Impact of COVID-19 on liver transplant recipients: A nationwide cohort study evaluating hospitalization, transplant rejection, and inpatient mortality.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has posed a major public health concern worldwide. Patients with comorbid conditions are at risk of adverse outcomes following COVID-19. Solid organ transplant recipients with concurrent immunosuppression and comorbidities are more susceptible to a severe COVID-19 infection. It could lead to higher rates of inpatient complications and mortality in this patient population. However, studies on COVID-19 outcomes in liver transplant (LT) recipients have yielded inconsistent findings. AIM: To evaluate the impact of the COVID-19 pandemic on hospital-related outcomes among LT recipients in the United States. METHODS: We conducted a retrospective cohort study using the 2019-2020 National Inpatient Sample database. Patients with primary LT hospitalizations and a secondary COVID-19 diagnosis were identified using the International Classification of Diseases, Tenth Revision coding system. The primary outcomes included trends in LT hospitalizations before and during the COVID-19 pandemic. Secondary outcomes included comparative trends in inpatient mortality and transplant rejection in LT recipients. RESULTS: A total of 15720 hospitalized LT recipients were included. Approximately 0.8% of patients had a secondary diagnosis of COVID-19 infection. In both cohorts, the median admission age was 57 years. The linear trends for LT hospitalizations did not differ significantly before and during the pandemic (P = 0.84). The frequency of in-hospital mortality for LT recipients increased from 1.7% to 4.4% between January 2019 and December 2020. Compared to the pre-pandemic period, a higher association was noted between LT recipients and in-hospital mortality during the pandemic, with an odds ratio (OR) of 1.69 [95% confidence interval (CI): 1.55-1.84), P < 0.001]. The frequency of transplant rejections among hospitalized LT recipients increased from 0.2% to 3.6% between January 2019 and December 2020. LT hospitalizations during the COVID-19 pandemic had a higher association with transplant rejection than before the pandemic [OR: 1.53 (95%CI: 1.26-1.85), P < 0.001]. CONCLUSION: The hospitalization rates for LT recipients were comparable before and during the pandemic. Inpatient mortality and transplant rejection rates for hospitalized LT recipients were increased during the COVID-19 pandemic.

Predicting short-term thromboembolic risk following Roux-en-Y gastric bypass using supervised machine learning.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is a widely recognized bariatric procedure that is particularly beneficial for patients with class III obesity. It aids in significant weight loss and improves obesity-related medical conditions. Despite its effectiveness, postoperative care still has challenges. Clinical evidence shows that venous thromboembolism (VTE) is a leading cause of 30-d morbidity and mortality after RYGB. Therefore, a clear unmet need exists for a tailored risk assessment tool for VTE in RYGB candidates. AIM: To develop and internally validate a scoring system determining the individualized risk of 30-d VTE in patients undergoing RYGB. METHODS: Using the 2016-2021 Metabolic and Bariatric Surgery Accreditation Quality Improvement Program, data from 6526 patients (body mass index ≥ 40 kg/m2) who underwent RYGB were analyzed. A backward elimination multivariate analysis identified predictors of VTE characterized by pulmonary embolism and/or deep venous thrombosis within 30 d of RYGB. The resultant risk scores were derived from the coefficients of statistically significant variables. The performance of the model was evaluated using receiver operating curves through 5-fold cross-validation. RESULTS: Of the 26 initial variables, six predictors were identified. These included a history of chronic obstructive pulmonary disease with a regression coefficient (Coef) of 2.54 (P < 0.001), length of stay (Coef 0.08, P < 0.001), prior deep venous thrombosis (Coef 1.61, P < 0.001), hemoglobin A1c > 7% (Coef 1.19, P < 0.001), venous stasis history (Coef 1.43, P < 0.001), and preoperative anticoagulation use (Coef 1.24, P < 0.001). These variables were weighted according to their regression coefficients in an algorithm that was generated for the model predicting 30-d VTE risk post-RYGB. The risk model's area under the curve (AUC) was 0.79 [95% confidence interval (CI): 0.63-0.81], showing good discriminatory power, achieving a sensitivity of 0.60 and a specificity of 0.91. Without training, the same model performed satisfactorily in patients with laparoscopic sleeve gastrectomy with an AUC of 0.63 (95%CI: 0.62-0.64) and endoscopic sleeve gastroplasty with an AUC of 0.76 (95%CI: 0.75-0.78). CONCLUSION: This simple risk model uses only six variables to assist clinicians in the preoperative risk stratification of RYGB patients, offering insights into factors that heighten the risk of VTE events.

PCR based early detection and antibiotic resistance pattern of Salmonella Gallinarum isolates from Pakistan poultry.

The poultry industry in developing countries is still combating mortality and economic loss due to Salmonella contamination. Salmonella Gallinarum is a common pathogen of poultry birds, being the etiologic agent of fowl typhoid, which specifically infects adult birds via the oral-fecal route. Timely detection of S. Gallinarum in poultry flocks can allow early treatment intervention leading to a decrease in economic losses. Detection of S. Gallinarum is challenging, while its PCR-based detection is a promising strategy, however, due to its high genomic similarity with other commonly existing Salmonella spp., identification of S. Gallinarum from poultry samples with high specificity is still a challenge. The current study was conducted to isolate S. Gallinarum from different districts of Pakistan, assess their antibiotic susceptibility profile, and develop a method for its early detection. A total of 20 strains were isolated using buffer peptone water, selenite cysteine broth, and Xylose Lysine Tergitol-4 (XLT-4) agar supplemented with tergitol and characterized by biochemical procedures. The antibiotic sensitivity profile highlighted the highest resistance of isolates towards novobiocin and nalidixic acid, commonly used antibiotics in Pakistan Poultry production. The primers designed to amplify a unique genomic region of S. Gallinarum, showed successful detection of twenty S. Gallinarum strains, while no amplification with genomic DNA from other common Salmonella spp. The reported method can be utilized to detect S. Gallinarum from tissue samples of infected birds in a short time leading to early diagnosis and timely treatment intervention.

Coupling CRISPR/Cas9 and Lambda Red Recombineering System for Genome Editing of Salmonella Gallinarum and the Effect of ssaU Knock-Out Mutant on the Virulence of Bacteria.

The poultry industry in developing countries still faces a significant threat from fowl typhoid, a disease caused by Salmonella Gallinarum that has been well contained in more economically developed countries. In addition to the virulence exhibited by large virulence plasmid (85 kb), Salmonella Pathogenicity Island 2 in S. Gallinarum plays a key role in mediating disease through its type III secretion systems (TTSS). The TTSS secrete effector protein across the Salmonella containing vacuoles and mediate the internalization of bacteria by modulating vesicular passage. In this study, candidate virulent ssaU gene (~1 kb) encoding type III secretion system was successfully deleted from indigenously isolated S. Gallinarum genome through homology-directed repair using CRISPR/Cas9 and lambda recombination systems. CRISPR/Cas9-based genome editing of poultry-derived Salmonella Gallinarum has not been previously reported, which might be linked to a lack of efficiency in its genetic tools. This is the first study which demonstrates a complete CRISPR/Cas9-based gene deletion from this bacterial genome. More importantly, a poultry experimental model was employed to assess the virulence potential of this mutant strain (ΔssaU_SG18) which was unable to produce any mortality in the experimentally challenged birds as compared to the wild type strain. No effect on weight gain was observed whereas bacteria were unable to colonize the intestine and liver in our challenge model. This in vivo loss of virulence in mutant strain provides an excellent functionality of this system to be useful in live vaccine development against this resistant and patho genic bacteria.

Angioedema as a Rare Presentation of Systemic Lupus Erythematosus.

Angioedema (AE) is an immune-mediated tissue swelling that can be life-threatening if it compromises the airway. This makes prompt diagnosis and management of the condition excruciatingly important. It can be hereditary or associated with infections, malignancies, and autoimmune diseases. There have been reported cases in the literature where Systemic lupus erythematosus (SLE) patients developed acquired angioedema raising suspicion of a possible association between the two conditions. We describe a case of a patient with no known medical issues, presenting with acute onset of her first episode of angioedema with airway compromise. Because of the rarity of awareness of the possible association of our conditions of interest, there was an inevitable delay in diagnosis and the patient was eventually diagnosed to have SLE and associated acquired angioedema as its first presentation.  This case report highlights the importance of maintaining high suspicion for SLE in patients with an isolated first episode of AE and discusses mechanisms involved in the disease process to shed light on available treatment modalities.

CRISPR/Cas9-Based Deletion of SpvB Gene From Salmonella gallinarum Leads to Loss of Virulence in Chicken.

Salmonella Gallinarum causes fowl typhoid in poultry leading to a huge economic loss to the poultry industry. The large virulence plasmid of S. gallinarum has been associated with various systemic infections in poultry. A five-gene spanning region (spvRABCD) of 7.8 kb on the large plasmid mainly confers virulence to the bacteria. However, the exact role of these genes in virulence has not been elucidated yet. SpvB exhibits delayed cell death by preventing actin polymerization followed by apoptosis during intracellular infection. The specific role of SpvB in causing the disease is not known yet. In the current study, the SpvB gene was deleted through CRISPR/Cas9 method from a large virulent plasmid of locally isolated S. gallinarum strain (SG18). The homology-directed repair method was used for complete deletion of SpvB gene using the modified pCas9 plasmid. The SpvB-deleted S. gallinarum strain (ΔSpvB_SG18), when tested for its virulence in broiler chicken showed no diseases signs and mortality. In addition, the avirulent strain does not affect the bird's weight and was rapidly cleared from the liver after infection. However, it cleared from the intestine only after 4-5 days, which suggests that the ΔSpvB_SG18 strain is unable to invade from the intestine to the liver. This is the first study to report a complete gene deletion from the S. gallinarum virulent plasmid and its effect. This method will be useful for the deletion of virulent genes from S. gallinarum, to study their role in pathogenesis, and to prepare an effective vaccine strain for controlling fowl typhoid in poultry.

Isolation, toxinotyping and antimicrobial susceptibility testing of Clostridium perfringens isolated from Pakistan poultry.

BACKGROUND AND OBJECTIVES: Clostridium perfringens is a causative agent of enteric infections in animals including poultry by producing twenty different types of toxins. A single strain produces only a subset of these toxins, which form the basis of its classification into seven toxinotypes (A-G). C. perfringens toxinotype A is a widespread cause of necrotic enteritis (NE) in poultry. The current study was conducted to determine the prevalence of different toxins and antimicrobial susceptibility of C. perfringens isolated from Pakistan NE affected poultry. METHODS: A total of 134 intestinal samples of the diseased birds were collected postmortem and processed for isolation of C. perfringens using tryptose sulphite cycloserine (TSC) agar supplemented with d-cycloserine. Isolates were confirmed by Gram's staining, biochemical and molecular analyses. Toxinotyping was performed by multiplex PCR. Antimicrobial susceptibility profile of isolates was performed by Kirby Bauer disc diffusion method. RESULTS: A total of 34 strains of C. perfringens were isolated from 134 samples with prevalence rate of 25.37%. All the isolated strains were toxinotype A, as they were positive for alpha toxin (CPA) and negative for other tested toxins such as beta (CPB), epsilon (ETX), iota (ITX), enterotoxin (CPE), toxin perfringens large (TpeL) and necrotic B-like toxin (NetB). Interestingly, all the isolated strains of C. perfringens were multidrug resistant. The highest resistance was observed against Neomycin, Trimethoprim, Tetracycline and Lincomycin which are routinely used at Pakistan poultry production. CONCLUSION: C. perfringens toxinotype A is prevalent in Pakistan poultry. Incidence of C. perfringens with prevalence rate of 25.37% can pose serious threat to Pakistan's poultry industry given that all the isolated strains were multidrug resistant. Our findings highlight the need for new antibiotics and antibiotic alternatives to overcome multidrug resistance.

Frequency of Electrolyte Imbalance in Patients Presenting With Acute Stroke.

Introduction Electrolyte disturbances are commonly reported in acute stroke in studies conducted in the western world. Presently, the data available about the prevalence of electrolyte disturbance in patients with stroke are not sufficient, especially from developing countries. The purpose of our study is to determine the frequency of occurrence of electrolyte imbalance in patients presenting with acute stroke in a tertiary care hospital. Methods This descriptive cross-sectional study was conducted in the department of internal medicine and neurology in a tertiary care hospital, Pakistan, from December 2019 to March 2021. A total of 300 patients, aged between 30 and 70 years, with either ischemic or hemorrhagic stroke, as diagnosed on contrast tomography (CT) scan of the head or magnetic resonance imaging (MRI) of the brain, were enrolled in the study. The biochemical analysis of the stroke patients was done. Results Out of the 300 participants, 139 (46.3%) participants were from the ischemic stroke group while 161 (53.7%) were from the hemorrhagic stroke group. The mean sodium level was significantly lower in the ischemic group as compared to the hemorrhagic group (129.41 ± 3.12 mEq/L vs. 134.42 ± 3.46 mEq/L; p-value: <0.0001). Potassium level was significantly higher in the hemorrhagic group compared to the ischemic group (6.27 ± 1.12 mmol vs. 4.31 ± 0.71 mmol; p-value: <0.0001). Conclusion Patients coming to emergency with stroke should be screened immediately for electrolyte imbalance. Early identification of rapid imbalances of serum electrolytes may aid in prompt medical intervention and resultant improved outcomes in stroke patients. It is crucial that electrolyte imbalances in these patients are closely monitored to avoid any complications.

Association Between Hypertension and Hearing Loss.

Introduction Hypertension (HTN) is a common health problem, diagnosed in every one out of four individuals. It is associated with various complications; however, its impact on hearing loss is not well studied. In this study, we will determine the impact of HTN on hearing. Methods This cross-sectional study was conducted in Jinnah Sindh Medical University from August 2020 to March 2021. Three hundred (300) patients with documented diagnosis of HTN, between the ages of 21 and 50 years, were enrolled in the study. Another 300 non-hypertensive participants were enrolled as a reference group. Participants were sent to trained otolaryngologist technicians, who performed audiometry at six different frequencies for each year (0.5, 1.0, 2.0, 3.0, 4.0, and 6.0 kilohertz (kHz)). The final hearing level was calculated by taking mean of hearing levels of both ears.  Results The hearing levels in audiometry were significantly higher in hypertensive participants compared to non-hypertensive participants (23.4 ± 8.67 dB vs 18.3 ± 6.02 dB; p-value: <0.0001). Participants who had been diagnosed with HTN for more than five years had higher hearing levels in audiometry test compared to participants with less than five years of HTN (24.21 ± 8.92 dB vs. 22.6 ± 8.02 dB; p-value 0.0001). Conclusion Based on our study, HTN is positively correlated with hearing loss. Therefore, longstanding hypertensive patients should be screened regularly in order to assess the status of their hearing abilities.

Association Between Helicobacter pylori Infection and Serum Iron Profile.

INTRODUCTION: Helicobacter pylori (H. pylori) infection is reported to be the most frequent cause of morbidity and mortality in cases of upper gastrointestinal (GI) diseases. There is paucity of research between the possible association of H. pylori and iron stores and iron deficiency anemia (IDA). In this study, we will determine if there is an association between serum total iron-binding capacity (TIBC), serum iron and ferritin levels, and H. pylori infection. METHODS: This case-control study was conducted in the gastroenterology ward of a major hospital in Pakistan from December 2020 to April 2021. Three hundred patients diagnosed with H. pylori were enrolled along with 300 participants in the control group. H. pylori was confirmed or excluded with the help of Giemsa stained gastric biopsy specimens. Blood was sent to the laboratory to test for ferritin, serum iron, and TIBC. Each sample was drawn in the morning to avoid any fluctuations. RESULTS: The mean serum iron level was significantly lower in participants with H. pylori infection compared to those who did not have H. pylori infection (110.72 ± 28.38 ug/dL vs. 162.5 ± 21.18 ug/dL; p-value: <0.0001). Serum ferritin level was significantly higher in participants with H. pylori infection (536.82 ± 117.0 ng/dL vs. 391.31 ± 101.54 ng/dL; p-value: <0.0001). CONCLUSION:  In comparison with the control group, TIBC and serum iron levels were found to be lower in the case group.

Association of Weight Loss With Improved Sexual Function in Females.

Introduction The prevalence of obesity in developing countries, including Pakistan, has increased several fold in recent times. Obesity appears to negatively affect sexual functioning, hence affecting the quality of life. Its impact on sexual function is understudied. In this study, we will determine the impact of weight loss in improving sexual function in the local setting. Methods This prospective study was conducted in the endocrinology unit of a tertiary care hospital in Pakistan from February 2019 to January 2021. After taking informed consent, 300 married female participants were enrolled in the study. The questionnaire was composed using the pointers from the female sexual function index (FSFI). The privacy of the participants was fully ensured. After the survey, participants were counseled on losing weight via various techniques. Participants were followed up on day 30, day 60, and finally on day 90. On day 90, the FSFI questionnaire was repeated to assess sexual function. Weight loss was measured at the end of day 90.  Result A total of 208 participants completed the study. Significant improvement in FSFI score was seen in participants with weight loss between 2% and 5% of their initial body weight (24.01 ± 2.2 vs. 26.07 ± 2.6; p-value: <0.0001). Similarly, a significant improvement in FSFI score was seen in participants with weight loss of more than 5% (24.17 ± 2.2 vs. 27.01 ± 2.6; p-value: <0.0001). Conclusion In conclusion, weight loss is associated with improved sexual function in females. While discussing complications of obesity, impact on sexual function should also be discussed.

Association Between Long-Term Use of Non-steroidal Anti-inflammatory Drugs and Hyperkalemia in Diabetic Patients.

Introduction The association between continuous use of nonsteroidal anti-inflammatory drugs (NSAIDs) and hyperkalemia is not consistent in the literature and creates grounds for further large-scale trials, particularly in patients with a chronic disease that affects renal function, such as diabetes mellitus (DM). In this study, we will compare mean serum potassium level and the prevalence of hyperkalemia in diabetic and non-diabetic patients based on their use of NSAIDs. Methods This case-control study was conducted in the internal medicine unit of a tertiary care hospital from May 2019 to December 2020. After taking informed consent, 700 patients with a confirmed diagnosis of type 2 DM, of either gender, were enrolled in the study via consecutive convenient non-probability technique. Another set of 700 participants from the public were enrolled as the reference or control group. Continuous NSAID use was defined as NSAID used for a minimum of 20 days in the last 30 days. Blood was drawn via phlebotomy and sent to the laboratory to test for potassium level. Results Serum potassium level was significantly higher in diabetic patients with continuous NSAID use compared to the diabetic patients without continuous use (4.8 ± 0.8 mmol/L vs. 4.5 ± 0.7 mmol/L; p-value: 0.0001). Additionally, serum potassium level was significantly higher in non-diabetic patients with continuous NSAID use compared to non-diabetic patients without continuous use (4.3 ± 0.7 mmol/L vs. 3.9 ± 0.5 mmol/L; p-value: 0.0001)  Conclusion In this study, the patients with continuous use of NSAIDs had higher levels of serum potassium level compared to patients without continuous use of NSAIDs. This difference was even higher in diabetic patients.

SGP-C: A Broad Host Range Temperate Bacteriophage; Against Salmonella gallinarum.

Salmonella gallinarum is a poultry restricted-pathogen causing fowl-typhoid disease in adult birds with mortality rates up-to 80% and exhibit resistance against commonly used antibiotics. In this current study, a temperate broad host range bacteriophage SGP-C was isolated against S. gallinarum from poultry digesta. It showed infection ability in all the 15 tested field strains of S. gallinarum. The SGP-C phage produced circular, turbid plaques with alternate rings. Its optimum activity was observed at pH 7.0 and 37-42°C, with a latent period of 45 min and burst size of 187 virions/bacterial cell. The SGP-C lysogens, SGPC-L5 and SGPC-L6 exhibited super-infection immunity against the same phage, an already reported feature of lysogens. A virulence index of 0.5 and 0.001 as MV50 of SGP-C suggests its moderate virulence. The genome of SGP-C found circular double stranded DNA of 42 Kbp with 50.04% GC content, which encodes 63 ORFs. The presence of repressor gene at ORF49, and absence of tRNA sequence in SGP-C genome indicates its lysogenic nature. Furthermore, from NGS analysis of lysogens we propose that SGP-C genome might exist either as an episome, or both as integrated and temporary episome in the host cell and warrants further studies. Phylogenetic analysis revealed its similarity with Salmonella temperate phages belonging to family Siphoviridae. The encoded proteins by SGP-C genome have not showed homology with any known toxin and virulence factor. Although plenty of lytic bacteriophages against this pathogen are already reported, to our knowledge SGP-C is the first lysogenic phage against S. gallinarum reported so far.