Comparative analysis of neutrophil to lymphocyte ratio and derived neutrophil to lymphocyte ratio with respect to outcomes of in-hospital coronavirus disease 2019 patients: A retrospective study

Introduction and objectivesIn patients with coronavirus disease 2019 (COVID-19), several abnormal hematological biomarkers have been reported. The current study aimed to find out the association of neutrophil to lymphocyte ratio (NLR) and derived NLR (dNLR) with COVID-19. The objective was to compare the accuracy of both of these markers in predicting the severity of the disease.Materials and methodsThe study was conducted in a single-center having patients with COVID-19 with a considerable hospital stay. NLR is easily calculated by dividing the absolute neutrophil count (ANC) with the absolute lymphocyte count (ALC) {ANC/ALC}, while dNLR is calculated by ANC divided by total leukocyte count minus ANC {ANC/(WBC-ANC)}. Medians and interquartile ranges (IQR) were represented by box plots. Multivariable logistic regression was performed obtaining an odds ratio (OR), 95% CI, and further adjusted to discover the independent predictors and risk factors associated with elevated NLR and dNLR.ResultsA total of 1,000 patients with COVID-19 were included. The baseline NLR and dNLR were 5.00 (2.91–10.46) and 4.00 (2.33–6.14), respectively. A cut-off value of 4.23 for NLR and 2.63 for dNLR were set by receiver operating characteristic (ROC) analysis. Significant associations of NLR were obtained by binary logistic regression for dependent outcome variables as ICU stay (p < 0.001), death (p < 0.001), and invasive ventilation (p < 0.001) while that of dNLR with ICU stay (p = 0.002), death (p < 0.001), and invasive ventilation (p = 0.002) on multivariate analysis when adjusted for age, gender, and a wave of pandemics. Moreover, the indices were found correlating with other inflammatory markers such as C-reactive protein (CRP), D-dimer, and procalcitonin (PCT).ConclusionBoth markers are equally reliable and sensitive for predicting in-hospital outcomes of patients with COVID-19. Early detection and predictive analysis of these markers can allow physicians to risk assessment and prompt management of these patients

Is the hygiene hypothesis a plausible explanation for the asymmetry in COVID-19 mortality?

Madam, there is large variation observed in COVID-19 outcomes that indicate the existence of individual and population-based factors influencing the infection course (1). By the second wave of COVID-19, mortality rates in twenty most affected countries were varying, ranging from 2% in Philippines to 11% in Mexico (1). A study evaluating WHO’s region-wise statistical observation of six regions showed an Infection Fatality Rate (IFR) of 0.02% for the American, European, and Eastern Mediterranean regions while for South-East Asian and the Western Pacific regions, it was 0.01% (2). Case Fatality Ratio (CFR) was highest in Europe of 7.3%, 5.3% in American region and a lowest of 1.1% in South-East Asian region (2). Pre-existing health conditions have become decisive feature in assessing disease progression, and aligned with this discourse, the Hygiene Hypothesis can be a plausible explanation for this pattern of COVID-19 infection and mortality. The theory states that the reduced pathogen exposure in high-income regions during important development phases leads to a decreased stimulation by evolutionary relevant pathogens resulting in immune dysregulation and increase in chronic inflammation, allergy, autoimmunity (2).The hyper-hygienic practice wards off potential problems before they progress into clinical condition and disturbs the balance of commensal organisms in surface locations such as gastrointestinal tract, skin and increasing COVID-19 susceptibility(3). Contrarily, extensive exposure to multiple microbes that express pathogen associated molecular patterns activates innate immunity. In this “trained immunity”, ascribed to many cell types, a response generated against one set of microbes can have bystander immune protection against other infections (3). In Ethiopia, the IFR obtained was 0.55% in urban neighbourhoods and 0.78% in remote settlements respectively, an estimate lower than that deduced for higher income countries (4). Further, background immunity against SARS-CoV-2: TCD4 cells observed in some individuals not exposed to SARS-CoV-2 was found to cross react to SARS-CoV-2 proteins (5). However, the hypothesis cannot be over generalized as the number of COVID-19 deaths might be unascertained in low-income countries due to inadequate reporting. Climatic conditions, age, gender, the type of spread of disease also account for differences (4). On the contrary, we can suspect a positive relation between Social Vulnerability Index and COVID-19 incidence as results from Brazil exhibit (5). The Hygiene Hypothesis, albeit cannot be heavily relied upon, offers new perspective in studying the effect of the environment and innate immunity on disease severity and progression. It also provides insights for augmenting standard hygiene practices. Continue..

“COVID-19 and Pregnancy: A Compelling Need for Vaccination"

Madam, Since the beginning of 2021, massive vaccination programmes have been initiated, aiming to curb the COVID-19 pandemic, yet certain groups remain vulnerable, especially pregnant women (1). A recent study has emphasized the implications of COVID-19 in pregnant females; evaluating statistics from various countries, the authors reported maternal mortality to be 22 times higher in pregnant women with COVID-19 diagnosis than those without (2). Compared with those without COVID-19, infected females giving birth showed significantly higher rates of ICU admission, respiratory intubation, mechanical ventilation, and a greater risk of having a preterm birth of fewer than 37 weeks (2). In Pakistan, Covid-19 is speculated to cause multiple complications among unvaccinated pregnant women. When local data was collected and presented at a webinar “Pregnancy in Covid-19 and importance of vaccine” held by a public medical university in association with the American Society of Microbiology, it was highlighted that Covid-19 caused a death rate of 8% in pregnant women. Each year, approximately 14% of pregnant women are susceptible to have medical complications. (3) These adverse outcomes during pregnancy accentuate the need for vaccination of pregnant individuals. Recent studies have started assessing the outcome of Covid-19 vaccination on the pregnant women population and demonstrated positive results. Blakeway et al reported that women who received at least one dose of COVID-19 vaccine in pregnancy versus unvaccinated females had similar rates of all adverse pregnancy outcomes and concluded that vaccines do not affect perinatal outcomes (4). Guidelines recommending urgent vaccination for pregnant people have also been released, stressing that the benefits of the vaccine supercede any potential risks (1). However, several factors have hindered the process of vaccination of pregnant women such as the exclusion of pregnant women from clinical trials that have caused difficulty in establishing confidence of pregnant women in the vaccines In addition, the prevailing conspiracy theories in Pakistan about vaccination programmes, being a Western agenda to induce sterility in Muslim women has further hindered the success of vaccination programme for pregnant women. (5) Physicians must implement the past positive findings of vaccination among pregnant women when counseling patients who are pregnant, planning a pregnancy, breastfeeding, or planning to breastfeed, and facilitate them in opting for government authorized vaccines for clinical use. At the same time, pregnant women who wish to wait for more data to make an informed decision must be supported and updated by their doctor regularly. ---continu

Navigating Neurotrauma Management in Pakistan

Madam, neurotrauma is defined as an injury to the brain and/or spinal cord. A WHO, sponsored study estimated that the annual global incidence of neurotrauma is approximately 500–800 per 100 000 and it accounts for about 11.8% of total global disability-adjusted life years1. In Pakistan, the annual incidence of head injured patients admitted to numerous neurosurgical centres was 50/100,000 population per year2. The lifetime medical treatment per neurotrauma case is estimated to range from US$600 000 to US$1.8 million. Neurotrauma management incorporates prehospital care lasting minutes to hours which encompasses accurate on site  diagnosis and systematic treatment or during the e shifting, to an organized, well-equipped health care management, in-hospital care for hours to weeks which comprises surgical and non-surgical intervention including imaging, neuro-monitoring and critical care and finally post-acute care lasting weeks to years and denotes any form of rehabilitative interventions to enable and empower patients to have an increased quality of life1. Each component of management requires trained personnel, specific equipment, and protocols3. However, Pakistan lags in various aspects. As of a last study in 2001, there were only 35 neurosurgical centres and about 1000 neurosurgical beds to accommodate a population of 130 million2. Of the 23 Karachi hospitals studied in 2020, only 57% were well-equipped and accredited [Trauma capacity score (TCS) 67%] to perform elementary resuscitation steps to secure early stability. A sizeable number,57%, s (TCS<34%) lacked space to accommodate head, neck, and spinal injuries; 65% s were partly inadequate (TCS<67%) in diagnosis, intensive care and safety4. With low medical insurance across the country2. Inadequate availability of essential medicines was also reported in 43% of hospitals4. An organized trauma care system must be introduced to mitigate trauma mortality for local needs. It should encompass enabling those at injury site to become first responders3, an ambulance service equipped with communication systems and with properly trained personnel that can commence life-saving measures such as IV fluid resuscitation3. Trauma centres should have a referral network and hospitals that provide optimal traumatic care should be identified beforehand to transfer injured patients to this specialized facilitys4.A protocol also needs to be established that assists local doctors in immediate referral to trauma centers3.  Proper allocation of resources and mobilization of staff and doctors timely can improve neurotrauma outcomes significantly. Continuous..

Comprehensive overview of human monkeypox: Epidemiology, clinical features, pathogenesis, diagnosis and prevention

Monkeypox (MPX) is a zoonotic disease caused by the monkeypox virus (MPXV), belonging to the orthopoxvirus genus with a presentation resembling smallpox making it historically challenging to distinguish the disease from smallpox clinically. Since a British citizen brought MPX into the country on 6 May 2022, there have been concerns about the re-emergence of the human MPXV. Since then, the WHO has reported 92 confirmed cases and 28 suspected cases in 13 nations where MPXV was not endemic. WHO declared MPX a \u27public health emergency of international concern\u27 on 23 July 2022. MPXV can spread either through human-human contact or animal-human contact. Respiratory droplets, direct contact with bodily fluids, contaminated patient surroundings or objects, and skin sores from an infected person have all been linked to the disease\u27s transmission from one person to another. Fever, headache, lethargy, asthenia, enlargement of the lymph nodes, weariness, back pain, and myalgia are some of the symptoms that last from 2 to 5 weeks. It can be diagnosed using a range of diagnostic methods, including electron microscopy, Immunoglobulin M, enzyme-linked immunosorbent assay, polymerase chain reactions, histological analysis, immunofluorescent antibody testing, virus isolation, etc. Smallpox immunization before infection may lessen clinical symptoms and is around 85% effective in protecting from the MPX

Efficacy and Safety of Concomitant Tricuspid Repair in Patients Undergoing Mitral Valve Surgery: a Systematic Review and Meta-Analysis.

Tricuspid valve repair (TVR) is recommended for patients with moderate primary tricuspid regurgitation (TR), those with moderate TR, and a history of heart failure without annular dilation, while being essential for patients with severe secondary TR undergoing MVS. The meta-analysis aimed to evaluate the efficacy and safety of tricuspid valve repair in patients undergoing MVS. We systematically searched PubMed, Embase, and Google Scholar through January 2022, and studies comparing patients with TVR and those without TVR were selected. The primary outcomes were 30-day, and all-cause mortality. In this meta-analysis, 20 studies were included with a patient population of 72,422. No significant differences were observed between patients undergoing TVR with MVS, in comparison to MVS group only for the primary outcomes i.e., 30-day mortality (RR: 1.14, 95% CI [0.69, 1.87], and all-cause mortality (RR: 1.16, 95% CI [0.86, 1.57]. From the secondary outcomes, pacemaker insertion (RR: 2.62, 95% CI [2.24, 3.06]), new-onset TR or progression (RR: 0.32, 95% CI [0.16, 0.66]), stroke (RR: 1.22, 95% CI [1.05, 1.42]), cross-clamp time (WMD: 17.67, 95% CI [13.96, 21.37]), surgery time (WMD: 43.59, 95% CI [37.07, 50.10]), ICU time (WMD: 19.50, 95% CI [9.31, 29.67]), and ventilation time (WMD: 6.62, 95% CI [0.69, 12.55]) were significant. However, major bleeding events, atrial fibrillation, renal failure, heart failure hospitalization, postoperative MI, wound infection, early or prolonged morbidity, cardiopulmonary bypass time, and duration of hospital stay were non-significant. Our meta-analysis has furthered the discussion for weighing the risks and benefits of pursuing TVR during MVS

Self-medication practices in medical students during the COVID-19 pandemic: A cross-sectional analysis

Background and objectives: During the pandemic, the growing influence of social media, accessibility of over-the-counter medications, and fear of contracting the virus may have led to self-medication practices among the general public. Medical students are prone to such practices due to relevant background knowledge, and access to drugs. This study was carried out to determine and analyze the prevalence of self-medication practices among medical students in Pakistan. Materials and methods: This descriptive, cross-sectional study was conducted online in which the participants were asked about the general demographics, their self-medication practices and the reasons to use. All participants were currently enrolled in a medical college pursuing medical or pharmacy degree. Non-probability sampling technique was used to recruit participants. Results: A total of 489 respondents were included in the final analysis. The response rate was 61%. Majority of the respondents were females and 18-20 years of age. Self-medication was quite prevalent in our study population with 406 out of 489 individuals (83.0%) were using any of the drugs since the start of pandemic. The most commonly utilized medications were Paracetamol (65.2%) and multivitamins (56.0%). The reasons reported for usage of these medications included cold/flu, or preventive measures for COVID-19. The common symptoms reported for self-medication included fever (67.9%), muscle pain (54.0%), fatigue (51.7%), sore throat (46.6%), and cough (44.4%). Paracetamol was the most commonly used drug for all symptoms. Female gender, being in 3rd year of medical studies, and individuals with good self-reported health were found more frequent users of self-medication practices. Conclusion: Our study revealed common self-medication practices among medical and pharmacy students. It is a significant health issue especially during the pandemic times, with high consumption reported as a prevention or treating symptoms of COVID-19

Understanding the impact of structural modifications at the NNAT gene’s post-translational acetylation site: in silico approach for predicting its drug-interaction role in anorexia nervosa

Abstract Purpose Anorexia nervosa (AN) is a neuropsychological public health concern with a socially disabling routine and affects a person’s healthy relationship with food. The role of the NNAT (Neuronatin) gene in AN is well established. The impact of mutation at the protein’s post-translational modification (PTM) site has been exclusively associated with the worsening of the protein’s biochemical dynamics. Methods To understand the relationship between genotype and phenotype, it is essential to investigate the appropriate molecular stability of protein required for proper biological functioning. In this regard, we investigated the PTM-acetylation site of the NNAT gene in terms of 19 other specific amino acid probabilities in place of wild type (WT) through various in silico algorithms. Based on the highest pathogenic impact computed through the consensus classifier tool, we generated 3 residue-specific (K59D, P, W) structurally modified 3D models of NNAT. These models were further tested through the AutoDock Vina tool to compute the molecular drug binding affinities and inhibition constant (Ki) of structural variants and WT 3D models. Results With trained in silico machine learning algorithms and consensus classifier; the three structural modifications (K59D, P, W), which were also the most deleterious substitution at the acetylation site of the NNAT gene, showed the highest structural destabilization and decreased molecular flexibility. The validation and quality assessment of the 3D model of these structural modifications and WT were performed. They were further docked with drugs used to manage AN, it was found that the ΔGbind (kcal/mol) values and the inhibition constants (Ki) were relatively lower in structurally modified models as compared to WT. Conclusion We concluded that any future structural variation(s) at the PTM-acetylation site of the NNAT gene due to possible mutational consequences, will serve as a basis to explore its relationship with the propensity of developing AN. Level of evidence No level of evidence—open access bioinformatics research