs are associated with a moderately increased risk of cardiovascular events.