An update in the pharmacological management of axial spondyloarthritis.

INTRODUCTION: Significant progress has been made in the diagnosis and management of axial spondyloarthritis (AxSpA) over recent decades. A greater understanding of the immunopathogenesis of the disease has paved the way for the development of targeted treatments. Their efficacy has been demonstrated in randomized controlled trials, meta-analyses and one head-to-head study of biologic DMARDs. Treatment decisions in AxSpA are currently influenced by patient choice, co-morbidity, clinician familiarity and cost. AREAS COVERED: We review the clinical trials that underpin the evidence base for treatments in AxSpA. We also cover the meta-analyses and head-to-head data that seek to support clinicians in personalizing treatment decisions. Further, we discuss the recent international guidelines that provide clinicians with treatment pathways and guidance. EXPERT OPINION: We conclude that treatment decisions in managing both radiographic and non-radiographic AxSpA should be based on shared decision-making with patients, the clinical effectiveness of drug class, co-morbidity and cost. At present, we have limited head-to-head data to prioritize one drug class over another for first-line treatment but can recommend tumor necrosis factor (TNF), interleukin 17 (IL17) and JAK inhibition as being comparable in terms of clinical, structural and patient-reported outcome measures. Further real-world data may guide treatment decision-making in individual patients.

Artificial Intelligence - Perception of Clinical Laboratories' Technical Staff a Nationwide Multicentre Survey in Pakistan.

Introduction: As Artificial Intelligence (AI) technology continues to assimilate into various industries, there is a huge scope in the healthcare industry specifically in clinical laboratories. The perspective of the laboratory professionals can give valuable insight on the ideal path to take for AI implementation. Methods: The study utilized a cross-sectional survey design and was conducted at the section of Chemical Pathology, Department of Pathology and Laboratory Medicine, the Aga Khan University (AKU), Karachi, Pakistan in collaboration with Consultant Pathologists of 9 clinical laboratories associated with teaching hospitals across Pakistan from October-November 2023. The survey was for a duration of 2 weeks and was circulated to all working laboratory technical staff after informed consent. Results: A total of 351 responses were received, of which 342 (male=146, female=196) responses were recorded after exclusion. Respondents ranged from technologists, faculty, residents, and coordinators, and were from different sections (chemical pathology, microbiology, haematology, histopathology, POCT). Out of the total 312 (91.2%) of respondents stated that they were at least somewhat familiar with AI technology. Experts in AI were only 2.0% (n=7) of all respondents, but 90% (n=6) of these were < 30 years old. 76.3% (n=261) of the respondents felt the need to implement more AI technology in the laboratories, with time saving (26.1%) and improving performances of tests (17.7%) cited to be the greatest benefits of AI. Security concerns (n=144) and a fear of decreasing personal touch (n=143) were the main concerns of the respondents while the younger employees had an increased fear of losing their jobs. 76.3% were in favour of an increase in AI usage in the laboratories. Conclusion: This study highlights a favourable perspective among laboratory professionals, acknowledging the potential of AI to enhance both the efficiency and quality of laboratory practices. However, it underscores the importance of addressing their concerns in the thoughtful implementation of this emerging technology.

From bench to bedside - is there a role of IL-17 drugs in rheumatoid arthritis?

INTRODUCTION: IL-17 has been described as a pro-inflammatory cytokine that is relevant in the seronegative spondylarthritides with IL-17 targeted therapies being licensed for their treatment.There is evidence to demonstrate that IL-17 is found in RA joints and contributes to the pro-inflammatory cascade. This results in synovial hyperplasia and osteoclastogenesis thus causing joint destruction and bony erosions. AREAS COVERED: This review article summarizes trials that have studied the use of IL-17 targeted therapies in RA patients who have failed conventional synthetic disease-modifying therapy (C-DMARDS) and biologic DMARDS. EXPERT OPINION: The trials that have studied IL-17 inhibitors in RA patients have only shown a modest improvement in disease activity. In several trials, the primary endpoint was not achieved whilst in others, when comparing with existing licensed biologics for RA, did not demonstrate any superiority.Tissue Necrosis Factor-alpha (TNF-α) likely plays more of a pivotal role in the pathogenesis of RA with IL-17 having a synergistic effect. Therefore, in our opinion, IL-17 inhibitors as an independent therapy for RA are less likely to provide a cost-effective benefit. There may be scope to potentially combine it with TNF-α-inhibitors (TNF-i), but this requires further research especially with the potential concerns related to increased immunosuppression.

Neutrophil-to-Lymphocyte Ratio and Blood Eosinophil Levels As Inflammatory Indicators in Smoker and Non-smoker Young Adult Patients With Chronic Obstructive Pulmonary Disease at a Tertiary Care Hospital.

Background Inflammatory markers are elevated in chronic obstructive pulmonary disease (COPD) and can be quantified to detect severity, prognosis, mortality risk, and response to treatment. However, the estimation costs are high. The blood neutrophil-to-lymphocyte ratio (NLR) and eosinophil levels are emerging as biomarkers in COPD, yet there is a paucity of data. Aim and objectives This study was designed to elucidate the roles of the NLR and eosinophil levels in smokers and non-smokers with stable COPD male subjects, correlating them with lung functions. Materials and methods A prospective observational clinical study was conducted from January to June 2023, after receiving approval from the Institutional Ethics Committee, on 73 COPD patients aged 30-60 years who gave voluntary informed consent. Complete blood counts and spirometry were performed. Patients with a forced expiratory volume in one second (FEV1) % predicted <70% and an FEV1/forced vital capacity (FVC) % <70% based on the pulmonary function test (MIR Spirolab) were included. They were further divided into mild (n=10), moderate (n=27), severe (n=26), and very severe (n=10) categories as per the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Subjects were also categorized into smoker (n=45) and non-smoker (n=28) groups. The complete blood count was analyzed using an automated analyzer (Beckman Coulter). Analysis was also carried out with an NLR of more or less than three. A P-value of less than 0.05 was considered significant. Results Smokers constituted 61.65% (n=45) of the subjects, and non-smokers 38.35% (n=28). Among smokers, 17.78% had very severe airflow obstruction. In all COPD subjects (n=73), lymphocytes, eosinophils, and lung functions were lower in the group where the NLR was greater than three. NLR in smokers (3.52±1.43) was higher than in non-smokers (3.39±0.94). In non-smokers (n=28), blood eosinophils and lymphocytes were elevated. In smokers (n=45), blood neutrophils, monocytes, and basophils were increased. Smokers showed a non-significant increase in RBC, mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH). Neutrophils, monocytes, eosinophils, and NLR increased with disease severity. NLR negatively correlated with FEV1 (r=-0.350, p=0.034) and positively with pack-years (r=0.546, p<0.001) in smokers. NLR negatively correlated with eosinophils, FVC, FEV1/FVC, and FEV1 % predicted. In all COPD subjects (n=73), NLR negatively correlated with blood eosinophils (r=-0.184, p=0.12), BMI, and lung functions. Conclusion NLR is elevated in COPD subjects and can serve as a marker of inflammation and a predictor of the risk and severity of airflow limitation. NLR correlates both positively and negatively with pack-years and lung functions, respectively.

Sustaining the Earth: Unraveling the Synergy of Workplace Spirituality, Responsible Leadership, and Pro-Environmental Behavior in Pakistan's SMEs.

Purpose: The purpose of this research is to investigate the synergistic impact of workplace spirituality (WPS), responsible leadership (RL), and pro-environmental behavior (PEB) within the context of Pakistan's Small and Medium Enterprises (SMEs) along with the mediating mechanism of Affective commitment (AC). Methods: Our study utilizes structural equation modeling (SEM) to analyze survey data collected from 390 employees within Pakistani SMEs. We develop a single unified framework to test the hypothesized relationships between RL, PEB, and AC as a mediator. Results: Our results unveil significant positive relationships between WPS, RL, and PEB. Our findings endorse both the direct connections between WPS, RL, and PEB, as well as the mediating mechanisms through AC. This study offers novel insights into the influence of PEB in the context of Pakistan's SMEs. Conclusion: The research significantly contributes to the existing literature by examining WPS, RL, PEB, and AC in the context of Pakistan's SMEs. The study's conclusions emphasize the potential benefits of integrating WPS and RL into business practices to encourage PEB. Additionally, we discuss the limitations of our research and suggest future avenues for further exploration in this vital area of sustainable business management.

The Effectiveness and Safety of Direct Oral Anticoagulants in Obese Patients With Atrial Fibrillation: A Network Meta-Analysis.

Atrial fibrillation (AF) is a cardiac condition characterized by an irregular heart rhythm, which is increasingly prevalent in the modern era. All international guidelines strongly advise the administration of anticoagulants to individuals with AF who are at high risk of stroke. These guidelines recommend the use of direct oral anticoagulants (DOACs) over warfarin because warfarin is significantly associated with increased rates of major bleeding, numerous interactions with food and drugs, and the necessity for frequent monitoring. The aim of this study is to compare the effectiveness and safety of direct oral anticoagulants (DOACs) in obese patients with atrial fibrillation. Two authors independently conducted a comprehensive literature search using electronic databases including PubMed, CINAHL, and EMBASE from inception to June 1, 2023. The efficacy outcome assessed in this meta-analysis included the composite of stroke and systemic embolism. For safety analysis, major bleeding events were compared among the study groups. Eleven studies fulfilled all the inclusion criteria and were included in the present meta-analysis enrolling 144,502 patients. In this study, DOACs demonstrate superior efficacy in preventing stroke/systemic embolism compared to warfarin. Among the DOACs, apixaban emerged as the most effective, followed by rivaroxaban, warfarin, and dabigatran. In terms of safety, apixaban was also found to be the most favorable treatment option, followed by rivaroxaban, dabigatran, and warfarin. In summary, our study concludes that apixaban exhibited greater effectiveness and safety when compared to other DOACs and warfarin in obese patients with AF.

Isolated pulmonary hemorrhage after electric shock: a rare phenomenon.

Any type of contact with electricity of low or high voltage can cause injury to the human body, with a variable effect on the body. Low-voltage injury is quite common worldwide, but there is very little information present in the available literature. The degree of organ damage depends on many factors, which include the duration of electric current exposure, current type, and nature of the affected tissue. The most common presentations are muscle injury, hyperkalemia, pulmonary edema, and rarely isolated diffuse pulmonary hemorrhage. We present a case of bilateral pulmonary hemorrhage due to electric shock with no visible signs of damage to the chest wall when exposed to a 220 V shock. The diagnosis was confirmed by fresh hemoptysis, chest imaging that showed bilateral perihilar ground glass opacities, and bronchoscopy findings. Given a life-threatening condition, a timely diagnosis is required, as massive hemoptysis can occlude the airways, leading to hypoxia and mortality.

Lovemarks and beyond: Examining the link between lovemarks and brand loyalty through customer advocacy in the automobile industry.

PURPOSE: Despite the potential for businesses, our understanding of lovemark brands and their consequences is limited. Numerous psychological and brand-related consequences are linked to lovemarks, but the role of influential underlining mechanisms is not fully understood. Inspired by the norms of reciprocity theory, the current study investigates the underlining role of customer advocacy in the relationship between perceived lovemarks and brand loyalty of customers in the automobile industry. METHODOLOGY: By adopting the survey method, a sample of 478 was drawn from Pakistani automobile customers. Structural equation modelling was used for the analysis. We conceptualised lovemarks and brand loyalty as reflective higher-order constructs that we analysed through a two-stage disjoint analysis. FINDINGS: Our results support the conceptualization of lovemarks and brand loyalty as higher-order constructs. The influence of lovemarks and customer advocacy on brand loyalty was statistically significant when we controlled for age, gender, and income. Our findings also reveal that customer advocacy, seen as a company's positive interactions, mediates and play a key role in influencing the relationship between lovemarks and brand loyalty. ORIGINALITY: This is among the first studies to examine the role of customer advocacy in the lovemarks-brand loyalty relationship. We examined these relationships in the automobile sector of Pakistan, which offers several theoretical and managerial implications for academia and practitioners. The implications are proposed and outlined in this study.

The correlation of spot urinary protein-to-creatinine ratio with 24-h urinary protein excretion in various glomerulopathies.

BACKGROUND: Proteinuria is an important and well-known biomarker of many forms of kidney injury. Its quantitation is of particular importance in the diagnosis and management of glomerular diseases. Its quantification can be done by several methods. Among these, the measurement of 24-h urinary protein excretion is the gold standard method. However, it is cumbersome, time-consuming, and inconvenient for patients and is not completely foolproof. Many alternative methods have been tested over time albeit with conflicting results. Among the latter, the measurement of urine protein-to-creatinine ratio (uPCR) in single-voided urinary samples is widely used. The majority of studies found a good correlation between uPCR in single urine samples with 24-h urinary protein estimation, whereas others did not. AIM: To investigate the correlation of spot uPCR with 24-h urinary protein estimation in patients suffering from different forms of glomerulopathies at a single large-volume nephrological center in Pakistan. METHODS: This cross-sectional, observational study was conducted at the Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan from September 2017 to March 2018. All newly presenting adult patients with proteinuria who were being investigated for suspected glomerulonephritis and persistent proteinuria with ages between 18 to 60 years were enrolled. All patients were given detailed advice regarding 24-h urine collection starting at 7:00 AM for total protein and creatinine excretion estimations. A spot urine sample was collected the next day at the time of submission of a 24-h urine sample for measuring uPCR along with a blood sample. The data of patients were collected in a proforma. SPSS version 20.0 was used for statistical analysis. RESULTS: A total of 157 patients were included. Their mean age was 30.45 ± 12.11 years. There were 94 (59.8%) males and 63 (40.2%) females. The mean 24-h urinary protein excretion was 3192.78 ± 1959.79 mg and the mean spot uPCR was 3.16 ± 1.52 in all patients. A weak but significant correlation was observed between spot uPCR and 24-h urinary protein excretion (r = 0.342, P = 0.01) among all patients. On subgroup analysis, a slightly better correlation was found in patients older than 47 years (r = 0.78), and those with body mass index > 25 kg/m2 (r = 0.45). The Bland and Altman's plot analysis comparing the differences between spot uPCR and 24-h protein measurement also showed a wide range of the limits of agreement between the two methods. CONCLUSION: Overall, the results from this study showed a significant and weakly positive correlation between spot uPCR and 24-h urinary protein estimation in different forms of glomerulopathies. The agreement between the two methods was also poor. Hence, there is a need for careful interpretation of the ratio in an unselected group of patients with kidney disease.

Perceived corporate social responsibility, ethical leadership, and moral reflectiveness impact on pro-environmental behavior among employees of small and medium enterprises: A double-mediation model.

Corporate social responsibility (CSR) is ever-evolving concept and gaining significance in the business world. This research proposes a research model that elucidates the mechanism by which Corporate social responsibility (CSR), ethical leadership, and moral reflectiveness promote pro-environmental behavior among employees of Small and Medium Enterprises (SMEs). In today's ever-changing environment, small and medium companies (SMEs) are critical for any economy to thrive and prosper. SMEs account for more than 30% of the GDP in Pakistan. However, little is known about the processes by which type of leadership influence the pro-environmental behavior, or the circumstances under which such impacts are strengthened or mitigated. The current study attempted to fill the gap by investigating a dual process model in which ethical leadership and a moral reflectiveness acted as two explanatory mechanisms in the impact of Corporate social responsibility (CSR) on pro-environmental behavior among employees working in small and medium enterprises (SMEs). The structural equation modeling technique was used to test the research model's hypothesized relationships. A survey was used to collect data from 390 employees. Results showed that perceived CSR directly impacted moral reflectiveness and ethical leadership. Moreover, the moral reflectiveness and ethical leadership mediated the relationship between the perceived CSR and pro-environmental behavior. These findings contributed significantly to perceived CSR, ethical leadership, moral reflectiveness, and pro-environmental behavior among employees by exploring and integrating the holistic research work into one framework to add to the body of knowledge. Practical implications and future research directions are also highlighted.

The role of five big personality traits and entrepreneurial mindset on entrepreneurial intentions among university students in Saudi Arabia.

The big five personality traits and entrepreneurial mindset (EM) are crucial individual-level elements that determine entrepreneurial intention (EI). This study examines the impact of big five personality traits and EM, on EI using the theory of planned behavior. Besides, this study examined the role of entrepreneurial self-efficacy (ESE) and attitude toward entrepreneurship (ATE) influences EI. To achieve the research objectives, a quantitative approach was used. Structural equation modeling (SEM) and path analysis were conducted using SmartPLS software. Data were collected from 270 respondents through online questionnaires. Findings of the study revealed that big five personality traits influence ESE and ATE which led to EI. Finally, the moderating role of entrepreneurial passion was also found to have strong effect on influence ESE and ATE. This study offers evidence and insights that academics, educators, and others involved in the creation or expansion of entrepreneurial knowledge can use as a reference point.

Green transformational leadership and green creativity? The mediating role of green thinking and green organizational identity in SMEs.

For countries and organizations to achieve sustainable development, radical green creativity is required. Despite the fact that the influencing elements of green creativity have received a lot of attention, there is little research on the antecedents of green creativity. The current study attempted to fill the gap by exploring the underlying mechanism of green thinking and green organizational identity as mediators. This study aimed to examine the impact of green transformational leadership on green creativity through mediators, such as green thinking and creative organizational identity in SMEs. We gathered data from 460 respondents from SMEs operating in Pakistan using a survey questionnaire. The findings revealed that green transformational leadership had a significant impact on green organizational identity, which cultivated green creativity in SMEs. Additionally, results portrayed that green organizational identity performed mediation in the relationship between green transformational leadership and green creativity. Moreover, green thinking mediates the association between green transformational leadership and green creativity. This study offers novel insights into how to stimulate green transformational leadership and cognitive processes in SMEs to encourage green creativity. The implications for management and practitioners are discussed in light of the study's findings.

Hydroxychloroquine plus personal protective equipment versus personal protective equipment alone for the prevention of laboratory-confirmed COVID-19 infections among healthcare workers: a multicentre, parallel-group randomised controlled trial from India.

OBJECTIVES: To determine whether hydroxychloroquine when used with personal protective equipment reduces the proportion of laboratory-confirmed COVID-19 among healthcare workers in comparison to the use of personal protective equipment alone. DESIGN: Multicentre, parallel-group, open-label randomised trial. Enrolment started on 29 June 2020 and stopped on 4 February 2021. Participants randomised in HydrOxychloroquine Prophylaxis Evaluation were followed for 6 months. SETTING: 9 hospitals across India. PARTICIPANTS: Healthcare workers in an environment with exposure to COVID-19 were randomised in a 1:1 ratio to hydroxychloroquine plus use of personal protective equipment or personal protective equipment alone. 886 participants were screened and 416 randomised (213 hydroxychloroquine arm and 203 personal protective equipment). INTERVENTION: Participants in intervention arm received 800 mg of hydroxychloroquine on day of randomisation and then 400 mg once a week for 12 weeks in addition to the use of personal protective equipment. In the control arm, participants continued to use personal protective equipment alone. MAIN OUTCOME: Proportion of laboratory-confirmed COVID-19 in the 6 months after randomisation. RESULTS: Participants were young (mean age 32.1 years, SD 9.1 years) with low-comorbid burden. 47.4% were female. In the 6 months after randomisation (primary analysis population=413), 11 participants assigned to the hydroxychloroquine group and 12 participants assigned to the standard practice group met the primary endpoint (5.2% vs 5.9%; OR 0.85, 95% CI 0.35 to 2.07, p=0.72). There was no heterogeneity of treatment effect in any prespecified subgroup. There were no significant differences in the secondary outcomes. The adverse event rates were 9.9% and 6.9% in the hydroxychloroquine and standard practice arms, respectively. There were no serious adverse events in either group. CONCLUSIONS AND RELEVANCE: Hydroxychloroquine along with personal protective equipment was not superior to personal protective equipment alone on the proportion of laboratory-confirmed COVID-19. Definitive conclusions are precluded as the trial stopped early for futility, and hence was underpowered. TRIAL REGISTRATION NUMBER: CTRI/2020/05/025067.

Development of a virtual classroom for pre-analytical phase of laboratory medicine for undergraduate medical students using the Delphi technique.

BACKGROUND: Amongst the pre-analytical, analytical, and post-analytical phase of laboratory testing, pre-analytical phase is the most error-prone. Knowledge gaps in understanding of pre-analytical factors are identified in the clinical years amongst undergraduate students due to lack of formal teaching modules on the pre-analytical phase. This study was conducted to seek experts' consensus in Clinical Chemistry on learning objectives and contents using the Delphi technique with an aim to develop an asynchronous virtual classroom for teaching pre-analytical factors of laboratory testing. METHODS: A mixed method study was conducted at the Aga Khan University. A questionnaire comprising of 16 learning objectives and their associated triggers was developed on Google Docs for developing the case vignettes. A four-point Likert Scale, which included strongly agree, agree, disagree and strongly disagree, was utilized for the learning objectives. An open-ended question was included for experts to suggest new items for inclusion. A cut off of at least 75% agreement was set to establish consensus on each item. A total of 17 Chemical Pathology faculty from 13 institutions across Pakistan were invited to participate in the first round of Delphi. Similar method of response was used in round two to establish consensus on the newly identified items suggested by the faculty in round 1. Later, the agreed-upon objectives and triggers were used to develop interactive scenarios over Moodle to concurrently test and teach medical students in a nonchalant manner. RESULTS: A total of 17 responses were received in Round 1 of the Delphi process (response rate = 100%), while 12 responses were received in Round 2 (response rate = 71%). In round 1, all 16 learning objectives reached the required consensus (≥ 75%) with no additional learning objectives suggested by the experts. Out of 75 triggers in round 1, 61 (81.3%) reached the consensus to be included while 39 were additionally suggested. In 2nd round, 17 out of 39 newly suggested triggers met the desired consensus. 14 triggers did not reach the consensus after two rounds, and were therefore eliminated. The virtual classroom developed using the agreed-upon learning objectives and triggers consisted of 20 items with a total score of 31 marks. The questions included multiple choice questions, fill in the blanks, drag and drop sequences and read-and-answer comprehensions. Specific learning points were included after each item and graphs and pictures were included for a vibrant experience. CONCLUSION: We developed an effective and interactive virtual session with expert consensus on the pre-analytical phase of laboratory testing for undergraduate medical students which can be used for medical technologist, graduate students and fellows in Chemical Pathology.

Management of LC Type I (LC-1) Pelvic Injuries with Complete Sacral Fracture: Comparison of Solitary Anterior Fixation with Combined Anterior-Posterior Fixation.

BACKGROUND: Management of LC-1 type pelvic injuries, particularly in patients with complete sacral fracture (LC-1 PICSF, OTA type 61-B2.1), remains controversial. Specific indications for solitary fixation remain unclear, and there is a paucity of outcomes data in comparison to combined fixation. We undertook a retrospective study in patients with LC-1 PICSFs to compare outcomes between solitary anterior fixation and combined anterior-posterior fixation. METHODS: A retrospective cohort study was conducted with enrollment from 2016 to 2018 at a single tertiary-referral center in China. Adults with operatively managed LC-1 PICSFs were enrolled. Patients with sacral displacement < 1 cm as assessed by axial CT received solitary anterior ring fixation (group A); patients with displacement ≥ 1 cm received combined fixation of both the anterior and posterior rings (group B). Reduction was confirmed by manipulation under anesthesia. Patients followed up for at least 24 months postoperatively. Primary outcome was function (Majeed score). Secondary outcomes included intraoperative characteristics, pain (VAS score), quality of fracture reduction (Tornetta and Matta radiographic grading), rate of nonunion, early weight-bearing status, and complication rate. RESULTS: 68 (89%) of 76 enrolled patients completed follow-up. Patients in group A exhibited improved operative times, less time under fluoroscopy, and less blood loss as compared to group B. There were no significant differences between groups A and B regarding quality of fracture reduction, rate of union, functional outcomes, or rate of complications. Notably, group B patients were more likely to achieve full early weight-bearing. CONCLUSION: LC-1 PFCSFs can get benefits from ORIF; the treatment algorithm should be differently made following the degree of the sacral fractures displacement. Less than 1 cm sacral fracture displacement may get good functional outcomes from solitary anterior fixation. However, for the sacral fractures displacement greater or equal to 1 cm, both the anterior and posterior pelvic rings should be surgical stabilization.

The Impact of Job Stress and State Anger on Turnover Intention Among Nurses During COVID-19: The Mediating Role of Emotional Exhaustion.

Based on the social exchange theory, the aim of this study is to identify the association between job stress state anger, emotional exhaustion and job turnover intention. This study postulates that job related stress and state anger among nurses during COVID-19 subsequently leads to their job turnover intentions. In addition, the study also aims to see the mediating role of emotional exhaustion between COVID-19-related job stress, state anger, and turnover intentions. The sample of this study is gathered from 335 registered nurses working in Pakistani hospitals dealing with COVID-19-related patients. The interrelationships between variables are checked by using structural equation modeling through AMOS. Key findings confirm that COVID-19-related job stress and state anger had a significant effect on nurses' turnover intentions. Furthermore, emotional exhaustion mediated the relationship between COVID-19-related job stress, state anger, and turnover intentions. There is a lack of research which has assessed the impact of Novel COVID-19-related job stress and state anger on nurses' turnover intentions in hospitals, providing empirical evidence from a developing country-Pakistan. This study offers managerial implications for hospital management and health policymakers. Moreover, nursing managers need to pay attention to nurses' turnover intentions who are facing the issue at the front line as patients receive their initial treatment from nurses in the COVID-19 outbreak.

Impact of One-Year Serum Creatinine on Long-term Renal Graft Survival in a Living-Related Renal Transplant Program.

This study was carried out to determine the impact of one-year posttransplant serum creatinine (SCr) levels on the long-term outcomes of living-related donor kidney transplants. A retrospective cohort study included 773 adult living-related renal transplant recipients from 2010 to 2012, with a minimum follow-up period of five years. Demographics and posttransplantation follow-up data including immunosuppression regimens, rejection episodes, and survival rates were evaluated. Patients were divided into four cohorts (G1, G2, G3, and G4 based on SCr at the end of the 1st year: G1, SCr <88.4 µ mol/L; G2, 88.5≤ SCr ≤ 132.6 µmol/L; G3, 132.7≤ SCr ≤176.8 mol/L; and G4, SCr ≥176.9 µ mol/L). Comparisons between the groups used the Chi-square test for qualitative parameters and analysis of variance for continuous variables. Five-year graft survival for G1 was 98% as compared to 76% in G4 (P <0.001). Recipients of G4 encountered more acute rejection episodes in 21% of the cases as compared to 7.3% in G1 (P = 0.001). Donors were older in G4 (42.07 ± 10.4 years) as compared to G1 (30.1 ± 8.5 years) (P = 0.001). A third of the donors in G1 were HLA identical as compared to 7% in G4. Prediction of long-term graft survival is possible by the SCr level at one year post transplant. This can be of great importance, especially to identify those patients who require close monitoring in follow-up. Donor age, HLA, and acute rejection impact SCr at one year and hence graft outcome.

Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania.

BACKGROUND: Treatment of diaphyseal open tibia fractures often results in reoperation and impaired quality of life. Few studies, particularly in resource-limited settings, have described factors associated with outcomes after these fractures. QUESTIONS/PURPOSES: (1) Which patient demographic, perioperative, and treatment characteristics are associated with an increased risk of reoperation after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? (2) Which patient demographic, perioperative, and treatment characteristics are associated with worse 1-year quality of life after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? METHODS: A prospective study was completed in parallel to a similarly conducted RCT at a tertiary referral center in Tanzania that enrolled adult patients with diaphyseal open tibia fractures from December 2015 to March 2017. Patients were treated with either a statically locked intramedullary nail or external fixator and examined at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. The primary outcome, reoperation, was any deep infection or nonunion treated with a secondary intervention. The secondary outcome was the 1-year EuroQol-5D (EQ-5D) index score. There were 394 patients screened and ultimately, 267 patients enrolled in the study (240 from the primary RCT and 27 followed for the purposes of this study). Of these, 90% (240 of 267) completed 1-year follow-up and were included in the final analysis. This group comprised 110 patients who underwent IMN and 130 who had external fixation; follow-up was similar between study groups. Patients were an average of 33 years old and were primarily males who sustained road traffic injuries resulting in AO/Orthopaedic Trauma Association (OTA) classification type A or B fractures. There were 51 reoperations. For the purposes of analysis, all patients were pooled to identify all other factors, in addition to treatment type, associated with increased risk of reoperation and 1-year quality of life. An exploratory bivariable analysis identifying various factors associated with reoperation risk and EQ-5D was subsequently included in a multivariate modeling procedure to control for confounding of effect on our primary outcome. Multivariable modeling was performed using standard hierarchical modeling simplification procedures with log-likelihood ratios. Alpha levels were set to 0.05. RESULTS: After controlling for potentially confounding variables such as gender, smoking status, mechanism of injury, and treatment type, the following factors were independently associated with reoperation: Time from hospital presentation to surgery more than 24 hours (odds ratio 7.7 [95% confidence interval 2.1 to 27.8; p = 0.002), AO/OTA fracture classification Type 42C fracture (OR 4.2 [95% CI 1.2 to 14.0]; p = 0.02), OTA-Open Fracture Classification muscle loss (OR 7.5 [95% CI 1.3 to 42.2]; p = 0.02), and varus coronal angle on an immediate postoperative AP radiograph (OR 4.8 [95% CI 1.2 to 14.0]; p = 0.002). After again controlling for confounding variables such as gender, smoking status, mechanism of injury, and treatment type factors independently associated with worse 1-year EQ-5D scores included: Wound length ≥ 10 cm (ß = [change in EQ-5D score] -0.081 [95% CI -0.139 to -0.023]; p = 0.006), OTA-Open Fracture Classification muscle loss (ß = -0.133 [95% CI -0.215 to -0.051]; p = 0.002), and OTA-Open Fracture Classification bone loss (ß = -0.111 [95% CI -0.208 to -0.013]; p = 0.03). We observed a modest, but independent association between reoperation and worse 1-year EQ-5D scores (ß = -0.113 [95% CI -0.150 to -0.077]; p < 0.001). CONCLUSIONS: We found two potentially modifiable factors associated with the risk of reoperation: reducing time to surgical treatment and avoiding varus coronal angulation during definitive stabilization. Hospitals may be able to minimize time to surgery, and thus, reoperation, by increasing the number of available operative personnel and space and emphasizing the importance of open tibia fractures as an injury requiring emergent orthopaedic management. Given the lack of fluoroscopy in the study setting and similar settings, surgeons should emphasize appropriate fracture alignment, even into slight valgus, to avoid varus angulation and subsequent reoperation risk. LEVEL OF EVIDENCE: Level II, therapeutic study.

Elevated Soluble Galectin-3 as a Marker of Chemotherapy Efficacy in Breast Cancer Patients: A Prospective Study.

PURPOSE: Galectin-3 (Gal-3) is a glycan-binding lectin with a debated role in cancer progression due to its various functions and patterns of expression. The current study investigates the relationship between breast cancer prognosis and secreted Gal-3. METHODS: Breast cancer patients with first time cancer diagnosis and no prior treatment (n = 88) were placed in either adjuvant or neoadjuvant setting based on their treatment modality. Stromal and plasma Gal-3 levels were measured in each patient at the time of diagnosis and then throughout treatment using immunohistochemistry (IHC) and ELISA, respectively. Healthy women (>18 years of age, n = 63) were used to establish baseline levels of plasma Gal-3. Patients were followed for 84 months for disease-free survival analysis. RESULTS: Enhanced levels of plasma (adjuvant) and stromal (neoadjuvant) Gal-3 were found to be markers of chemotherapy efficacy. The patients with chemotherapy-induced increase in extracellular Gal-3 had longer disease-free interval and significantly lower rate of recurrence during 84-month follow-up compared to patients with unchanged or decreased secretion. CONCLUSION: The findings support the use of plasma Gal-3 as a marker for chemotherapy efficacy when no residual tumor is visible through imaging. Furthermore, stromal levels in any remaining tumors postchemotherapy can also be used to predict long-term prognosis in patients.