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The recommended daily dose of vitamin D is 2000 IU was found to be insufficient in many patients. The objective of the present study is to find whether the daily dose of vitamin D should be based on BMI. Two hundred and thirty patients with an established vitamin D deficiency (serum level of 25 Hydroxy vitamin D3 (25OHD3) of ≤20 ng/ml) and patients with BMI ≥30 kg/m2 were included in the study. Demographic data, comorbidities and BMI were recorded. Pre-treatment and post-treatment serum 25OHD3, calcium, phosphorus and parathyroid hormone (PTH) were tested at 0-, 3- and 6-month periods. Patients were treated with a standard dose of 50 000 IU of vitamin D weekly and 600/1200 mg of calcium a day. Once their level of 25OHD3 reached ≥30 ng/ml, patients were randomised into two groups. Group A received a standard recommended maintenance dose of 2000 IU daily and Group B patients received 125 IU/kg/m2 of vitamin D3. The data were entered in the database and analysed. The mean age of Group A was 50⋅74 ± 7⋅64 years compared to 52⋅32 ± 7⋅21 years in Group B. In both groups, pre-treatment vitamin D level was ≤15 ng/ml and increased to 34⋅6 ± 2⋅6 and 33⋅7 ± 2⋅4 ng/ml at the end of 3 months treatment with a dose 50 000 IU of vitamin D3 and calcium 600/1200 mg once a day for group A and group B, respectively. At 6 months, patients in Group A 25OHD3 level was 22⋅8 ± 3⋅80 and in Group B was 34⋅0 ± 1⋅85 ng/ml (P < 0⋅001). This preliminary study suggests that obese patients need higher dosage of vitamin D than the recommended dose. It is prudent that the dosage should be based on the BMI to maintain normal levels for a healthy musculoskeletal system.
The prenatal period represents a critical time for brain growth and development. These rapid neurological advances render the fetus susceptible to various influences with life-long implications for mental health. Maternal distress signals are a dominant early life influence, contributing to birth outcomes and risk for offspring psychopathology. This prospective longitudinal study evaluated the association between prenatal maternal distress and infant white matter microstructure. Participants included a racially and socioeconomically diverse sample of 85 mother–infant dyads. Prenatal distress was assessed at 17 and 29 weeks’ gestational age (GA). Infant structural data were collected via diffusion tensor imaging (DTI) at 42–45 weeks’ postconceptional age. Findings demonstrated that higher prenatal maternal distress at 29 weeks’ GA was associated with increased fractional anisotropy, b = .283, t(64) = 2.319, p = .024, and with increased axial diffusivity, b = .254, t(64) = 2.067, p = .043, within the right anterior cingulate white matter tract. No other significant associations were found with prenatal distress exposure and tract fractional anisotropy or axial diffusivity at 29 weeks’ GA, or earlier in gestation.
Cardiovascular disease (CVD) is the most common non-communicable disease occurring globally. Although previous literature has provided useful insights into the important role that diet plays in CVD prevention and treatment, understanding the causal role of diets is a difficult task considering inherent and introduced weaknesses of observational (e.g. not properly addressing confounders and mediators) and experimental research designs (e.g. not appropriate or well designed). In this narrative review, we organised current evidence linking diet, as well as conventional and emerging physiological risk factors, with CVD risk, incidence and mortality in a series of diagrams. The diagrams presented can aid causal inference studies as they provide a visual representation of the types of studies underlying the associations between potential risk markers/factors for CVD. This may facilitate the selection of variables to be considered and the creation of analytical models. Evidence depicted in the diagrams was systematically collected from studies included in the British Nutrition Task Force report on diet and CVD and database searches, including Medline and Embase. Although several markers and disorders linked to conventional and emerging risk factors for CVD were identified, the causal link between many remains unknown. There is a need to address the multifactorial nature of CVD and the complex interplay between conventional and emerging risk factors with natural and built environments, while bringing the life course into the spotlight.
Suicide is one of the leading mental health crises and takes one life every 40 seconds. Four out of every five suicides occur in low- and middle-income countries. Despite religion being a protective factor against suicide, the estimated number of suicides is rapidly increasing in Pakistan.
Our review focuses on the trends of suicide and means of self-poisoning in the past three decades, and the management of commonly used poisons.
We searched two electronic databases (PubMed and PakMediNet) for published English-language studies describing agents used for suicide in different regions of Pakistan. A total of 46 out of 85 papers (N = 54 747 cases) met our inclusion criteria.
Suicidal behaviour was more common among individuals younger than 30 years. Females comprised 60% of those who attempted suicide in our study sample, although the ratio of completed suicides favoured males. There were regional trends in the choice of agent for overdose. Organophosphate poisoning was reported across the nation, with a predominance of cases from the agricultural belt of South Punjab and interior Sindh. Aluminium phosphide (‘wheat pills’) was a preferred agent in North Punjab, whereas paraphenylenediamine (‘kala pathar’) was implicated in deaths by suicide from South Punjab. Urban areas had other means for suicide, including household chemicals, benzodiazepines, kerosene oil and rat poison.
Urgent steps are needed, including psychoeducational campaigns on mental health and suicide, staff training, medical resources for prompt treatment of self-poisoning and updated governmental policy to regulate pesticide sales.
Urban density is erroneously regarded as the main factor in the spread of COVID-19 in cities. A review of extant literature and findings from our case study of Karachi, Pakistan indicate that inequalities in income, healthcare, and living conditions play a key role in the spread of contagions along with government responsiveness to the pandemic. Moving forward, urban policies need to address these inequalities through changes in housing policies and decentralized governance systems. Cities must adapt to sustainable modes of travel, reduce digital inequalities, and encourage people friendly urban planning to become resilient in the face of pandemics.
COVID-19 has changed how urban residents relate to their cities. Urban centers have become epicenters of disease, which has raised questions about the long-term sustainability of high-density settlements and public transport usage. However, the spread of COVID-19 in cities is incorrectly attributed to urban density.
Using the case study of Karachi, Pakistan, we find that inequality of income, healthcare, and living conditions is a major contributing factor to the spread of COVID-19. Data on positive COVID-19 cases, density, and socioeconomic status were obtained at the Union Council level from administrative districts of Karachi, Pakistan between March 2020, and July 2020. Despite low population densities, low-to-middle income neighborhoods in Karachi had a higher proportion of positive cases. Further, the experience of dense cities such as Hanoi in Vietnam and New York in the US differs regarding the spread of COVID-19. Hence, the government's response to the pandemic is also a major factor in containing the outbreak.
Our findings suggest that a crisis in a city is exacerbated by its inability to take advantage of its density, inequality in the distribution of resources, lack of inclusiveness, and centralized governance mechanisms that make it difficult to respond quickly to situations. Thus, urban planning scholarship and practice should take an interdisciplinary approach to make cities equitable, inclusive, and adaptive.
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Cities in the developing world have an opportunity for more resilient renewal in the post-COVID world.
This article reports the establishment of an isolated, fully functional field intensive care unit (FICU) unit equipped with all necessary critical care facilities as a part of the national pre-emptive preparedness to treat an unexpected surge outbreak of coronavirus disease 2019 (COVID-19) patients in Bahrain. One floor of an existing car parking structure was converted into a 130-bed FICU set-up by the in-house project implementation team comprised of multidisciplinary departments. The setting was a military hospital in the Kingdom of Bahrain, and the car park was on the hospital premises. The FICU contained a 112-bed fully equipped ICU and an 18-bed step-down ICU, and was built in 7 d to cater to the intensive care of COVID-19 patients in Bahrain.
Short-term peripheral venous catheter–related bloodstream infection (PVCR-BSI) rates have not been systematically studied in resource-limited countries, and data on their incidence by number of device days are not available.
Prospective, surveillance study on PVCR-BSI conducted from September 1, 2013, to May 31, 2019, in 727 intensive care units (ICUs), by members of the International Nosocomial Infection Control Consortium (INICC), from 268 hospitals in 141 cities of 42 countries of Africa, the Americas, Eastern Mediterranean, Europe, South East Asia, and Western Pacific regions. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System.
We followed 149,609 ICU patients for 731,135 bed days and 743,508 short-term peripheral venous catheter (PVC) days. We identified 1,789 PVCR-BSIs for an overall rate of 2.41 per 1,000 PVC days. Mortality in patients with PVC but without PVCR-BSI was 6.67%, and mortality was 18% in patients with PVC and PVCR-BSI. The length of stay of patients with PVC but without PVCR-BSI was 4.83 days, and the length of stay was 9.85 days in patients with PVC and PVCR-BSI. Among these infections, the microorganism profile showed 58% gram-negative bacteria: Escherichia coli (16%), Klebsiella spp (11%), Pseudomonas aeruginosa (6%), Enterobacter spp (4%), and others (20%) including Serratia marcescens. Staphylococcus aureus were the predominant gram-positive bacteria (12%).
PVCR-BSI rates in INICC ICUs were much higher than rates published from industrialized countries. Infection prevention programs must be implemented to reduce the incidence of PVCR-BSIs in resource-limited countries.
This study provides an overview of the extent, nature and quality of reporting on mental health compared with physical health in Qatari newspapers. We analysed 1274 news reports from daily newspapers in Qatar. The majority of the articles provided general information and were either positive or neutral in tone, reporting purely on physical health matters. A small proportion made associations with violence or reported on suicide or substance use. Our results highlight the underrepresentation of mental health in Qatari newspapers. A collaboration between media and health professionals is recommended to improve reporting on mental health.
To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications.
Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit.
Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases.
In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive.
We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.
Drought stress ‘particularly at seedling stage’ causes morpho-physiological differences in wheat which are crucial for its survival and adaptability. In the present study, 209 recombinant inbred lines (RILs) from synthetic wheat (W7984)× ‘Opata’ (also known as SynOpRIL) population were investigated under well-watered and water-limited conditions to identify quantitative trait loci (QTL) for morphological traits at seedling stage. Analysis of variance revealed significant differences (P < 0.01) among RILs, and water treatments for all traits with moderate to high broad sense heritability. Pearson's coefficient of correlation revealed positive correlation among all traits except dry root weight that showed poor correlation with fresh shoot weight (FSW) under water-limited conditions. A high-density linkage map was constructed with 2639 genotyping-by-sequencing markers and covering 5047 cM with an average marker density of 2 markers/cM. Composite interval mapping identified 16 QTL distributed over nine chromosomes, of which six were identified under well-watered and 10 in water-limited conditions. These QTL explained from 4 to 59% of the phenotypic variance. Six QTL were identified on chromosome 7B; three for shoot length under water-limited conditions (QSL.nust-7B) at 64, 104 and 221 cM, two for fresh root weight (QFRW.nust-7B) at 124 and 128 cM, and one for root length (QRL.nust-7B) at 122 cM positions. QFSW.nust-7B appeared to be the most significant QTL explaining 59% of the phenotypic variance and also associated with FSW at well-watered conditions. These QTL could serve as target regions for candidate gene discovery and marker-assisted selection in wheat breeding.
Apis mellifera jemenitica, the only indigenous honey bee race of Saudi Arabia, is well adapted to the harsh local environmental conditions. A large-scale field survey was conducted to screen major Saudi Arabian beekeeping locations for infection by Paenibacillus larvae. Paenibacillus larvae is one of the major bacterial pathogens of honey bee broods and is the causative agent of American foulbrood disease. Larvae from samples suspected of infection were collected from different apiaries and homogenized in phosphate-buffered saline. Bacteria were isolated on MYPGP agar medium. Two bacterial isolates, ksuPL3 and ksuPL5 (16S rRNA GenBank accession numbers, KR780760 and KR780761, respectively), were subjected to molecular identification using P. larvae-specific primers. A BLAST sequence analysis revealed that the two isolates were P. larvae with more than 98% sequence identity. This detection of P. larvae in the indigenous honey bee is the first recorded incidence of this pathogen in Saudi Arabia. This study emphasizes the need for the relevant authorities to take immediate steps towards treating and limiting the spread of this disease throughout the country.
Patients who experience Transient Ischaemic Attack (TIA) should be assessed and treated in a specialist clinic to reduce risk of further TIA or stroke. But referrals are often delayed. We aimed to identify published studies describing pathways for emergency assessment and referral of patients with suspected TIA at first medical contact: primary care; ambulance services; and emergency department.
We conducted a scoping literature review. We searched four databases (PubMed, CINAHL, Web of Science, Scopus). We screened studies for eligibility. We extracted and analysed data to describe setting, assessment and referral processes reported in primary research on referral of suspected TIA patients directly to specialist outpatient services.
We identified eight studies in nine papers from five countries: 1/9 randomized trial; 6/9 before-and-after designs; 2/9 descriptive account. Five pathways were used by family doctors and three by Emergency Department (ED) physicians. None were used by paramedics. Clinicians identified TIA patients using a checklist incorporating the ABCD2 tool to describe risk of further stroke, online decision support tool or clinical judgement. They referred to a specialist clinic, either directly or via a telephone helpline. Anti-platelet medication was often given, usually aspirin unless contraindicated. Some patients underwent neurological and blood tests before referral and discharge. Five studies reported reduced incident of stroke at 90 days, from 6–10 percent predicted rate to 1.2-2.1 percent actual rate. Between 44 percent and 83 percent of suspected TIA cases in these studies were directly referred to stroke clinics through the pathways.
Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalization of TIA patients. No pathways for paramedic use were reported. Since many suspected TIA patients present to ambulance services, effective pre-hospital assessment and referral pathways are needed. We will use review results to develop a paramedic referral pathway to test in a feasibility trial.
Transient Ischaemic Attack (TIA) is a neurologic event with symptom resolution within 24 hours. Early specialist assessment of TIA reduces risk of stroke and death. National United Kingdom (UK) guidelines recommend patients with TIA are seen in specialist clinics within 24 hours (high risk) or seven days (low risk).
We aimed to develop a complex intervention for patients with low risk TIA presenting to the emergency ambulance service. The intervention is being tested in the TIER feasibility trial, in line with Medical Research Council (MRC) guidance on staged development and evaluation of complex interventions.
We conducted three interrelated activities to produce the TIER intervention:
• Survey of UK Ambulance Services (n = 13) to gather information about TIA pathways already in use
• Scoping review of literature describing prehospital care of patients with TIA
• Synthesis of data and definition of intervention by specialist panel of: paramedics; Emergency Department (ED) and stroke consultants; service users; ambulance service managers.
The panel used results to define the TIER intervention, to include:
1. Protocol for paramedics to assess patients presenting with TIA and identify and refer low risk patients for prompt (< 7day) specialist review at TIA clinic
2. Patient Group Directive and information pack to allow paramedic administration of aspirin to patients left at home with referral to TIA clinic
3. Referral process via ambulance control room
4. Training package for paramedics
5. Agreement with TIA clinic service provider including rapid review of referred patients
We followed MRC guidance to develop a clinical intervention for assessment and referral of low risk TIA patients attended by emergency ambulance paramedic. We are testing feasibility of implementing and evaluating this intervention in the TIER feasibility trial which may lead to fully powered multicentre randomized controlled trial (RCT) if predefined progression criteria are met.
Lladó and Moragas [‘Cycle-magic graphs’, Discrete Math.307 (2007), 2925–2933] showed the cyclic-magic and cyclic-supermagic behaviour of several classes of connected graphs. They discussed cycle-magic labellings of subdivided wheels and friendship graphs, but there are no further results on cycle-magic labellings of other families of subdivided graphs. In this paper, we find cycle-magic labellings for subdivided graphs. We show that if a graph has a cycle-(super)magic labelling, then its uniform subdivided graph also has a cycle-(super)magic labelling. We also discuss some cycle-supermagic labellings for nonuniform subdivided fans and triangular ladders.
This paper reports on the training of primary care physicians in the family medicine programme at the University of Gezira, Sudan, using the World Health Organization's Mental Health Gap Action Programme Intervention Guide (mhGAP-IG). The training had a positive impact on their knowledge of and attitudes to mental disorder. More field tests of the mhGAP-IG would be useful to make further recommendations on its cultural relevance and its adaptation for use in low- and middle-income countries. Distance supervision of training of primary care physicians by internal facilitators is seen as critical for the sustainability of the intervention.
The rapid tracing of vasculature, and quantification of visual landmarks such as those corresponding to the branching and crossover points from images is extremely useful in a variety of fields including ophthalmology, radiology, and neurobiology. A novel algorithm that enables rapid, automatic, robust, adaptive, and accurate tracing of vasculature has been developed. Given an image (Fig 1), it automatically generates a labeled graph representation of the vasculature (Fig 2), and a table listing the locations of visual landmarks such as crossover and branching points (Fig 3). For each such point, it also lists the intersection angles, and the local thickness of the intersecting vasculature segments. This data is often useful by itself. They can also be used for image registration and montage building.
This algorithm greatly improves upon previous work in several ways. First, it is fully automatic, and free of parameters that need to be adjusted carefully (just needs optional sensitivity setting).
Between February 1980 and February 1992, 28 children (17 males and 11 females) were treated for endocarditis on congenital cardiac lesions, most commonly the mitral valve (32%). Their ages ranged between four months and 14 years (mean 8.2 years). The most common infecting organism (in 25% of patients) was Staphylococcus aureus. Patients were divided into two groups. In the first, made up of eight patients, cardiac surgery was undertaken within one week of the start of antibiotic therapy. The second group of 20 patients was further divided into a group of seven patients who underwent surgery during the initial, active stage of endocarditis because of failure of medical management and a group of 13 patients who initially received antibiotic therapy alone. In this last group, three infections with the same organism recurred within two months and surgical intervention was necessary in the active phase of the recurrence. Subsequently, surgery for “healed” endocarditis was undertaken in three more patients. Mortality in the 21 patients undergoing surgery was 19%—one of eight (12.5%) in those undergoing surgery within one week of starting treatment and two of 10 in the remaining patients. Overall, three patients (15%) died from those in whom surgery was not undertaken within one week of the start of treatment. There were also fewer pre- and postoperative complications as well as a lower mortality rate in those undergoing early surgery. We conclude that early surgical intervention, in our hands, is the most appropriate management for endocarditis in congenital cardiac lesions.
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