Journey of medication reconciliation compliance in a lower middle-income country: a retrospective chart review.

OBJECTIVE: There were three main objectives of the study: to determine the overall compliance of medication reconciliation over 4 years in a tertiary care hospital, to compare the medication reconciliation compliance between paper entry (initial assessment forms) and computerised physician order entry (CPOE), and to identify the discrepancies between the medication history taken by the physician at the time of admission and those collected by the pharmacist within 24 hours of admission. METHODS: This study was conducted at a tertiary care hospital in a lower middle-income country. Data were gathered from two different sources. The first source involved retrospective data obtained from the Quality and Patient Safety Department (QPSD) of the hospital, consisting of records from 8776 patients between 2018 and 2021. The second data source was also retrospective from a quality project initiated by pharmacists at the hospital. Pharmacists collected data from 1105 patients between 2020 and 2021, specifically focusing on medication history and identifying any discrepancies compared with the history documented by physicians. The collected data were then analysed using SPSS V.26. RESULTS: The QPSD noted an improvement in physician-led medication reconciliation, with a rise from 32.7% in 2018 to 69.4% in 2021 in CPOE. However, pharmacist-led medication reconciliation identified a 25.4% (n=281/1105) overall discrepancy in the medication history of patients admitted from 2020 to 2021, mainly due to incomplete medication records in the initial assessment forms and CPOE. Physicians missed critical drugs in 4.9% of records; pharmacists identified and updated them. CONCLUSION: In a lower middle-income nation where hiring pharmacists to conduct medication reconciliation would be an additional cost burden for hospitals, encouraging physicians to record medication history more precisely would be a more workable method. However, in situations where cost is not an issue, it is recommended to adopt evidence-based practices, such as integrating clinical pharmacists to lead medication reconciliation, which is the gold standard worldwide.

Association between long COVID and vaccination: A 12-month follow-up study in a low- to middle-income country.

OBJECTIVE: There is a lack of estimates regarding the at-risk population associated with long COVID in Pakistan due to the absence of prospective longitudinal studies. This study aimed to determine the prevalence of long COVID and its association with disease severity and vaccination status of the patient. DESIGN AND DATA SOURCES: This prospective cohort study was conducted at the Aga Khan University Hospital and recruited patients aged > 18 years who were admitted between February 1 and June 7, 2021. During this time, 901 individuals were admitted, after excluding patients with missing data, a total of 481 confirmed cases were enrolled. RESULTS: The mean age of the study population was 56.9±14.3 years. Among patients with known vaccination status (n = 474), 19%(n = 90) and 19.2%(n = 91) were fully and partially vaccinated, respectively. Severe/critical disease was present in 64%(n = 312). The mortality rate following discharge was 4.58%(n = 22). Around 18.9%(n = 91) of the population required readmission to the hospital, with respiratory failure (31.8%, n = 29) as the leading cause. Long COVID symptoms were present in 29.9%(n = 144), and these symptoms were more prevalent in the severe/critical (35.5%, n = 111) and unvaccinated (37.9%, n = 105) cohort. The most prominent symptoms were fatigue (26.2%, n = 126) and shortness of breath (24.1%, n = 116), followed by cough (15.2%, n = 73). Vaccinated as compared to unvaccinated patients had lower readmissions (13.8% vs. 21.51%) and post-COVID pulmonary complications (15.4% vs. 24.2%). On multivariable analysis, after adjusting for age, gender, co-morbidity, and disease severity, lack of vaccination was found to be an independent predictor of long COVID with an Odds ratio of 2.42(95% CI 1.52-3.84). Fully and partially vaccinated patients had 62% and 56% reduced risk of developing long COVID respectively. CONCLUSIONS: This study reports that the patients continued to have debilitating symptoms related to long COVID, one year after discharge, and most of its effects were observed in patients with severe/critical disease and unvaccinated patients.

Clinical Outcomes And Predictors Of Mortality In COVID-19 Patients Admitted To A High Dependency Unit In Pakistan-A Cross-Sectional Study.

Objectives: To determine the outcomes and predictors of in-hospital mortality of patients admitted to high dependency unit with coronavirus disease 2019 infection. METHODS: The retrospective study was conducted at a tertiary care hospital in Karachi, and comprised data of adult coronavirus disease 2019 patients of either gender admitted to the high dependency unit from March 1 to June 30, 2020. Outcomes were categorised as patients 'recovered without deterioration', 'deteriorated but survived', and 'deteriorated but expired'. Data was analysed using SPSS 22. RESULTS: Of the 525 patients with confirmed infection, 245(46.6%) were admitted to the high dependency unit. Leaving out 38(15.5%) cases with missing data, 207(84.5%) cases formed the study sample; 156(75.4%) males and 51(24.6%) females. The overall mean age was 56.9±14years (range: 24-86 years). The most common comorbid condition was hypertension 105(50.7%), and the most common reason for critical care was hypoxic respiratory failure 199(96.1%). Of the total, 153(74%) patients recovered, 31(15%) deteriorated, and mortality was the outcome in 23(11%). There was no significant effect of drug treatment on mortality (p>0.05). Age, multimorbidity and high D-Dimer level were significantly associated with disease progression and mortality (p<0.05). CONCLUSIONS: Mortality was high among coronavirus disease 2019 patients who were older and had multimorbidity.

Cryo-derived plants through embryogenesis showed same levels of vinblastine and vincristine (anticancer) in Catharanthus roseus and had normal genome size.

Cryopreservation of rare plant materials is an important approach for preserving germplasms and is a good added concept to tissue banking. The preservation of embryogenic cell suspensions is even more valuable as the tissues facilitate in producing millions of embryos, plantlets and generates transgenics en masse. Catharanthus roseus is a medicinally important plant that produces a variety of anticancerous phytocompounds and needs conservation of alkaloid producing cell lines. In this study, embryogenic tissue banking has been attempted in C. roseus by the two-step cryopreservation method combining cryoprotection and dehydration. Prior to plunging into liquid nitrogen (LN), the tissues were exposed to osmotic-and cryoprotective agents. Two osmotic agents (sugar and sorbitol) and three cryoprotective compounds, polyethylene glycol (PEG), dimethyl sulfoxide (DMSO) and glycerol were used at varying concentrations to protect cells from freezing damages. Both sucrose and sorbitol increased callus biomass post-cryopreservation; the influence of sucrose was however, more prominent. Embryogenic tissue treated in medium with 0.4 M sucrose for 2 days followed by 5% PEG for 2 h showed maximum viability before (83%) and after (55%) cryopreservation, high regrowth percentage (77%) and produced an average 9 cell colonies per Petri dish. Additionally, dehydration (1-5 h) was tested to reduce water content for improving viability and regrowth of cryopreserved embryogenic cells. Among the various tested cryoprotective conditions, the highest (72%) viability was observed following the combination of treatments with 0.4 M sucrose (2 days),10% PEG (2 h) and dehydration (2 h). Maximum regrowth percentage (88%) and 12 colonies/petri dish was noted in combination of 0.4 M sucrose + 5% PEG. The cryopreserved calli differentiated into somatic embryos (52.78-54.33 globular embryos/callus mass) in NAA (0.5 mg/l) and BAP (0.5-1.0 mg/l) added media. Plantlets were successfully regenerated from cryopreserved tissue and the 2C DNA was estimated through flow cytometry. The genome size of cryopreserved regenerant was 1.51 pg/2C, which is similar to field-grown Catharanthus plants. Vinblastine and vincristine levels were nearly the same in mother plant's and frozen (cryopreserved) leaf tissue. The post cryopreservation embryogenesis protocol may be used for continuous production of plants for future applications.

Gamma ray-induced tissue responses and improved secondary metabolites accumulation in Catharanthus roseus.

The present study investigated the impact of gamma ray irradiation on callus biomass growth and the yield of vincristine and vinblastine of in vitro grown tissues of Catharanthus roseus. The biochemical alteration underlying the synthesis of secondary metabolites has also been studied and a comparison of yield was prepared. The embryogenic tissues were exposed to 20, 40, 60, 80, and 100 Gy gamma ray doses and the callus biomass fresh weight, the embryogenesis (the embryo numbers, germination, plant regeneration), the alteration of protein, proline, and sugar attributes at different morphogenetic stages were monitored. The callus biomass growth was maximum (1.65 g) in 20 Gy exposed tissues and was less in 100 Gy treatment (0.33 g). The gamma-irradiated embryogenic tissues differentiated into embryos but the embryogenesis % and somatic embryo number per culture reduced with increasing doses. It was least in 80 Gy where very low numbers of embryos were formed (3.45 and 3.30 mean torpedo and cotyledonary embryo numbers per callus mass, respectively) which later germinated into plantlets. Protein, proline, sugar, and different antioxidant enzymes, i.e., superoxide dismutase (SOD), ascorbate peroxidase (APX), and catalase (CAT) activities, were investigated as the tissues were exposed to gamma ray elicitation/signaling, evoking cellular stress. Increased 80 Gy gamma dose inhibited a 42.73% decrease in protein accumulation at initiation stages of embryogenic tissue. Soluble sugar level also declined gradually being least in 80 Gy treated tissues (14.51 mg gm-1 FW) compared to control (20.2 mg gm-1 FW). Proline content, however, increased with increasing gamma doses, maximum at 80 Gy (8.28 mg gm-1 FW). The SOD, APX, and CAT activity increased linearly with enhanced level of gamma doses and maximum, i.e., 3.91 EU min-1 mg-1, 1.71 EU min-1 mg-1, and 4.89 EU min-1 mg-1, protein activity was noted for SOD, APX, and CAT, respectively, at 80 Gy gamma rays treated tissues. The quantification of vinblastine and vincristine in gamma ray elicitated tissues was made by using high-pressure thin layer chromatography (HPTLC). Somatic embryo-regenerated plant's leaves had the maximum yield of vinblastine (15.13 µgm gm-1 DW) at 40 Gy irradiation dose compared to control (13.30 µgm gm-1 DW)-the increased yield % is 13.75. The stem is also rich source producing 11.98 µgm gm-1 DW of vinblastine. Among the various developmental stages of embryos, vinblastine content was highest in germinating stage of embryos (10.14 µgm gm-1 DW) compared to other three, i.e., initiation, proliferation, and maturation embryo stages. Similarly, highest accumulation of vincristine (6.32 µg gm-1 DW) was noted at low gamma irradiation dose (20 Gy) in leaf tissues. The present study indicates that the synthesis of vinblastine and vincristine was growth- and development-specific and the lower 20-40 Gy gamma levels were more effective in enriching alkaloids while higher doses declined yield. KEY POINTS: • Vinblastine and vincristine yield was quantified in in vitro grown tissues and leaves of embryo regenerated Catharanthus roseus after gamma ray treatment. • The accumulation of vinblastine and vincristine was maximum in regenerated leaves; low doses were more efficient in improving yield. • Gamma ray irradiation impacted biochemical profiles, caused cellular stress, and perhaps responsible for improved alkaloid yield.

COVID-19 infection among vaccinated and unvaccinated: Does it make any difference?

OBJECTIVE: There is a probability that vaccination may lead to reduction in the severity and complications associated with COVID-19 infection among hospitalized patients. This study aimed to determine the characteristics, clinical profiles, and outcomes of COVID-19 infection in vaccinated and non-vaccinated patients. DESIGN AND DATA SOURCES: This prospective observational cohort study was conducted at the Aga Khan University Hospital (AKUH) and recruited COVID-19 patients admitted between June 1st and September 30th, 2021. Patients' demographics, date of admission and discharge, comorbid conditions, immunization status for COVID-19 infection, presenting complaints, lab workup and computed tomography (CT) scan findings were obtained from the medical records. The primary outcome of the study was patients' condition at discharge and the secondary outcomes included level of care, length of stay (LOS), requirement of non-invasive ventilation (NIV) and inotropic support. RESULTS: Among a cohort of 434 patients, 37.7% (n = 164), 6.6% (n = 29) and 55.5% (n = 241) were fully vaccinated, partially vaccinated, and unvaccinated, respectively. Around 3% and 42.9% of the patient required inotropic and NIV support respectively; however, there was no discernible difference between them in terms of vaccination status. In case of unvaccinated patients there were significantly increased number of critical care admissions (p-value 0.043). Unvaccinated patients had significantly higher median serum procalcitonin, ferritin, LDH and D-dimer levels. Around 5.3% (n = 23) of the patient required invasive ventilation and it was more common in unvaccinated patients (p-value 0.04). Overall, mortality rate was 12.2% (n = 53) and this was higher (16.2%, n = 39) in unvaccinated patients as compared to fully vaccinated patients (6.1%, n = 10, p-value 0.006). CONCLUSIONS: Through this preliminary data, we can conclude that patient can develop severe and critical COVID-19 infection despite being vaccinated but this proportion is low as compared to unvaccinated population. So, uninterrupted endeavors need to be done to vaccinate as many individuals as possible. Furthermore, more effective vaccinations need to be developed to lessen the high death toll of COVID-19 infection.

Comparative assessment of various cephalometric facial planes with intercanine width in orthodontic patients.

OBJECTIVE: The study was conducted to evaluate the relationship of various cephalometric skeletal patterns in the vertical and anteroposterior planes with intercanine width in untreated orthodontic patients. METHOD AND MATERIAL: This study included dental cast and cephalometric radiographs of 100 patients (69 females and 31 males) of the age range 13 to 33 years. Skeletal parameters including SNA, SNB, SNMP angles were found from lateral cephalometric radiographs. Intercanine widths including upper intercanine widths (UICW) and lower intercanine widths (LICW) were measured by a digital caliper. RESULTS: The correlation of intercanine width with SNA, SNB, and SNMP angles was analyzed by applying Pearson correlation coefficient. According to statistical analysis, the only insignificant correlation was analyzed between UICW with SNB and LICW with SN-MP. CONCLUSIONS: The overall result showed statistically significant relationship of various cephalometric skeletal patterns in the sagittal and vertical planes with intercanine width.

Hospital readmissions in Internal Medicine Specialty: Frequency, associated factors and outcomes.

OBJECTIVES: Hospital readmission has become a focus of national attention as a potential indicator of healthcare quality and has a significant financial impact on healthcare system. Limited data is available regarding readmissions to Internal Medicine specialty from our sub-continent. It is, therefore, essential to determine the frequency and factors leading to readmissions, in order to avoid preventable readmissions and improve quality of healthcare provision. METHODS: This retrospective study reviewed adult discharges from Internal Medicine specialty between October 2018 and February 2019 at Aga Khan University Hospital. Out of 1,835 discharges, 491 were randomly selected after excluding expiries. The frequency, factors and outcomes of readmission were noted. The studied outcomes included length of stay and in-hospital mortality. RESULTS: Out of 491 patients, 15.3% were readmitted within 30-days of their discharge. Most of the readmitted patients were females (56%) and elderly with a mean age 67.1±14.9 years. Majority of the patient who got readmitted had multi-morbidities (68%) and were of functional Class-II (39%).The mean length of stay for index and readmission was between 4-7days. Eighty-percent readmissions were discharged as planned, 13% on request and seven-percent left against medical advice in their index admission. The most common causes of readmission were persistence of symptoms (43%) and nosocomial infection (29%). Avoidable causes included hospital-associated pneumonia, urinary tract infections and septic shock. Mortality in readmitted patients was 12%. CONCLUSIONS: The causes of readmission is multi-factorial, including advanced age, multi-morbidities, persistence of symptoms and nosocomial infections. Early follow-ups should be advised to prevent avoidable readmissions.

The discrepancy between admission and discharge diagnoses: Underlying factors and potential clinical outcomes in a low socioeconomic country.

OBJECTIVE: The discrepancy between admission and discharge diagnosis can lead to possible adverse patient outcomes. There are gaps in integrated studies, and less is understood about its characteristics and effects. Therefore, this study was conducted to determine the frequency, characteristics, and outcomes of diagnostic discrepancies at admission and discharge. DESIGN AND DATA SOURCES: This retrospective study reviewed the admitting and discharge diagnoses of adult patients admitted at Aga Khan University Hospital (AKUH), Internal Medicine Department between October 2018 and February 2019. The frequency and outcomes of discrepancies in patient diagnoses were noted among Emergency Department (ED) physician versus admitting physician, admitting physician versus discharge physician, and ED physician versus discharge physician for the full match, partial match, and mismatch diagnoses. The studied outcomes included interdepartmental transfer, Intensive Care Unit (ICU) transfer, in-hospital mortality, readmission within 30 days, and the length of stay. For simplicity, we only analyzed the factors for the discrepancy among ED physicians and discharge physicians. RESULTS: Out of 537 admissions, there were 25.3-27.2% admissions with full match diagnoses while 18.6-19.4% and 45.3-47.9% had mismatch and partial match diagnoses respectively. The discrepancy resulted in an increased number of interdepartmental transfers (5-5.8%), ICU transfers (5.6-8.7%), in-hospital mortality (8-11%), and readmissions within 30 days in ED (14.4%-16.7%). A statistically significant difference was observed for the ward's length of stay with the most prolonged stay in partially matched diagnoses (6.3 ± 5.4 days). Among all the factors that were evaluated for the diagnostic discrepancy, older age, multi-morbidities, level of trainee clerking the patient, review by ED faculty, incomplete history, and delay in investigations at ED were associated with significant discrepant diagnoses. CONCLUSIONS: Diagnostic discrepancies are a relevant and significant healthcare problem. Fixed patient or physician characteristics do not readily predict diagnostic discrepancies. To reduce the diagnostic discrepancy, emphasis should be given to good history taking and thorough physical examination. Patients with older age and multi-morbidity should receive significant consideration.

Microbial lipase production: A deep insight into the recent advances of lipase production and purification techniques.

Importance of enzymes is ever-rising particularly microbial lipases holding great industrial worth owing to their potential to catalyze a diverse array of chemical reactions in aqueous as well as nonaqueous settings. International lipase market is anticipated to cross USD 797.7 million till 2025, rising at a 6.2% compound annual growth rate from 2017 to 2025. The recent breakthrough in the field of lipase research is the generation of new and upgraded versions of lipases via molecular strategies. For example, integration of rational enzyme design and directed enzyme evolution to attain desired properties in lipases. Normally, purification of lipase with significant purity is achieved through a multistep procedure. Such multiple step approach of lipase purification entails both conventional and novel techniques. The present review attempts to provide an overview of different aspects of lipase production including fermentation techniques, factors affecting lipase production, and purification strategies, with the aim to assist researchers to pick a suitable technique for the production and purification of lipase.

Alliin obtained from leaf extract of garlic grown under in situ conditions possess higher therapeutic potency as analyzed in alloxan-induced diabetic rats.

CONTEXT: Garlic, Allium sativum L. (Liliaceae), possesses high therapeutic and pharmacological properties. Hypoglycemic activity is attributed to alliin (S-allyl cysteine sulfoxide), the main active principle localized in garlic cloves. OBJECTIVE: To compare the production and therapeutic efficiency of alliin extracted from garlic leaves of plants grown under ex situ and in situ conditions. MATERIALS AND METHODS: Alliin content of leaves was quantified and aqueous leaf extracts (from ex situ and in situ grown plants) were given to normal and alloxan-induced diabetic rats for five weeks. RESULTS: Alliin production noted ~50% enhancement in leaves from plants grown under in situ conditions. Serum glucose, triglycerides, total lipids, total cholesterol, low-density lipoprotein (LDL)-, and very low-density lipoprotein (VLDL)-cholesterol in diabetic rats treated with alliin produced from in situ grown plants noted significant reduction of ~54%, 15%, 14%, 20%, 24%, and 15%, while 35%, 14%, 10%, 12%, 17% and 11% reduction was noted in diabetic rats treated with alliin produced from ex situ grown plants in comparison with those administered with distilled water. High-density lipoprotein (HDL)-cholesterol did not show any significant change. Leaf extract of plants lowered serum enzyme levels (alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase) toward the norm better than glibenclamide. The histopathological alteration in pancreas caused by alloxan was also reduced by leaf extract. DISCUSSION AND CONCLUSION: These findings demonstrate leaf extract obtained from plants grown under in situ condition possess higher therapeutic efficiency in comparison with leaf extract obtained from plants grown under ex situ condition. Studies suggest that environmental factors influence production of alliin and its therapeutic potential.