Publications by authors named "Imran Ahmed"

138 Publications

Direct maternal morbidity and the risk of pregnancy-related deaths, stillbirths, and neonatal deaths in South Asia and sub-Saharan Africa: A population-based prospective cohort study in 8 countries.

PLoS Med 2021 Jun 28;18(6):e1003644. Epub 2021 Jun 28.

London School of Hygiene & Tropical Medicine, London, United Kingdom.

Background: Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa.

Methods And Findings: This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We used standard operating procedures, data collection tools, and training to harmonise study implementation across sites. Three home visits during pregnancy and 2 home visits after birth were conducted to collect maternal morbidity information and maternal, foetal, and newborn outcomes. We measured blood pressure and proteinuria to define hypertensive disorders of pregnancy and woman's self-report to identify obstetric haemorrhage, pregnancy-related infection, and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28 weeks or those who died during pregnancy were included in the analysis. We used meta-analysis to combine site-specific estimates of burden, and regression analysis combining all data from all sites to examine associations between the maternal morbidities and adverse outcomes. Among approximately 735,000 women of reproductive age in the study population, and 133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927 pregnancies had morbidity data collected at least once in both antenatal and in postnatal period, and 114,050 of them were included in the analysis. Overall, 32.7% of included pregnancies had at least one major direct maternal morbidity; South Asia had almost double the burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia; 23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95% CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI 0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95% CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about 11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepartum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of postpartum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per 1,000 live births with variation by country and region. Direct maternal morbidities were associated with each of these outcomes.

Conclusions: Our findings imply that health programmes in sub-Saharan Africa and South Asia must intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and stillbirths.

Trial Registration: The study is not a clinical trial.
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http://dx.doi.org/10.1371/journal.pmed.1003644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277068PMC
June 2021

Clinical Utility of Protein Induced by Vitamin K Absence-II in Patients with Hepatocellular Carcinoma.

Asian Pac J Cancer Prev 2021 Jun 1;22(6):1731-1736. Epub 2021 Jun 1.

Department of Pathology, Shifa International Hospital, Islamabad Pakistan.

Objective: Despite moderate sensitivity, alpha fetoprotein (AFP) is widely used in screening and prognostication for hepatocellular carcinoma (HCC). The objective of the current study was to assess clinical utility of Prothrombin induced by Vitamin K absence-II (PIVKAII) in addition to AFP in patients with HCC.

Methods: We retrospectively reviewed 244 patients with documented AFP, PIVKA II and dynamic imaging of the liver. Using ROC curves, cutoff values for AFP and PIVKAII for HCC detection, tumor grade and microvascular invasion (MVI) were assessed. In patients who underwent liver transplantation (LT) for HCC, survival was determined using Kaplan Meier curves.

Results: The median PIVKAII in healthy living donors was 28.6mAU/ml (15.9-55). In cirrhotics, the sensitivity of an AFP cutoff of 7.6 ng/ml or PIVKAII  cutoff of 250 mAU/ml for HCC detection was 91.7% (176/192) and specificity was 62.9%(68/108) (p <0.0001). In patients with HCC, PIVKAII values were significantly elevated with tumor size > 5 cm (P < 0.0001), tumor nodules > 3(P=0.01), and macrovascular invasion(p <0.0001).  The high risk group (patients with AFP ≥ 40 ng/ml + PIVKAII ≥ 350 mAU/ml), had a sensitivity of (23/33) 69.6% and specificity of (22/22)100% for MVI (P <0.001). The estimated 3 year RFS after LT in the low risk group (AFP.
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http://dx.doi.org/10.31557/APJCP.2021.22.6.1731DOI Listing
June 2021

Effect of community-based kangaroo mother care package on neonatal mortality among preterm and low birthweight infants in rural Pakistan: Protocol for a cluster randomized controlled trial.

JMIR Res Protoc 2021 May 17. Epub 2021 May 17.

Aga Khan University, Center of Excellence in Women & Child Health, Stadium Road, Karachi, PK.

Background: Neonatal mortality, due to preterm birth and low birthweight, remains a major challenge for Pakistan. Kangaroo mother care (KMC) is a unique, low-cost intervention proven to reduce neonatal mortality and morbidity and increase exclusive breastfeeding rates. Kangaroo mother care has not been tried in community settings in Pakistan. We aim to implement and evaluate the effectiveness of community-based kangaroo mother care package to reduce neonatal morbidity and mortality among preterm/low birthweight infants. This will provide evidence for policy development and large-scale implementation of KMC across the country to reduce neonatal.

Objective: The primary objective of this trial is to reduce neonatal mortality among preterm/low birthweight infants. The secondary objectives are growth measured as weight gain, reduction in incidence of possible serious bacterial infection (PSBI), increased exclusive breastfeeding and continued breastfeeding practices.

Methods: We designed a community-based cluster randomized controlled trial in one rural district of Pakistan. Stable, low birth weight babies ≥1200-<2500 grams are included in the study. Kangaroo mother care package consisting of KMC kit, information and counseling material and community mobilization through KMC champion (village volunteers) is design after formative research in same geography is implement in intervention clusters. The standard essential newborn care offered in the control clusters. Infants would be recruited and followed up by independent teams of data collectors. Data is collected on the duration of skin-to-skin contact, growth, breastfeeding practices, morbidities, neonatal mortality and neurodevelopment status. Data analysis will be by intention to treat principle. The cox regression model will be used for the primary outcome of neonatal mortality. The secondary outcomes will be assessed using linear or logistic regression.

Results: The study protocol was approved by the Ethics Review Committee of Aga Khan University, Pakistan in February 2017. Data collection began in August 2019 and will be completed in December 2021. Data analyses are yet to be completed.

Conclusions: This intervention, if effective, has the "potential to be translated into a safe, effective, affordable, and widely utilized intervention" to prevent sepsis and subsequently improve survival in LBW neonates in Pakistan, and other low-and middle-income countries.
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http://dx.doi.org/10.2196/28156DOI Listing
May 2021

Co-benefits of protecting mangroves for biodiversity conservation and carbon storage.

Nat Commun 2021 06 23;12(1):3875. Epub 2021 Jun 23.

Henan Key Laboratory of Earth System Observation and Modeling, Henan University, Kaifeng, China.

The conservation of ecosystems and their biodiversity has numerous co-benefits, both for local societies and for humankind worldwide. While the co-benefit of climate change mitigation through so called blue carbon storage in coastal ecosystems has raised increasing interest in mangroves, the relevance of multifaceted biodiversity as a driver of carbon storage remains unclear. Sediment salinity, taxonomic diversity, functional diversity and functional distinctiveness together explain 69%, 69%, 27% and 61% of the variation in above- and belowground plant biomass carbon, sediment organic carbon and total ecosystem carbon storage, respectively, in the Sundarbans Reserved Forest. Functional distinctiveness had the strongest explanatory power for carbon storage, indicating that blue carbon in mangroves is driven by the functional composition of diverse tree assemblages. Protecting and restoring mangrove biodiversity with site-specific dominant species and other species of contrasting functional traits would have the co-benefit of maximizing their capacity for climate change mitigation through increased carbon storage.
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http://dx.doi.org/10.1038/s41467-021-24207-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8222281PMC
June 2021

Maternal and Fetal Vascular Lesions of Malperfusion in the Placentas Associated with Fetal and Neonatal Death: Results of a Prospective Observational Study.

Am J Obstet Gynecol 2021 Jun 7. Epub 2021 Jun 7.

Columbia University, New York NY USA.

Background: Fetal death, one of the major adverse pregnancy outcomes, is especially common in low and middle-income countries. Placental lesions may play an important role in the etiology of fetal and possibly neonatal death. Prior research relating placental lesions to fetal death causation was often hindered by the lack of agreement on a placental classification scheme. The Amsterdam Consensus statement, published in 2016, focused attention on malperfusions in the maternal and fetal placental circulations.

Objectives: Our purpose was to investigate the relationships of placental maternal vascular (MVM) and fetal vascular malperfusion (FVM) to fetal and neonatal death with a focus on the most important maternal clinical conditions in the pathway to fetal and neonatal death; maternal hypertension, antepartum haemorrhage and decreased fetal growth.

Study Design: This was a prospective, observational cohort study conducted at two Asian sites. Data collected included clinical history, gross and histologic evaluation of the placenta, and a number of other investigations to determine cause of death. The placenta was evaluated at both sites using the Amsterdam Consensus framework. We estimated the risk of placental MVM and FVM among fetal and neonatal deaths.

Results: Between July 2018 and January 2020 in India and Pakistan, 814 women with a fetal death, 618 with a preterm live birth and subsequent neonatal death, and 201 term live births, all with a placenta available for study, provided consent. The prevalence of MVM was higher in placentas of fetal deaths (58.4%) and preterm neonatal deaths (31.1%) compared to the term live births (15.4%). Adjusting for site, MVM had a RR of 3.88 (95% CI 2.70-5.59) among fetal deaths vs. term live births and a RR of 2.07 (95% CI 1.41-3.02) for preterm neonatal deaths vs. term live births. Infarcts and distal villous hypoplasia were the most common histological components of MVM. FVM was found less frequently in the placentas of fetal deaths (19.0%) than was MVM (58.4%). However, there were higher frequencies of FVM in fetal death placentas (19.0%) than in placentas from neonatal deaths (8.3%) or in the term live birth placentas (5.0%). Adjusting for site, FVM had a RR of 4.09 (95% CI 2.15-7.75) among fetal deaths vs. term live births and RR 1.77 (95% CI 0.90-3.49) for preterm neonatal deaths vs. term live births. There was a higher incidence of MVM in cases of maternal hypertension (71.4%), SGA (69.9%) and antepartum hemorrhage (59.1%) compared to the incidence of MVM in fetal deaths with none of these conditions (43.3%). There were no significant differences in the occurrence of FVM among the four clinical categories.

Conclusion(s): Histological examination of the placenta, especially for malperfusion disorders, is crucial in elucidating pathways to fetal death and likely for neonatal death in preterm infants. Possibly more important is the potential to focus on placental MVM and FVM during pregnancy as a means to identify fetuses at risk and to reduce the risk of fetal death by early delivery. It is our additional hope that the increased risk of fetal and neonatal death in these pregnancies can be reduced by development of an intervention to reduce the likelihood of developing MVM and/or FVM in the first place.
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http://dx.doi.org/10.1016/j.ajog.2021.06.001DOI Listing
June 2021

Patient beliefs and perceptions play a crucial role in the decision-making process when managing a meniscal tear. A qualitative systematic review of the literature.

Eur J Orthop Surg Traumatol 2021 May 30. Epub 2021 May 30.

Warwick Clinical Trials Unit, Coventry, CV4 7AL, UK.

Introduction: There has been an increase in research on the effectiveness of treatment options for the management of meniscal tears. However, there is very little evidence about the patient experiences of meniscal tears.

Aim: To summarise the available qualitative evidence on patients' experiences and expectations of meniscal tears.

Method: A search of EMBASE, Medline, Sociofile and Web of Science up to November 2020 was performed to identify studies reporting patient experiences of meniscal tears. Studies were critically appraised using the CASP (Critical Appraisal Skills Program) checklist, and a meta-synthesis was performed to generate third-order constructs (new themes).

Results: Two studies reporting semi-structured interviews from 34 participants (24 male; 10 female) were included. The mean interview length ranged from 16 to 45 min. Five themes were generated: (1) the imaging (MRI) results are a key driver in the decision-making process, (2) surgery is perceived to be the definitive and quicker approach, (3) physiotherapy and exercise is a slower approach which brought success over time, (4) patient perceptions and preferences are important in the clinical decision-making process and, (5) the impact on patient lives is a huge driver in seeking care and treatment decisions.

Conclusion: This is the first study to summarise the qualitative evidence on patient experiences with meniscal tears. The themes generated demonstrate the importance of patient perceptions of MRI findings and timing of treatment success as important factors in the decision-making process. This study demonstrates the need to strengthen our understanding of patients' experiences of meniscal tears.
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http://dx.doi.org/10.1007/s00590-021-03019-8DOI Listing
May 2021

Characterizing Micronutrient Status and Risk Factors among Late Adolescent and Young Women in Rural Pakistan: A Cross-Sectional Assessment of the MaPPS Trial.

Nutrients 2021 Apr 9;13(4). Epub 2021 Apr 9.

Department of Nutritional Sciences, University of Toronto, Toronto, ON M5S 1A8, Canada.

Nutritional deficiencies are a leading underlying risk factor contributing to the global burden of disease. In Pakistan, late adolescence is considered a nutritionally vulnerable period, as micronutrient requirements are increased to support maturation, and dietary staples are nutrient poor. However, there has been limited evaluation of micronutrient status beyond anemia and its determinants. Using cross-sectional data from late adolescent and young women (15-23 years) at enrolment in the Matiari emPowerment and Preconception Supplementation (MaPPS) Trial, we aimed to describe the prevalence of key micronutrient deficiencies of public health concern, and generate hierarchical models to examine associations with proxies for social determinants of health (SDoH). The prevalence of micronutrient deficiencies was high: 53.6% (95% confidence interval (CI): 53.0-54.3%) had anemia; 38.0% (95% CI: 36.4-39.6%) iron deficiency anemia; 31.8% (95% CI: 30.2-33.3%) vitamin A deficiency; and 81.1% (95% CI: 79.8-82.4%) vitamin D deficiency. At least one deficiency was experienced by 91.0% (95% CI: 90.1-92.0%). Few SDoH were maintained in the final hierarchical models, although those maintained were often related to socioeconomic status (e.g., education, occupation). To improve the micronutrient status of late adolescent and young women in Pakistan, a direct micronutrient intervention is warranted, and should be paired with broader poverty alleviation methods.
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http://dx.doi.org/10.3390/nu13041237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8069550PMC
April 2021

The use of magnetic resonance imaging (MRI) of the knee in current clinical practice: A retrospective evaluation of the MRI reports within a large NHS trust.

Knee 2021 Mar 26;29:557-563. Epub 2021 Mar 26.

Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratory, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom. Electronic address:

Background: Magnetic resonance imaging (MRI) is one of the most widely used investigations for knee pain as it provides detailed assessment of the bone and soft tissues. The aim of this study is to report the frequency of each diagnosis identified on MRI scans of the knee and explore the relationship between MRI results and onward treatment.

Methods: Consecutive MRI reports from a large NHS trust performed in 2017 were included in this study. The hospital electronic system was consulted to identify whether a patient underwent x-ray prior to the MRI, attended an outpatient appointment or underwent surgery.

Results: 4466 MRI knees were performed in 2017 with 71.2% requested in primary care and 28.1% requested in secondary care. The most common diagnosis was signs of arthritis (55.2%), followed by meniscal tears (42.8%) and ACL tears (8.3%). 49.4% of patients who had an MRI attended outpatients and 15.6% underwent surgery. The rate of knee surgery was significantly higher for patients who had their scans requested in secondary care (32.9% vs 8.9%, p < 0.001).

Conclusion: The rate of surgical intervention following MRI is low and given these results it seems unlikely that the scan changes practice in most cases. The rate of surgery and outpatient follow up was significantly higher in scans requested by secondary care. We urge clinicians avoid wasteful use of MRI and recommend the use of plain radiography prior to MRI where arthritis may be present.
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http://dx.doi.org/10.1016/j.knee.2021.02.034DOI Listing
March 2021

Dismantling the anti-vaxx industry.

Authors:
Imran Ahmed

Nat Med 2021 03;27(3):366

Center for Countering Digital Hate, Washington, DC, USA.

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http://dx.doi.org/10.1038/s41591-021-01260-6DOI Listing
March 2021

Female genital tuberculosis in Pakistan - A retrospective review of 10-year laboratory data and analysis of 32 cases.

Int J Mycobacteriol 2021 Jan-Mar;10(1):66-70

Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan.

Background: Female genital tuberculosis (FGTB) is an underobserved clinical entity owing to diagnostic challenges stemming from difficulty of obtaining diagnostic specimens and paucibacillary nature of the disease. Yet, FGTB is a cause of infertility, pelvic pain, or menstrual irregularities in high-burden countries. To assess laboratory and microbiology diagnostic utilization for FGTB in Pakistan, we have collected data from 2007 to 2016 to inform the need for improved laboratory diagnostics. The objectives of this study were to determine the proportion of FGTB as culture-confirmed extrapulmonary tuberculosis (EPTB) and to describe the characteristics of women with culture-confirmed FGTB in a nationwide laboratory network in Pakistan.

Method: A retrospective database was established by accessing laboratory archives and analyzed by sex and source to determine extrapulmonary cases among women. Data were checked for quality, and after removing patient identifiers and duplicate samples, frequencies were calculated in MS Excel. Clinical characteristics of patients were derived from a linked hospital database for those patients who were diagnosed and managed at the affiliated university hospital in Karachi, Pakistan.

Results: Over 10 years, 410,748 mycobacterial cultures were received from multiple geographic sites throughout Pakistan and processed at the study laboratory. The overall mean culture positivity rate was 5.9% ± 3.5%, while the mean culture positivity rate among females was 2.8% ± 0.8%. Among female culture-confirmed tuberculosis cases, the pulmonary-to-EPTB ratio of infection was 5. Over 10 years, a total of 32 FGTB cases were reported on the basis of positive cultures for Mycobacterium tuberculosis; 3 (9.4%) were rifampin resistant.

Conclusions: FGTB currently constitutes a small but significant proportion of culture-confirmed EPTB. A fewer number of laboratory requisitions suggest the need to increase awareness and testing. The advent of high-sensitivity molecular testing on extrapulmonary specimens has the potential to improve diagnostic accuracy and improved detection of FGTB cases in high-burden regions.
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http://dx.doi.org/10.4103/ijmy.ijmy_6_21DOI Listing
March 2021

Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery.

Bone Joint J 2021 May 8;103-B(5):830-839. Epub 2021 Mar 8.

Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.

Aims: Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.

Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.

Results: We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87).

Conclusion: TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery. Cite this article:  2021;103-B(5):830-839.
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http://dx.doi.org/10.1302/0301-620X.103B.BJJ-2020-1926.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8091001PMC
May 2021

Social distance monitoring framework using deep learning architecture to control infection transmission of COVID-19 pandemic.

Sustain Cities Soc 2021 Jun 17;69:102777. Epub 2021 Feb 17.

Department of Embedded Systems Engineering, Incheon National University, Incheon, Republic of Korea.

The recent outbreak of the COVID-19 affected millions of people worldwide, yet the rate of infected people is increasing. In order to cope with the global pandemic situation and prevent the spread of the virus, various unprecedented precaution measures are adopted by different countries. One of the crucial practices to prevent the spread of viral infection is social distancing. This paper intends to present a social distance framework based on deep learning architecture as a precautionary step that helps to maintain, monitor, manage, and reduce the physical interaction between individuals in a real-time top view environment. We used Faster-RCNN for human detection in the images. As the human's appearance significantly varies in a top perspective; therefore, the architecture is trained on the top view human data set. Moreover, taking advantage of transfer learning, a new trained layer is fused with a pre-trained architecture. After detection, the pair-wise distance between peoples is estimated in an image using Euclidean distance. The detected bounding box's information is utilized to measure the central point of an individual detected bounding box. A violation threshold is defined that uses distance to pixel information and determines whether two people violate social distance or not. Experiments are conducted using various test images; results demonstrate that the framework effectively monitors the social distance between peoples. The transfer learning technique enhances the overall performance of the framework by achieving an accuracy of 96% with a False Positive Rate of 0.6%.
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http://dx.doi.org/10.1016/j.scs.2021.102777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889035PMC
June 2021

ARthroscopy in Knee OsteoArthritis (ARK-OA): a multicentre study assessing compliance to national guidelines.

Eur J Orthop Surg Traumatol 2021 Feb 21. Epub 2021 Feb 21.

Department of Trauma and Orthopaedics, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX, UK.

Introduction: The use of arthroscopy to alleviate the symptoms of osteoarthritis has been questioned by recent high quality evidence. This has led to the development of guidelines by specialist and national bodies advocating against its use.

Aims: To examine the trends of the rates of arthroscopy in patients with knee osteoarthritis over the past five years and determining compliance with guidelines.

Methods: Multi-centre, retrospective audit in five hospital trusts in the United Kingdom. The number of arthroscopies performed by month from 2013 to 2017 was identified through hospital coding. Fifty randomly selected records from the year 2017 were further analysed to assess compliance with NICE guidelines.

Results: Between 2013 and 2017, the number of arthroscopies performed annually in five trusts dropped from 2028 to 1099. In the year 2017, 17.7% of patients with no mechanical symptoms and moderate-to-severe arthritis pre-operatively had arthroscopy.

Conclusion: Knee arthroscopy continues to be used as a treatment for osteoarthritis, against national guidelines. Whilst overall numbers are declining, further interventions, including implementation of high-quality conservative care is required to further eliminate unnecessary procedures.
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http://dx.doi.org/10.1007/s00590-021-02905-5DOI Listing
February 2021

Meniscal tears are more common than previously identified, however, less than a quarter of people with a tear undergo arthroscopy.

Knee Surg Sports Traumatol Arthrosc 2021 Feb 1. Epub 2021 Feb 1.

Warwick Clinical Trials Unit, Clinical Sciences Research Laboratories, University Hospital Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV22DX, UK.

Purpose: The management of meniscal tears is a widely researched and evolving field. Previous studies reporting the incidence of meniscal tears are outdated and not representative of current practice. The aim of this study was to report the current incidence of MRI confirmed meniscal tears in patients with a symptomatic knee and the current intervention rate in a large NHS trust.

Methods: Radiology reports from 13,358 consecutive magnetic resonance imaging scans between 2015 and 2017, performed at a large UK hospital serving a population of 470,000, were assessed to identify patients with meniscal tears. The hospital database was interrogated to explore the subsequent treatment undertaken by the patient. A linear regression model was used to identify if any factors predicted subsequent arthroscopy.

Results: 1737 patients with isolated meniscal tears were identified in patients undergoing an MRI for knee pain, suggesting a rate of 222 MRI confirmed tears per 100,000 of the population aged 18 to 55 years old. 47% attended outpatient appointments and 22% underwent arthroscopy. Root tears [odds ratio (95% CI) 2.24 (1.0, 4.49); p = 0.049] and bucket handle tears were significantly associated with subsequent surgery, with no difference between the other types of tears. The presence of chondral changes did not significantly affect the rate of surgery [0.81 (0.60, 1.08); n.s].

Conclusion: Meniscal tears were found to be more common than previously described. However, less than half present to secondary care and only 22% undergo arthroscopy. These findings should inform future study design and recruitment strategies. In agreement with previous literature, bucket handle tears and root tears were significant predictors of subsequent surgery.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-021-06458-2DOI Listing
February 2021

Tourniquet use in total knee replacement surgery: a feasibility study and pilot randomised controlled trial (SAFE-TKR study).

BMJ Open 2021 01 22;11(1):e043564. Epub 2021 Jan 22.

Warwick Clinical Trials Unit, University of Warwick Warwick Medical School, Coventry, UK.

Introduction: Tourniquets are routinely used during total knee replacement (TKR) surgery. They could increase the risk of thromboembolic events including cerebral emboli, cognitive decline, pain and other adverse events (AEs). A randomised controlled trial to assess whether tourniquet use might safely be avoided is therefore warranted but it is unclear whether such a trial would be feasible.

Methods: In a single-site feasibility study and pilot randomised controlled trial, adults having a TKR were randomised to surgery with an inflated tourniquet versus a non-inflated tourniquet. Participants underwent brain MRI preoperatively and within 2 days postoperatively. We assessed cognition using the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and Oxford Cognitive Screen (OCS) and thigh pain using a Visual Analogue Scale at baseline and days 1 and 2, and 1 week postsurgery. AEs related to surgery were recorded up to 12 months.

Results: We randomised 53 participants (27 tourniquet inflated and 26 tourniquet not inflated). Fifty-one participants received care per-protocol (96%) and 48 (91%) were followed up at 12 months. One new ischaemic brain lesion was detected. Of the cognitive tests, MoCA was easy to summarise, sensitive to change with lower ceiling effects compared with OCS and MMSE. There was a trend towards more thigh pain (mean 49.6 SD 30.4 vs 36.2 SD 28 at day 1) and more AEs related to surgery (21 vs 9) in participants with an inflated tourniquet compared with those with a tourniquet not inflated.

Conclusion: A full trial is feasible, but using MRI as a primary outcome is unlikely to be appropriate or feasible. Suitable primary outcomes would be cognition measured using MoCA, pain and AEs, all of which warrant investigation in a large multicentre trial.

Trial Registration Number: ISRCTN20873088.
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http://dx.doi.org/10.1136/bmjopen-2020-043564DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825264PMC
January 2021

Open versus percutaneous tracheostomy in COVID-19: a multicentre comparison and recommendation for future resource utilisation.

Eur Arch Otorhinolaryngol 2021 Jun 9;278(6):2107-2114. Epub 2021 Jan 9.

Department of Otolaryngology and Head and Neck Surgery, Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK.

Purpose: The COVID-19 pandemic placed an unprecedented demand on critical care services for the provision of mechanical ventilation. Tracheostomy formation facilitates liberation from mechanical ventilation with advantages for both the patient and wider critical care resource, and can be performed using both percutaneous dilatational and surgical techniques. We compared outcomes in those patients undergoing percutaneous dilatational tracheostomy to those undergoing surgical tracheostomy and make recommendations for provision of tracheostomy services in any future surge.

Methods: Multicentre multidisciplinary retrospective observational cohort study including 201 patients with COVID-19 pneumonitis admitted to an ICU in one of five NHS Trusts within the South London Adult Critical Care Network who required mechanical ventilation and subsequent tracheostomy.

Results: Percutaneous dilatational tracheostomy was performed in 124 (62%) of patients, and surgical tracheostomy in 77 (38%) of patients. There was no difference between percutaneous dilatational tracheostomy and surgical tracheostomy in either the rate of peri-operative complications (16.9 vs. 22.1%, p = 0.46), median [IQR(range)] time to decannulation [19.0 (15.0-30.2 (5.0-65.0)] vs. 21.0 [15.5-36.0 (5.0-70.0) days] or mortality (13.7% vs. 15.6%, p = 0.84). Of the 172 patients that were alive at follow-up, two remained ventilated and 163 were decannulated.

Conclusion: In patients with COVID-19 pneumonitis that require tracheostomy to facilitate weaning from mechanical ventilation, there was no difference in outcomes between those patients that had percutaneous dilatational tracheostomy compared with those that had surgical tracheostomy. Planning for future surges in COVID-19-related critical care demands should utilise all available resource and expertise.
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http://dx.doi.org/10.1007/s00405-020-06597-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796696PMC
June 2021

Furunculosis and its complications: A cause of morbidity in renal transplant recipients: A retrospective observational study from Sindh Institute of Urology and Transplantation Karachi.

J Pak Med Assoc 2020 Nov;70(11):2043-2045

Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi.

Furunculosis in renal transplant recipients may be associated with increased morbidity. With the aim to study the presentation, morbidity, and risk factors for furunculosis, this observational study was conducted at the Sindh Institute of Urology and Transplantation, between January to December 2014. All patients with furuncles or abscesses were included. The clinical presentation and risk factors were recorded. A morbidity scale of 0 and 1 was made on the basis of hospital stay for ≥7 days, bacteraemia, large abscesses and repeated furunculosis. Out of 38 patients, 29 (76%) had large abscesses and 9 (24%) had furuncles, with gluteal region being the most common site. Twelve (32%) had severe disease; 29 (76%) had morbidity scale of ≥1. High dose immunosuppression was significantly associated with severe disease while repeated furunculosis had significantly more risk factors. Furunculosis is a severe disease with high morbidity in renal transplant recipients and more studies are needed on skin colonisation and preventive strategies.
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http://dx.doi.org/10.5455/JPMA.28650DOI Listing
November 2020

Tourniquet use for knee replacement surgery.

Cochrane Database Syst Rev 2020 12 8;12:CD012874. Epub 2020 Dec 8.

Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.

Background: Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. A tourniquet may be associated with increased risk of pain and complications.

Objectives: To determine the benefits and harms of tourniquet use in knee replacement surgery.

Search Methods: We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to 26 March 2020. We searched clinicaltrials.gov, the World Health Organization trials portal, and several international registries and joint registries up to March 2020.

Selection Criteria: We included randomised controlled trials (RCTs) comparing knee replacement with use of a tourniquet versus without use of a tourniquet and non-randomised studies with more than 1000 participants. Major outcomes included pain, function, global assessment of success, health-related quality of life, serious adverse events (including venous thromboembolism, infection, re-operation, and mortality), cognitive function, and survival of the implant. Minor outcomes included blood loss, economic outcomes, implant stability, and adverse events.

Data Collection And Analysis: Two review authors screened abstracts and full texts, extracted data, performed risk of bias assessments, and assessed the certainty of the evidence using the GRADE approach.

Main Results: We included 41 RCTs with 2819 participants. Trials included from 20 to 199 participants. Mean age ranged between 58 and 84 years. More than half of the RCTs had unclear risk of selection bias and unclear risk of performance and detection bias due to absence of blinding of participants and surgeons. Major outcomes Pain: at postoperative day 1, pain (on a scale from zero to 10, with higher scores indicating worse pain) was ranked at 4.56 points after surgery without a tourniquet and at 1.25 points (MD) higher (95% CI 0.32 higher to 2.19 higher) with a tourniquet (8 studies; 577 participants), for an absolute difference of 12.5% higher pain scores (95% CI 3.2% higher to 21.9% higher) and a relative difference of 19% higher pain scores (95% CI 3.4% higher to 49% higher) with a tourniquet. Evidence for these findings was of moderate certainty, downgraded due to risk of bias. Knee replacement with a tourniquet probably led to higher postoperative pain scores at day 1, although this difference may or may not be noticeable to patients (based on a minimal clinically important difference (MCID) of 1.0). Function: at 12 months, tourniquet use probably makes little or no difference to function, based on an MCID of 5.3 for Knee Society Score (KSS) and 5.0 for Oxford Knee Score (OKS). Mean function (on a scale from 0 to 100, with higher scores indicating better outcomes) was 90.03 points after surgery without a tourniquet and was 0.29 points worse (95% CI 1.06 worse to 0.48 better) on a 0 to 100 scale, absolute difference was 0.29% worse (1.06% worse to 0.48% better), with a tourniquet (5 studies; 611 participants). This evidence was downgraded to moderate certainty due to risk of bias. Global assessment of success: low-certainty evidence (downgraded due to bias and imprecision) indicates that tourniquet use may have little or no effect on success. At six months, 47 of 50 (or 940 per 1000) reported overall successful treatment after surgery without a tourniquet and 47 of 50 (or 940 per 1000) with a tourniquet (risk ratio (RR) 1.0, 95% CI 0.91 to 1.10) based on one study with 100 participants. Health-related quality of life: at six months, tourniquet may have little or no effect on quality of life. The 12-Item Short Form Survey (SF-12) score (mental component from zero to 100 (100 is best)) was 54.64 after surgery without a tourniquet and 1.53 (MD) better (95% CI 0.85 worse to 3.91 better) with a tourniquet (1 study; 199 participants); absolute difference was 1.53% better (0.85% worse to 3.91% better). Evidence was of low certainty, downgraded due to risk of bias and small number of participants. Serious adverse events: the risk of serious adverse events was probably higher with tourniquet; 26 of 898 (29 per 1000) reported events following surgery without a tourniquet compared to 53 of 901 (59 per 1000) with a tourniquet (RR 1.73, 95% CI 1.10 to 2.73) in 21 studies (1799 participants). Twenty-nine more per 1000 patients (95% CI 3 to 50 more per 1000 patients) had a serious adverse event with a tourniquet. Forty-eight (95% CI 20 to 345) participants would need to have surgery without a tourniquet to avoid one serious adverse event. This evidence was downgraded to moderate certainty due to risk of bias. Cognitive function: one study reported cognitive function as an outcome; however the data were incompletely reported and could not be extracted for analysis. Survival of implant: it is uncertain if tourniquet has an effect on implant survival due to very low certainty evidence (downgraded for bias, and twice due to very low event rates); 2 of 107 (19 per 1000) required revision surgery in the surgery with a tourniquet group compared to 1 of 107 (9 per 1000) without a tourniquet group at up to two years' follow-up (RR 1.44, 95% CI 0.23 to 8.92). This equates to a 0.4% (0.7% lower to 7% more) increased absolute risk in surgery with a tourniquet.

Authors' Conclusions: Moderate certainty evidence shows that knee replacement surgery with a tourniquet is probably associated with an increased risk of serious adverse events. Surgery with a tourniquet is also probably associated with higher postoperative pain, although this difference may or may not be noticeable to patients. Surgery with a tourniquet does not appear to confer any clinically meaningful benefit on function, treatment success or quality of life. Further research is required to explore the effects of tourniquet use on cognitive function and implant survival, to identify any additional harms or benefits. If a tourniquet continues to be used in knee replacement surgery, patients should be informed about the potential increased risk of serious adverse events and postoperative pain.
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http://dx.doi.org/10.1002/14651858.CD012874.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094224PMC
December 2020

'Breakpoint broth microdilution plate' for susceptibility testing of Gram negative bacilli against colistin sulfate.

Pract Lab Med 2020 Nov 24;22:e00192. Epub 2020 Nov 24.

Department of Pathology & Laboratory Medicine, Aga Khan University, Pakistan.

The MIC method applicable to Gram negative bacilli including spp. is broth microdilution (BMD). Cost and/or availability issues limit the use of commercial MIC panels in resource limited settings.

Objectives: To design and implement an in-house breakpoint BMD panel (BBMD) for colistin against Gram negative bacilli.

Design: BBMD panel was prepared in 96-well plate. MIC concentrations of 1, 2, & 4 ​μg/mL for test, and 0.25, 0.5, 1, 2 & 4 ​μg/mL for control strains were selected to accommodate 19 test and 3 quality control strains per plate. Plates were frozen at -80 ​°C until testing. Validation was performed using strains from a previously published study and compared with freshly prepared MIC panel of 16-0.03 ​μg/mL.

Results: Validation showed 100% agreement with the reference method and BBMD was introduced into routine laboratory practice for colistin susceptibility of carbapenem resistant (CRE), complex and . From 2nd July-16th September 2018, a total of 1294 (mean 16.8 ​± ​5.5 isolates/day) clinical isolates were tested; 1157/1294 were reported (MIC ≤2 ​μg/mL) within 24-h, whereas 133 required resistance confirmation by full-range BMD. Resistance was confirmed for all but 24 isolates. These discrepancies were mostly due to contamination with bacterial genera inherently resistant to colistin.

Conclusion: This BBMD plate is a high through-put and practical method that could reliably be utilized in a routine microbiology laboratory for colistin susceptibility testing of CRE, complex and .
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http://dx.doi.org/10.1016/j.plabm.2020.e00192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7702188PMC
November 2020

Prognostic Significance of CMR Findings in Patients with Known Coronary Artery Disease - Experience from a South Asian Country.

J Clin Imaging Sci 2020 21;10:75. Epub 2020 Nov 21.

Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan.

Objectives: South Asians (SA) have a higher burden of coronary artery disease (CAD) and are known to have a worse prognosis compared to other ethnicities. Therefore, it is imperative to improve the risk stratification of SA patient with CAD and to seek out newer prognostic markers beyond the conventional echocardiography.The aim of this study was to investigate whether variables obtained by cardiac magnetic resonance (CMR) improve risk stratification of South Asian patients with known CAD.

Material And Methods: We retrospectively analyzed 147 patients with evidence of CAD that had a CMR at our center between January 2011 and January 2019. LV volumes and regional wall motions were acquired by cine images, while infarct size (IS) was measured by late gadolinium enhancement. At a mean follow-up of 3.36 ± 2.22 years, cardiac events (non-fatal myocardial infarction, hospitalization due to heart failure, life-threatening arrhythmia, or cardiac death) occurred in 49 patients. An IS ≥35%, left ventricular ejection fraction (LVEF) ≤31%, and a wall motion score index (WMSI) ≥1.9 were strongly associated with follow-up cardiac events ( < 0.001). Patients that had none or less than 3 of these factors, showed a lower risk of cardiac events (HR 0.22 CI [0.11-0.44] < 0.001 and HR 0.12 CI [0.04-0.32] < 0.001, respectively) compared to those with all three factors.

Conclusion: Integration of CMR derived factors such as IS and WMSI with LVEF can improve the prognostication of the SA population with CAD. Better risk stratification of patients can lead to improved and cost-effective therapeutic strategies to ameliorate the prognosis of these patients.
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http://dx.doi.org/10.25259/JCIS_153_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7708965PMC
November 2020

Impact of COVID-19 on clinical outcomes for patients with fractured hip: a multicentre observational cohort study.

Bone Jt Open 2020 Nov 4;1(11):697-705. Epub 2020 Nov 4.

South Warwickshire NHS Foundation Trust, Warwick, UK.

Aims: There are reports of a marked increase in perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in the UK, USA, Spain, and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic.

Methods: We completed a multicentre cohort study across ten hospitals in England. Data were collected from 1 March 2020 to 6 April 2020, during which period the World Health Organization (WHO) declared COVID-19 to be a pandemic. Patients ≥ 60 years of age admitted with hip fracture and a minimum follow-up of 30 days were included for analysis. Primary outcome of interest was mortality at 30 days post-surgery or postadmission in nonoperative patients. Secondary outcomes included length of hospital stay and discharge destination.

Results: In total, 404 patients were included for final analysis with a COVID-19 diagnosis being made in 114 (28.2%) patients. Overall, 30-day mortality stood at 14.4% (n = 58). The COVID-19 cohort experienced a mortality rate of 32.5% (37/114) compared to 7.2% (21/290) in the non-COVID cohort (p < 0.001). In adjusted analysis, 30-day mortality was greatest in patients who were confirmed to have COVID-19 (odds ratio (OR) 5.64, 95% confidence interval (CI) 2.95 to 10.80; p < 0.001) with an adjusted excess risk of 20%, male sex (OR 2.69, 95% CI 1.37 to 5.29; p = 0.004) and in patients with ≥ two comorbidities (OR 4.68, CI 1.5 to 14.61; p = 0.008). Length of stay was also extended in the COVID-19 cohort, on average spending 17.6 days as an inpatient versus 12.04 days in the non-COVID-19 group (p < 0.001).

Conclusion: This study demonstrates that patients who sustain a neck of femur fracture in combination with COVID-19 diagnosis have a significantly higher risk of mortality than would be normally expected.Cite this article: 2020;1-11:697-705.
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http://dx.doi.org/10.1302/2633-1462.111.BJO-2020-0132.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690757PMC
November 2020

Maternal infection and stillbirth: a review.

J Matern Fetal Neonatal Med 2020 Nov 24:1-9. Epub 2020 Nov 24.

Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.

Maternal infections likely are an important cause of stillbirths, especially in sub-Saharan Africa and south Asia, where the burden is highest. Due to the lack of routine testing for infection, which can be complex and often expensive, the prevalence of infection during pregnancy and the association of many infections with stillbirth are not well-documented, especially in low-resource countries. Following an extensive literature review of infection and stillbirth initially published in 2010, we conducted a review of literature in the last 10 years to identify infections associated with stillbirth, focused on those in low-resource settings. During the last 10 years, over 40 bacterial, viral and other pathogens have been associated with stillbirth. Newly emerging viral infections such as Denge as well as several well-established, but not yet eliminated infections such as rubella have been associated with stillbirth. Two of the maternal infections most strongly associated with stillbirth, each with about a 2-fold risk, are malaria and syphilis but others have been associated with risk in a range of studies. With a lack of routine antenatal screening, many pathogens are identified as associated with stillbirth only through case reports. Infection remains an important, yet understudied, cause of stillbirth. Research studies to determine definitive associations between various infections and stillbirth are important to better understand the role of infections and strategies to reduce infection-related stillbirth. This review explores the association between infections and stillbirths focusing on low-income country studies published in the last 10 years. Much information about these relationships comes from case reports. Research resulting in a better understanding of the causes and strategies to reduce infection-related stillbirth is necessary.
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http://dx.doi.org/10.1080/14767058.2020.1852206DOI Listing
November 2020

A deep learning-based social distance monitoring framework for COVID-19.

Sustain Cities Soc 2021 Feb 1;65:102571. Epub 2020 Nov 1.

Department of Information and Communication Engineering, Yeungnam University, South Korea.

The ongoing COVID-19 corona virus outbreak has caused a global disaster with its deadly spreading. Due to the absence of effective remedial agents and the shortage of immunizations against the virus, population vulnerability increases. In the current situation, as there are no vaccines available; therefore, social distancing is thought to be an adequate precaution (norm) against the spread of the pandemic virus. The risks of virus spread can be minimized by avoiding physical contact among people. The purpose of this work is, therefore, to provide a deep learning platform for social distance tracking using an overhead perspective. The framework uses the YOLOv3 object recognition paradigm to identify humans in video sequences. The transfer learning methodology is also implemented to increase the accuracy of the model. In this way, the detection algorithm uses a pre-trained algorithm that is connected to an extra trained layer using an overhead human data set. The detection model identifies peoples using detected bounding box information. Using the Euclidean distance, the detected bounding box centroid's pairwise distances of people are determined. To estimate social distance violations between people, we used an approximation of physical distance to pixel and set a threshold. A violation threshold is established to evaluate whether or not the distance value breaches the minimum social distance threshold. In addition, a tracking algorithm is used to detect individuals in video sequences such that the person who violates/crosses the social distance threshold is also being tracked. Experiments are carried out on different video sequences to test the efficiency of the model. Findings indicate that the developed framework successfully distinguishes individuals who walk too near and breaches/violates social distances; also, the transfer learning approach boosts the overall efficiency of the model. The accuracy of 92% and 98% achieved by the detection model without and with transfer learning, respectively. The tracking accuracy of the model is 95%.
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http://dx.doi.org/10.1016/j.scs.2020.102571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603992PMC
February 2021

Chronic Lymphoproliferative Disorder of Natural Killer Cells: A Rare Event.

Cureus 2020 Sep 10;12(9):e10353. Epub 2020 Sep 10.

Hematology, Shifa International Hospital, Islamabad, PAK.

Chronic lymphoproliferative disorders are a diverse group of diseases derived from thymus lymphocytes (T cells), bursa of Fabricius cells (B cells), or natural killer (NK) cells. The diagnosis of chronic lymphoproliferative disorders of NK cells (CLPD-NK) is confirmed using antibody panels that are able to detect various stages of maturation of malignant cells. Autoimmune diseases and viral infections are often associated with an increase in circulating NK cells. It is hypothesized that certain viruses trigger the activation of NK cells which leads to the formation of NK cell clones. Majority of the cases are asymptomatic. However, some patients have systemic symptoms and cytopenias. Here, we report a case of CLPD-NK. Our patient's history and marked lymphocytosis on peripheral film raised the suspicion of a hematolymphoid malignancy for which flow cytometric analysis was done using an extensive panel which confirmed the diagnosis of CLPD-NK.
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http://dx.doi.org/10.7759/cureus.10353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549851PMC
September 2020

Evaluating implementation of "management of Possible Serious Bacterial Infection (PSBI) when referral is not feasible" in primary health care facilities in Sindh province, Pakistan.

PLoS One 2020 14;15(10):e0240688. Epub 2020 Oct 14.

Center of Excellance in Women & Child Health, Aga Khan University, Karachi, Pakistan.

Background: The World Health Organization (WHO) launched a guideline in 2015 for managing Possible Serious Bacterial Infection (PSBI) when referral is not feasible in young infants aged 0-59 days. This guideline was implemented across 303 Basic Health Unit (BHU) Plus primary health care (PHC) facilities in peri-urban and rural settings of Sindh, Pakistan. We evaluated the implementation of PSBI guideline, and the quality of care provided to sick young infants at these facilities.

Methods: Thirty (10%) out of 303 BHU Plus facilities were randomly selected for evaluation. A survey team visited each facility for one day, assessed the health system support, observed the management of sick young infants by health care providers (HCP), validated their management, interviewed HCPs and caretakers of sick infants. HCPs who were unable to see a young infant on the day of survey were evaluated using pre-prepared case scenarios.

Results: Thirty (100%) BHU Plus facilities had oral amoxicillin, injectable gentamicin, thermometers, baby weighing scales and respiratory timers available; 29 (97%) had disposable syringes and needles; 28 (93%) had integrated management of childhood illness (IMCI)/PSBI chart booklets and job aids and 18 (60%) had a functional ambulance. Each facility had at least one HCP trained in PSBI, and 21 (70%) facilities had been visited by a supervisor in the preceding six months. Of 42 HCPs, 19 (45.3%) were trained within the preceding 12 months. During the survey, 26 sick young infants were identified in 18 facilities. HCPs asked about history of breastfeeding in 23 (89%) infants, history of vomiting in 17 (65%), and history of convulsions in 14 (54%); weighed 25 (97%) infants; measured respiratory rate in all (100%) and temperature in 24 (92%); assessed 20 (77%) for movement and 14 (54%) for chest indrawing. HCPs identified two infants with fast breathing pneumonia and managed them correctly per IMCI/PSBI protocol. HCPs identified six (23%) infants with clinical severe infection (CSI), two of them were referred to a higher-level facility, only one accepted the referral advice. Only one CSI patient was managed correctly per IMCI/PSBI protocol at the outpatient level. HCPs described the PSBI danger signs to eight (31%) caretakers. Caretakers of five infants with CSI and two with pneumonia were not counselled for PSBI danger signs. Five of the six CSI cases categorized by HCPs were validated as CSI on re-examination, whereas one had pneumonia. Similarly, one of the two pneumonia patients categorized by HCPs had CSI and one identified as local bacterial infection was classified as CSI upon re-examination.

Conclusion: Health system support was adequate but clinical management and counselling by HCPs was sub-optimal particularly with CSI cases who are at higher risk of adverse outcomes. Scaling up PSBI management is potentially feasible in PHC facilities in Pakistan, provided that HCPs are trained well and mentored, receive refresher training to appropriately manage sick young infants, and have adequate supplies and counselling skills.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240688PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7556471PMC
December 2020

Management of sleep apnea in New York City during the COVID-19 pandemic.

Sleep Med 2020 10 18;74:86-90. Epub 2020 Jul 18.

University of Arkansas for Medical Sciences Northwest, Fayetteville, Arkansas, USA.

Background: With the onset of the COVID-19 outbreak there has been concern that patients with obstructive sleep apnea (OSA) who develop COVID-19 may be at risk of greater morbidity and mortality than patients without OSA. COVID-19 is associated with an increased mortality in the elderly and particularly those with obesity, hypertension and diabetes, features which are typically seen in patients with OSA. This article describes the COVID-19 environment in New York City in which patients were evaluated and treated for OSA.

Methods: A telephone questionnaire survey of 112 OSA patients determined the occurrence of COVID-19 in the sleep apnea population and the patients' perspective on sleep apnea Positive Airway Pressure (PAP) management during the COVID-19 outbreak. The three main objectives of the survey were as follows: (1) To discover how patients were coping with COVID-19 pandemic in terms of their sleep apnea and PAP use, (2) To determine whether PAP usage changed after the onset of the outbreak in terms of adherence, and (3) To find out if patients were concerned about whether they were at greater risk of contracting COVID-19 because of their sleep apnea and, if they became infected, whether COVID-19 might result in greater complications because of the presence of sleep apnea.

Results/conclusions: The adjustment in clinical management of OSA patients is described both during the peak of the outbreak in New York State (NYS), as well as the proposed modifications that will be instituted in order to return to full sleep center activities.
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http://dx.doi.org/10.1016/j.sleep.2020.07.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368649PMC
October 2020

Community-level interventions for pre-eclampsia (CLIP) in Pakistan: A cluster randomised controlled trial.

Pregnancy Hypertens 2020 Oct 28;22:109-118. Epub 2020 Jul 28.

the CLIP Pakistan Trial Working Group (Table S1).

Objectives: To reduce all-cause maternal and perinatal mortality and major morbidity through Lady Health Worker (LHW)-facilitated community engagement and early diagnosis, stabilization and referral of women with preeclampsia, an important contributor to adverse maternal and perinatal outcomes given delays in early detection and initial management.

Study Design: In the Pakistan Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial (NCT01911494), LHWs engaged the community, recruited pregnant women from 20 union councils (clusters), undertook mobile health-guided clinical assessment for preeclampsia, and referral to facilities after stabilization.

Main Outcome Measures: The primary outcome was a composite of maternal, fetal and newborn mortality and major morbidity.

Findings: We recruited 39,446 women in intervention (N = 20,264) and control clusters (N = 19,182) with minimal loss to follow-up (3∙7% vs. 4∙5%, respectively). The primary outcome did not differ between intervention (26·6%) and control (21·9%) clusters (adjusted odds ratio, aOR, 1∙20 [95% confidence interval 0∙84-1∙72]; p = 0∙31). There was reduction in stillbirths (0·89 [0·81-0·99]; p = 0·03), but no impact on maternal death (1·08 [0·69, 1·71]; p = 0·74) or morbidity (1·12 [0·57, 2·16]; p = 0·77); early (0·95 [0·82-1·09]; p = 0·46) or late neonatal deaths (1·23 [0·97-1·55]; p = 0·09); or neonatal morbidity (1·22 [0·77, 1·96]; p = 0·40). Improvements in outcome rates were observed with 4-7 (p = 0·015) and ≥8 (p < 0·001) (vs. 0) CLIP contacts.

Interpretation: The CLIP intervention was well accepted by the community and implemented by LHWs. Lack of effects on adverse outcomes could relate to quality care for mothers with pre-eclampsia in health facilities. Future strategies for community outreach must also be accompanied by health facility strengthening.

Funding: The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337).
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http://dx.doi.org/10.1016/j.preghy.2020.07.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7694879PMC
October 2020

Meniscal Tear Outcome (METRO) review: a protocol for a systematic review summarising the clinical course and patient experiences of meniscal tears in the current literature.

BMJ Open 2020 08 4;10(8):e036247. Epub 2020 Aug 4.

Clinical Trials Unit, University of Warwick, Coventry, UK.

Introduction: Meniscal tears are a common knee injury with an incidence of 60 per 100 000. Management of meniscal tears can include either non-operative measures or operative procedures such as arthroscopic partial meniscectomy (APM). Despite substantial research evaluating the effectiveness of APM in the recent past, little is known about the clinical course or the experiences of patients with a meniscal tear.

Aim: To summarise the short to long-term patterns of variability in outcome in patients with a meniscal tear.To summarise the evidence on patient experiences of meniscal tears. In particular, we will focus on patient experiences of treatment options, treatment pathways and their views of the outcomes used in meniscal tear research.

Methods And Analysis: Two search strategies will be developed to identify citations from EMBASE, MEDLINE, AMED, CENTRAL, Web of Science and Sociofile. The date of our planned search is 14 August 2020. For the quantitative review we will identify studies reporting patient-reported outcome measures in patients after a meniscal tear. The standardised mean change will be used to assess the variation in size of response and summarise the overall response to each treatment option. All studies will undergo quality assessment using either the Cochrane risk of bias or the Newcastle-Ottawa tool.A qualitative systematic review will be used to identify studies reporting views and experiences of patients with a meniscal tear. All studies will be assessed using the Critical Appraisal Skills Programme tool and if sufficient data are present a meta-synthesis will be performed to identify first, second and third-order constructs.

Ethics And Dissemination: Given the nature of this study, no formal ethical approval will be sought. Results from the review will be disseminated at national conferences and will be submitted to a peer-reviewed journal for publication. Lay summaries will be freely available via the study Twitter page.

Prospero Registration Number: CRD42019122179.
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http://dx.doi.org/10.1136/bmjopen-2019-036247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406020PMC
August 2020
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