In Silico Screening of Chlorogenic Acids from Plant Sources against Human Translocase-I to Identify Competitive Inhibitors to Treat Diabetes.

Chlorogenic acids (CHLs) are known to competitively bind to translocase-I (T1) of the glucose-6-phosphatase (G6 Pase) system, thereby inhibiting the transport of glucose-6-phosphate (G6P). This competitive binding results in a consequential reduction in blood sugar levels. In this study, steered molecular dynamics (SMD) simulation is employed to investigate the interaction between T1 and G6P, aiming to gain insights into the binding dynamics and diffusion process of G6P through T1. A database comprising 41 CHLs sourced from various plants was developed, subjected to minimization, and screened against T1 through conventional docking methods. The docked conformations were fed into a newly developed customized scoring method incorporating contact-based weights to assess the binding affinities that systematically rank and identify the most effective competitive inhibitors. Among the screened CHLs, 1-methoxy 3,5-dicaffeoylquinic acid, 3,4 dicaffeoyl quinic acid, and 3,4,5-tricaffeoylquinic acid stood out as the top three inhibitors, showcasing crucial atomic interactions with key residues within the binding pocket of T1, and these CHLs are sourced from readily available plants, diminishing reliance on coffee as the predominant CHL source. Along with the devised scoring function, which serves as a valuable tool for virtual screening and lead optimization in drug development, this study also marks a pioneering effort as it involves the modeling of the human translocase and unravels the mechanism of binding and diffusion of G6P within human T1, providing valuable insights into the structural prerequisites for successfully inhibiting the G6P system, laying the foundation for a rational approach to drug design. This research contributes to the progress of drug discovery strategies focused on the G6P system, presenting potential therapeutic avenues for addressing metabolic disorders linked to an impaired glucose metabolism.

Enhancing early functional independence following cardiac surgery: a quality improvement programme.

Early mobility and activity programmes following cardiac surgery are vital for improved patient outcomes, as they accelerate the recovery of functional capacity and walking distance. We observed that only 5.3% of our patients achieved a Functional Independence Measurement (FIM) score of 80% or more by the third postoperative day (POD). Additionally, the average 6-minute walk distance achieved by the fourth POD was only 188 m. Therefore, a quality improvement (QI) project was implemented with the aim of attaining a FIM score of 80% by the third POD for more than 80% of patient underwent/undergoing cardiac surgery without complications.A model-for-improvement framework was used to drive continuous improvement. This project was implemented in February 2021. Baseline data were prospectively collected between November 2020 and January 2021 (preintervention). Outcomes were analysed using standard control chart rules to detect changes over time. Unpaired Student t-tests assessed significant differences in mean levels between two groups, (preintervention vs postintervention).χ2 tests were conducted between the two groups according to gender and patient satisfaction scores.The percentage of patients who achieved a FIM score of 80% or more by the third POD gradually increased to 91.4% 5 months following programme implementation and was sustained thereafter. The mean patient FIM score significantly improved to 81.20±3.77 (p<0.001) by the third POD. Similarly, the mean 6-minute walk distance increased to 267.90±36.10 m (p<0.001) by the fourth POD. The percentage of patients who displayed the level of confidence needed to carry out activities of daily living (ADL) and exercises independently at home increased to 89.4% (p<0.001) by the fifth POD. No adverse events associated with the mobility and activity programme were reported.This QI project demonstrated a substantial improvement in patient functional independence, walking distance and the level of confidence needed to independently carry out ADL and exercises following cardiac surgery.

Surveillance of central line associated bloodstream infection (CLABSI) - comparison of current (CDC/NHSN) and modified criteria: A prospective study.

Background and Aims: There is a huge load of central line-associated bloodstream infection (CLABSI) being reported in developing countries, with increased mortality and healthcare costs. Effective surveillance is a must to reduce the incidence of CLABSI. The current criteria (Centre for Disease Control and Prevention/National Healthcare Safety Network [CDC/NHSN]) for CLABSI surveillance have their own shortcomings. For diagnosing CLABSI, current CDC/NHSN CLABSI surveillance criteria are laborious and time consuming with low predictive power. Hence, modified criteria have been postulated, which are simple and implementable at resource-constrained setups. The primary objective was to compare modified criteria with CDC criteria. The secondary objective was to determine the prevalence of CRBSI. Material and Methods: A total of 98 patients with central line in situ or having the central venous line removed ≤24 hrs prior to the date of the event were enrolled. Paired blood cultures were obtained and results were analyzed using differential time to positivity. Results: The incidence of CLBSI was 8.16% and the device utilization rate was 11.6%. The negative predictive value of both the surveillance criteria was found to be excellent and comparable (96.2% for modified criteria and 97.1% for CDC criteria), therefore both can be used for screening purposes. AUC for current CDC/NHSN criteria was better than modified criteria (0.76 versus 0.66, P < 0.0001), suggesting it to be a better criterion for surveillance of CLABSI. Conclusion: Modified criteria were not superior to CDC/NHSN criteria for surveillance. Thus, there is a scope of improving the modified criteria for the purpose of surveillance. CLBSI load was higher; CLABSI bundle for prevention is thus highly recommended.

Study of the Role of Cerebrospinal Fluid C-reactive Protein and Adenosine Deaminase to differentiate Various Types of Meningitis.

OBJECTIVE: (1) To study cerebrospinal fluid (CSF) adenosine deaminase (ADA) and CSF C-reactive protein (CRP) levels in the differentiation of viral, pyogenic, and tuberculous meningitis (TBM). (2) To estimate the borderline levels of CRP in CSF in viral, pyogenic, and TBM. METHODS: A prospective and cross-sectional study was conducted at the Department of Medicine, SRN Hospital, Prayagraj, Uttar Pradesh, India, between August 2016 and September 2018. In this study, a total of 100 patients with meningitis were included applying specific inclusion and exclusion criteria after proper ethical approval. RESULTS: Out of 100 patients, 61 were TBM, 31 were pyogenic meningitis, and eight were viral meningitis (VM). CSF CRP level was significantly increased in pyogenic meningitis (1.05 ± 0.36 mg/dL) compared to nonpyogenic meningitis [TBM (0.42 ± 0.13 mg/dL) and VM (0.37 ± 0.09 mg/dL)]. At the cut-off level of CRP in CSF > 0.6 mg/dL, its diagnostic sensitivity in pyogenic meningitis was 93.55% and specificity 94.20%. While CSF ADA levels were higher in the TBM group (13.32 ± 3.21 U/L) compared to the other two groups [pyogenic meningitis (6.15 ± 1.27 U/L) and VM (4.86 ± 0.88 U/L)]. At a cut-off, CSF ADA level of >10 U/L, its diagnostic sensitivity for TBM was 91.67% and specificity 90%. CONCLUSION: Cerebrospinal fluid (CSF) CRP levels were found to be raised in pyogenic meningitis, and CSF ADA was found to be elevated in TBM. While both ADA level and CRP level in CSF are found low in VM.

Developing and delivering a hybrid Cardiac Rehabilitation Phase II exercise program during the COVID-19 pandemic: a quality improvement program.

The COVID-19 pandemic resulted in the cessation of approximately 75% of cardiac rehabilitation (CR) programmes worldwide. In March 2020, CR phase II (CRP2) services were stopped in Qatar. Multiple studies had shown safety, effectiveness, reduced cost of delivery and improved participation with hybrid CR. A multidisciplinary team reviewed various alternative models for delivery and decided to implement a hybrid CRP2 exercise programme (HCRP2-EP) to ensure continuation of our patient care. Our aim was to enrol in the HCRP2-EP 70% of all eligible patients by 30 September 2020. Institute for Health Care Improvement's collaborative model was adopted. Multiple plan-do-study-act cycles were used to test change ideas. The outcomes of the project were analysed using standard run chart rules to detect the changes in outcomes over time. This project was implemented from March 2020, and the male patients enrolled between August 2020 and April 2021, with sustained monthly median enrolment above target of 70% throughout. As for our secondary outcome, 75.8% of the male patients who completed HCRP2-EP showed a meaningful change in peak exercise capacity of ≥10% (mean change 17%±6%). There were no major adverse events reported, and the median Patient Satisfaction Score was 96% well above the institutional target of 90%. This shows a well-designed quality improvement programme is an appropriate strategy for implementing HCRP2-EP in a clinical setting, and HCRP2-EP is a feasible, effective and safe intervention in eligible male patients with cardiovascular disease.

Reducing catheter-associated urinary tract infections in the cardiac intensive care unit with a coordinated strategy and nursing staff empowerment.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. The use of urinary catheters is associated with several complications and increased mortality and morbidity. At the coronary intensive care unit (CICU) of a tertiary cardiac care facility, the CAUTI rate was 7.6/1000 catheter days in January 2017. In collaboration with the Institute for Healthcare Improvement, we implemented evidence-based practices in the form of bundles based on the value improvement methodology to eliminate CAUTIs in the CICU. METHODS: This initiative aimed to reduce the CAUTI rate using a multifaceted approach. The key interventions were empowering front-line nurses for automatic stop orders and ensuring compliance to the catheter insertion and maintenance bundles. We used a model for improvement and tested the changes using small plan-do-study-act cycles. Surveillance methods and CAUTI definitions proposed by the National Healthcare Safety Network were used to monitor the outcomes. Monthly rates of CAUTIs 24 months before the intervention were compared with those 44 months after the intervention using an independent t-test. Statistical significance was set at p<0.05. RESULTS: The rate of CAUTIs dropped from 7.6 per 1000 catheter days in January 2017 to 0 from October 2021 to August 2022. The unit had achieved 280 calendar days free of CAUTI untill August 2022. CONCLUSIONS: Behavioural changes, including empowerment of nurses and adherence to all elements of the care bundle, led to significant and sustained improvement in reducing the CAUTI rate in the adult CICU.

A MEMS-enabled portable gas chromatography injection system for trace analysis.

Growing concerns about environmental conditions, public health, and disease diagnostics have led to the rapid development of portable sampling techniques to characterize trace-level volatile organic compounds (VOCs) from various sources. A MEMS-based micropreconcentrator (µPC) is one such approach that drastically reduces the size, weight, and power constraints offering greater sampling flexibility in many applications. However, the adoption of µPCs on a commercial scale is hindered by a lack of thermal desorption units (TDUs) that easily integrate µPCs with gas chromatography (GC) systems equipped with a flame ionization detector (FID) or a mass spectrometer (MS). Here, we report a highly versatile µPC-based, single-stage autosampler-injection unit for traditional, portable, and micro-GCs. The system uses µPCs packaged in 3D-printed swappable cartridges and is based on a highly modular interfacing architecture that allows easy-to-remove, gas-tight fluidic, and detachable electrical connections (FEMI). This study describes the FEMI architecture and demonstrates the FEMI-Autosampler (FEMI-AS) prototype (9.5 cm × 10 cm x 20 cm, ≈500 gms). The system was integrated with GC-FID, and the performance was investigated using synthetic gas samples and ambient air. The results were contrasted with the sorbent tube sampling technique using TD-GC-MS. FEMI-AS could generate sharp injection plugs (≈240 ms) and detect analytes with concentrations <15 ppb within 20 s and <100 ppt within 20 min of sampling time. With more than 30 detected trace-level compounds from ambient air, the demonstrated FEMI-AS, and the FEMI architecture significantly accelerate the adoption of µPCs on a broader scale.

Association of Serum Ferritin, Folate, Vitamin B12 with Thyroid Hormone Levels in Patients with Thyroid Disorders.

INTRODUCTION: Anemia frequently occurs during course of clinical thyroid diseases. Without proper diagnosis & effective treatment of underlying thyroid disease, it is often difficult to achieve complete correction of anemia. AIM: The present study was conducted to assess prevalence & types of anaemia in patients with thyroid disorders. MATERIALS: A cross sectional study was conducted on 160 patients including both hypothyroid & hyperthyroid patients at OPD/IPD in SRN Hospital affiliated to MLN Medical college Prayagraj between July 2021 & August 2022. Blood samples were taken to estimate CBC, GBP with Retic count, S. ferritin, S. folate, S. Vitamin B12, Thyroid profile. Data was entered in MS Excel Spreadsheet & appropriate statistical package applied. RESULT: Out of 144 hypothyroid patients, 102 (70.83%) were found to be anaemic & out of 16 hyperthyroid patients, 6 (37.5%) were found to be anaemic. In 102 anaemic hypothyroid patients, 56 (54.9%)had normocytic normochromic, 25 (24.5%) had microcytic and 21 (20.5%) had macrocytic anaemia. In 6 anaemic hyperthyroid patients, 3 (50%) had normocytic normochromic, 2(33.33%) had microcytic and 1 (16.67%) had macrocytic anaemia. CONCLUSION: High prevalence of anaemia was found in patients with thyroid disorders. Anaemia is an uncommon finding in hyperthyroidism but when present may be similar to that present in hypothyroidism. The most common type of anaemia in both hyperthyroidism & hypothyroidism was found to be normocytic normochromic, followed by microcytic & least common being macrocytic. References Suhail N, Abu Alsel BT, Batool S. Prevalence and association of thyroid dysfunction with anemia/body iron status among northern border Saudi population. Int J Med Res Health Sci 2020;9(3):1-7. Peraka SA, Karre S, Ravuri S, et al., To evaluate prevalence of anemia in hypothyroid patients. J Diagn Pathol Oncol 2019;4(2):110-113.

An Observational Study of Genetic Diversity of HIV-1 vpu in Rapid Progressors in India.

BACKGROUND: The genetic diversity in HIV-1 genes affects viral pathogenesis in HIV-1 positive patients. Accessory genes of HIV-1, including vpu, are reported to play a critical role in HIV pathogenesis and disease progression. Vpu has a crucial role in CD4 degradation and virus release. The sequence heterogeneity in the vpu gene may affect disease progression in patients, therefore, the current study was undertaken to identify the role of vpu in patients defined as rapid progressors. OBJECTIVE: The objective of the study was to identify the viral determinants present on vpu that may be important in disease progression in rapid progressors. METHODS: Blood samples were collected from 13 rapid progressors. DNA was isolated from PBMCs and vpu was amplified using nested PCR. Both strands of the gene were sequenced using an automated DNA Sequencer. The characterization and analysis of vpu was done using various bioinformatics tools. RESULTS: The analysis revealed that all sequences had intact ORF and sequence heterogeneity was present across all sequences and distributed all over the gene. The synonymous substitutions, however, were higher than nonsynonymous substitutions. The phylogenetic tree analysis showed an evolutionary relationship with previously published Indian subtype C sequences. Comparatively, the cytoplasmic tail(77 - 86) showed the highest degree of variability in these sequences as determined by Entropy- one tool. CONCLUSION: The study showed that due to the robust nature of the protein, the biological activity of the protein was intact and sequence heterogeneity may promote disease progression in the study population.

Vitamin B12 deficiency in northern India tertiary care: Prevalence, risk factors and clinical characteristics.

Background: Vitamin B12 deficiency leads to a diversity of symptoms and affects many systems. It is often overlooked or sometimes even misdiagnosed in clinical practice. Aims and Objectives: The purposes of this study were to report the prevalence of vitamin B12 deficiency, the spectrum of clinical features and to draw attention to the possibility of rare hidden characteristics. Materials and Methods: This study was a multicenter, retrospective, and prospective conducted at a tertiary care teaching hospital and multispecialty hospital. All cases of vitamin B12 deficiency of either sex or age attending the Medicine Department were enrolled in this study from Aug 2015 to Dec 2020. Parenteral vitamin B12 was given, and cases were evaluated for the response on follow-up for more than three months. Results: Of 220 cases, 52.27% were males. Maximum cases were reported from the age group 50 to 65 years (27.27%) and belonged to urban areas (59.1%). The majority were strict vegetarian (86.36%). Among comorbidities, diabetes (20.91%) followed by malabsorption (10.45%) were most common. The cutaneous manifestations were revealed at 38.18%. The most frequent neurological manifestation was paraesthesia (98.18%). Head heaviness/ache was the most frequent (95%) psychiatric manifestation. Anemia was revealed in 87.73% of cases with 88.64% macrocytosis. Axonal sensorimotor (52.63%) neuropathy was a prevalent finding of NCV study. Conclusions: A high index of clinical suspicion is needed in cases with vague manifestations, especially in the pure vegetarian population. Early recognition can prevent further damage as most of its related disorders are generally reversible with treatment.

Assessment of Delirium as an Independent Predictor of Outcome among Critically Ill Patients in Intensive Care Unit: A Prospective Study.

Background: Delirium is frequently observed among critically ill patients in the intensive care unit. Although a preventable and reversible process, it is associated with greater morbidity and mortality. Early recognition and interpreting the predisposing and precipitating risk factors for delirium can improve outcomes among these patients. Objective: A prospective observational study was conducted with the primary objective to evaluate the incidence of delirium in a mixed adult intensive care unit. The secondary objectives were the evaluation of risk factors and outcomes of delirium. Methods: All patients who were more than 18 years of age and with an ICU stay of more than 24 hours were included in the study. Patients with prior history of neurological disorders, psychosis, and who were deaf were excluded. Eligible patients were evaluated by the residents to detect delirium using confusion assessment method for the intensive care unit (CAM-ICU) as a tool. Results: A total of 110 patients were included, and delirium was detected in 41 patients (37.3%). Among the predisposing risk factors, only hypertension was significantly associated with delirium. Among precipitating factors, mechanical ventilation, use of physical restraints and presence of window/natural light exposure, high Acute Physiology and Chronic Health Evaluation II scores, use of opioids, and benzodiazepines were associated with delirium. In multivariate risk regression analysis, presence of window/natural light exposure [odds ratio (OR), 55.52; 95% CI (8.887-346.904)]; (p <0.001) and duration of stay in ICU OR (1.145); 95% CI (1.058-1.238) (p = 0.001) were independent risk factors of delirium. Also, high mortality (53.7%) was observed among the delirious group of patients. Conclusion: Delirium is a common problem in the ICU and is associated with poor outcomes. Various risk factors are linked to ICU environment. How to cite this article: Junior MM, Kumar A, Kumar P, Gupta P. Assessment of Delirium as an Independent Predictor of Outcome among Critically Ill Patients in Intensive Care Unit: A Prospective Study. Indian J Crit Care Med 2022;26(6):676-681.

Colistin-induced Bartter-like Syndrome: Ponder before Treatment!

Bartter-like syndrome (BLS) is a constellation of biochemical abnormalities which include metabolic alkalosis, hypokalemia, hypocalcemia, hypomagnesemia with normal kidney function. BLS is a very rare syndrome and can be induced by certain diseases, antibiotics, diuretics, and antineoplastic drugs. Colistin is a polymicrobial bactericidal drug and currently re-emerged as the only salvation therapy against multidrug resistant bacilli especially in critically ill patients at intensive care units. Only an anecdotal case report of colistin-induced Bartter-like syndrome has been reported. We here report a case series of four critically ill patients who were on treatment with colistin and presented with serious metabolic disturbances. How to cite this article: Kumari A, Gupta P, Verma H, Kumar A, Thakur P, Sharma K. Colistin-induced Bartter-like Syndrome: Ponder before Treatment! Indian J Crit Care Med 2022;26(2):239-243.

Prognostic Role of Ngal in Critically Ill Patients.

Acute kidney injury (AKI) is a frequently encountered outcome in critically ill patients, accounting for increased mortality. Neutrophil gelatinase associated lipocalin (NGAL) has been of paramount importance as a novel biomarker of AKI. This study is an attempt to assess the use of NGAL in critically ill patients so that timely interventions can be done to reduce morbidity and mortality in such patients. MATERIAL: A prospective observational study was conducted at SRN Hospital, Prayagraj from August 1st 2020 to March 15th 2021, which included only critically ill patients with SOFA score>1 and requiring ICU admission. Patients of known renal diseases were excluded from the study. Blood as well as urinary samples for NGAL and other laboratory parameters were collected within 8 hours of admission. Patients who developed renal dysfunction were noted as our cases and the others were noted as controls. OBSERVATION: The study was done on 125 patients, out of which 67 developed AKI while 58 did not develop AKI. Higher mortality was seen in patients with higher stage of AKI (P- 0.011). The cutoff of serum and urinary NGAL for predicting AKI were >42.3 ng/mL, >40.5 ng/mL respectively (P value <0.001). Hazard Ratio for all cause mortality of raised serum and urinary NGAL was 2.0062 (p value- 0.0001, 95% CI-1.0031 to 1.0092) and 2.0046 (p value-0.0035, 95% CI-1.0015 to 1.0078) respectively. Serum and urinary neutrophil gelatinase associated lipocalin at values >91 and >131 respectively were found to predict requirement of hemodialysis (p value<0.001). CONCLUSION: A single measurement of NGAL at the time of admission had good predictive ability for AKI. Higher values of NGAL were associated with staging of AKI and thus, correlated with need of hemodialysis. Furthermore, mortality was found to be associated with development of AKI and raised NGAL. Thus, NGAL maybe used to assess the prognosis of ICU patients so that patients at high risk may be managed aggressively, thus reducing mortality.

To assess the feasibility and diagnostic accuracy of preoperative ultrasound and ultrasound-guided fine needle aspiration cytology of axillary lymph nodes in patients of breast carcinoma.

Background: Metastasis of the lymph node is one of the most significant prognostic factors for breast cancer (BC). Aim: To predict positivity of the lymph node in BC patients with help of USG and USG-guided FNAC and thus to prevent unnecessary morbidity. Methods: 50 patients of incisional/true cut biopsy-proven BC patients were included. All were subjected to mammography, USG and FNAC of the lump breast. USG-guided FNAC of the axillary lymph node was done in 25 of these patients. These findings were assessed by histological examination following dissection of the axillary lymph node. Results: Axillary lymph node (ALN) metastasis was present in 42 patients on histopathology; 21 patients suspicious of malignancy on preoperative USG were confirmed by HPE. Out of 88 confirmed lymph nodes evaluated on ultrasonography, 4 were benign, 18 were indeterminate and 66 were suspicious. The most promising features were tumour length/depth ratio of <1.5 in 81, absent fatty hilum in 73% and hypoechoic cortex in 74%. Assessment of axilla with USG had a sensitivity of 50%, a specificity of 100%, a PPV of 100%, an NPV of 27.59% and a diagnostic accuracy of 58%. Preoperative USG-guided FNAC had a sensitivity of 91.67%, a specificity of 100%, a PPV of 100%, an NPV of 33.33% and a diagnostic accuracy of 92%. Conclusion: USG can detect non-palpable axillary lymph nodes and FNAC can increase the sensitivity and specificity of this technique, which makes this procedure very promising in detecting axillary metastases in BC patients.

Uncommon manifestations in tuberculosis: An expanding clinical spectrum from North India.

Background: Despite being given the best by the health department to eradicate the disease, an alarming rise of tuberculosis (TB) remains a significant public health concern in India. Recently, highly variable clinical manifestations of TB have been reported. This study highlights the unusual presentations of TB with a comprehensive overview of epidemiology, demography and risk factors in the expended clinical spectrum of TB patients and their outcomes. Methods: It is a retrospective study using the records of 503 TB patients of all age groups of either sex from July 2017 to January 2021 at two tertiary care hospitals in North India. Results: Out of 503 cases, pulmonary, extrapulmonary, and disseminated TB were 77.7%, 19.5%, and 2.8%, respectively. Among all TB cases, 36 (7.2%) had uncommon manifestations, including the most common was pyrexia of unknown origin in 12 (33.3%) cases and liver abscess in 5 (13.9%) cases, followed by pancytopenia in 4 (11.1%) cases and chyluria in 3 (8.3%) cases. Atypical skin nodules and multiple swellings were also noted in three (8.3%) cases. Male sex (58%) and rural area (66.7%) were dominant in TB with uncommon manifestation (TBU) cases. The mean age in TBU cases was 46.92 years, whereas 34.26 years in all TB cases. It was extremely significant. The statistically significant risk factors in the TBU case were low socioeconomic status (24, 66.7%), inadequate nutrition (11, 30.6%), and smoking (19, 52.8%). Conclusions: Early recognition of uncommon presentations is imperative to respond better.

Drug resistance mutations in protease gene of HIV-1 subtype C infected patient population.

Failure of antiretroviral therapy (ART) in HIV-1 infection is a critical issue for the physicians treating HIV patients. The major cause of drug failure is the development of resistance mutations in reverse transcriptase (RT) and/or protease (PR) genes. Mutations associated with drug resistance decrease drug effectiveness. This study was conducted to assess drug resistance profile of the entire PR gene in 90 HIV-1 patients consisting of 23 ART non-responsive, 32 ART responsive and 35 drug naive patients. It was observed that the majority of the sequences (94.4%) belonged to subtype C and (5.5%) to subtype A1. The ART non-responsive and responsive patients were treated with either first line of ART regimen (two NRTI and one NNRTI) or second line of ART regimen that included additional one protease inhibitor (PI). All the patients in each group except one responsive patient had various minor resistance mutations. Thus, drug failures in ART non-responsive patients may not always be due to drug resistance mutations instead other factors may also be responsible for drug failures such as non-compliance, suboptimal dose or drug interaction. The presence of minor drug resistance mutations in drug naive patients is suggestive of transmitted resistance mutations.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme.

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient's physical and psychological recovery following surgery. We observed that patients admitted to the cardiothoracic intensive care unit (CTICU) following cardiac surgery had only bed exercises and were confined to bed until the chest tubes were removed, which may have delayed patients achieving functional independence. Therefore, the CTICU team implemented a quality improvement (QI) project aimed at the early mobilisation of patients after cardiac surgery.A retrospective analysis was undertaken to define the current mobilisation practices in the CTICU. The multidisciplinary team identified various practice gaps and tested several changes that led to the implementation of a successful early mobility programme. The tests were carried out and reported using rapid cycle changes. A model for improvement methodology was used to run the project. The outcomes of the project were analysed using standard 'run chart rules' to detect changes in outcomes over time and Welch's t-test to assess the significance of these outcomes.This project was implemented in 2015. Patient compliance with early activity and mobilisation gradually reached 95% in 2016 and was sustained over the next 3 years. After the programme was implemented, the mean hours required for initiating out-of-bed-mobilisation was reduced from 22.77 hours to 11.74 hours. Similarly, functional independence measures and intensive care unit mobility scores also showed a statistically significant (p<0.005) improvement in patient transfers out of the CTICU.Implementing an early mobility programme for post-cardiac surgery patients is both safe and feasible. This QI project allowed for early activity and mobilisation, a substantial reduction in the number of hours required for initiating out-of-bed mobilisation following cardiac surgery, and facilitated the achievement of early ambulation and functional milestones in our patients.

Associations between parents' exposure to a multisectoral programme and infant and young child feeding practices in Nepal.

In Nepal, an at-scale, multisectoral programme-Suaahara (2011-2023)-aims to improve nutrition behaviours. Suaahara II (2016-2023) transitioned from a mother/child dyad focus to explicitly targeting all family members. Evidence is scant, however, regarding how exposure by men to social and behaviour change interventions relates to nutrition outcomes. This study uses a 2019 cross-sectional monitoring dataset to test associations between maternal and male household head exposure to Suaahara II interventions (interacting with a frontline worker, participating in a community event or listening to the Bhanchhin Aama radio programme) and adoption of three infant and young child feeding practices: minimum dietary diversity, minimum acceptable diet and sick child feeding, in households with a child under 2 years (n = 1827). Maternal exposure to Suaahara II had a positive association with minimum dietary diversity (OR: 1.71, 95% CI [1.27, 2.28], P < 0.001), minimum acceptable diet (OR: 1.60, 95% CI [1.19, 2.14], P = 0.002) and increased feeding to a sick child (OR: 2.11, 95% CI [1.41, 3.17], P < 0.001). Male household head exposure was only associated with increased feeding to a sick child (OR: 2.21, 95% CI [1.27, 3.84], P = 0.005). Among households with an exposed mother, having an exposed male household head nearly tripled the odds of appropriate sick child feeding (OR: 2.90, 95% CI [1.57, 5.34], P = 0.001) but was not significantly associated with the other two outcomes. These findings suggest that the relationships between exposure to nutrition programmes and outcomes are complex and further research is needed to understand variation by family member, behavioural outcome and context.