A sustainable approach for fluoride treatment using coconut fiber cellulose as an adsorbent.

In developing countries like India, an economically viable and ecologically approachable strategy is required to safeguard the drinking water. Excessive fluoride intake through drinking water can lead to dental fluorosis, skeletal fluorosis, or both. The present study has been under with an objective to investigate the feasibility of using cellulose derived from coconut fiber as an adsorbent under varying pH conditions for fluoride elimination from water. The assessment of equilibrium concentration of metal ions using adsorption isotherms is an integral part of the study. This present finding indicates the considerable effect of variation of adsorbent dosages on the fluoride removal efficiency under constant temperature conditions of 25 ± 2 °C with a contact period of 24 h. It is pertinent to mention that maximum adsorption of 88% has been observed with a pH value of 6 with 6 h time duration with fluoride dosage of 50 mg/L. The equilibrium concentration dwindled to 0.4 mg/L at fluoride concentration of 20 mg/L. The Langmuir model designates the adsorption capacity value of 2.15 mg/L with initial fluoride concentration of 0.21 mg/g with R2 value of 0.660. Similarly, the adsorption capacity using Freundlich isotherms is found to be 0.58 L/g and 0.59 L/g with fluoride concentration of 1.84 mg/L and 2.15 mg/L respectively. The results from the present study confirm that coconut fiber possesses appropriate sorption capabilities of fluoride ion but is a pH dependent phenomenon. The outcomes of the study indicate the possible use of cellulose extracted from waste coconut fiber as a low-cost fluoride adsorbent. The present study can be well implemented on real scale systems as it will be beneficial economically as well as environmentally.

Associations Between Built Environment Factors and SARS-CoV-2 Infections at the Neighbourhood Level in a Metropolitan Area in Germany.

COVID-19-related health outcomes displayed distinct geographical patterns within countries. The transmission of SARS-CoV-2 requires close spatial proximity of people, which can be influenced by the built environment. Only few studies have analysed SARS-CoV-2 infections related to the built environment within urban areas at a high spatial resolution. This study examined the association between built environment factors and SARS-CoV-2 infections in a metropolitan area in Germany. Polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infections of 7866 citizens of Essen between March 2020 and May 2021 were analysed, aggregated at the neighbourhood level. We performed spatial regression analyses to investigate associations between the cumulative number of SARS-CoV-2 infections per 1000 inhabitants (cum. SARS-CoV-2 infections) up to 31.05.2021 and built environment factors. The cum. SARS-CoV-2 infections in neighbourhoods (median: 11.5, IQR: 8.1-16.9) followed a marked socially determined north-south gradient. The effect estimates of the adjusted spatial regression models showed negative associations with urban greenness, i.e. normalized difference vegetation index (NDVI) (adjusted ß = - 35.36, 95% CI: - 57.68; - 13.04), rooms per person (- 10.40, - 13.79; - 7.01), living space per person (- 0.51, - 0.66; - 0.36), and residential (- 0.07, 0.16; 0.01) and commercial areas (- 0.15, - 0.25; - 0.05). Residential areas with multi-storey buildings (- 0.03, - 0.12; 0.06) and green space (0.03, - 0.05; 0.11) did not show a substantial association. Our results suggest that the built environment matters for the spread of SARS-CoV-2 infections, such as more spacious apartments or higher levels of urban greenness are associated with lower infection rates at the neighbourhood level. The unequal intra-urban distribution of these factors emphasizes prevailing environmental health inequalities regarding the COVID-19 pandemic.

Therapeutic potential of marine peptides in malignant melanoma.

Malignant melanoma is the most dangerous type of skin cancer. It is becoming more common globally and is increasingly resistant to treatment options. Despite extensive research into its pathophysiology, there are still no proven cures for metastatic melanoma. Unfortunately, current treatments are frequently ineffective and costly, and have several adverse effects. Natural substances have been extensively researched for their anti-MM capabilities. Chemoprevention and adjuvant therapy with natural products is an emerging strategy to prevent, cure or treat melanoma. Numerous prospective drugs are found in aquatic species, providing a plentiful supply of lead cytotoxic chemicals for cancer treatment. Anticancer peptides are less harmful to healthy cells and cure cancer through several different methods, such as altered cell viability, apoptosis, angiogenesis/metastasis suppression, microtubule balance disturbances and targeting lipid composition of the cancer cell membrane. This review addresses marine peptides as effective and safe treatments for MM and details their molecular mechanisms of action.

Remote Health Monitoring Systems for Elderly People: A Survey.

This paper addresses the growing demand for healthcare systems, particularly among the elderly population. The need for these systems arises from the desire to enable patients and seniors to live independently in their homes without relying heavily on their families or caretakers. To achieve substantial improvements in healthcare, it is essential to ensure the continuous development and availability of information technologies tailored explicitly for patients and elderly individuals. The primary objective of this study is to comprehensively review the latest remote health monitoring systems, with a specific focus on those designed for older adults. To facilitate a comprehensive understanding, we categorize these remote monitoring systems and provide an overview of their general architectures. Additionally, we emphasize the standards utilized in their development and highlight the challenges encountered throughout the developmental processes. Moreover, this paper identifies several potential areas for future research, which promise further advancements in remote health monitoring systems. Addressing these research gaps can drive progress and innovation, ultimately enhancing the quality of healthcare services available to elderly individuals. This, in turn, empowers them to lead more independent and fulfilling lives while enjoying the comforts and familiarity of their own homes. By acknowledging the importance of healthcare systems for the elderly and recognizing the role of information technologies, we can address the evolving needs of this population. Through ongoing research and development, we can continue to enhance remote health monitoring systems, ensuring they remain effective, efficient, and responsive to the unique requirements of elderly individuals.

A Self-Decoupling Technique to Realize Dense Packing of Antenna Elements in MIMO Arrays for Wideband Sub-6 GHz Communication Systems.

A self-decoupled technique is described that enables the radiating elements in the antenna array to be densely packed for multiple-input multiple-output (MIMO) wireless communications systems. High isolation between the adjacent antenna elements is obtained by fixing the radiating elements in an orthogonal configuration with respects to each other. Current from the adjacent ports cancels their impact which results in low mutual coupling. The additional benefit of this configuration is realizing a densely packed array. The ground plane of each radiating element on the array board itself are isolated to mitigate surface wave propagations to suppress mutual coupling between the antenna elements. The radiating elements are based on a modified edge-fed circular patch antenna that includes a curved slot line and open-circuited stub to widen the array's impedance bandwidth with no impact on the antenna's footprint size. The proposed technique was verified with the design of an antenna array of matrix size 4 × 4 centered at 3.5 GHz. The array had a measured impedance bandwidth of 4 GHz from 1.5 GHz to 5.5 GHz, which corresponds to a fractional bandwidth of 114%, peak gain of 3 dBi and radiation efficiency of 84%. Its average diversity gain and envelope correlation coefficient (ECC) over its operating band are 9.6 dB and <0.016, respectively. The minimum isolation achieved between the radiating elements is better than 15 dB. The dimensions of the array are 0.4 × 0.4 × 0.039λ_g^3. The proposed array has characteristics suitable for sub-6 GHz wireless communication systems

Therapeutic potential of marine peptides in cervical and ovarian cancers.

Cervical and ovarian cancers contribute significantly to female morbidity and mortality worldwide. The current standard of treatment, including surgical removal, radiation therapy, and chemotherapy, offers poor outcomes. There are many side effects to traditional chemotherapeutic agents and treatment-resistant types, and often the immune response is depressed. As a result, traditional approaches have evolved to include new alternative remedies, such as natural compounds. Aquatic species provide a rich supply of possible drugs. The potential anti-cancer peptides are less toxic to normal cells and can attenuate multiple drug resistance by providing an efficacious treatment approach. The physiological effects of marine peptides are described in this review focusing on various pathways, such as apoptosis, microtubule balance disturbances, suppression of angiogenesis, cell migration/invasion, and cell viability. The review also highlights the potential role of marine peptides as safe and efficacious therapeutic agent for the treatment of cervical and ovarian cancers.

New-onset and relapsed liver diseases following COVID-19 vaccination: a systematic review.

BACKGROUND: Liver diseases post-COVID-19 vaccination is extremely rare but can occur. A growing body of evidence has indicated that portal vein thrombosis, autoimmune hepatitis, raised liver enzymes and liver injuries, etc., may be potential consequence of COVID-19 vaccines. OBJECTIVES: To describe the results of a systematic review for new-onset and relapsed liver disease following COVID-19 vaccination. METHODS: For this systematic review, we searched Proquest, Medline, Embase, PubMed, CINAHL, Wiley online library, Scopus and Nature through the Preferred Reporting Items for Systematic Reviews and Meta Analyses PRISMA guideline for studies on the incidence of new onset or relapsed liver diseases post-COVID-19 vaccination, published from December 1, 2020 to July 31, 2022, with English language restriction. RESULTS: Two hundred seventy-five cases from one hundred and eighteen articles were included in the qualitative synthesis of this systematic review. Autoimmune hepatitis (138 cases) was the most frequent pathology observed post-COVID-19 vaccination, followed by portal vein thrombosis (52 cases), raised liver enzymes (26 cases) and liver injury (21 cases). Other cases include splanchnic vein thrombosis, acute cellular rejection of the liver, jaundice, hepatomegaly, acute hepatic failure and hepatic porphyria. Mortality was reported in any of the included cases for acute hepatic failure (n = 4, 50%), portal vein thrombosis (n = 25, 48.1%), splanchnic vein thrombosis (n = 6, 42.8%), jaundice (n = 1, 12.5%), raised liver enzymes (n = 2, 7.7%), and autoimmune hepatitis (n = 3, 2.2%). Most patients were easily treated without any serious complications, recovered and did not require long-term hepatic therapy. CONCLUSION: Reported evidence of liver diseases post-COIVD-19 vaccination should not discourage vaccination against this worldwide pandemic. The number of reported cases is relatively very small in relation to the hundreds of millions of vaccinations that have occurred and the protective benefits offered by COVID-19 vaccination far outweigh the risks.

Therapeutic Potential of Marine Peptides in Prostate Cancer: Mechanistic Insights.

Prostate cancer (PCa) is the leading cause of cancer death in men, and its treatment is commonly associated with severe adverse effects. Thus, new treatment modalities are required. In this context, natural compounds have been widely explored for their anti-PCa properties. Aquatic organisms contain numerous potential medications. Anticancer peptides are less toxic to normal cells and provide an efficacious treatment approach via multiple mechanisms, including altered cell viability, apoptosis, cell migration/invasion, suppression of angiogenesis and microtubule balance disturbances. This review sheds light on marine peptides as efficacious and safe therapeutic agents for PCa.

Enhanced Anomaly Detection System for IoT Based on Improved Dynamic SBPSO.

The Internet of Things (IoT) supports human endeavors by creating smart environments. Although the IoT has enabled many human comforts and enhanced business opportunities, it has also opened the door to intruders or attackers who can exploit the technology, either through attacks or by eluding it. Hence, security and privacy are the key concerns for IoT networks. To date, numerous intrusion detection systems (IDS) have been designed for IoT networks, using various optimization techniques. However, with the increase in data dimensionality, the search space has expanded dramatically, thereby posing significant challenges to optimization methods, including particle swarm optimization (PSO). In light of these challenges, this paper proposes a method called improved dynamic sticky binary particle swarm optimization (IDSBPSO) for feature selection, introducing a dynamic search space reduction strategy and a number of dynamic parameters to enhance the searchability of sticky binary particle swarm optimization (SBPSO). Through this approach, an IDS was designed to detect malicious data traffic in IoT networks. The proposed model was evaluated using two IoT network datasets: IoTID20 and UNSW-NB15. It was observed that in most cases, IDSBPSO obtained either higher or similar accuracy even with less number of features. Moreover, IDSBPSO substantially reduced computational cost and prediction time, compared with conventional PSO-based feature selection methods.

An infrequent case of adult nasopharynx rhabdomyosarcoma with bony involvement: A case report.

Rhabdomyosarcoma is a rare and highly aggressive malignancy arising from the striated skeletal muscle fibre. It is commonly a childhood tumour and rarely seen in adults. The most predominant part commonly involved is head and neck. We are reporting a rare case of a 54 year old adult male with Rhabdomyosarcoma of nasopharynx with a non specific presentation of weight loss for past four months, fever, a perianal abscess and backache since 10 days. The haematological and biochemical parameters were within normal limits however C reactive protein and erythrocyte sedimentation rate were raised. An MRI for the pelvis, which was done for the extension of perianal abscess, also displayed some heterogeneous marrow signal, which raised the suspicion of some infiltrative process. Later, a bone scan, PET scan, and a biopsy of the nasopharaynx was done. The biopsy confirmed the findings of Rhabdomyosarcoma by showing marked pleomorphism with strong positive desmin and myogin stain. The patient was then referred to the oncology department for further management.

Cepharanthine action in preventing obesity and hyperlipidemia in rats on a high-fat high sucrose diet.

Background: It was demonstrated that cepharanthine (CEP), derived from Stephania cepharantha hayata, is a potent inhibitor of the ABCC10 transmembrane protein. It is approved to be a natural product or remedy. The present study focuses on investigating whether cepharanthine effectively reduces hyperlipidemia and obesity in an experimental hyperlipidemic rat model. Method: Four groups of Wistar rats were assigned randomly to the following groups: a high-fat high sucrose diet (HFHS), normal-fat diet (NFD), HFHS plus cepraranthine (10 mg/kg) (HFHS-C), and a HFHS diet with atorvastatin (HFHS-A). The responses of rats were observed on the basis of serum and hepatic biochemical parameters, food intake, and body weight after CEP treatment, and assessing the histopathological modifications by the optical microscope in the liver and its cells. Results: Significant improvement in the serum total cholesterol (TC), serum triglycerides (TG), and serum low-density lipoprotein (LDL) levels were observed following CEP treatment. We have also observed significant improvement in the structure of liver tissue and reduced-fat droplets in the cytoplasm. Moreover, CEP had a significant effect in preventing the gain in body weight of animals, and food intake was not significantly affected. Conclusion: Our research results revealed that CEP significantly improved dyslipidemia and prevented the accumulation of fatty deposits in the rats' liver tissue fed an HFHS diet. In addition, CEP exerted an anti-obesity effect.

Diuretic and anti-diarrheal potential of four fruit extracts of Capsicum annum L.

Capsicum has been an important part of diet since centuries and has been widely used traditionally for ailments. The objective of the present analysis was to determine the diuretic and antidiarrheal potentials of four variations of Capsicum annum L. fruits available in local market of Karachi, Pakistan. It belongs to family Solanaceae and extracts were prepared in 95% ethanol and was given in doses of 200 and 400mg/kg and the activity was correlated with commonly used diuretics and anti-diarrheal further reinforcing its conventional use. Fruits extracts were evaluated for anti-diarrheal properties in castor-oil induced diarrhea to confirm its activity. The diuretic activity of the 95% ethanolic extracts of Capsicum annum L. was assessed based on diuresis of 24 hr. collected through metabolic cage. Urinary excretion of water and electrolytes (Na+ and K+) is significantly increased by the standard diuretic drug furosemide, which is comparable with the extract. The anti-diarrheal effects of 95% ethanolic extracts of Capsicum annum L. were examined by castor oil induced diarrhea and all varieties of Capsicum annum L. significantly inhibited the number of defecations.

Pharmacognostic and phytochemical study of the flowers of Cordia sebestena L.

The present study shows the pharmacognostic and phytochemical studies on the flowers of Cordia sebestena L. belongs to the family Boraginaceae. C. sebestena L. is found primarily in tropical and subtropical regions of the American, Asian and African continents. Though it is an important plant, until date no pharmacognostic work is found on its parts such as flowers. Various organoleptic characters were recorded by macroscopic study. Microscopic study of the flowers were also conducted which shows the presence of fibers, calcium oxalate crystals and multiple types of trichomes, along with fluorescence analysis. The present study also deals with the Fourier transform infrared spectroscopic analysis of C. sebestena L. FT-IR spectra revealed the presence of C-H, C=C, C-N, C-O and aromatic groups. Chemical composition of the hexane extract of the flowers of C. sebestena L. was detected through GC-MS and spectrum achieved through GC-MS were correlated with the database of National Institute of Standards and Technology (NIST) which comprise of beyond 62000 outlines of the mass spectrum. GC-MS analysis of n-hexane extract shown the existence of Retinoic acid, lupeol, ß-sitosterol, stigmasterol, hexadecanoic acid along with fatty acids, esters, alkaloids and alcohols. These pharmacognostic and phytochemical studies can be valuable towards giving reliable proof of the quality of the plant which can benefit health professionals and herbal medicine manufacturers.

Assessment of COVID-19 vaccine booster dose acceptance, reluctance and concerns among elderly diabetes patients in Pakistan.

People around the globe rumored so many things about the safety and efficacy of initial two doses and booster dose of Covid-19 vaccine, which eventually affected the acceptance of the only tool available against the fight between humans and virus. The aim of current study is to evaluate the acceptance and reluctance level among the population specifically elderly diabetes patients. The cross-sectional study was conducted during a time period of 3 months i.e. from July 2021 until September 2021. A 16-item questionnaire was used to assess the acceptance, reluctance and concerns of the Covid-19 vaccine booster dose among elderly diabetes patients. A 16-item questionnaire was used to assess the acceptance, reluctance and concerns of the Covid-19 vaccine booster dose among elderly diabetes patients. A total of 497 responses were collected and analyzed. Approximately 32% of respondents believed that they need additional information about the Covid-19 vaccine booster dose will be ineffective due to not enough information about the potential side effects of the vaccine dose, while around 80% of respondents showed concerns about safety, efficacy, newness and not enough information about vaccine contents. Around 47.1% of respondents expressed robust concerns about possible side effects of the Covid-19 vaccine booster dose.

Assessment of empagliflozin add-on therapy to metformin and glimepiride in patients with inadequately controlled type-2 diabetes mellitus.

Diabetes mellitus is a multifaceted metabolic disorder, which often required frequent blood glucose monitoring, poly-pharmacy and timely adjustments for its management. The present study focuses to check the effectiveness of empagliflozin add-on therapy in diabetic patients already taking metformin and glimepiride. This was observational, comparative and follow-up cohort study, conducted in a tertiary care hospital of Pakistan. Ninety subjects were enrolled and evenly distributed in Group A (patients on oral therapy of Metformin & Glimepiride) and Group B (patients on oral therapy of metformin, glimepiride and empagliflozin) randomly. The results showed that the addition of empagliflozin to metformin and glimepiride standard therapy provided better control over blood sugar with a significant decrease in HbA1c (16.1% decrease in HbA1c for Group B patients against 8.2% in Group A patients), FBS (23.8% decrease as compared to 14.6% decrease) and BMI (1.5% decrease in Group B patients against 0.06% increase in Group A). The addition of empagliflozin did not exacerbate the toxicity of the existing regimen and is safe to be included in multiple drug regimens. Empagliflozin addition to standard antidiabetic therapy might possess beneficial impacts in managing poorly controlled Type-2 Diabetes Mellitus in the Pakistani population.

Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes.

BACKGROUND: Advancing health equity entails reducing disparities in care. African-American patients with chronic kidney disease (CKD) have poorer outcomes, including dialysis access placement and transplantation. Estimated glomerular filtration rate (eGFR) equations, which assign higher eGFR values to African-American patients, may be a mechanism for inequitable outcomes. Electronic health record-based registries enable population-based examination of care across racial groups. OBJECTIVE: To examine the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and care delivery. DESIGN: Cross-sectional study SETTING: Two large academic medical centers and affiliated community primary care and specialty practices. PARTICIPANTS: A total of 56,845 patients in the Partners HealthCare System CKD registry in June 2019, among whom 2225 (3.9%) were African-American. MEASUREMENTS: Exposures included race, age, sex, comorbidities, and eGFR. Outcomes were transplant referral and dialysis access placement. RESULTS: Of 2225 African-American patients, 743 (33.4%) would hypothetically be reclassified to a more severe CKD stage if the race multiplier were removed from the CKD-EPI equation. Similarly, 167 of 687 (24.3%) would be reclassified from stage 3B to stage 4. Finally, 64 of 2069 patients (3.1%) would be reassigned from eGFR > 20 ml/min/1.73 m2 to eGFR ≤ 20 ml/min/1.73 m2, meeting the criterion for accumulating kidney transplant priority. Zero of 64 African-American patients with an eGFR ≤ 20 ml/min/1.73 m2 after the race multiplier was removed were referred, evaluated, or waitlisted for kidney transplant, compared to 19.2% of African-American patients with eGFR ≤ 20 ml/min/1.73 m2 with the default CKD-EPI equation. LIMITATIONS: Single healthcare system in the Northeastern United States and relatively small African-American patient cohort may limit generalizability. CONCLUSIONS: Our study reveals a meaningful impact of race-adjusted eGFR on the care provided to the African-American CKD patient population.

Utilization of radiation therapy in multiple myeloma: trends and changes in practice.

Plasma cell disorders including plasmacytomas and multiple myeloma (MM) are exquisitely radiosensitive, and thus, radiation therapy (XRT) is used effectively in their management. The role of XRT in the setting of novel MM therapeutics has not been explored. The 2016 National Cancer Database (NCDB) for MM with patients diagnosed between 2004 and 2013 was studied. Association between utilization of XRT as part of initial therapy and patient, disease, or treating facility characteristics was studied. A total of 111,281 cases with 91.6% MM, 7% osseous plasmacytoma (PLA-O), and 1.4% extramedullary plasmacytoma (PLA-E) were identified. XRT was utilized as part of initial therapy in 25.4% cases, including 69.3% of PLA-O, 60% of PLA-E, and 21.5% of MM patients. Patients with PLA-E and MM were significantly less likely to receive XRT as compared to PLA-O (p < 0.001). A significantly decreased use of XRT was noted over time (p < 0.001), and for advancing patient age (p < 0.001), women (p < 0.001), and blacks (p < 0.001), and with increasing income (p = 0.015). Patients with Medicare were less likely to receive XRT (OR 0.86, 95% CI 0.78, 0.94) as compared to uninsured as were those with initial treatment at academic or high-volume facilities and facilities performing stem cell transplant. There was overall decreased utilization of XRT in recent years, possibly due to advent of efficacious systemic agents for MM therapy, with a higher XRT utilization for plasmacytomas. Patterns of XRT use need to be explored prospectively, so that uniform standards of healthcare delivery can be maintained and treatment heterogeneity can be minimized.

Acute kidney injury in renal transplant recipients undergoing cardiac surgery.

BACKGROUND: Acute kidney injury (AKI) is a key risk factor for chronic kidney disease in the general population, but has not been investigated in detail among renal transplant recipients (RTRs). We investigated the incidence, severity and risk factors for AKI following cardiac surgery among RTRs compared with non-RTRs with otherwise similar clinical characteristics. METHODS: We conducted a retrospective cohort study of RTRs (n = 83) and non-RTRs (n = 83) who underwent cardiac surgery at two major academic medical centers. Non-RTRs were matched 1:1 to RTRs by age, preoperative (preop) estimated glomerular filtration rate and type of cardiac surgery. We defined AKI according to Kidney Disease: Improving Global Outcomes criteria. RESULTS: RTRs had a higher rate of AKI following cardiac surgery compared with non-RTRs [46% versus 28%; adjusted odds ratio 2.77 (95% confidence interval 1.36-5.64)]. Among RTRs, deceased donor (DD) versus living donor (LD) status, as well as higher versus lower preop calcineurin inhibitor (CNI) trough levels, were associated with higher rates of AKI (57% versus 33% among DD-RTRs versus LD-RTRs; P = 0.047; 73% versus 36% among RTRs with higher versus lower CNI trough levels, P = 0.02). The combination of both risk factors (DD status and higher CNI trough level) had an additive effect (88% AKI incidence among patients with both risk factors versus 25% incidence among RTRs with neither risk factor, P = 0.004). CONCLUSIONS: RTRs have a higher risk of AKI following cardiac surgery compared with non-RTRs with otherwise similar characteristics. Among RTRs, DD-RTRs and those with higher preop CNI trough levels are at the highest risk.

Utility, Appropriateness, and Content of Electronic Consultations Across Medical Subspecialties.

BACKGROUND: Electronic consultations (e-consults) can facilitate patient access to specialists, minimize travel, and reduce unnecessary in-person visits. However, metrics to enable study of e-consults and their effect on processes and patient care are lacking. OBJECTIVE: To assess novel metrics of e-consult appropriateness and utility. DESIGN: Retrospective cohort study. SETTING: Primary and specialty care practices at 2 large academic and 2 community hospitals of an integrated health system. PARTICIPANTS: Patients with e-consult requests to 5 specialties-hematology, infectious disease, dermatology, rheumatology, and psychiatry-between October 2017 and November 2018. MEASUREMENTS: The appropriateness of e-consult inquiries was assessed by review of medical records and defined as meeting the following 4 criteria: not answerable by reviewing evidence-based summary sources ("point-of-care resource test"), not merely requesting logistic information, having appropriate clinical urgency, and having appropriate patient complexity. Interrater agreement in assessments of e-consult appropriateness was assessed by the κ statistic. Utility of e-consults was assessed by the rate of avoided visits (AVs), defined by the absence of an in-person visit to the same specialty within 120 days. RESULTS: Overall, 6512 eligible e-consults were made by 1096 referring providers to 121 specialist consultants. Inquiries were characterized as diagnostic, therapeutic, for provider education, or at the request of the patient. Most consultations were answered within 1 day, with variation across specialties (73.1% for psychiatry to 87.8% for infectious disease). Overall, 70.2% of e-consults met all 4 criteria for appropriateness; the frequency of unmet criteria varied among specialties. Raters agreed on the appropriateness of 94% of e-consults (κ = 0.57 [95% CI, 0.36 to 0.79]), indicating moderate agreement. The overall rate of AVs across the 5 specialties was 81.2%; the highest rate was in psychiatry (92.6%) and the lowest in dermatology (61.9%). LIMITATION: Generalizability is unknown outside a single integrated health system, where requesting and consulting providers share a common electronic health record. CONCLUSION: Novel metrics to assess the appropriateness and utility of e-consults provide meaningful insight into practice, provide a rubric for comparison in future studies in additional settings, and suggest areas to improve resource use and patient care. PRIMARY FUNDING SOURCE: None.

Frequency and impact of slow flow / no flow in primary percutaneous coronary intervention.

OBJECTIVE: To determine the frequency of slow/no flow in primary percutaneous coronary intervention, to know the clinical and angiographical predictors of the phenomenon, and to investigate the immediate impact of slow/no flow on haemodnamics. METHOD: The cross-sectional study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from June 2018 to July 2019, and comprised patients presenting with ST elevation myocardial infarction who underwent primary percutaneous coronary intervention. Demographic and clinical details of the patients were recorded. The antegrade flow was assessed and determined using the thrombolysis in myocardial infarction criterion. Patients were assessed for the occurrence, predictors and impact of slow/no flow. Data was analysed using SPSS 21. RESULTS: Of the 559 patients, 441(78.9%) were males. The overall mean age of the sample was 55.86±11.07 years. Angiographical slow/no flow during the procedure occurred in 53 (9.5%) patients, while normal flow was achieved in 506(90.5%). The thrombolysis in myocardial infarction grade in the affected patients was 0 in 10(1.8%), 1 in 15(2.7%), and 2 in 28(5%) patients. Smoking status, prior myocardial infarction, prior heart failure, no history of pre-infarct angina, cerebrovascular disease, New York Heart Association class III or IV, Killip class III or IV, and lower ejection fraction were significant predictors of slow/no flow (p<0.05). The angiographical and procedural predictors were total occlusion of culprit vessel and high thrombus burden (p<0.05). Direct stenting and use of bare metal stents had significantly less chance of developing slow/no flow (p<0.05). The most common immediate impact was hypotension 26(49.1%) and bradyarrhythmia 5(9.4%). However, 2(3.8%) patients developed haemodnamically unstable ventricular tachycardia that resulted in mortality. CONCLUSIONS: Predictors on the basis of history and angiographical features can be taken into account to anticipate the occurrence of slow/no flow phenomenon.