The 2021 WHO catalogue of Mycobacterium tuberculosis complex mutations associated with drug resistance: a genotypic analysis.

Background: Molecular diagnostics are considered the most promising route to achievement of rapid, universal drug susceptibility testing for Mycobacterium tuberculosis complex (MTBC). We aimed to generate a WHO-endorsed catalogue of mutations to serve as a global standard for interpreting molecular information for drug resistance prediction. Methods: In this systematic analysis, we used a candidate gene approach to identify mutations associated with resistance or consistent with susceptibility for 13 WHO-endorsed antituberculosis drugs. We collected existing worldwide MTBC whole-genome sequencing data and phenotypic data from academic groups and consortia, reference laboratories, public health organisations, and published literature. We categorised phenotypes as follows: methods and critical concentrations currently endorsed by WHO (category 1); critical concentrations previously endorsed by WHO for those methods (category 2); methods or critical concentrations not currently endorsed by WHO (category 3). For each mutation, we used a contingency table of binary phenotypes and presence or absence of the mutation to compute positive predictive value, and we used Fisher's exact tests to generate odds ratios and Benjamini-Hochberg corrected p values. Mutations were graded as associated with resistance if present in at least five isolates, if the odds ratio was more than 1 with a statistically significant corrected p value, and if the lower bound of the 95% CI on the positive predictive value for phenotypic resistance was greater than 25%. A series of expert rules were applied for final confidence grading of each mutation. Findings: We analysed 41 137 MTBC isolates with phenotypic and whole-genome sequencing data from 45 countries. 38 215 MTBC isolates passed quality control steps and were included in the final analysis. 15 667 associations were computed for 13 211 unique mutations linked to one or more drugs. 1149 (7·3%) of 15 667 mutations were classified as associated with phenotypic resistance and 107 (0·7%) were deemed consistent with susceptibility. For rifampicin, isoniazid, ethambutol, fluoroquinolones, and streptomycin, the mutations' pooled sensitivity was more than 80%. Specificity was over 95% for all drugs except ethionamide (91·4%), moxifloxacin (91·6%) and ethambutol (93·3%). Only two resistance mutations were identified for bedaquiline, delamanid, clofazimine, and linezolid as prevalence of phenotypic resistance was low for these drugs. Interpretation: We present the first WHO-endorsed catalogue of molecular targets for MTBC drug susceptibility testing, which is intended to provide a global standard for resistance interpretation. The existence of this catalogue should encourage the implementation of molecular diagnostics by national tuberculosis programmes. Funding: Unitaid, Wellcome Trust, UK Medical Research Council, and Bill and Melinda Gates Foundation

Enhancement of Esterification of Propionic Acid with Isopropyl Alcohol by Pervaporation Reactor

With increasing cost of raw materials and energy, there is an increasing inclination of chemical process industries toward new processes that result in lesser waste generation, greater efficiency, and substantial yield of the desired products. Esterification is a chemical reaction in which two reactants carboxylic acid and alcohol react to form an ester and water. This reaction is a reversible reaction and the equilibrium conversion can be altered by varying the process parameters. Pervaporation reactor can enhance the conversion by shifting the equilibrium of reversible esterification reactions. Polyvinyl alcohol-polyether sulfone composite hydrophilic membrane was used for pervaporation-assisted esterification of propionic acid with isopropyl alcohol. The experiments were carried out in the presence of sulphuric acid as a catalyst at 50°C to 80°C with various reactants ratios. The esterification was carried out for catalyst loadings of 0.089 kmol/m3 to 0.447 kmol/m3. The molar ratios of isopropyl to propionic acid used for the experiment were 1 to 1.5. Maximum conversion was obtained for the ratio of 1.4. Also effect of other parameters such as process temperature and catalyst concentration was discussed. It was found that the use of pervaporation reactor increased the conversion of the propionic acid considerably

Optimization of fluoride removal using ultrasonically improved electrochemically generated adsorbent: A Taguchi approach

Ultrasonically improved electrochemically generated adsorbent (UEGA) has been synthesized and used for adsorption of fluoride ions from fluoride laden waste water. UEGA was prepared in two major steps, firstly electrochemically generated adsorbent (EGA) was prepared using electrolytic method followed by ultrasonication treatment. Ultrasonication causes size reduction which leads to increase in surface area viz. active site which helps to enhance attachment of negatively charged fluoride ion on positively changed UEGA from waste water. UEGA was prepared at three different amplitude i.e. 50, 70 and 90% respectively. Taguchi optimization for defluoridation was carried out considering operating parameters such as initial concentration; contact time; adsorbent dose; and temperature. The results obtained demonstrated that adsorption showed different fluoride removal at varying frequency. This study proved that varying percentage amplitude of ultrasonication significantly affects defluoridation efficiency

Enhancement of Esterification of Propionic Acid with Isopropyl Alcohol by Pervaporation Reactor

With increasing cost of raw materials and energy, there is an increasing inclination of chemical process industries toward new processes that result in lesser waste generation, greater efficiency, and substantial yield of the desired products. Esterification is a chemical reaction in which two reactants carboxylic acid and alcohol react to form an ester and water. This reaction is a reversible reaction and the equilibrium conversion can be altered by varying the process parameters. Pervaporation reactor can enhance the conversion by shifting the equilibrium of reversible esterification reactions. Polyvinyl alcohol-polyether sulfone composite hydrophilic membrane was used for pervaporation-assisted esterification of propionic acid with isopropyl alcohol. The experiments were carried out in the presence of sulphuric acid as a catalyst at 50 ∘ C to 80 ∘ C with various reactants ratios. The esterification was carried out for catalyst loadings of 0.089 kmol/m 3 to 0.447 kmol/m 3 . The molar ratios of isopropyl to propionic acid used for the experiment were 1 to 1.5. Maximum conversion was obtained for the ratio of 1.4. Also effect of other parameters such as process temperature and catalyst concentration was discussed. It was found that the use of pervaporation reactor increased the conversion of the propionic acid considerably

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)