Doctors' adherence to guidelines recommendations and glycaemic control in diabetic patients in Quetta, Pakistan: Findings from an observational study.

Background: Poor control of diabetes mellitus (DM) is partly attributed to doctors' poor adherence to guidelines. Objective: To evaluate doctors' adherence to pharmacotherapeutic recommendations of DM management guidelines and factors associated with guidelines adherence and glycaemic control. Methods: This prospective observational study included 30 doctors who were treating DM patients in their private clinics in Quetta, Pakistan. On visit 1, a total of 600 prescriptions written by 30 enrolled doctors (20 patients per doctor) were noted along with patients' sociodemographic and clinical characteristics. American Diabetes Association guidelines was used as a reference. The prescriptions noted were judged for guidelines compliance. Of 600 enrolled patients, 450 patients (15 patients per doctor) were followed for one more visit and included in final analysis. Glycated hemoglobin (HbA1c) level noted one visit 2 was related with the respective prescription on visit 1. Data were analyzed by SPSS (version 23). A p-value <0.05 was considered statistically significant. Results: Patients received a median of two antidiabetic drugs (range: 1-5). A total of 73.1% patients were on polytherapy. Metformin was the most frequently prescribed (88.4%) antidiabetic followed by gliptins (46.2%). A total of 41.6% prescriptions were judged guidelines compliant. In multivariate binary logistic regressions (MVBLR) analysis, chronic kidney disease (CKD) (OR = 0.422) and polytherapy (OR = 0.367) had statistically significant negative associations (p-value <0.05) with guidelines' compliant prescriptions. The group of doctors comprised of specialists and consultants wrote significantly (p-value = 0.004) high number of guidelines adherent prescriptions (mean rank = 20.25) than the group comprised of medical officers (mean rank = 11.34). On visit 2, only 39.5% patients were on goal glycemic levels. In MVBLR analysis, suffering from dyslipidemia (OR = 0.134) and CKD (OR = 0.111), receiving sulfonylurea (OR = 0.156) and guidelines' compliant prescription (OR = 4.195) were significantly (p-value <0 .05) associated with glycemic control. Conclusion: Although guidelines compliant prescriptions produced better glycemic control, but doctors' adherence to guidelines and glycemic control were poor. Polytherapy and CKD emerged as risk factors for guidelines divergent prescriptions. Dyslipidemia, CKD and reception of sulfonylureas had negative association with glycemic control.

Spectrum of Microorganisms, Antibiotic Resistance Pattern, and Treatment Outcomes Among Patients With Empyema Thoracis: A Descriptive Cross-Sectional Study From the Bahawal Victoria Hospital Bahawalpur, Punjab, Pakistan.

Background: This study involves the analysis of spectrum of microorganisms, antibiotic resistance pattern, and treatment outcomes among empyema thoracis patients. This study also analyzes the factors associated with unsuccessful treatment outcome and duration of hospital stay among the patients. Methods: This was a descriptive, cross-sectional study carried out in the Pulmonology Ward of the Bahawal Victoria hospital, Bahawalpur, Pakistan. All patients with empyema thoracis registered at the study site during the period of 1 year were included in the study. Multivariate regression analysis was used to analyze the factors associated with duration of hospital stay and unsuccessful treatment outcome among the patients. Results: A total 110 patients were included in the study. Most of the patients (n = 73, 66.4%) were treated with piperacillin/tazobactam alone and in combination with either one or more than one antibiotics as an empiric therapy. Culture was positive in 58 (52.7%) patients and the most commonly identified organisms included, gram-negative Pseudomonas aeruginosa (n = 20; 18.8%) and Klebsiella sp. (n = 11, 10%) followed by same proportion of E. coli. The most commonly identified bacterial isolates showed high level of resistance against antibiotics used as an empiric therapy, while these showed low level of resistance against amoxicillin, clarithromycin, ertapenem, colistin, tigecycline, fosfomycin, rifampicin, and vancomycin. In this study, 82 (74.5%) patients successfully completed the treatment, while 12 (11%) showed no clinical improvement, 5 (4.5%) lost to follow up and 11 (10%) died. In multivariate binary logistic regression analysis, none of the patient attributes were significantly associated with unsuccessful treatment outcome, while in multivariate linear regression analysis, the factors which were significantly associated with duration of hospital stay included; duration of symptoms <2 weeks prior to admission (p = 0.008, beta = -0.247) and resistance to five antibiotic classes (p = 0.02, beta = 0.280). Conclusion: Close to 25% of the patients did not complete the treatment successfully. Most of the common bacterial isolates showed high level of resistance against the broad-spectrum antibiotics used as an empiric therapy. This is alarming. However, better sensitivity of common bacterial isolates against standardized first line treatment for empyema thoracis is promising.

Positive Selection Drives the Adaptive Evolution of Mitochondrial Antiviral Signaling (MAVS) Proteins-Mediating Innate Immunity in Mammals.

The regulated production of filamentous protein complexes is essential in many biological processes and provides a new paradigm in signal transmission. The mitochondrial antiviral signaling protein (MAVS) is a critical signaling hub in innate immunity that is activated when a receptor induces a shift in the globular caspase activation and recruitment domain of MAVS into helical superstructures (filaments). It is of interest whether adaptive evolution affects the proteins involved in innate immunity. Here, we explore and confer the role of selection and diversification on mitochondrial antiviral signaling protein in mammalian species. We obtined the MAVS proteins of mammalian species and examined their differences in evolutionary patterns. We discovered evidence for these proteins being subjected to substantial positive selection. We demonstrate that immune system proteins, particularly those encoding recognition proteins, develop under positive selection using codon-based probability methods. Positively chosen regions within recognition proteins cluster in domains involved in microorganism recognition, implying that molecular interactions between hosts and pathogens may promote adaptive evolution in the mammalian immune systems. These significant variations in MAVS development in mammalian species highlights the involvement of MAVS in innate immunity. Our findings highlight the significance of accounting for how non-synonymous alterations affect structure and function when employing sequence-level studies to determine and quantify positive selection.

COVID19 Acute respiratory distress syndrome and extra-corporeal membrane oxygenation; A mere option or ultimate necessity.

Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in patients with acute respiratory distress syndrome (ARDS) and refractory hypoxemia (hypoxemia persisting despite lung-protective ventilation). One aspect of ECMO is whether there would be an application of the technology related to the Coronavirus pandemic. The number of people diagnosed with Coronavirus disease (COVID19) has crossed the five million mark on 9 August 2020, with a case fatality rate of 5.2%. Due to this exponential increase in the number of coronavirus disease (COVID19) cases particularly the ones associated with ARDS, experts are evaluating the need for ECMO in intensive care units. Herein, we chronicle a review encompassing the available evidence on ECMO and its potential role in COVID19 ARDS, as we aim for optimal patient care with appropriate resource utilization and conservation.

What's in a Name? Factors Associated with Documentation and Evaluation of Incidental Pulmonary Nodules.

RATIONALE: Radiologist reports of pulmonary nodules discovered incidentally on computed tomographic (CT) images of the chest may influence subsequent evaluation and management. OBJECTIVES: We sought to determine the impact of the terminology used by radiologists to report incidental pulmonary nodules on subsequent documentation and evaluation of the nodules by the ordering or primary care provider. METHODS: We conducted a retrospective cohort study of patients with incidentally discovered pulmonary nodules detected on CT chest examinations performed during 2010 in a large urban safety net medical system located in northeastern Ohio. MEASUREMENTS AND MAIN RESULTS: Twelve different terms were used to describe 344 incidental pulmonary nodules. Most nodules (181 [53%]) were documented in a subsequent progress note by the provider, and 140 (41%) triggered subsequent clinical activity. In a multivariable analysis, incidental pulmonary nodules described in radiology reports using the terms density (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.01-0.47), granuloma (OR, 0.07; 95% CI, 0.01-0.65), or opacity (OR, 0.09; 95% CI, 0.01-0.68) were less likely to be documented by the provider than those that used the term mass. Patients with nodules described in radiology reports using the term nodule (OR, 0.15; 95% CI, 0.02-0.99), nodular density (OR, 0.09; 95% CI, 0.01-0.63), granuloma (OR, 0.06; 95% CI, 0.01-0.69), or opacity (OR, 0.05; 95% CI, 0.01-0.43) were less likely to receive follow-up than were patients with nodules described using the term mass. The factor most strongly associated with follow-up of pulmonary nodules was documentation by the provider (OR, 5.85; 95% CI, 2.93-11.7). CONCLUSIONS: Within one multifacility urban health system in the United States, the terms used by radiologists to describe incidental pulmonary nodules were associated with documentation of the nodule by the ordering physician and subsequent follow-up. Standard terminology should be used to describe pulmonary nodules to improve patient outcomes.

Mai infection simulating metastatic breast cancer.

We represent a case of an asymptomatic female who was found to have a mass in the right breast which confirmed an invasive ductal carcinoma by core biopsy. After 3 months of completion of chemo-radiotherapy, the patient remained totally asymptomatic. However, positron emission tomography scan showed four hypermetabolic lesions in the left lung thought to be consistent with metastatic disease. Standard uptake value ranged between 3.86 and 6; the results were consistent with metastatic breast cancer, so wedge resection was performed. Caseating granulomatous inflammation with necrosis was reported. Ultimately culture revealed Mycobacterium avium intracellulare infection. The lesions resolved completely after a course of antibiotics.