Continued circulation of mpox: an epidemiological and phylogenetic assessment, European Region, 2023 to 2024.

During the summer of 2023, the European Region experienced a limited resurgence of mpox cases following the substantial outbreak in 2022. This increase was characterised by asynchronous and bimodal increases, with countries experiencing peaks at different times. The demographic profile of cases during the resurgence was largely consistent with those reported previously. All available sequences from the European Region belonged to clade IIb. Sustained efforts are crucial to control and eventually eliminate mpox in the European Region.

The role of digital clinical decision support tool in improving quality of intrapartum and postpartum care: experiences from two states of India.

BACKGROUND: Computerized clinical decision support (CDSS) -digital information systems designed to improve clinical decision making by providers - is a promising tool for improving quality of care. This study aims to understand the uptake of ASMAN application (defined as completeness of electronic case sheets), the role of CDSS in improving adherence to key clinical practices and delivery outcomes. METHODS: We have conducted secondary analysis of program data (government data) collected from 81 public facilities across four districts each in two sates of Madhya Pradesh and Rajasthan. The data collected between August -October 2017 (baseline) and the data collected between December 2019 - March 2020 (latest) was analysed. The data sources included: digitized labour room registers, case sheets, referral and discharge summary forms, observation checklist and complication format. Descriptive, univariate and multivariate and interrupted time series regression analyses were conducted. RESULTS: The completeness of electronic case sheets was low at postpartum period (40.5%), and in facilities with more than 300 deliveries a month (20.9%). In multivariate logistic regression analysis, the introduction of technology yielded significant improvement in adherence to key clinical practices. We have observed reduction in fresh still births rates and asphyxia, but these results were not statistically significant in interrupted time series analysis. However, our analysis showed that identification of maternal complications has increased over the period of program implementation and at the same time referral outs decreased. CONCLUSIONS: Our study indicates CDSS has a potential to improve quality of intrapartum care and delivery outcome. Future studies with rigorous study design is required to understand the impact of technology in improving quality of maternity care.

Attacks on healthcare: what information is needed to understand their impact? - a Delphi study.

The scale of attacks on healthcare in emergencies has become better understood through data collection. But less well un\derstood are the consequences of attacks. The purpose of this study was to establish what information could improve our understanding of the impacts of attacks on healthcare. Using the three-round Delphi method, we sought consensus among experts in this field of study of attacks on healthcare to answer the study question. Seventeen experts agreed to take part. The experts generated a total of 222 unique statements identifying those data and information that would improve understanding of the impacts of attacks on healthcare, of which 162 reached consensus. All statements were categorized into 12 themes, each addressing different types of impacts. This Delphi study prepares the groundwork for a research agenda to explore the impacts of attacks on healthcare. These statements will be of use to academics working to expand the evidence base of attacks on healthcare. The study revealed disagreement on how widely the World Health Organization definition of an attack on healthcare should be interpreted and therefore what constitutes an impact of an attack. This is an important finding and further work is required to establish workable definitions for data collection.

A scoping review of the wider and long-term impacts of attacks on healthcare in conflict zones.

Attacks on health care in conflict zones are widespread and show no signs of relenting. Since 2011 several organizations have systemically collected data of these attacks and revealed their scale. However, little is known of the consequences of these attacks. The purpose of this scoping review was to explore the literature on attacks on health care in conflict zones to understand what is known of the wider and long-term impacts. Using the Arksey and O'Malley framework we identified 233 articles for inclusion. Extracting descriptions of impacts, we were able to categorize this information into 15 broad themes. However, there are limitations in the data collection on impacts. Firstly it is not systemically collected after every attack or in all regions where attacks take place. Secondly, this data stops short of working down the chain of impacts to describe the full range of consequences. Lastly, the literature does not often distinguish between the impacts of attacks on health care and the impact of conflict on health. Discussion is needed as to how we define and understand attacks on health care and therefore the impacts of these attacks. Systematic methods for data collection on the impacts of attacks on healthcare are also needed to produce comprehensive data sets.

Purification and characterization of cloned alkaline protease gene of Geobacillus stearothermophilus.

Thermostable alkaline serine protease gene of Geobacillus stearothermophilus B-1172 was cloned and expressed in Escherichia coli BL21 (DE3) using pET-22b(+), as an expression vector. The growth conditions were optimized for maximal production of the protease using variable fermentation parameters, i.e., pH, temperature, and addition of an inducer. Protease, thus produced, was purified by ammonium sulfate precipitation followed by ion exchange chromatography with 13.7-fold purification, with specific activity of 97.5 U mg(-1) , and a recovery of 23.6%. Molecular weight of the purified protease, 39 kDa, was determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). The enzyme was stable at 90 °C at pH 9. The enzyme activity was steady in the presence of EDTA indicating that the protease was not a metalloprotease. No significant change in the activity of protease after addition of various metal ions further strengthened this fact. However, an addition of 1% Triton X-100 or SDS surfactants constrained the enzyme specific activity to 34 and 19%, respectively. Among organic solvents, an addition of 1-butanol (20%) augmented the enzyme activity by 29% of the original activity. With casein as a substrate, the enzyme activity under optimized conditions was found to be 73.8 U mg(-1) . The effect of protease expression on the host cells growth was also studied and found to negatively affect E. coli cells to certain extent. Catalytic domains of serine proteases from eight important thermostable organisms were analyzed through WebLogo and found to be conserved in all serine protease sequences suggesting that protease of G. stearothermophilus could be beneficially used as a biocontrol agent and in many industries including detergent industry.

Tick-borne Diseases in Sheep and Goats in Pakistan: A Systematic Review and Meta-analysis.

BACKGROUND: Ticks are blood-sucking ectoparasites and transmit various types of protozoal, bacterial, and viral diseases in a wild as well as domestic animals and humans globally. Only a few  published reports are avaliable on the prevalence of tick-borne diseases in sheep and goats in Pakistan. AIM AND OBJECTIVE: The aim of this systematic review and meta-analysis was to evaluate the prevalence (2000-2020) of tick-borne disease (theileriosis, babesiosis, Crimean-Congo hemorrhagic fever infection, and anaplasmosis) in sheep and goats in Pakistan. METHODS: A systematic review of articles published in English language (since 2000-2020) was conducted using PubMed and Google Scholar. Diagnostic methods used in the original reference articles were PCR, PCR-RLB, microscopy, and ELISA. RESULTS: The overall prevalence of theileriosis, babesiosis, anaplasmosis, and Crimean-Congo hemorrhagic fever (CCHF) infections was 15.40%, 21.18%, 26.78%, and 11.62%, respectively. The prevalence of anaplasmosis was 22.06% (90/408) in sheep, 21.11% (76/360) in goats, and 40% (120/300) in both sheep and goats with substantial differences (P < 0.001). The prevalence of babesiosis among sheep was 29.88% (104/348) with highly significant differences (P < 0.001), in goats was 29.88% (25/60) with slightly significant differences (P < 0.031%), and in both sheep and goats were 7% (21/300) with highly significant differences (P < 0.001) according to subgroup analysis. The percentage of prevalence of theileriosis was 17.70% (207/1169) in sheep with highly substantial differences (P < 0.001), 4.51% (31/687) in goats with significant differences (P < 0.133), and 25% (125/500) in both sheep and goats with a significant difference among them (P < 0.001). The prevalence of CCHF among sheep was 18.63% (149/800) and 4.63% (37/800) in goats, respectively. The widely used detection method was microscopy (45.56%) followed by ELISA (38.38%), PCR (12.56%), and PCR-RLB (3.48%) test, respectively. This is a comprehensive report on the status of tick-borne disease in sheep and goats in Pakistan. CONCLUSION: Based on our results, among tick-borne diseases anaplasmosis had the highest prevalence rate in sheep and goats. Due to its high prevalence, control measures should be taken to diagnose and prevent it.

Possible Reversible Cerebral Vasoconstriction Syndrome Associated with Eucalyptus: Case Report.

BACKGROUND: Reversible cerebral vasoconstrictive syndrome (RCVS) has characteristic clinical features, brain imaging and Angiographic features. The majority of RCVS cases are associated with the use of antidepressants, polysubstance abuse, and nasal decongestants. We here present a case that highlights the use of eucalyptus herbs as a possible precipitant factor for RCVS formation. CASE PRESENTATION: A 42-year-old woman presented to the emergency department with a tingling sensation on the right-hand side of her body and a two-week progressive throbbing severe holocranial headache radiating to the neck, with associated nausea, photophobia, and phonophobia. She denied any seizures and recent trauma or fevers. She was not taking scheduled medications, but she had used inhaling vapors obtained from boiling eucalyptus leaves to alleviate sinus congestion. Initial imaging revealed subarachnoid hemorrhage at bilateral posterior parietal convexity leading to her admission into the intensive care unit. Further work up disclosed the presence of findings consistent with RCVS. CONCLUSION: In conclusion, we hereby postulate that some herbal remedies used in alternative medicine, including eucalyptus, could play a role in causing serotonergic symptoms including dizziness, diarrhea, and cerebral vasoconstriction. Understanding that eucalyptus has the potential to contribute to RCVS due to its serotoninergic activity may be of importance in the diagnosis and management of these patients.

Factors affecting the survival following surgical treatment of chronic subdural haematoma: Single institutional experience.

BACKGROUND: Chronic subdural haematoma (CSDH) is one of the most commonly treated condition in neurosurgery. It affects elderly populations who often have significant medical co-morbidities resulting in poor prognosis. The study aimed at identifying clinical factors influencing the survival following surgical management of CSDH. METHODS: Retrospective study included 267 cases that underwent surgery for CSDH and followed over 5-year period (2010-2015); data retrieved with reference to operation details, radiology reports and discharge. Using logistic and Cox regression analysis, the patient survival data was analysed with respect to patient demographics, type of surgery, co-morbidities, anticoagulation treatment, and discharge destination. RESULTS: The overall survival in the cohort was 37.0months (IQR: 20.0-60.0). The median age of the patients was 76years (IQR: 66-82) and the median length of hospital stay was 10days (range 1-126days; IQR: 6-17days). The recurrence rate was 6.37% (n=17). Fifty-three (19.85%) patients recorded deceased on the IPM database as of October 2016 and of those 11 died in hospital. Univariate Cox-regression analysis revealed increased age (HR: 1.80; 95%CI: 1.04-3.11), length of hospital stay (HR: 2.50; 95%CI: 1.41-4.41) and number of co-morbidities (HR: 2.19; 95%CI: 1.26-3.79) were associated with poor prognosis. Glasgow coma scale (GCS) at discharge was found to be significantly associated with survival whilst anticoagulation treatment did not. Multivariate analysis confirmed similar findings significant statistically. CONCLUSION: Age at admission, median length of hospital stay, number of co-morbidities, GCS at discharge and discharge destination have been found to influence survival significant statistically.

Ventricular Tachycardia Ablation in Severe Heart Failure: An International Ventricular Tachycardia Ablation Center Collaboration Analysis.

BACKGROUND: Ventricular tachycardia (VT) radiofrequency ablation has been associated with reduced VT recurrence and mortality, although it is typically not considered among New York Heart Association class IV (NYHA IV) heart failure patients. We compared characteristics and VT radiofrequency ablation outcomes of those with and without NYHA IV in the International VT Ablation Center Collaboration. METHODS AND RESULTS: NYHA II-IV patients undergoing VT radiofrequency ablation at 12 international centers were included. Clinical variables, VT recurrence, and mortality were analyzed by NYHA IV status using Kaplan-Meier analysis and Cox proportional hazard models. There were significant differences between NYHA IV (n=111) and NYHA II and III (n=1254) patients: NYHA IV had lower left ventricular ejection fraction; more had diabetes mellitus, kidney disease, cardiac resynchronization implantable cardioverter-defibrillator, and VT storm despite greater antiarrhythmic drug use (P<0.01). NYHA IV subjects required more hemodynamic support, were inducible for more and slower VTs, and were less likely to undergo final programmed stimulation. There was no significant difference in acute complications. In-hospital deaths, recurrent VT, and 1-year mortality were higher in the NYHA IV group, in the context of greater baseline comorbidities. Importantly, NYHA IV patients without recurrent VT had similar survival compared with NYHA II and III patients with recurrent VT (68% versus 73%). Early VT recurrence (≤30 days) was significantly associated with mortality, especially in NYHA IV patients. CONCLUSIONS: Despite greater baseline comorbidities, VT radiofrequency ablation can be safely performed among NYHA IV patients. Early VT recurrence is significantly associated with subsequent mortality regardless of NYHA status. Elimination of recurrent VT in NYHA IV patients may reduce mortality to a level comparable to NYHA II and III with arrhythmia recurrence.

Lymphadenopathy in adults. A clinicopathological analysis.

OBJECTIVE: To describe the clinicopathological features of patients admitted to adult wards with a primary presenting feature of lymphadenopathy. METHODS: A retrospective study of all patients admitted to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia between April 1996 through to March 2000. RESULTS: The patients mean age was 35.2 years (standard deviation 15.7 years) and 59.5% were females while 56.2% were Saudis. Swelling was the primary presenting symptom in 39.3% of the patients, while fever, night sweats, and pain occurred in 17.3%, 10.3% and 8.5% patients. There was considerable overlap between benign and malignant causes of lymphadenopathy but in 56.6% of patients, lymphadenopathy was the only sign. The cervical group of lymph nodes was the most commonly affected site. Hepatomegaly, splenomegaly and both organ enlargement occurred in 59 (22.9%) patients. The presence of generalized lymphadenopathy and other physical signs (serositis and organomegaly) highly suggested a malignant process. Granulomatous lymphadenopathy due to tuberculosis was the most frequent pattern 98 (37.9%) followed by lymphoma 85 (32.9%). Tuberculosis was also more common in females than males (51% versus 19%). Among patients with Hodgkin's disease, nodular sclerosis was the most frequent (75%). Routine investigations did not discriminate between benign and malignant causes of lymphadenopathy. The overall mortality rate was 8.1%: with metastatic disease accounting for 52.4%. CONCLUSION: There were significant similarities and differences between these findings and other previous studies in the Kingdom of Saudi Arabia and elsewhere.

The 'swallow tail' appearance of the healthy nigrosome - a new accurate test of Parkinson's disease: a case-control and retrospective cross-sectional MRI study at 3T.

There is no well-established in vivo marker of nigral degeneration in Parkinson's disease (PD). An ideal imaging marker would directly mirror the loss of substantia nigra dopaminergic neurones, which is most prominent in sub-regions called nigrosomes. High-resolution, iron-sensitive, magnetic resonance imaging (MRI) at 7T allows direct nigrosome-1 visualisation in healthy people but not in PD. Here, we investigated the feasibility of nigrosome-1 detection using 3T - susceptibility-weighted (SWI) MRI and the diagnostic accuracy that can be achieved for diagnosing PD in a clinical population. 114 high-resolution 3T - SWI-scans were reviewed consisting of a prospective case-control study in 19 subjects (10 PD, 9 controls) and a retrospective cross-sectional study in 95 consecutive patients undergoing routine clinical SWI-scans (>50 years, 9 PD, 81 non-PD, 5 non-diagnostic studies excluded). Two raters independently classified subjects into PD and non-PD according to absence or presence of nigrosome-1, followed by consensus reading. Diagnostic accuracy was assessed against clinical diagnosis as gold standard. Absolute inter- and intra-rater agreement was ≥94% (kappa≥0.82, p<0.001). In the prospective study 8/9 control and 8/10 PD; and in the retrospective study 77/81 non-PD and all 9 PD subjects were correctly classified. Diagnostic accuracy of the retrospective cohort was: sensitivity 100%, specificity 95%, NPV 1, PPV 0.69 and accuracy 96% which dropped to 91% when including non-diagnostic scans ('intent to diagnose'). The healthy nigrosome-1 can be readily depicted on high-resolution 3T - SWI giving rise to a 'swallow tail' appearance of the dorsolateral substantia nigra, and this feature is lost in PD. Visual radiological assessment yielded a high diagnostic accuracy for PD vs. an unselected clinical control population. Assessing the substantia nigra on SWI for the typical 'swallow tail' appearance has potential to become a new and easy applicable 3T MRI diagnostic tool for nigral degeneration in PD.

Novel genes associated with colorectal cancer are revealed by high resolution cytogenetic analysis in a patient specific manner.

Genomic abnormalities leading to colorectal cancer (CRC) include somatic events causing copy number aberrations (CNAs) as well as copy neutral manifestations such as loss of heterozygosity (LOH) and uniparental disomy (UPD). We studied the causal effect of these events by analyzing high resolution cytogenetic microarray data of 15 tumor-normal paired samples. We detected 144 genes affected by CNAs. A subset of 91 genes are known to be CRC related yet high GISTIC scores indicate 24 genes on chromosomes 7, 8, 18 and 20 to be strongly relevant. Combining GISTIC ranking with functional analyses and degree of loss/gain we identify three genes in regions of significant loss (ATP8B1, NARS, and ATP5A1) and eight in regions of gain (CTCFL, SPO11, ZNF217, PLEKHA8, HOXA3, GPNMB, IGF2BP3 and PCAT1) as novel in their association with CRC. Pathway and target prediction analysis of CNA affected genes and microRNAs, respectively indicates TGF-ß signaling pathway to be involved in causing CRC. Finally, LOH and UPD collectively affected nine cancer related genes. Transcription factor binding sites on regions of >35% copy number loss/gain influenced 16 CRC genes. Our analysis shows patient specific CRC manifestations at the genomic level and that these different events affect individual CRC patients differently.

Presentation, diagnosis and outcome of predominantly hepatic Wilson's disease in adult Saudi patients: a single centre experience.

BACKGROUND/AIM: To evaluate the clinical manifestations, diagnostic features, disease course and response to treatment among Saudi adults with predominantly hepatic Wilson's disease. A retrospective cohort study of 40 adult patients diagnosed with predominantly hepatic Wilson's disease between 1994 and 2008 at King Abdulaziz Medical City, Riyadh was carried out. PATIENTS AND METHODS: The diagnosis was based on varying combinations of clinical and laboratory evidence of liver disease, presence of Kayser Fleisher rings, low serum ceruloplasmin levels, elevated 24 hour urinary copper excretion and histopathological findings on liver biopsy. RESULTS: The most frequent clinical presentation was decompensated chronic liver disease in 19 (47.5%), followed by chronic hepatitis in 15 (37.5%) and fulminant hepatic failure (FHF) in 5 (12.5%) patients. Eight (20%) patients with end-stage liver disease had liver transplantation, while 24 (60%) patients followed up on medical treatment for a variable period of 1-12 years showed clinical and laboratory improvement. One patient was lost early in follow up. Eight (20%) patients died during the study period, 5 with FHF, and 2 with advanced hepatic and neurological disease and one seven years after liver transplantation. Mortality rate was 100% in FHF without liver transplantation. CONCLUSION: A predominantly hepatic Wilson's disease has varied clinical presentations with decompensated chronic liver disease being the most common among adult patients. Majority of the patients show stabilization of the disease on medical treatment. FHF in Wilson's disease has a grave prognosis without liver transplantation, the later remains a definitive treatment option for decompensated cirrhotics and patients with FHF.

Green tea modulates reserpine toxicity in animal models.

Reserpine, a natural product extracted from Rauwolfia serpintina or Rauwolfia vomitoria, is a known dopamine depleter that inhibits several neurotransmitters. Reserpine has been used clinically to control hypertension, schizophrenia, insomnia and insanity. The use of this drug, however, has been limited because of its side effects which include oxidative damage to organs, including the liver. Green tea catechins are potent antioxidants that have the potential to counteract reserpine induced oxidative stress. This study investigated the merits of administering green tea concurrently with reserpine to prevent oxidative hepatic damage in Sprague-Dawely (SD) rats. Reserpine was found to cause hepatic damage, with elevated levels of oxidative stress markers, such as Thiobarbituric Acid Reactive Substances (TBARS), transaminases and cholesterol. Reserpine also induced hepatic ultra-structural damage in the cytoplasmic membrane, nuclear envelope, endoplasmic reticulum (rER), ribosomal stripping and mitochondria. Electron microscopy examination showed revival of liver cells as a result of green tea extract administration to experimental rats.

Documenting a transfusion: how well is it done?

BACKGROUND: Current practice in transfusion medicine promotes clear documentation of transfusion-related events including the fact that the patient has been informed of the related risks and benefits. STUDY DESIGN AND METHODS: A retrospective review of 1005 patient charts was carried out to determine documentation. RESULTS: Most patients were from general surgery (10.8%) and cardiac surgery (14.1%). In 75 percent of cases the physician had not documented that any discussion had occurred regarding the risks and/or benefits or alternatives. Only 12 percent of charts included information that the patient was subsequently told what blood components were given to them. The discharge summary recorded transfusion information in 32.1 percent of cases whereas the consult note had this information in 26.3 percent. Chart records matched the transfusion medicine records in 60.6 percent of cases. The most common error was in the blood unit identification number. CONCLUSIONS: While accepted in theory, the practice of documenting patient information on transfusion is not well done.