Presence of SARS-CoV-2-like coronaviruses in bats from east coast Malaysia

Most of the public health importance coronaviruses, such as Severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV) and SARS-CoV-2 are likely originated from bats and spread to humans through intermediate hosts; civet cats, dromedary camel and Malayan pangolin, respectively. SARS-CoV-2-like coronaviruses were detected in Thailand, which is neighbouring with Kelantan in East Coast Malaysia. To date, there is no report on the presence of public health concerns (SARS-CoV, SARS-CoV-2 and MERS-CoV) coronaviruses in bats from Malaysia. This study was aimed to elucidate the presence of these coronaviruses in bat samples from East Coast, Malaysia. A total of hundred seventy oropharyngeal swab samples were collected from three states of East Coast Malaysia. Reverse Transcription-Polymerase Chain Reaction (RT-PCR) was conducted based on partial 3' Untranslated region (3'UTR) or ORF10 gene and the products were sequenced. The sequences were compared with all coronavirus sequences from the National Center for Biotechnology Information-GenBank (NCBI-GenBank) using NCBI-Basic Local Alignment Search Tool (NCBI-BLAST) software. A phylogenetic tree was constructed to determine the genetic relationship among the detected coronaviruses with the reference coronaviruses from the NCBI-GenBank. Our results showed that SARSCoV-2-like viruses were present in 3% (5/170) of the bats from East Coast Malaysia that have 98-99% sequence identities and are genetically related to SARS-CoV-2 from humans. This finding indicates the presence of SARS-CoV-2-like viruses in bats from East Coast Malaysia that may become a public health concern in the future.

Needlestick Injuries With Insulin Injections: Risk Factors, Concerns, and Implications of the Use of Safety Pen Needles in the Asia-Pacific Region

Globally, health care workers (HCWs) are at a high risk of occupational exposure to needlestick injuries (NSIs). Needlestick injuries not only are associated with an increased risk of infections caused by bloodborne pathogens but are also a primary source of emotional distress and job burnout for HCWs and patients. Insulin injection-related NSIs are common among HCWs working in hospitals in the Asia-Pacific (APAC) region and impose a significant burden. Insulin pen needles have a high risk of transmitting infections (at both the patient-end and cartridge end of the sharp) after use. Recapping a needle after administering an insulin injection poses a major risk to HCWs. Currently, several safety-engineered needle devices (SENDs) are available with active or passive safety mechanisms. Passive insulin safety pen needles with dual-ended protection and automatic recapping capabilities have resulted in a significant drop in accidental punctures to HCWs while administering insulin to patients with diabetes. In this article, we have reviewed the burden and common causes of NSIs with insulin injections among HCWs in the APAC region. We have discussed current approaches to address the issues associated with NSIs and the benefits of introducing SENDs in health care settings, including long-term care facilities, nursing homes, and home care settings where patients may require assisted insulin injections. This review also summarizes key strategies/recommendations to prevent NSIs in HCWs and patients with diabetes in the APAC region.

Practical guide in using insulin degludec/insulin aspart: A multidisciplinary approach in Malaysia

Insulin degludec/insulin aspart (IDegAsp) co-formulation provides both basal and mealtime glycaemic control in a single injection. The glucose level-lowering efficacy of IDegAsp is reported to be superior or non-inferior to that of the currently available insulin therapies with a lower rate of overall hypoglycaemia and nocturnal hypoglycaemia. An expert panel from Malaysia aims to provide insights into the utilisation of IDegAsp across a broad range of patients with type 2 diabetes mellitus (i.e. treatment-naive or insulin-naive patients or patients receiving treatment intensification from basal-only regimens, premixed insulin and basal-bolus insulin therapy). IDegAsp can be initiated as once-daily dosing for the main meal with the largest carbohydrate content with weekly dose adjustments based on patient response. A lower starting dose is recommended for patients with cardiac or renal comorbidities. Dose intensification with IDegAsp may warrant splitting into twice-daily dosing. IDegAsp twice-daily dosing does not need to be split at a 50:50 ratio but should be adjusted to match the carbohydrate content of meals. The treatment of patients choosing to fast during Ramadan should be switched to IDegAsp early before Ramadan, as a longer duration of titration leads to better glycated haemoglobin level reductions. The pre-Ramadan breakfast/lunch insulin dose can be reduced by 30%-50% and taken during sahur, while the preRamadan dinner dose can be taken without any change during iftar. Education on the main meal concept is important, as carbohydrates are present in almost all meals. Patients should not have a misconception of consuming more carbohydrates while taking IDegAsp.

A Randomized, Placebo-Controlled Crossover Study to Evaluate Postprandial Glucometabolic Effects of Mulberry Leaf Extract, Vitamin D, Chromium, and Fiber in People with Type 2 Diabetes

INTRODUCTION

Reducing postprandial (PP) hyperglycemia and PP glucose excursions is important for overall glycemic management. Although most therapeutic lifestyle interventions that reduce caloric intake would affect this, there is no particular nutritional intervention favored.

METHODS

We evaluated the effects of a novel natural food adjuvant combining mulberry leaf extract (MLE) with other bioactive ingredients, in people with type 2 diabetes (T2D) originating from Asia, on improving PP glucometabolic response in a randomized controlled exploratory crossover, two-center study (USA, Singapore). A 2-g blend of 250 mg MLE [containing 12.5 mg of 1-deoxynojirimycin (DNJ)], fiber (1.75 g), vitamin D₃ (0.75 μg), and chromium (75 μg), compared with a similar blend without the MLE, was sprinkled over a 350-kcal breakfast meal (55.4 g carbs) and PP blood glucose (primary exploratory endpoint), insulin, and incretin hormones (GLP-1, GIP) were evaluated in blood samples over 3 h. Changes in incremental areas under the concentration curve (iAUC) and maximum concentrations (C_max) were compared.

RESULTS

Thirty individuals (12 women, mean age 59 years, HbA1c 7.1%, BMI 26.5 kg/m²) were enrolled and the MLE-based blend relative to the blend without MLE significantly reduced glucose iAUC at 1 h (- 20%, p < 0.0001), 2 h (- 17%, p = 0.0001), and 3 h (- 15%, p = 0.0032) and C_max [mean (95% CI) difference - 0.8 (- 1.2, - 0.3) mmol/L, p = 0.0006]. A statistically significant reduction in 1 h insulin iAUC (- 24%, p = 0.0236) was observed, but this reduction was no longer present at either 2 h or 3 h. No difference in GLP-1 was seen, but GIP response (iAUC and C_max) was less with the MLE-based blend.

CONCLUSIONS

The observation of a significant glucose reduction paralleled with a significant lower insulin response supports a reduced gastrointestinal glucose absorption. These results support the use of a 2-g natural blend of MLE, fiber, vitamin D, and chromium in T2D as a convenient dietary adjuvant to improve PP glucometabolic response.

CLINICALTRIALS

gov identifier NCT04877366.

A81 OPTIMIZING THE INDICATIONS FOR BILIARY STENT PLACEMENT IN PATIENTS WITH CBD STONES: A QUALITY IMPROVEMENT INITIATIVE TO ENHANCE PATIENT CARE AND REDUCE HEALTHCARE RESOURCE UTILIZATION

Background

A retrospective chart audit was performed to review biliary stent utilization from January 2020 to 2021 at the University of Alberta Hospital (UAH). Inappropriate stent usage was identified in 16% of patients with common bile duct (CBD) stones presenting for endoscopic retrograde cholangiopancreatography (ERCP). To improve this clinical practice, a quality improvement (QI) initiative was developed and completed.

Purpose

To reduce the number of inappropriately inserted biliary stents in patients with CBD stones.

Method

The results of the chart audit (pre-intervention) were shared with the ERCP group. The QI intervention was to align biliary stent insertion in accordance with published guidelines. A chart audit (post-intervention) was then performed on all ERCPs from July, 2021 to June, 2022. The indication for biliary stent insertion was assessed independently by two blinded reviewers.

Result(s)

A total of 661 patients (337 F) with mean age of 59±19 years (range 12-98 years) underwent 885 ERCPs during this post-intervention period. Of the 661 patients, 384 (58%) were referred for CBD stones. A total of 192 biliary stents (105 plastic, 85 metal) were placed during the first ERCP (192/661, 29%), as compared to the pre-intervention year (223/598, 37%, p=ns). However, only 13/192 stents (7%) were placed not in accordance with published guidelines (kappa=0.53), compared with 63/223 (28%) in the pre-intervention year (p<0.0001). This accounts for a 75% reduction in overall unnecessary stent placement. This reduction was mainly seen in the CBD stone subgroup, where there was an 88% reduction in inappropriate biliary stent placement compared to the pre-intervention year (8/384, 2% vs. 61/376, 16%, p<0.0001).

Image

Conclusion(s)

Education to align practice in accordance with published guidelines has demonstrated a significant improvement in biliary stent insertion during ERCP in patients with CBD stones. This has resulted in significantly fewer inappropriate stent placements, a reduction in unnecessary follow-up ERCPs, and an overall saving of healthcare resources.

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None

Disclosure of Interest

None Declared

A78 BILIARY STENT USE IN ERCP: A QUALITY ASSURANCE STUDY ASSESSING ADHERENCE TO CLINICAL GUIDELINES AND COST OUTCOMES

Background

A perceived increase in the use of biliary stents during endoscopic retrograde cholangiopancreatography (ERCP) was observed by our nursing team leader and brought to the attention of the Director of Endoscopy.

Purpose

To assess a) biliary stent utilization during ERCP, b) the adherence for stent placement based on published guidelines, and c) the associated cost.

Method

A chart review of all consecutive patients that underwent ERCP for one year (January 2020 to 2021) at the University of Alberta Hospital (UAH) was performed. The need for biliary stent placement was assessed independently by two blinded reviewers and compared with published guidelines. Costs were calculated using Alberta Health Services fee codes.

Result(s)

A total of 598 patients (316 F) with mean age of 60±19 years (range 3-99 years) underwent 842 ERCPs. Clinical indications for the initial ERCP were common bile duct (CBD) stones (376, 63%), malignant stricture (84, 14%), benign stricture (49, 8%), bile leak (27, 5%), stent removal (15, 3%), and others (47, 8%). Of the 244 patients that had a follow-up ERCP, the most common indications were stent removal (126, 52%), stent replacement (61, 25%), stent placement (28, 11%), and stone extraction (8, 3%). A total of 296 biliary stents were inserted, of which 223 stents (114 plastic, 109 metal) were inserted during the first ERCP (223/598, 37%) and 73 stents (43 plastic, 30 metal) during follow-up ERCP (73/244, 30%).

Of the 296 stents, 79 (27%) were inserted for indications not in accordance with published guidelines (63/223 initial ERCP, and 16/73 follow-up ERCP, kappa=0.62). Most of these were placed in CBD stone cases (61/63 initial ERCP, 6/16 follow-up ERCP). In the subgroup of 376 patients with CBD stones, 61 (16%) underwent stent placement not in accordance with published guidelines. The added cost of such stent insertions and follow-up ERCPs for stent removal was $130,000.

Conclusion(s)

Stent insertion not in accordance with published guidelines was identified in some patients with CBD stones presenting for ERCP. To reduce unnecessary follow-up procedures and healthcare resource utilization, ERCP stent insertion education based on published guidelines, as well as regular practice audit and feedback are required.

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None

Disclosure of Interest

None Declared

A290 PHENOTYPE AND OUTCOME OF PATIENTS HOSPITALIZED FOR ACUTE PANCREATITIS IN A TERTIARY PEDIATRIC CENTER

Background

A recent meta-analysis of 48 studies, showed an equal prevalence of AP (16%) among the following etiologies; systemic disease, alcohol, medication, genetics, gallstones and infection in North American hospitalized and ambulatory pediatric patients. However, data on the epidemiology of severe pediatric acute pancreatitis (AP) in Canada are lacking.

Purpose

We aim to evaluate the clinical presentation, etiologies, comorbidities and outcome of pediatric patients with AP admitted to a tertiary hospital in Quebec, Canada.

Method

A retrospective observational cohort study (January 2014-December 2021) was performed at the CHU Sainte-Justine. Descriptive analyses were performed with SAS statistical softwar

Result(s)

Among the 214 patients included (110 (51%) males), 58 (27.1%) were already hospitalized at time of AP diagnosis (AP as secondary diagnosis) while 156 (72.9%) were admitted from the emergency room mainly with a presentation of abdominal pain (AP as primary diagnosis). Thirty-two patients (15.0%) were transferred to the ICU due to hemodynamic instability or respiratory failure. Comorbidities included cancer (38 patients (17.7%)), obesity (17 (7.9%)) and inflammatory bowel disease (15 (7.0%)). The three most commonly identified etiologies were medication (19.6%), biliary disease (16.3%) and infection (14,9%). Despite extensive investigations, 26.2% of cases were idiopathic. The main complications were, ascites (48 patients (22.4%)), necrotic pancreatitis (10 (4.6%)) and pancreatic pseudocyst (10 (4.6%)). The median duration of hospitalization for AP as a primary diagnosis was 4 days (interquartile range (IQR) 2-7) as compared to 22 (11-37) for AP as a secondary diagnosis.

Conclusion(s)

Approximately one third of hospitalized patients had an underlying condition requiring treatments that could cause AP, which explains the high prevalence of drug-induced AP in this report. The longest hospitalizations were associated with AP as secondary diagnosis. Ongoing work will identify factors associated with disease severity and outcome in particular in primary AP.

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None

Disclosure of Interest

None Declared

A127 TIMING OF CHOLECYSTECTOMY AFTER ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN A TERTIARY CENTRE: EVALUATION OF OUTCOMES

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for patients with choledocholithiasis. Early cholecystectomy (within 24 to 72 hours) is recommended after the initial ERCP to reduce the risk of subsequent biliary events.

Purpose

To investigate the timing of cholecystectomy after ERCP in patients with choledocholithiasis and its associated outcomes in a single tertiary care centre.

Method

This is a retrospective analysis of adult patients who underwent cholecystectomy after ERCP from August 2021 to April 2022 at the University of Alberta Hospital. Outcomes data were stratified according to the length of time between ERCP and cholecystectomy, within 72 hours (early) or after 72 hours (delayed).

Result(s)

During the study period, 55 subjects were examined. Indications for ERCP included gallstone pancreatitis (24/55, 44%), choledocholithiasis (19/55, 34%), and acute cholangitis (12/55, 21%).

In total, 30 (55%) subjects received cholecystectomy within 72 hours, while 25 (45%) subjects received cholecystectomy after 72 hours. The two groups were comparable in age, sex ratios, and comorbidities. Out of the patients who received cholecystectomy after 72 hours, 8 (32%) subjects received their cholecystectomy on a subsequent admission. Of these, 2 subjects developed recurrent biliary events before their cholecystectomy, and 1 subject required a conversion to open cholecystectomy. There were no recurrent biliary events amongst the individuals with early cholecystectomy.

Subjects who received early cholecystectomy had a shorter total hospital stay compared to those with delayed cholecystectomy (4.5 days vs 7.3 days, p=0.0002). There was no significant difference between early and late cholecystectomy in conversion rate (3% vs 8%, p=0.58), average operating time (86min vs 83min, p=0.79), intraoperative complications including adhesions (13% vs 12%, p>0.05) and empyema (27% vs 28%, p>0.05), as well as histological rate of chronic cholecystitis (88% vs 92%, p=0.68).

Reasons associated with significantly delayed (>7 days) cholecystectomy after ERCP (n=12) include requiring coordination/consultation with other services prior to operation (3 subjects), prolonged course of gallstone pancreatitis (3 subjects), poor candidate for operation due to comorbidities (2 subjects), surgical cancellation/delays (2 subjects), post-ERCP pancreatitis (1 subject), and patient preference (1 subject).

Image

Conclusion(s)

Early cholecystectomy is associated with a shorter length of hospital stay and absence of recurrent biliary events. Other post-cholecystectomy outcomes were comparable. Early laparoscopic cholecystectomy should continue to be encouraged through an interdisciplinary approach.

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None

Disclosure of Interest

None Declared

Current Insights on Dyslipidaemia Management for Prevention of Atherosclerotic Cardiovascular Disease: A Malaysian Perspective

Dyslipidaemia is highly prevalent in the Malaysian population and is one of the main risk factors for atherosclerotic cardiovascular disease (ASCVD). Low-density lipoprotein cholesterol (LDL-C) is recognised as the primary target of lipid-lowering therapy to reduce the disease burden of ASCVD. Framingham General CV Risk Score has been validated in the Malaysian population for CV risk assessment. The Clinical Practice Guidelines (CPG) on the management of dyslipidaemia were last updated in 2017. Since its publication, several newer randomised clinical trials have been conducted with their results published in research articles and compared in meta-analysis. This underscores a need to update the previous guidelines to ensure good quality care and treatment for the patients. This review summarises the benefits of achieving LDL-C levels lower than the currently recommended target of < 1.8mmol/L without any safety concerns. In most high and very high-risk individuals, statins are the first line of therapy for dyslipidaemia management. However, certain high-risk individuals are not able to achieve the LDL-C goal as recommended in the guideline even with high-intensity statin therapy. In such individuals, lower LDL-C levels can be achieved by combining the statins with non-statin agents such as ezetimibe and PCSK9 inhibitors. Emerging non-statin lipid-lowering therapies and challenges in dyslipidaemia management are discussed in this article. The review also summarises the recent updates on local and international guidelines for dyslipidaemia management.

Detection of pathogenic Vibrio species and antibiogram activity in Asian Seabass (Lates calcarifer) in Tumpat, Kelantan

Some of Vibrio species is well known as pathogenic bacteria in aquaculture and the marine industry. Its infection is able to generate a massive outbreak and affect the fish population, especially for net caged fish such as seabass. This study was conducted to investigate the prevalence of Vibrio spp. isolated from seabass (Lates calcarifer) in Sri Tujuh Lagoon, Tumpat, Kelantan. Then, to determine the antibiotic resistance in Vibrio isolates. Polymerase chain reaction (PCR) was used to detect Vibrio species using specific primer VR169 and VR744 with estimation base pair size band, 597 bp and further identified by sequencing. On the other hand, antibiotic susceptibility tests were continued by using 13 types of antibiotics; kanamycin (K30), chloramphenicol (C30), neomycin (N10), ampicillin (AMP10), nitrofurantoin (F300), tetracycline (TE30), streptomycin (S10), norfloxacin (NOR10), ciprofloxacin (CIP5), nalidixic acid (NA30), gentamicin (CN10), doxycycline (DO30) and sulfamethoxazole (SXT100). As a result, 14 Vibrio isolates were identified, including Vibrio fluvialis (n=6), Vibrio parahaemolyticus (n=3), Vibrio harveyi (n=2) and each isolate for Vibrio vulnificus, Vibrio alginolyticus and Vibrio spp. The results showed that all isolates were sensitive to most antibiotics except ampicillin, neomycin and streptomycin. The MAR index value was ranging from 0 to 0.31. This study demonstrates the prevalence of Vibrio spp. in seabass and the report on multidrug resistance strains that could be of concern to the fish farmers. In addition, data from this study can be further used in fish disease management plans.

Safety of sodium-glucose cotransporter 2 inhibitors in Asian type 2 diabetes populations

The prevalence of type 2 diabetes mellitus continues to increase in many Asian countries, with possible contributing factors, such as younger-onset disease, diabetes development at lower body mass index, higher visceral fat accumulation and poorer β-cell function, among Asian populations. Sodium-glucose cotransporter 2 inhibitors have been shown to confer favorable effects in type 2 diabetes mellitus patients, such as improved glycemic control, weight and blood pressure reduction, and importantly, cardiorenal benefits. Sodium-glucose cotransporter 2 inhibitors are generally well-tolerated, and have a well-defined safety profile based on evidence from numerous clinical trials and post-marketing pharmacovigilance reporting. To our knowledge, this review is the first to provide a comprehensive coverage of the adverse events of sodium-glucose cotransporter 2 inhibitors, as well as their management and counseling aspects for Asian type 2 diabetes mellitus populations.

Impact of COVID-19 on cardiac procedure activity in England and associated 30-day mortality

Background

The COVID-19 pandemic had a significant impact on the quality of healthcare provision across all specialities and disciplines. However, there are limited data on the scale of its disruption to cardiac procedure activity from a national perspective and whether procedural outcomes different before and during the COVID-19 pandemic.

Methods

Major cardiac procedures (n=374,899) performed between 1st January and 31st May for the years 2018, 2019 and 2020 were analysed, stratified by procedure type and time-period (pre-COVID: January-May 2018 and 2019 and January-February 2020 and COVID: March-May 2020). Multivariable logistic regression modelling was undertaken to examine the odds ratio (OR) of 30-day mortality for procedures performed in the COVID period (vs. pre-COVID).

Results

There was a deficit of 45,501 procedures during the COVID period compared to the monthly averages (March-May) in 2018–2019. Cardiac catheterisation and cardiac electronic device implantations were the most affected in terms of numbers (n=19,637 and n=10,453) while surgical procedures including mitral valve replacement, other valve replacement/repair, atrial and ventricular septal defect repair, and CABG were the most affected as a relative percentage difference (D) to previous years' averages. TAVR was the least affected (D-10.6%). No difference in 30-day mortality was observed between pre-COVID and COVID time-periods for all cardiac procedures except cardiac catheterisation (OR 1.25 95% confidence interval (CI) 1.07–1.47, p=0.006) and cardiac device implantation (OR 1.35 95% CI 1.15–1.58, p&lt;0.001).

Conclusion

There was a significant decline in national cardiac procedural activity in England during the COVID-19 pandemic, with a deficit in excess of 45000 procedures over the study period. However, there was no increase in risk of mortality for most cardiac procedures performed during the pandemic. While health service pressures are gradually easing given the increased roll out of vaccination and decline in infection rates, there is a need for major restructuring of cardiac services deal with this significant backlog of procedures, which would inevitably impact longer-term morbidity and mortality.

Funding Acknowledgement

Type of funding sources: None.

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.

Dating Ultrasounds are Fundamental to Modern Obstetric Care

Aims Dating ultrasounds for all women remains a goal of the National Maternity Strategy. We sought to examine the utility of guideline based first trimester scanning when performed in a tertiary maternity unit. Methods A retrospective review of all public dating ultrasound scans was preformed over a one year period. Results 6,077 scans were reviewed. Viability was confirmed in 97.9% (n=5953), 1.5% (n=94) were deemed non-viable, and 0.48% (n=29) required follow up for uncertain viability. There were 97.9% (n=5,951) singleton pregnancies, 1.8% (n=112) multiple pregnancies, and 0.2% (n=14) with an absent fetal pole. Of those attending for a first dating ultrasound, 81.7% (n=4,966) were between 10 and 13+6 weeks. 16% (n=977) of women relied on dating scans rather than last menstrual period (LMP) to estimate gestational age. Overall, the mean difference between ultrasound scan and recalled menstrual dates was 3.9 gestational days. Other findings of significance included 0.4% (n=25) pregnancies with fetal anomalies diagnosed and 1.2% (n=78) of women were reported as having uterine anomalies. Conclusion Dating ultrasound confirms viability, pregnancy number and due date. These factors are the basis of antenatal care. This study reinforces the need for routine scanning of all pregnancies in the first trimester.

Ventilation support in SARS-CoV-2 pneumonia. Strategy and indications

The SARS-CoV2 pandemic has generated a need for knowledge, new concepts in pathophysiology and an increase of the use of respiratory support in highly complex patients. This fact has provoked the need to evolve to the concept of personalized ventilatory support according to the patient’s response to treatment.

Effect of a Web-Based Management Guide on Risk Factors in Patients With Type 2 Diabetes and Diabetic Kidney Disease: A JADE Randomized Clinical Trial

IMPORTANCE

Diabetic kidney disease (DKD) and its comorbidities can be prevented by treating multiple targets. Technology-assisted team-based care with regular feedback and patient empowerment can improve the attainment of multiple targets and clinical outcomes in patients with type 2 diabetes, but the effects of this intervention on patients with DKD are unclear.

OBJECTIVE

To evaluate the effect of the Joint Asia Diabetes Evaluation (JADE) web portal, nurse reminders, and team-based care on multiple risk factors in patients with DKD.

DESIGN, SETTING, AND PARTICIPANTS

This 12-month multinational, open-label randomized clinical trial was conducted between June 27, 2014, and February 19, 2019, at 13 hospital-based diabetes centers in 8 countries or regions in Asia. All patients who participated had DKD. The intention-to-treat data analysis was performed from April 7 to June 30, 2020.

INTERVENTIONS

Patients were randomized in a 1:1:1 ratio at each site to usual care, empowered care, or team-based empowered care. All patients underwent a JADE web portal-guided structured assessment at baseline and month 12. Patients in the usual care and empowered care groups received a medical follow-up. Patients in the empowered care group also received a personalized JADE report and nurse telephone calls every 3 months. Patients in the team-based empowered care group received additional face-to-face reviews every 3 months from a physician-nurse team.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of patients who attained multiple treatment targets (defined as ≥3 of 5 targets: HbA1c level <7.0% [53 mmol/mol], blood pressure <130/80 mm Hg, low-density lipoprotein cholesterol level <1.8 mmol/L, triglyceride level <1.7 mmol/L, and/or persistent use of renin-angiotensin-aldosterone system inhibitors).

RESULTS

A total of 2393 patients (mean [SD] age, 67.7 [9.8] years; 1267 men [52.9%]) were randomized to the usual care group (n = 795), empowered care group (n = 802), and team-based empowered care group (n = 796). At baseline, 34.7% patients (n = 830) were on 3 treatment targets. On intention-to-treat analysis, the team-based empowered care group had the highest proportion of patients who had further increase in attainment of multiple treatment targets (within-group differences: usual care group, 3.9% [95% CI, 0.0%-7.8%]; empowered care group, 1.3% [95% CI, -2.8% to 5.4%]; team-based empowered care group, 9.1% [95% CI, 4.7%-13.5%]). The team-based empowered care group was more likely to attain multiple treatment targets than the usual care group (risk ratio [RR], 1.17; 95% CI, 1.00-1.37) and the empowered care group (RR, 1.25; 95% CI, 1.06-1.48) after adjustment for site. Compared with the group that did not attain multiple treatment targets, the group that attained multiple treatment targets reported a lower incidence of cardiovascular, kidney, and cancer events (8.4% [n = 51] vs 14.5% [n = 134]; P = .004). Analysis of the per-protocol population yielded similar results.

CONCLUSIONS AND RELEVANCE

This trial found that technology-assisted team-based care for 12 months improved the attainment of multiple treatment targets as well as empowerment in patients with DKD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02176278.

Diabetes and Ramadan: Practical guidelines 2021

Fasting during Ramadan is one of the five pillars of Islam and is obligatory for all healthy Muslims from the age of puberty. Though individuals with some illness and serious medical conditions, including some people with diabetes, can be exempted from fasting, many will fast anyway. It is of paramount importance that people with diabetes that fast are given the appropriate guidance and receive proper care. The International Diabetes Federation (IDF) and Diabetes and Ramadan (DaR) International Alliance have come together to provide a substantial update to the previous guidelines. This update includes key information on fasting during Ramadan with type 1 diabetes, the management of diabetes in people of elderly ages and pregnant women, the effects of Ramadan on one's mental wellbeing, changes to the risk of macrovascular and microvascular complications, and areas of future research. The IDF-DAR Diabetes and Ramadan Practical Guidelines 2021 seek to improve upon the awareness, knowledge and management of diabetes during Ramadan, and to provide real-world recommendations to health professionals and the people with diabetes who choose to fast.

385 Improving Neurosurgical Handover: A Quality Improvement Project

Aim

Efficient, succinct, and salient handover of current issues of surgical inpatients between doctors is an essential process which, if done ineffectively can contribute to patient harm. It was recognised that existing junior neurosurgical handover could be improved and using the Royal College of Surgeons’ and NICE guidelines for clinical handover we aimed to improve the existing handover system, improving doctor’s satisfaction with handover and patient safety.

Method

19 junior doctors on the SHO rota were surveyed to establish their perspective on the existing handover process. Based on this feedback, we redesigned handover combining national bodies’ guidance and local ideas. We resurveyed following these changes to measure improvement.

Results

Initial results showed only 36 % of junior doctors were satisfied with the existing handover procedure and only 50.5% felt the existing handover was safe. After these changes there was a 44% improvement in satisfaction with handover and a 24% improvement in the perceived safety of the handover process.

Conclusions

Handovers should be optimised to improve patient care and doctors working environment. We have improved our existing handover procedure increasing the perceived safety and doctor’s satisfaction of the handover process.

Prognosticating outcome using magnetic resonance imaging in patients with moderate to severe traumatic brain injury: a machine learning approach

INTRODUCTION

Over the last decade advancements in computer processing have enabled the application of machine learning (ML) to complex medical problems. Convolutional neural networks (CNN), a type of ML, have been used to interrogate medical images for variety of purposes. In this study, we aimed to investigate the potential application of CNN in prognosticating patients with traumatic brain injury (TBI).

METHODS

Patients with moderate to severe TBI and evidence of diffuse axonal injury (DAI) were selected retrospectively. A CNN model was developed using a training subgroup and a holdout subgroup was used as a testing dataset. We reported the model characteristics including area under the receiver operating characteristic curve (AUC).

RESULTS

We included a total of 38 patient, of which we generated 725 MRI sections. We developed a CNN model based on a modified AlexNet architecture that interpreted the brain stem injury to generate outcome predictions. The model was able to predict GOS outcomes with a specificity of 0.43 and a sensitivity of 0.997. It showed an AUC of 0.917.

CONCLUSION

The utilization of machine learning MRI analysis for prognosticating patients with TBI is a valued method that require further investigation. This will require multicentre collaboration to generate large datasets.

Remission of T2DM by digital twin technology with reduction of cardiovascular risk: interim results of randomised controlled clinical trial

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): TWIN HEALTH INC

Background

 Twin Precision Treatment (TPT) is a novel intervention designed to improve glycemia and reverse T2D using a Whole-Body Digital Twin (WBDT) platform powered by Artificial Intelligence and the Internet of Things. Technology enabled precision nutrition, a combination of macro, micro and biota nutrients, along with Continuous Glucose Monitoring (CGM) have been demonstrated to be a key for reversal of diabetes. WBDT platform captures 174 health markers and 3000 daily data points through a panel of blood tests and connected devices that measure weight, physical activity, sleep and BP. CGM is used initially and then the algorithm predicts personalized glucose responses from multiple inputs. Nutritional, physical activity and sleep counseling is through an app or phone to provide individualized meal plans that balance 87 macro, micro and probiotic nutrients to reduce glucotoxicity and lipotoxicity. Program physicians titrate medications and monitor metabolic outcomes. 

Purpose

 To assess the initial change, in glycemic, extra glycemic, cardiovascular parameters for patients who completed 3 months longitudinal follow up.

Methods

 We performed an interim analysis [n = 173, 139 TWIN Intervention arm (T), 34 Control group (C)] of ongoing randomized controlled trial of TPT across India

Results

 The mean age (years) in the T was 43.04 (±8.6, 95% CI 41.57 to 44.52) which was significantly less as compared to the C 51.4 (±9.6, 95% CI 48.3 to 54.5); p &lt; 0.0001. The mean duration of diabetes (years) in the T was 3.5 (±2.6) which was comparable to the C 4.3 (±2.6); p = 0.12 ns. In the T there were 113 male (84.3%) and 21 female (15.6%) as compared to C, 15 male (38.4%) and 24 female (61.5%); p &lt; 0.0001. The difference of change for HbA1c (%), small dense LDL-C sdLDL (mg/dL), TG/HDL Ratio, HOMA 2IR (%), Visceral Adiposity Index (VAI), Systolic BP (mmHg), BMI (kg/m2), Framingham Risk Score (%), in T when compared to C, were significant. The mean reduction HbA1c, sdLDL, HOMA 2IR, VAI, SBP, BMI, FRS in T was -3.2 % (8.8 to 5.6), -14.1 mg/dL, (52.6 to 38.5), -0.9 % (1.9 to 1), -2.3 (4.6 to 2.3), -10.3mmHg (128.4 to 118.1), -2.9 kg/m2 (27.1 to 24.2), -7.9% (16 to 8.1), respectively. (figure) At baseline in T, mean daily intake of medication was 1.7 which reduced significantly (p &lt; 0.0001) to 0.05. 96 patients in T were able to stop anti-diabetic medications

Discussion

 The initial results are an early indicator for the translation of the scientific rationale for the technological intervention, through digital twin technology, powered by Internet of Things and Artificial Intelligence, as a modality to enable reversal of diabetes. TPT appears to have potential to mitigate the cardiovascular risk as assessed by Framingham Risk Score and modulate the non glycemic parameters, including BMI and SBP. However, larger, long-term studies would yield precise insights for the durability of the significant change that has been observed in this study Abstract Figure. Comparison for the Change in the Glycemi

ARISE-a prospective, non-interventional, single-arm study assessing clinical parameters associated with the use of insulin degludec/insulin aspart in patients with type 2 diabetes in real-world settings: rationale and design

PURPOSE

IDegAsp, a co-formulation of long-acting basal (insulin degludec) and rapid-acting bolus (insulin aspart) insulin, provides separate prandial and basal glucose-lowering effects with relatively low risk of hypoglycaemia. Its efficacy and safety have been investigated in a large clinical trial programme (BOOST). We present the rationale and design of the ARISE study, which aims to assess glycaemic control and other clinical parameters associated with IDegAsp use in real world.

METHODS

ARISE is a ~26-wk-long, prospective, non-interventional, single-arm study of patients with type 2 diabetes (T2D) initiating IDegAsp treatment. Approximately 1112 patients with T2D aged ≥18 years previously on anti-hyperglycaemic drugs except IDegAsp will be enroled across six countries from 15 Aug 2019 to 12 Nov 2020. IDegAsp treatment will be initiated at the physicians' discretion and as per the local label. Key exclusion criteria include previous participation, or previous IDegAsp treatment. The primary and secondary endpoints are change in HbA_1c from baseline (wk 0) to study end (wk 26-36) and the proportion of patients achieving the target HbA_1c level of <7% at the study end, respectively. A mixed model for repeated measurements will analyse the primary endpoint.

CONCLUSION

Between-country differences in the prescription patterns of glucose-lowering agents in people with T2D warrant examination of their clinical use in different geographical settings. The ARISE study is designed to assess the clinical use of IDegAsp from real world in six different countries. Findings from the ARISE study will supplement those of previous randomised controlled studies by establishing real-world evidence of IDegAsp use in the participating countries.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04042441. Registered 02 August 2014, https://clinicaltrials.gov/ct2/show/NCT04042441.

463 “The ABCD Team – Reducing Patient Harm: Non-Technical Skills-Based Education”

Background

Although health-care workers are trained to provide basic, intermediate, or advanced life support from a technical perspective, working as a team is a more complex process in acute situations. Responding to the emergency buzzer from the ward staff, and before the medical emergency arrival, could be sometimes chaotic. This may result in deficient initial management or missing basic measures.

Context

The “ABC Team” is a project, aimed to enhance the health care providers' skills in dealing with emergency situations, within the surgical ward, in an organized manner.

Innovation

Guidance for the staff was created to identify an exact job for every health care provider in the shift by assigning one job/person. Over a period of 5 months, individual training was given to the ward staff. Roles are assigned in the shift handover and A, B, C, D cards (to be attached to the ID) were printed with the information needed for a quick response. Simulation training sessions were organized before launching the project.

Implications

Streamline patient care significantly improved and ABCD assessment time is broken down to half. Pre and post project surveys showed approximately 80% of staff are now satisfied, confident and clear with their role in the emergency event.

Trends of sex differences in outcomes of cardiac electronic device implantations in the United States

Background

There is limited evidence on the differences in procedural outcomes between sexes after de novo cardiac implantable electronic device implantation (CIED). Furthermore, it is unclear whether any sex-based disparities have changed over the years.

Purpose

To compare procedural outcomes of de novo CIED implantation between sexes and study the trends of these outcomes over a 11-year period in a nationally representative sample.

Methods

Using the National Inpatient Sample, all hospitalisations between 2004 and 2014 for de novo CIED implantation were included, stratified by sex. Multivariable logistic regression was performed to 1) examine the association between sex and in-hospital complications of CIED implantation, expressed as odds ratios (OR) with 95% confidence intervals (CI), and 2) analyse trends of in-hospital outcomes by assessing the interaction term between time (years) and sex as covariates.

Results

Out of 2,815,613 hospitalisations for de novo CIED implantation, 41.9% were performed on women. Women were associated with increased adjusted odds of major adverse cardiovascular events (composite of mortality, thoracic and cardiac complications; OR 1.17 95% CI 1.16, 1.19), procedure-related bleeding (OR 1.13 95% CI 1.12, 1.15), and local complications (thoracic: OR 1.42 95% CI 1.40, 1.44, cardiac: OR 1.44 95% CI 1.38, 1.50). (p&lt;0.001 for all) Notably, there was no difference in odds of all-cause mortality between sexes (OR women: 0.96 95% CI 0.94, 1.00). The odds of adverse complications in the overall CIED cohort were persistently raised in women throughout the study period, whereas similar odds of all-cause mortality across the sexes were observed throughout the study period (see Figure).

Conclusion

In a national cohort of CIED implantations we demonstrate that women are at a persistently higher risk of procedure-related adverse events other than mortality compared to men. This trend is concerning and warrants further work on procedural techniques to neutralise these sex disparities.

Trends of odds of complications in women

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This work constitutes part of a PhD for MOM that is supported by Medtronic Ltd. Medtronic Ltd. was not involved in the conceptualization, design, conduct, analysis, or interpretation of the current study.

Incidence and predictors of postoperative ischaemic stroke after coronary artery bypass grafting in the United States

Background

Postoperative acute ischemic stroke (AIS) is a catastrophic complication of coronary artery bypass grafting (CABG). There is limited data on the incidence and outcomes of AIS complicating CABG in the contemporary era, and whether these have changed over the years.

Purpose

To study the incidence and outcomes of postoperative AIS in a nationally representative cohort of CABG procedures over a 12-year period and examine predictors of AIS in patients undergoing CABG.

Methods

The National Inpatient Sample was used to identify all adult patients (&gt;18 years old) who underwent CABG in the United States between January 2004 and September 2015. Multivariable logistic regression was performed to examine the associations between postoperative AIS and in-hospital mortality and identify predictors of AIS after CABG, expressed as odds ratios (OR) with corresponding 95% confidence intervals (CI).

Results

A total of 2,569,597 CABG operations were analysed. The incidence of postoperative AIS was 1.8% (n=47,279) in the overall cohort increasing from 1.2% in 2004 to 2.3% in 2015 (p&lt;0.001). Significantly higher rates of AIS were observed amongst patients with atrial fibrillation (AF) and those undergoing non-elective or concomitant valve operations over the study period (see Figure). Patient risk profiles increased over time in both AIS and no-AIS cohorts, with higher Charlson comorbidity scores observed amongst AIS patients. AIS was independently associated with increased odds of in-hospital mortality (OR 3.03, 95% CI 2.93, 3.13) and prolonged hospital stay (∼6 more days) and a higher hospitalisation cost (∼$80,000 more) (p&lt;0.001 for all). Several factors were predictors of AIS including age&gt;60 years (61–70 years: OR 1.33, 95% CI 1.29, 1.37; 71–80 years: OR 1.49, 95% CI 1.44, 1.54; &gt;80 years: OR 1.42, 95% CI 1.37, 1.48), female sex (OR 1.33, 95% CI 1.31, 1.36) and AF (OR 1.14 95% CI 1.12, 1.16) (p&lt;0.001 for all). In contrast, on-pump CABG was not an independent predictor of stroke (OR 1.01, 95% CI 0.94, 1.09) (p=0.784).

Conclusion

In this nationally representative study, we have shown that the rates of postoperative stroke following CABG have increased over time in line with complexity of patient risk profiles. The present findings emphasise the need for further work on strategies to reduce the risk of postoperative stroke after CABG.

Trends of postoperative AIS (2004-2015)

Funding Acknowledgement

Type of funding source: None

The association between osteoarthritis and invasive treatment and clinical outcomes in 6.5 million patients presenting with acute myocardial infarction

Background

People with osteoarthritis (OA) have an increased risk of cardiovascular disease, including acute myocardial infarction (AMI). Despite OA being the most common joint condition and the fastest increasing major health condition, there is limited information on the management strategies and subsequent outcomes of OA patients presenting with AMI.

Purpose

To describe the association between OA and invasive management strategies (including coronary angiography (CA), percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG)) and clinical outcomes.

Methods

We analysed all hospitalisations for AMI between 2004 and 2015 recorded in the National Inpatient Sample (NIS), the largest inpatient electronic health record database in the United States. The proportion of patients receiving CA, PCI, and CABG were compared between patients with and without OA, as were the proportions of in-hospital adverse events including major acute cardiovascular and cerebrovascular events (MACCE; composite of mortality, cardiac complications and acute stroke), in-hospital mortality, stroke, and major bleeding. Multivariate logistic regression modelling with adjustment for potential confounders (demographics, medical history, and comorbidities) was performed to examine associations between OA and in-hospital clinical outcomes; results are expressed as adjusted odds ratios (AdjOR) with 95% confidence intervals (95% CI).

Results

A total of 6,561,940 people were hospitalised for AMI between January 2004 and September 2015, of which 444,217 (6.8%) had a concurrent diagnosis of OA. On average, those with OA were older (median: 77 vs. 67 years), more likely to be female (55.7% vs. 38.6%), and less likely to receive CA (55.3% vs. 65.2%), PCI (33.3% vs. 43.6%), and CABG (7.4% vs. 8.5%) (Figure 1A, p&lt;0.001 for all). After adjustment for confounders, OA was associated with a lower likelihood of receiving CA (AdjOR 0.89; 95% CI 0.87, 0.90), PCI (0.85; 0.84, 0.87), and CABG (0.92; 0.90, 0.94). With reference to outcomes, OA was associated with lower likelihood of in-hospital adverse events (MACCE: AdjOR 0.71; 95% CI 0.69, 0.72; in-hospital mortality: 0.69; 0.67, 0.71; stroke: 0.81; 0.77, 0.85; and major bleeding: 0.73; 0.70, 0.75) (Figure 1B, p&lt;0.001 for all).

Conclusion

In a national cohort of AMI hospitalisations, patients with OA were less likely to receive invasive management compared to those without OA. However, they were also less likely to experience adverse events. Further work is required to investigate treatment disparities in this increasingly prevalent patient group when presenting with AMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Acute myocardial infarction in several mental illness: a nationwide analysis of prevalence, management strategies and outcomes

Background

Severe mental illness (SMI) is associated with an increased risk of cardiovascular disease and mortality. However, it is unclear whether SMI patients are just as likely to receive guideline-recommended therapy for AMI as those without mental illness.

Purpose

To examine national-level estimates of the prevalence, management strategies and in-hospital clinical outcomes of SMI patients presenting with AMI.

Methods

All AMI hospitalisations from the United States National Inpatient Sample were included, stratified by mental health status in to 5 groups: no-SMI, Schizophrenia, “Other non-organic psychoses” (ONOP), Bipolar Disorder and Major Depression. Multivariable logistic regression modelling was performed to examine the association between SMI subtypes and receipt of invasive management and subsequent in-hospital clinical outcomes, expressed as adjusted odds ratios (aOR) and 95% confidence intervals (CI).

Results

Out of 6,968,777 AMI hospitalisations between 2004 and 2014, a total of 439,544 (6.5%) had an SMI diagnosis. The prevalence of SMI amongst the ACS population doubled over the study period (from 4.5% in 2004 to 9.5% in 2014), primarily due to an increase in Major Depression and Bipolar Disorder diagnoses. All SMI subtypes were less likely to receive coronary angiography and PCI, with the Schizophrenia group being at least odds of either procedure (aOR 0.46 95% CI 0.45, 0.48 and aOR 0.57 95% CI 0.55, 0.59, respectively). Although patients with Schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared to those without SMI, only Schizophrenia patients were associated with increased odds of mortality (aOR 1.10 95% CI 1.04, 1.16), while ONOP were the only group at increased odds of stroke (aOR 1.53 95% CI 1.42,1.65) following multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared to those without SMI (aOR 1.11 95% CI 1.04,1.17).

Conclusion

Patients with SMI are less likely to receive invasive management for AMI, with women and schizophrenia diagnosis being the strongest predictors of conservative management. Schizophrenia and “other non-organic psychoses” are the only SMI subtypes associated with adverse clinical outcomes after AMI. A multidisciplinary approach between psychiatrists and cardiologists could improve outcomes of this high-risk population.

Odds of management and clinical outcomes

Funding Acknowledgement

Type of funding source: None

Isolation Of Anticancer Drug Taxol Producing Endophytic Fungus Alternaria Alternata By Using HPLC And LC- MS

Introduction/Objective

In the exploration of an alternative source, optimum and numerous solvents with different percentage were exploited to extract Taxol from plant palm branche. The fungal endophytes producing secondary metabolites that are effective against the human infections have fascinated many researchers across the world.

Among these, the exploration for novel cancer therapeutic agents is of countless reputation due to upsurge in the number of cancer deaths, high worth of the drugs and the side effects concomitant with cancer treatments.

Accordingly, in the current study, an endophytic fungal strain was isolated from its host plant palm branche and identified as Alternaria Alternata based on its morphological features and internal transcribed spacer sequence analysis.

Methods

Firstly, palm branche were collected for the isolation of endophytic fungi. The samples were placed on PDA plates and after 72 h, the mycelium produced were isolated and sub-cultured. Secondly, further analysis for the presence of Taxol by using chromatographic and spectrometric techniques. Illustratively, ethanol or acetone and 50% and 20% of ethanol. Then, the residues were dissolved in 5 ml of methanol and filtered. By using the internal standard, the resulting solution was subjected to the HPLC to determine the extraction efficiencies of tested solvents. Finally, filtrate was also subjected to the LC-MS – ESI using water/acetonitrile (10/90) as mobile phase to identify the authenticity of Taxol

Results

HPLC analysis revealed that Taxol could be quantified by UV detection using standard curve. Furthermore, the standard curve covering the concentration was linear (r2= 0.9992) and CV% ranged from 0.52 to 15.36. The peaks of fraction 5 obtained by HPLC analysis were quite similar to that of standard taxol confirming the presence of taxol. A parent ion peak of m/z 851.85 was observed in the LC–ESI–MS spectrum which was similar to paclitaxel with reported m/z of 854 [M+H] + ion. A. Alternata produced about 113.193 mg/L taxol as quantified through HPLC

Conclusion

we are recording for the first time the production of taxol by an endophytic fungus Alternaria Alternata. In a final word, present study results advocate that the endophytic fungus A.Alternata aids as a potential source for the production of taxol isolated from Palm branche plant

COVID-19 Mortality in Transplant Recipients

BACKGROUND

Organ transplant recipients are vulnerable to multiple infectious agents and in a world with a circulating SARS-CoV-2 virus, it would be expected that patients who are immunosuppressed would have higher mortality.

OBJECTIVE

To determine the COVID-19 mortality in transplant recipients.

METHODS

We conducted a search in PubMed and Google scholar databases using the keywords for COVID-19 and transplantation. All related studies between January 1, 2020 and May 7, 2020 were reviewed. All relevant published articles related to COVID-19 in transplant recipients were included.

RESULTS

46 articles were included; they studied a total of 320 transplant patients-220 kidney transplant recipients, 42 liver, 19 heart, 22 lung, 8 HSCT, and 9 dual organ transplant recipients. The overall mortality rate was 20% and was variable among different organs and different countries. 65 transplant recipients died of complications attributable to COVID-19; 33 were males (15% of males in this cohort), 8 females (8% of females in this cohort), and 24 whose sex was not determined. They had a median age of 66 (range: 32-87) years. The median transplantation duration was 8 years (range: 30 days to 20 years). The most frequent comorbidity reported was hypertensions followed by diabetes mellitus, obesity, malignancy, ischemic heart disease, and chronic obstructive pulmonary disease. The most frequent cause of death reported was acute respiratory distress syndrome.

CONCLUSION

Transplant recipients in our cohort had a high mortality rate. However, outcomes were not the same in different countries based on outbreak settings. Mortality was noted in elder patients with comorbidities.