Ask twice: The importance of repeated faecal calprotectin testing prior diagnostic colonoscopy in an adult inception cohort

Background: Elevated Faecal Calprotectin (FCP) is established as a valuable tool in differentiating Inflammatory Bowel Disease (IBD) from Irritable bowel syndrome (IBS) and monitoring IBD activity. Initial implementation studies in the UK demonstrated benefit from repeat testing to exclude false positives. This is not currently mandated by IBD consensus guidelines. Growing waiting times are increasing pressure to include a single result in straight to test pathways. No one level for significant elevation is defined with levels between 100-250ug/g used We present our experience of the real-world utility of FCP used in a primary care referral pathway Methods: From Jan 2021-Nov 2022, new referrals were streamed into a rapid access 'Inception IBD' clinic on the basis of symptoms and raised FCP. A repeat FCP (kit sent in advance) was brought to the first appointment, with same day processing using the Buhlmann fCAL Turbo Test. Results and accompanying diagnosis and outcome data was collected prospectively. There was no standardised testing interval but median time from referral to review was 34 days Results: A single FCP was available for 425 patients with a final diagnosis Two pre-treatment FCPs were available in 185. Median initial FCP was 949ug/g in those subsequently diagnosed with IBD (Ulcerative colitis 1162ug/g, Crohn's 893ug/g) vs 353ug/g in those without IBD This difference heightened on retesting, with median FCP in IBD 749ug/g vs 34ug/g in non-IBD (Fig 1). FCP fell between 1st and 2nd measurement in 88.6% of patients who had IBD excluded In IBD, baseline FCP showed strong correlation with established disease activity markers (Fig 2) Baseline FCP levels were significantly higher in IBD patients who went on to require biologic treatment (Mann-Whitney U 2763, p<0.001) A variety of FCP cut-off values were assessed (Fig 4). A two sample >200ug/g cut off performed best as assessed by Area Under the Curve (AUC). However, sensitivity fell to 81.5% at this level Of 15 IBD patients who didn't have two FCPs >200ug/g, 7 had an increase between the 1st and 2nd FCP (median 147 vs 487ug/g). The remaining 8 comprised 4 ileal Crohn's, 3 mild proctitis and 1 stricturing colonic Crohn's in whom FCP failed to correlate with disease activity Overall, 83% (48/58) of patients with increasing 1st to 2nd FCP were diagnosed with IBD Conclusion(s): Our data supports repeat testing of FCP to avoid unnecessary investigations adding to post COVID endoscopy backlogs. A cut off of two values >200ug/g had the best overall performance but can miss a small number of IBD cases, particularly those with isolated ileal disease or a more indolent disease course. This cut off should not be used in those with a marked increase between 1st and 2nd result, where IBD is likely.

Geo-Spatial Disease Clustering for Public Health Decision Making

An explosion of interest has been observed in disease mapping with the developments in advanced spatial statistics, data visualization and geographic information system (GIS) technologies. This technique is known as "Geo-Spatial Disease Clustering," mainly used for visualization and future disease expansion prediction. Its importance has been overwhelmingly observed since the COVID-19 pandemic outbreak. Government, Medical Institutes, and other medical practices gather large amounts of data from surveys and other sources. This data is in the form of notes, databases, spread sheets and text data files. Mostly this information is in the form of feedback from different groups like age group, gender, provider (doctors), region, etc. Incorporating such heterogeneous nature of data is quite challenging task. In this regard, variety of techniques and algorithms have been proposed in the literature, but their effectiveness varies due to data types, volume, format and structure of data and disease of interest. Mostly, the techniques are confined to a specific data type. To overcome this issue, in this research, a data visualization technique combined with data warehousing and GIS for disease mapping is proposed. This includes data cleansing, data fusion, data dimensioning, analysis, visualization, and prediction. Motivation behind this research is to create awareness about the disease for the guidance of patients, healthcare providers and government bodies. By this, we can extract information that describes the association of disease with respect to age, gender, and location. Moreover, the temporal analysis helps earlier prediction and identification of disease, to be care of and necessary avoiding arrangements can be taken.

Troponin Elevation a Marker of Mortality in COVID-19 Patients

Introduction: Troponin I test has been used as a biomarker for the diagnosis of ACS since 1965. Troponin I has a prognostic value in hospitalized patients with non-cardiac diagnosis. In 2019, The WHO declared COVID-19 as a deadly infectious disease. Given the global impact of this disease, there is a need to identify biomarkers associated with mortality in hospitalized patients. Biomarkers associated with mortality are an important tool for escalation of care in patients deemed at risk of clinical decompensation. The following study demonstrated an association between troponin I elevation and increased mortality among COVID-19 patients. Hypothesis: We sought to determine if Troponin I elevation within 24 hours of admission is associated with increased mortality in COVID-19 patients. Method(s): In a retrospective, multicenter study at Atlantic Health System in New Jersey, we analyzed 10,980 first-drawn troponin I values within 24 hours of admission in 34,625 patients between 12/2020-02/2021. Data was analyzed using logistic regression and cox proportional hazard ratio to determine our primary outcome, which is the association of troponin elevation and mortality among COVID-19 patients. Result(s): The characteristic of 10,980 patients that survived COVID-19 and patients that expired due to COVID-19 during the hospitalization were analyzed. Total of 6,083 were male and 4897 were females. In the survival group, the mean age was 60 with STD 17.2, while in the deceased group the mean age was 74 with STD 13. Logistic regression revealed thatpatients with elevated troponin have increased odds of death compared to others with non-elevated troponin levels (Point estimate 3.301665). Females with elevated troponin have greater odds of death than males with elevated troponin (point estimate 4.484406 in females vs point estimate men 3.301665). Patients with elevated troponin have increased hazard by a factor of 1.78 or increased chance of death by 78%. As supporting evidence of our hypothesis patients with an elevated troponin in the first 24 hours have 3.74 increase odds of death. Conclusion(s): In conclusion, Troponin I elevation within 24 hours of admission is associated with increased mortality in hospitalized COVID-19 patients with 3.7 increase odds of death.

INVESTIGATING IDA: LARGE-SCALE DATA SHOWING PERSISTENT GAPS AT THE FRONT DOOR

Introduction Iron deficiency anaemia (IDA) can be a sign of serious underlying disease but often overlooked. Recently updated guidelines of the British Society of Gastroenterology (BSG) recommend male and postmenopausal female patients with IDA should be screened for coeliac disease and undergo dual endoscopy (or CT). Aims This project looked to assess current adherence to these guidelines at the Queen Elizabeth Hospital in Birmingham. Methods A retrospective audit was performed using health informatics for patients who attended AMU/CDU from April 2018 to March 2021. The number of patients with IDA in this time frame was identified. A further analysis of this group was made to determine the proportion of patients with IDA who had IgA TTG measured as well as those who had OGD and colonoscopy/CT colonoscopy requested. Results There were 67797 patients in this study period. 32422 (47.8%) were anaemic (Hb < 120g/dl for women, <130g/dl for men as per WHO guidelines) of which 6357 (19.6%;9.38% of total) had a microcytic anaemia (MCV <83 as per University Hospitals Birmingham laboratory reference range). Ferritin was tested in 3337 (52.5%) of this group, and of those, 1041 (31.2%) were found to have overt IDA (ferritin <30 mg/mL). Rate of investigation The patient cohort with confirmed IDA comprised 334 males (32.0%), 556 post-menopausal females (53.4%, defined as age ≥45) and 151 pre-menopausal females (14.5%). A further analysis was made to explore how male and postmenopausal female cases were investigated, and if the rate of investigation was affected by the COVID-19 pandemic from 1st March 2020 onwards in this subgroup. Results are shown in the table below. In general, only a minority of patients underwent further investigation with males more likely to undergo OGD than females. Surprisingly, apart from increased TTG check latterly, little difference was seen after onset of the COVID-19 pandemic. Conclusions This large-scale study found that only a small minority of patients with IDA underwent further investigation. Whilst the study period includes the pandemic era, our results don't suggest this made a significant impact on practice. Nevertheless, these findings indicate a strong need for increased awareness and quality improvement about optimising IDA investigation according to BSG guidelines.

Deep Learning based Analysis of Covid-19 Mortality Risk

Viral infectious diseases such as Covid-19 present a major threat to public health. Despite extreme research efforts, how, when and where such new outbreaks appear is still a source of substantial uncertainty. Deep learning (DL) is playing an increasingly important role in our lives. This paper presents one of the popular deep learning technique, Long Short Term Memory (LSTM) for prediction of Corona-Virus cases. The handcrafted feature extraction of traditional methods is less scalable on large data-sets, but deep learning algorithms perform extremely well on large data-sets, because of automatic feature extraction. Deep learning has already made a huge impact in areas, such as cancer diagnosis, precision medicine, self-driving cars, predictive forecasting, and speech recognition. This paper highlights the approaches where deep learning can be helpful to tackle the Covid-19 virus and similar outbreaks. This paper also discusses the structure and functioning of Covid-19. The utilization of different deep learning concepts like Convolutional Neural Networks, Transfer Learning for this pandemic is also highlighted. © 2022 University of Bahrain. All rights reserved.

Covid 19 Vaccination Status, Hesitancy and Barriers;A Multicenter Study of Medical Students from Pakistan

Introduction: The key factor to fight with COVID-19 is vaccination for the development of which global stakeholders allocated huge resources. But at the same time many conspiracies arose and a phenomenon of vaccine hesitancy also developed which is restricting a large no of population to be vaccinated. The current study was designed to find out vaccination status of medical students and their families, vaccine hesitancy and barriers they faced in convincing their families to be vaccinated. Methods: Around 1400 students of 4th year and 5th year from 8 medical colleges of Punjab province were invited to participate in this online survey. This Validated Questionnaire consisted of three parts, demographic information, vaccination status and barriers for vaccination. Results: Out of 522 participants, 41.1% were males and 58.6% were females. The mean age of the participants was 22.33 ±1.17 SD. An encouraging finding is that majority of medical students were vaccinated (91%, n=475). Same is the case with their nuclear family members. Majority of medical students have at least tried to convince their family members for vaccination (80%). A significant proportion of participants experienced barriers to convince their nuclear and extended family members. Among these, serious complications/death, clotting episodes, may inject something in body to be controlled by others in future were mention worthy. The phenomenon of vaccine hesitancy is impeding the people from COVID-19 vaccination. Steps must be taken at all levels to curb this cumbersome conspiracy. So, the fantasy of bringing this global calamity to an end could be fulfilled. Conclusion: The study concludes that a significant number of medical students got vaccinated and also tried to convince their nuclear and extended families. However, the phenomenon of vaccine hesitancy is impeding the drive for mass vaccination. Apart from the interventions at multiple levels, medical students must be encouraged and directed to play their role for community awareness.

Analyzing COVID-19 Vaccine Hesitancy among University Students in UAE: A Cross-Sectional Study

Introduction: While vaccines may be a key measure in overcoming the pandemic, their hesitancy among the population may impede the ongoing efforts of governments and health authorities in a country. Universities are considered the hubs of the transition of individuals to young adults, understanding the hesitancy of this population stratum and addressing apprehensions that may exist is of utmost importance. This study aims to explore the attitude and hesitancy of students in UAE universities toward the COVID-19 vaccines along with comparing two particular demographics to see if there exists a difference in outcomes-medical and nonmedical students. Methods: A web-based self-administered questionnaire was sent following Ethics Committee approval, to students at various universities in the UAE containing questions regarding general demographic data, COVID-19 related anamnestic characteristics as well as questions on motivational factors and refusal factors regarding the vaccine. Using Statistical Package for the Social Sciences version 28, descriptive analyses were performed for the demographic variables and inferential statistics were carried out using Pearson's Chi-squared (χ2) test. Results: A total of 385 participants consented to the survey, with a majority of female respondents (76.6%). In our demographics which included respondents of an average age of 21 years, 91.4% were expatriates, and 48.1% were based in Dubai. Approximately 67% of those surveyed had been vaccinated, with Sinopharm being the most commonly taken vaccine (70.4%). "Concerns over side effects"seems to be the most common reason for vaccine refusal (58.7%) among all demographics whether vaccinated or not. Our sample included a majority of students with a medical and health sciences background (58.7%), who disagreed more often with the belief that they were completely protected by receiving the COVID-19 vaccine as compared to the nonmedical students. Conclusion: COVID-19 vaccination rates among university students in UAE are lower than the national average, demonstrating the importance of integrating a specific awareness program for this group. Preparing medical students for the future is a beneficial long-term strategy, and hence, further research regarding vaccine hesitancy must be done focusing primarily on them to ensure their future patients receive the best vaccine-related recommendations.

Incidence and significance of vitamin d deficiency at inflammatory bowel disease inception in the covid era

Background: Vitamin D, a key regulator of immune response, is known to be lower in Inflammatory Bowel Disease (IBD) patients than the general population. Disparity in the incidence of deficiency between ethnic groups has previously been demonstrated. We measured vitamin D in a unique multi-ethnic inception cohort to correlate this with traditional IBD scores and patient reported outcome measures including the 'IBD Disk'. Methods: Data regarding demographics, ethnicity, faecal calprotectin (FCAL) and baseline blood results including Vitamin D was collected prospectively from January-October 2021, from adults presenting with suspected IBD. Montreal classification, Harvey-Bradshaw Index or Partial Mayo score, endoscopic disease severity indices and IBD Disk score were documented in those with confirmed diagnosis at endoscopy. Vitamin D deficiency was defined as <50nmol/l. Results: 179 patients had a Vitamin D level recorded;58 Ulcerative colitis (UC), 58 Crohn's disease (CD), 53 non-IBD controls and 10 still awaiting diagnosis. 44(76%) CD, 32(55%) UC and 28(53%) non-IBD control patients were Vitamin D deficient at first presentation. Median levels were lowest in CD, with a significant difference between CD and non-IBD (median 35nmol/l;IQR 24.05 vs. median 48.9nmol/l;IQR 49.1;p=0.004). Regression analysis demonstrated patients with Crohn's disease were four times more likely to have Vitamin D deficiency compared to UC (OR 4.08;95% CI 1.35-12.36) at diagnosis. No correlation was seen between absolute vitamin D levels or vitamin deficiency state and faecal calprotectin when controlled for various factors regardless of the IBD subtype. The cohort distributions are demonstrated in Figure 1. Within the IBD cohort, Vitamin D levels were significantly lower in Black or Asian patients vs White patients (median 28.5;IQR 20.85 vs median 43.3;IQR 33.95;p=0.004). Figure 2 provides an overview of the cohort distributions. Vitamin D levels at presentation, as demonstrated in Table 1, did not correlate with Disease activity markers (DAMS) whereas baseline haemoglobin did, albeit weakly. Interestingly, Vitamin D and Haemoglobin correlated without reaching statistical significance (Spearman's rho 0.149;p=0.08). Conclusion: Our inception dataset demonstrates high rates of Vitamin D deficiency comparable to prior studies in IBD patients. Both CD and Black or Asian ethnicity were strongly associated with Vitamin D deficiency. Baseline Vitamin D did not correlate with disease activity markers whereas anaemia showed consistent weak association. Our study demonstrates the problem of hypovitaminosis D and the importance of measurement and supplementation, particularly in Black and Asian CD patients, from diagnosis.

Insights into Off-Label therapeutic strategies against mild and severe COVID-19 infection

Currently, prevention and control of the coronavirus disease pneumonia epidemic situation are grim globally. To cope with total sheer carriers and patients of COVID-19 requires intensive medical support and adjunctive therapies to overcome the disease. The epidemic can be controlled with the help of both, disease suppression via community health measures and adjunctive therapies for patients suffering from infection. Till date, we do not have any proper antiCOVID-19 therapy. In order to achieve the overall realization of this pandemic, there is a need to identify treatments depending upon their direct or indirect targets;like inhibition of polyprotein synthesis, transmembrane serine protease, inhibition of viral entry and endocytosis. This could be possible by turning the focus in the direction towards the development of numerous tentative drugs, particularly in the severe to badly ill. Though, majority of these off-label adjunctive medicines are being inspected in a lot of clinical trials at different stages, scientific organizations have endeavored to elucidate the situation where these adjunctive drugs might be practiced as off-label, open- label or compassionate. Our review compiles the adjunctive therapies adopted in COVID-19 infected patients according to clinical severity in conjugation with practicing recommendations from existing guidance rules issued by global professional bodies in healthcare. © 2021 Pakistan Journal of Pharmaceutical Sciences. All rights reserved.

Review-Insights into Off-Label therapeutic strategies against mild and severe COVID-19 infection

Currently, prevention and control of the coronavirus disease pneumonia epidemic situation are grim globally. To cope with total sheer carriers and patients of COVID-19 requires intensive medical support and adjunctive therapies to overcome the disease. The epidemic can be controlled with the help of both, disease suppression via community health measures and adjunctive therapies for patients suffering from infection. Till date, we do not have any proper anti-COVID-19 therapy. In order to achieve the overall realization of this pandemic, there is a need to identify treatments depending upon their direct or indirect targets;like inhibition of polyprotein synthesis, transmembrane serine protease, inhibition of viral entry and endocytosis. This could be possible by turning the focus in the direction towards the development of numerous tentative drugs, particularly in the severe to badly ill. Though, majority of these off-label adjunctive medicines are being inspected in a lot of clinical trials at different stages, scientific organizations have endeavored to elucidate the situation where these adjunctive drugs might be practiced as off-label, open- label or compassionate. Our review compiles the adjunctive therapies adopted in COVID-19 infected patients according to clinical severity in conjugation with practicing recommendations from existing guidance rules issued by global professional bodies in healthcare.

Psychological sequelae of covid 19 calamity on medical personnel in pakistan

Aim: To gauge the physiological sequelae of covid-19 pandemic on medical personnel in Pakistan. Place & duration: An online cross sectional study was conducted from May, 2020 to August, 2020 in Lahore. Methodology: 17 score PTSD check list civilian version was used to assess the symptoms of post-Traumatic stress disorder in medical personnel. Results: Mean post-Traumatic stress score (PTSS) was 39±15 with a range of 18-89. 66% (n=240) of the participants experienced moderate to extreme stress level. Chi Square test was used to determine an association between higher stress level and age, gender and staff category. Higher stress scores were associated with females (p<0.01). Conclusion: Rewarding the health personnel with gratitude, acknowledgement, financial compensations and provision of personal protective equipments (PPEs) can halt the psychological sequelae and is a promise to win this battle.

Can SARS-CoV-2 Viral RNA Continually Persist in an Asymptomatic COVID-19 Patient?

An asymptomatic 39-year-old male patient with well-controlled hypertension on a combination of antihypertensives including angiotensin receptor blocker was screened positive for SARS-CoV-2 by RT-PCR nasopharyngeal (NP) swab and was admitted to an isolation facility in Dubai on March 23, 2020. He had a history of exposure to a COVID-19 patient a few days prior to the screening test. His chest X-ray showed signs of pneumonitis. He was discharged from the isolation facility on day 28 with 2 consecutive negative SARS-CoV-2 RT-PCR NP swab results, 24 h apart. After 14 days of home quarantine, he tested positive again for SARS-CoV-2 on day 44 and was again isolated in our facility. He continued testing positive until day 51, after which he was discharged again following 2 consecutive negative tests 24 h apart.