Mycoplasma pneumoniae Pneumonia with Worsening Pleural Effusion Despite Treatment with Appropriate Antimicrobials: Case report

Mycoplasma pneumoniae is a common cause of community-acquired pneumonia. As M. pneumoniae pneumonia is usually a mild and self-limiting disease, complications such as pleural effusion occur only rarely. We report a 22-year-old woman who presented to the Emergency Medicine Department of the Sultan Qaboos University Hospital, Muscat, Oman, in 2017 with an eight-day history of fever associated with coughing, chills and rigors. She was diagnosed with M. pneumoniae pneumonia, but subsequently developed pleural effusion which worsened despite treatment with appropriate antimicrobials. The pleural effusion required drainage, which revealed that it was of the more severe exudative type. Following drainage, the patient improved dramatically. She was discharged and advised to continue taking antibiotics.Keywords: Mycoplasma pneumoniae; Bacterial Pneumonia; Pleural Effusion; Antimicrobial Agents; Drainage; Case Report; Oman

Evolution of Minimally Invasive Adrenal Surgery at a Tertiary Care Centre in Oman

Objective: We reviewed the case records of adrenalectomy cases at our institution between January 2010 and December 2020 and report the outcomes of both open and laparoscopic adrenalectomy (LA). Methods: This retrospective study included patients who underwent adrenal surgery from January 2010 to December 2020. We recorded demographic details, indications, surgical approach, intra operative data and complications. The final pathology and outcome at the last follow up was also documented. Data was analyzed through the SPSS program. Results: Fifty two patients underwent 61 adrenalectomy procedures. Six patients had bilateral procedure and 3 patients underwent redo surgery accounting for 55 subjects. Open adrenalectomy (OA) was performed on 11 patients and 44 patients underwent LA. Majority of the patients (27) were obese having BMI > 30. Functional adenoma was excised in 36 patients with final diagnosis of Conn’s syndrome in 15, Pheochromocytoma in 13 and Cushing syndrome in 9 patients. Five patients had surgery for oncological indications. Nonfunctional adenoma was excised in 13 patients, with a mean size of 8.9 cm (range 4-15 cm). The mean duration of surgery was less in laparoscopic procedure (199 min) compared to open (246 min). The mean estimated blood loss in LA was significantly less (108ml vs 450 ml, p-value < 0.05). Out of 55 subjects only 1 patients developed Clavien-dindo grade 2 complication. Conclusion: At our institution both laparoscopic and open adrenalectomy were safely performed. There is a trend to perform LA and with experience the duration of surgery and EBL are demonstrating positive trend. Keywords: Adrenal Gland Surgery; Laparoscopic Adrenalectomy; Open Adrenalectomy; Pheochromocytoma; Adrenal Metastasis; Nonfunctional Adrenal Tumors; Oman

Damage identification in a concrete beam using curvature difference ratio

Previous studies utilising changes in mode shape or curvature to locate damage rely on the fact that the greatest change occurs around the defect. However, in concrete beams this fact is undermined due to the nature of the defect as distributed multi-site cracks. In addition, differences in mode shape and curvature as ways to locate the damage is unstable because of occurrence of modal nodes and inflection points. In this paper, one interesting solution to this problem is being tested by establishing a new non-dimensional expression designated the 'Curvature Difference Ratio (CDR)'. This parameter exploits the ratio of differences in curvature of a specific mode shape for a damaged stage and another reference stage. The expression CDR is reasonably used to locate the damage and estimate the dynamic bending stiffness in a successively loaded 6m concrete beam. Results obtained by the proposed technique are tested and validated with a case study results done by Ren and De Roeck [1] also by Maeck and De Roeck [2]. Another contribution of this work is that relating changes in vibration properties to the design bending moment at beam sections as defined in Eurocode 2 specifications [3]. Linking between a beam section condition and the change in vibration data will help to give a better comprehension on the beam condition than the applied load

Damage and repair classification in reinforced concrete beams using frequency domain data

This research aims at developing a new vibration-based damage classification technique that can efficiently be applied to a real-time large data. Statistical pattern recognition paradigm is relevant to perform a reliable site-location damage diagnosis system. By adopting such paradigm, the finite element and other inverse models with their intensive computations, corrections and inherent inaccuracies can be avoided. In this research, a two-stage combination between principal component analysis and Karhunen-Loéve transformation (also known as canonical correlation analysis) was proposed as a statistical-based damage classification technique. Vibration measurements from frequency domain were tested as possible damage-sensitive features. The performance of the proposed system was tested and verified on real vibration measurements collected from five laboratory-scale reinforced concrete beams modelled with various ranges of defects. The results of the system helped in distinguishing between normal and damaged patterns in structural vibration data. Most importantly, the system further dissected reasonably each main damage group into subgroups according to their severity of damage. Its efficiency was conclusively proved on data from both frequency response functions and response-only functions. The outcomes of this two-stage system showed a realistic detection and classification and outperform results from the principal component analysis-only. The success of this classification model is substantially tenable because the observed clusters come from well-controlled and known state conditions

Mental health in distance learning: a taxonomy of barriers and enablers to student mental wellbeing

Student mental health is a critical issue in higher education. It is understood that higher education can act to trigger or exacerbate mental health difficulties, but research in this area has focused primarily on campus environments, identifying stressors such as halls of residence. Since distance learning students disclose mental health issues at a higher rate than campus students, and completion and progression gaps are on a par with the sector, it is critical that the barriers and enablers to mental wellbeing in distance learning are understood. This paper reports on a qualitative study that investigated barriers and enablers to mental wellbeing and study success that students experienced in distance learning. 15 distance learning students and 5 tutors were interviewed using narrative enquiry; students told their own stories and tutors told stories of students they had supported. Barriers and enablers were identified across different aspects of study, skills-development and the distance learning environment, and are presented in a taxonomy of barriers and enablers that suggest a range of implications for distance learning educators and policy developers

Poverty and Wellbeing Impacts of Microfinance : What Do We Know?

Over the last 35 years, microfinance has been generally regarded as an effective policy tool in the fight against poverty. Yet, the question of whether access to credit leads to poverty reduction and improved wellbeing remains open. To address this question, we conduct a systematic review of the quantitative literature of microfinance’s impacts in the developing world, and develop a theory of change that links inputs to impacts on several welfare outcomes. Overall, we find that the limited comparability of outcomes and the heterogeneity of microfinance-lending technologies, together with a considerable variation in socio-economic conditions and contexts in which impact studies have been conducted, render the interpretation and generalization of findings intricate. Our results indicate that, at best, microfinance induces short-term dynamism in the financial life of the poor; however, we do not find compelling evidence that this dynamism leads to increases in income, consumption, human capital and assets, and, ultimately, a reduction in poverty

Development of a quality indicator set to measure and improve quality of ICU care in low- and middle-income countries

PURPOSE: To develop a set of actionable quality indicators for critical care suitable for use in low- or middle-income countries (LMICs). METHODS: A list of 84 candidate indicators compiled from a previous literature review and stakeholder recommendations were categorised into three domains (foundation, process, and quality impact). An expert panel (EP) representing stakeholders from critical care and allied specialties in multiple low-, middle-, and high-income countries was convened. In rounds one and two of the Delphi exercise, the EP appraised (Likert scale 1–5) each indicator for validity, feasibility; in round three sensitivity to change, and reliability were additionally appraised. Potential barriers and facilitators to implementation of the quality indicators were also reported in this round. Median score and interquartile range (IQR) were used to determine consensus; indicators with consensus disagreement (median < 4, IQR ≤ 1) were removed, and indicators with consensus agreement (median ≥ 4, IQR ≤ 1) or no consensus were retained. In round four, indicators were prioritised based on their ability to impact cost of care to the provider and recipient, staff well-being, patient safety, and patient-centred outcomes. RESULTS: Seventy-one experts from 30 countries (n = 45, 63%, representing critical care) selected 57 indicators to assess quality of care in intensive care unit (ICU) in LMICs: 16 foundation, 27 process, and 14 quality impact indicators after round three. Round 4 resulted in 14 prioritised indicators. Fifty-seven respondents reported barriers and facilitators, of which electronic registry-embedded data collection was the biggest perceived facilitator to implementation (n = 54/57, 95%) Concerns over burden of data collection (n = 53/57, 93%) and variations in definition (n = 45/57, 79%) were perceived as the greatest barrier to implementation. CONCLUSION: This consensus exercise provides a common set of indicators to support benchmarking and quality improvement programs for critical care populations in LMICs

Progressive Visceral Leishmaniasis Is Driven by Dominant Parasite-induced STAT6 Activation and STAT6-dependent Host Arginase 1 Expression

The clinicopathological features of the hamster model of visceral leishmaniasis (VL) closely mimic active human disease. Studies in humans and hamsters indicate that the inability to control parasite replication in VL could be related to ineffective classical macrophage activation. Therefore, we hypothesized that the pathogenesis of VL might be driven by a program of alternative macrophage activation. Indeed, the infected hamster spleen showed low NOS2 but high arg1 enzyme activity and protein and mRNA expression (p<0.001) and increased polyamine synthesis (p<0.05). Increased arginase activity was also evident in macrophages isolated from the spleens of infected hamsters (p<0.05), and arg1 expression was induced by L. donovani in primary hamster peritoneal macrophages (p<0.001) and fibroblasts (p<0.01), and in a hamster fibroblast cell line (p<0.05), without synthesis of endogenous IL-4 or IL-13 or exposure to exogenous cytokines. miRNAi-mediated selective knockdown of hamster arginase 1 (arg1) in BHK cells led to increased generation of nitric oxide and reduced parasite burden (p<0.005). Since many of the genes involved in alternative macrophage activation are regulated by Signal Transducer and Activator of Transcription-6 (STAT6), and because the parasite-induced expression of arg1 occurred in the absence of exogenous IL-4, we considered the possibility that L. donovani was directly activating STAT6. Indeed, exposure of hamster fibroblasts or macrophages to L. donovani resulted in dose-dependent STAT6 activation, even without the addition of exogenous cytokines. Knockdown of hamster STAT6 in BHK cells with miRNAi resulted in reduced arg1 mRNA expression and enhanced control of parasite replication (p<0.0001). Collectively these data indicate that L. donovani infection induces macrophage STAT6 activation and STAT6-dependent arg1 expression, which do not require but are amplified by type 2 cytokines, and which contribute to impaired control of infection

Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial

BACKGROUND Non-alcoholic steatohepatitis (NASH) is a common type of chronic liver disease that can lead to cirrhosis. Obeticholic acid, a farnesoid X receptor agonist, has been shown to improve the histological features of NASH. Here we report results from a planned interim analysis of an ongoing, phase 3 study of obeticholic acid for NASH. METHODS In this multicentre, randomised, double-blind, placebo-controlled study, adult patients with definite NASH, non-alcoholic fatty liver disease (NAFLD) activity score of at least 4, and fibrosis stages F2-F3, or F1 with at least one accompanying comorbidity, were randomly assigned using an interactive web response system in a 1:1:1 ratio to receive oral placebo, obeticholic acid 10 mg, or obeticholic acid 25 mg daily. Patients were excluded if cirrhosis, other chronic liver disease, elevated alcohol consumption, or confounding conditions were present. The primary endpoints for the month-18 interim analysis were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of fibrosis, with the study considered successful if either primary endpoint was met. Primary analyses were done by intention to treat, in patients with fibrosis stage F2-F3 who received at least one dose of treatment and reached, or would have reached, the month 18 visit by the prespecified interim analysis cutoff date. The study also evaluated other histological and biochemical markers of NASH and fibrosis, and safety. This study is ongoing, and registered with ClinicalTrials.gov, NCT02548351, and EudraCT, 20150-025601-6. FINDINGS Between Dec 9, 2015, and Oct 26, 2018, 1968 patients with stage F1-F3 fibrosis were enrolled and received at least one dose of study treatment; 931 patients with stage F2-F3 fibrosis were included in the primary analysis (311 in the placebo group, 312 in the obeticholic acid 10 mg group, and 308 in the obeticholic acid 25 mg group). The fibrosis improvement endpoint was achieved by 37 (12%) patients in the placebo group, 55 (18%) in the obeticholic acid 10 mg group (p=0·045), and 71 (23%) in the obeticholic acid 25 mg group (p=0·0002). The NASH resolution endpoint was not met (25 [8%] patients in the placebo group, 35 [11%] in the obeticholic acid 10 mg group [p=0·18], and 36 [12%] in the obeticholic acid 25 mg group [p=0·13]). In the safety population (1968 patients with fibrosis stages F1-F3), the most common adverse event was pruritus (123 [19%] in the placebo group, 183 [28%] in the obeticholic acid 10 mg group, and 336 [51%] in the obeticholic acid 25 mg group); incidence was generally mild to moderate in severity. The overall safety profile was similar to that in previous studies, and incidence of serious adverse events was similar across treatment groups (75 [11%] patients in the placebo group, 72 [11%] in the obeticholic acid 10 mg group, and 93 [14%] in the obeticholic acid 25 mg group). INTERPRETATION Obeticholic acid 25 mg significantly improved fibrosis and key components of NASH disease activity among patients with NASH. The results from this planned interim analysis show clinically significant histological improvement that is reasonably likely to predict clinical benefit. This study is ongoing to assess clinical outcomes. FUNDING Intercept Pharmaceuticals