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Diagnosis and management of vitamin D deficiency in the Gulf Cooperative Council (GCC) countries: an expert consensus summary statement from the GCC vitamin D advisory board.
No full textOBJECTIVE
A summary of recommendations is given within the Gulf Cooperation Council (GCC) setting on the assessment and management of vitamin D deficiency in the region.
METHODS
An assembly of 11 regional experts gathered to formulate an all-inclusive approach to vitamin D deficiency within GCC.
RESULTS AND CONCLUSION
Several gaps were identified before regional guidelines could be developed. These include adequacy and standardization of vitamin D testing, frequency of repeated testing and reference ranges, distinguishing prevention from the treatment of vitamin D deficiency, quality assurance of vitamin D products sold within GCC including contents and origins of products, and cut-points for vitamin D levels in local populations. A platform is created that can be further developed for overall regional implementation
CHD Risk Minimization through Lifestyle Control: Machine Learning Gateway.
No full textStudies on the influence of a modern lifestyle in abetting Coronary Heart Diseases (CHD) have mostly focused on deterrent health factors, like smoking, alcohol intake, cheese consumption and average systolic blood pressure, largely disregarding the impact of a healthy lifestyle in mitigating CHD risk. In this study, 30+ years' World Health Organization (WHO) data have been analyzed, using a wide array of advanced Machine Learning techniques, to quantify how regulated reliance on positive health indicators, e.g. fruits/vegetables, cereals can offset CHD risk factors over a period of time. Our research ranks the impact of the negative outliers on CHD and then quantifies the impact of the positive health factors in mitigating the negative risk-factors. Our research outcomes, presented through simple mathematical equations, outline the best CHD prevention strategy using lifestyle control only. We show that a 20% increase in the intake of fruit/vegetable leads to 3-6% decrease in SBP; or, a 10% increase in cereal intake lowers SBP by 3%; a simultaneous increase of 10% in fruit-vegetable can further offset the effects of SBP by 6%. Our analysis establishes gender independence of lifestyle on CHD, refuting long held assumptions and unqualified beliefs. We show that CHD risk can be lowered with incremental changes in lifestyle and diet, e.g. fruit-vegetable intake ameliorating effects of alcohol-smoking-fatty food. Our multivariate data model also estimates functional relationships amongst lifestyle factors that can potentially redefine the diagnostics of Framingham score-based CHD-prediction
Typical and atypical carcinoid tumors of the lung: A Clinicopathological correlation OF OF 783 cases with Emphasis on histological features.
No full textWe present 783 surgical resections of typical and atypical carcinoid tumors of the lung identified in the pathology files of 20 different pathology departments. All cases were critically reviewed for clinical and pathological features and further correlated with clinical outcome. Long-term follow-up was obtained in all the patients and statistically analyzed to determine significance of the different parameters evaluated. Of the histopathological features analyzed, the presence of mitotic activity of 4 mitoses or more per 2mm, necrosis, lymphatic invasion and lymph node metastasis were identified as statistically significant. Tumors measuring 3 cm or more were also identified as statistically significant and correlate with clinical outcome. Based on our analysis, we consider that the separation of low and intermediate grade neuroendocrine neoplasms of the lung needs to be readjusted in terms of mitotic count as the risk of over grading these neoplasms exceeds 10% under the current criteria. We also consider that tumor size is an important feature to be considered in the assessment of these neoplasms and together with the histological grade of the tumor offers important features that can be correlated with clinical outcome
FibroScan-AST (FAST) score for the non-invasive identification of patients with non-alcoholic steatohepatitis with significant activity and fibrosis: a prospective derivation and global validation study.
No full textBACKGROUND
The burden of non-alcoholic fatty liver disease (NAFLD) is increasing globally, and a major priority is to identify patients with non-alcoholic steatohepatitis (NASH) who are at greater risk of progression to cirrhosis, and who will be candidates for clinical trials and emerging new pharmacotherapies. We aimed to develop a score to identify patients with NASH, elevated NAFLD activity score (NAS≥4), and advanced fibrosis (stage 2 or higher [F≥2]).
METHODS
This prospective study included a derivation cohort before validation in multiple international cohorts. The derivation cohort was a cross-sectional, multicentre study of patients aged 18 years or older, scheduled to have a liver biopsy for suspicion of NAFLD at seven tertiary care liver centres in England. This was a prespecified secondary outcome of a study for which the primary endpoints have already been reported. Liver stiffness measurement (LSM) by vibration-controlled transient elastography and controlled attenuation parameter (CAP) measured by FibroScan device were combined with aspartate aminotransferase (AST), alanine aminotransferase (ALT), or AST:ALT ratio. To identify those patients with NASH, an elevated NAS, and significant fibrosis, the best fitting multivariable logistic regression model was identified and internally validated using boot-strapping. Score calibration and discrimination performance were determined in both the derivation dataset in England, and seven independent international (France, USA, China, Malaysia, Turkey) histologically confirmed cohorts of patients with NAFLD (external validation cohorts). This study is registered with ClinicalTrials.gov, number NCT01985009.
FINDINGS
Between March 20, 2014, and Jan 17, 2017, 350 patients with suspected NAFLD attending liver clinics in England were prospectively enrolled in the derivation cohort. The most predictive model combined LSM, CAP, and AST, and was designated FAST (FibroScan-AST). Performance was satisfactory in the derivation dataset (C-statistic 0·80, 95% CI 0·76-0·85) and was well calibrated. In external validation cohorts, calibration of the score was satisfactory and discrimination was good across the full range of validation cohorts (C-statistic range 0·74-0·95, 0·85; 95% CI 0·83-0·87 in the pooled external validation patients' cohort; n=1026). Cutoff was 0·35 for sensitivity of 0·90 or greater and 0·67 for specificity of 0·90 or greater in the derivation cohort, leading to a positive predictive value (PPV) of 0·83 (84/101) and a negative predictive value (NPV) of 0·85 (93/110). In the external validation cohorts, PPV ranged from 0·33 to 0·81 and NPV from 0·73 to 1·0.
INTERPRETATION
The FAST score provides an efficient way to non-invasively identify patients at risk of progressive NASH for clinical trials or treatments when they become available, and thereby reduce unnecessary liver biopsy in patients unlikely to have significant disease.
FUNDING
Echosens and UK National Institute for Health Research
Cardiovascular Functional Reserve Before and After Kidney Transplant.
No full textImportance
Restitution of kidney function by transplant confers a survival benefit in patients with end-stage renal disease. Investigations of mechanisms involved in improved cardiovascular survival have relied heavily on static measures from echocardiography or cardiac magnetic resonance imaging and have provided conflicting results to date.
Objectives
To evaluate cardiovascular functional reserve in patients with end-stage renal disease before and after kidney transplant and to assess functional and morphologic alterations of structural-functional dynamics in this population.
Design, Setting, and Participants
This prospective, nonrandomized, single-center, 3-arm, controlled cohort study, the Cardiopulmonary Exercise Testing in Renal Failure and After Kidney Transplantation (CAPER) study, included patients with stage 5 chronic kidney disease (CKD) who underwent kidney transplant (KTR group), patients with stage 5 CKD who were wait-listed and had not undergone transplant (NTWC group), and patients with hypertension only (HTC group) seen at a single center from April 1, 2010, to January 1, 2013. Patients were followed up longitudinally for up to 1 year after kidney transplant. Clinical data collection was completed February 2014. Data analysis was performed from June 1, 2014, to March 5, 2015. Further analysis on baseline and prospective data was performed from June 1, 2017, to July 31, 2019.
Main Outcomes and Measures
Cardiovascular functional reserve was objectively quantified using state-of-the-art cardiopulmonary exercise testing in parallel with transthoracic echocardiography.
Results
Of the 253 study participants (mean [SD] age, 48.5 [12.7] years; 141 [55.7%] male), 81 were in the KTR group, 85 in the NTWC group, and 87 in the HTC group. At baseline, mean (SD) maximum oxygen consumption (V̇O2max) was significantly lower in the CKD groups (KTR, 20.7 [5.8] mL · min-1 · kg-1; NTWC, 18.9 [4.7] mL · min-1 · kg-1) compared with the HTC group (24.9 [7.1] mL · min-1 · kg-1) (P < .001). Mean (SD) cardiac left ventricular mass index was higher in patients with CKD (KTR group, 104.9 [36.1] g/m2; NTWC group, 113.8 [37.7] g/m2) compared with the HTC group (87.8 [16.9] g/m2), (P < .001). Mean (SD) left ventricular ejection fraction was significantly lower in the patients with CKD (KTR group, 60.1% [8.6%]; NTWC group, 61.4% [8.9%]) compared with the HTC group (66.1% [5.9%]) (P < .001). Kidney transplant was associated with a significant improvement in V̇O2max in the KTR group at 12 months (22.5 [6.3] mL · min-1 · kg-1; P < .001), but the value did not reach the V̇O2max in the HTC group (26.0 [7.1] mL · min-1 · kg-1) at 12 months. V̇O2max decreased in the NTWC group at 12 months compared with baseline (17.7 [4.1] mL · min-1 · kg-1, P < .001). Compared with the KTR group (63.2% [6.8%], P = .02) or the NTWC group (59.3% [7.6%], P = .003) at baseline, transplant was significantly associated with improved left ventricular ejection fraction at 12 months but not with left ventricular mass index.
Conclusions and Relevance
The findings suggest that kidney transplant is associated with improved cardiovascular functional reserve after 1 year. In addition, cardiopulmonary exercise testing was sensitive enough to detect a decline in cardiovascular functional reserve in wait-listed patients with CKD. Improved V̇O2max may in part be independent from structural alterations of the heart and depend more on ultrastructural changes after reversal of uremia
Design, implementation, and evaluation of a novel curriculum to teach transurethral resection of the prostate (TURP): a 3-year experience of urology simulation bootcamp course.
No full textOBJECTIVES
To present the three-year experience of the multi-component TURP module at Urology Simulation Bootcamp Course (USBC) and demonstrate trainee's competence progression and satisfaction.
METHODS
During the USBC, a 4-h TURP module was developed and consisted of (a) familiarisation and assembly of resectoscope instrument, (b) didactic lecture on TURP operative techniques and postoperative complications, (c) learning hands-on resection on validated simulators [Samed, GmBH, Dresden, Germany; TURP Mentor™, Simbionix, Israel], and (d) practicing clot evacuation using the Ellik bladder Evacuator. Trainee's level of instrument knowledge, operative competence, and confidence were assessed pre- and post-course. Trainee's feedback was also collected.
RESULTS
One hundred thirty trainees participated in the USBC between 2016 and 2018. Eighty-seven percent of trainees scored themselves as 1-3 (low confidence in resection) on a 5-point Likert scale. Trainees significantly improved in their ability to perform resectoscope assembly for resection, coagulation and incision by 33.6% (p < 0.001), 28.1% (p < 0.001) and 34.0% (p < 0.001), respectively. There was a significant improvement in scores in itemised technical skill on the TURP simulator following completion of the TURP module (Mean difference = 3.4 points, 95% CI 2-4, p < 0.001). Ninety-one percent of trainees agreed that the TURP module was useful for their development in urological training.
CONCLUSION
Our results demonstrated that it is feasible to develop and implement a focussed module for teaching TURP with significant improvement in learning. Trainee feedback suggests that they were highly satisfied with the teaching provided and models used. This style of training can be implemented for other common surgical procedures
Adherence with Medical Therapy for Primary Open-Angle Glaucoma in Kenya - A Pilot Study.
No full textBackground/Objectives
Adherence is a major challenge in topical glaucoma therapy, particularly in an African context. We report a pilot study assessing adherence independently for the first time in an African context.
Subjects/Methods
Participants with newly diagnosed open-angle glaucoma received a weighed bottle of Lumigan 0.01% with counselling on therapy. The bottles were returned monthly for renewal and weighed on return to estimate drops taken during the period. Data collection was for one year with a short compliance questionnaire.
Results
11 patients participated. 5 (45%) failed to complete one full year of topical therapy. The overall mean number of drops per eye per day was 1.74 (SD 0.69) for the 6 with one year of monthly returned bottles and controlled IOPs at each visit. Self-perception of compliance in these patients was good.
Conclusion
The signs of poor adherence based on both self-report (previous literature), and in this small-scale study of an objective measure suggest medication may not be the first-line treatment of choice in this environment. Our report does, however, raise the possibility that those patients who return for repeat prescriptions and review are indeed adhering to their treatment regimens
How do pharmacy students select their pre-registration training providers? A mixed methods evaluation of the national recruitment scheme in England and Wales.
No full textOBJECTIVES
A national pre-registration pharmacist recruitment scheme, which replaces the local recruitment models, was introduced in England and Wales in 2017. This study aimed to explore pharmacy students' behaviour and associated factors in their selection of pre-registration training programmes.
METHODS
A mixed-method study using (a) analysis of data from all applicants (n = 2694) of the national recruitment scheme, (b) an online survey and (c) a virtual focus group was undertaken. Survey and focus group questions were developed based on the Theoretical Domains Framework (TDF). Descriptive and inferential analysis of quantitative data was undertaken using Stata software. Qualitative data from focus groups and responses from the open-ended questions were analysed using framework technique.
KEY FINDINGS
A vast majority of applicants (n = 2182, 83.9%) selected a hospital training programme as their first ranked preference, with the rest opting for community pharmacy. Urban areas, particularly London, were most popular geographically. A total of 307 survey responses were returned. Long-term career aspirations, followed by geographical factors, were rated most highly in applicants' decision-making. Qualitative data from survey and focus group demonstrated information about programmes/employers, perceived opportunity for skills development and aspiration towards a career path as key contributory factors in their decision-making.
CONCLUSIONS
Secondary care was the most desirable destination for pharmacy students to undertake early career training. The clinical roles and career opportunities in community pharmacy needs to be promoted as there is a risk that community pharmacy training programme places may be seen as a 'left over' opportunity for less competitive candidates to uptake
Serum free light chain level at diagnosis in myeloma cast nephropathy-a multicentre study.
No full textMyeloma cast nephropathy (MCN) is a common cause of severe renal impairment in multiple myeloma (MM). The level of free light chain (FLC) that causes MCN varies substantially and there is uncertainty about the threshold level that should be used to inform clinical practice. In a multicentre cohort study of 103 patients with a diagnosis of MM and biopsy-confirmed MCN made between 2002-2014, we report prospectively measured levels of serum FLC at diagnosis obtained using a single nephelometric assay (Freelite®) and we explore the relationship between serum FLC level at diagnosis with renal outcome and patient survival. Using a landmark approach, overall survival (OS) was compared between patients who achieved independence from dialysis compared to those who remained dialysis dependent at 3-month, 6-month, 9-month, and 12-month time points. The median serum FLC level at diagnosis was 7531 mg/L (range 107-114600). Serum creatinine was 535 μmol/L (range 168-2993) and eGFR 7 ml/min/1.73 m (range 1-34). Six patients (5.8%) had an FLC level 500 mg/L should be considered the threshold level associated with the development of MCN