Study the effectiveness and safety of vitamin D as an additional treatment for type 2 diabetic patients using oral anti-diabetics at a tertiary care hospital

Background: The prevalence of type 2 DM is alarmingly rising on a global scale. Improved treatments for type 2 DM are still needed, in order to slow the disease’s development. A role in the pathophysiology of type 2 DM has been suggested by the correlation between vitamin D insufficiency and several non-skeletal illnesses, including DM. The goal of the study was to determine if vitamin D supplementation may help type 2 DM patients whose glycemic status was uncontrolled even after using oral antidiabetics. Methods: 60 individuals with type 2 DM and vitamin D insufficiency participated in this 12-week open-label, before-and-after study. For 12 weeks, in addition to oral anti-diabetic medications, these patients also received 60,000 IU of vitamin D3 orally every week. HbA1c, FBS, and 25(OH)D levels parameters were included. Results: The majority of the patients were from 41-50 years of age group (48.3%) with a male predominance (60%). Most of them were having >1 year of type 2 DM duration (78.3%) with a high family history of type 2 DM (70%). After 12 weeks, there was a substantial (p<0.001*) drop in FBG levels and a significant (p<0.001*) decrease in HbA1c. 25(OH)D levels showed a high rise (p<0.001*). None of the patients had any side effects. Conclusions: Vitamin D treatment improves glycemic status, which slows the development of type 2 DM and its associated effects. As such, vitamin D supplementation is a safe and promising adjuvant treatment for individuals with type 2 diabetes who are low in vitamin D

Antimicrobial resistance patterns among Acinetobacter baumannii isolated from burn intensive care unit in Tripoli, Libya

Background: Acinetobacter baumannii is a troublesome and increasingly problematic healthcare-associated pathogen, especially in critical care unit. These organisms have a capacity for long-term survival in the hospital environment. Aim: This study aimed to investigates the drug resistance patterns of Acinetobacter baumannii strains isolated from burn ICU (BICU). Method: The antibiotic susceptibility of 176 isolates to imipenem, meropenem, gentamicin, ciprofloxacin, fusidic acid, amikacin, trimethoprim, cefepime, ceftazidime, ceftriaxone, cefotaxime, and amoxicillin-calvulanic acid was determined by disk agar diffusion test. Findings: The overall proportion of A. baumannii isolates among all clinical isolates has increased slightly throughout the study from 3.5% to 4.2%. Carpabenem remained the antimicrobial most active antibiotic against A. braumannii isolates compared with other antibiotics, during the two years there was an increase in resistance from 50.6% to 71.3% to imipenem (P<0.01), and meropenem from 50.6% to 74.5% (P<0.01). ICU isolates exhibited significantly higher level of resistance to imipenem (71.6%) and meropenem (73.4%) compared with non-ICU strains (42.6% and 44.6% respectively) (P<0.01). Conclusion: In conclusion, the high prevalence of multidrug resistance A. baumannii (97.7%) and increased resistance to imipenem and meropenem in our unit might be due to long hospital stay, intubation, surgery and previous antibiotic prescription. It would seem that practices to prevent cross-transmission are more important in controlling resistance

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Comment and Controversy Edited by Stephen P. Stone, MD Applying to dermatology residency without a home program: Advice to medical students in the COVID-19 pandemic and beyond

Dermatology has historically been one of the most competitive residencies for matching. Successful candidates generally have stellar United States Medical Licensing Examination (USMLE) scores, often with significant amounts of research and excellent letters of recommendation

Prescribing Pattern of Drugs Used in Chronic Liver Disease with Co Morbid Conditions and Assessment of Severity using MELD Score: A Prospective Observational Study

Objectives: To study the prescribing pattern of drugs &amp; its use in the treatment of CLD &amp; assess the pattern of co-morbidities associated with CLD. To Study the mortality rate of the patient using MELD score at a department of general medicine at Osmania general Hospital to produce a result which would aid better rational drug use and improve quality of life. Methodology: A Prospective, observational study was carried out at OGH for a period of 6 months in 100 old patients. Population of either sex or ≥&nbsp;18 years of age were included. Conclusion: There is a considerable scope for improving prescribing pattern in CLD by minimizing the use, reduction of doses of drugs to reduce the consequence of hepatotoxicity and Antibiotic Resistance. The prognostic impact of individual comorbidities, on the other hand, may point to areas where cirrhosis and comorbid diseases interact. Studies of individual comorbidities may therefore improve our understanding of the pathophysiology of cirrhosis. MELD showed that the subjects were less likely to get a Liver transplant. Keywords: Chronic liver disease (CLD), Model for end stage liver disease (MELD), Diabetes Mellitus (DM), hypertension (HTN