Do we achieve LDL-cholesterol targets in routine clinical practice? Evidence from a tertiary care hospital in Sri Lanka

Background: Statins are widely used for primary and secondary prevention of cardiovascular disease (CVD). European Society of Cardiology / European Atherosclerosis Society (ESC/EAS) guidelines recommend LDL-cholesterol targets based on CVD risk.Objectives: This study aimed to determine whether LDL-cholesterol targets recommended by2016 ESC/EASare achieved in routine clinical practice.Methods: This paper is based on baseline data of patients recruited to a controlled clinical trial conducted at a tertiary care hospital. Participants have been on atorvastatin for >2 months. Demographic and clinical data were obtained using clinic records and interviewer administered questionnaires. LDL-cholesterol was assessed using Friedewald equation (when triglyceride was <400mg/dL) or by direct measurement (when triglyceride was ≥400mg/dL). Each participant’s CVD risk level and appropriate LDL-cholesterol target (very-high CVD risk:<70mg/dL; high CVD risk:<100mg/dL; low to moderate CVD risk:<115mg/dL) was determined according to 2016 ESC/EAS Guideline.Results: 101 patients were studied. (Women: 76.2%; mean-age: 61.2:±9.3years). Prevalence of coronary heart disease, ischaemic stroke, diabetes, hypertension and smoking was 30.7%, 4%, 77.2%, 80.2% and 4%, respectively. According to CVD risk level 80.2%, 15.8% and 4% were in very-high, high and moderate risk categories, respectively. Most were on atorvastatin 10mg (45.5%) followed by 20mg (43.6%), 40mg (8.9%), 30mg (1%) and 5mg (1%). Median duration of treatment was 41-months. Overall, only 12.9% had achieved target LDL-cholesterol (very-high risk: 7.4%; high risk: 37.5%, moderate risk: 25%; p=0.003). Men did better than women in achieving target LDL-cholesterol (men: 29.2%, women: 7.8%; p=006). There was no difference based on age, comorbidities or atorvastatin dose.Conclusions: In the study population majority has failed to achieve LDL-cholesterol targets recommended by 2016 ESC/EAS. Failure to achieve targets was more common among women and those having very-high CVD risk. Reason for suboptimal target achievement has to be studied further.Acknowledgement: Funded by University of Sri Jayewardenepura Research Grant (ASP/01/RE/MED/2015/54) and Ceylon College of Physicians Research Grant (2014)

Down‐regulation of key genes involved in carbon metabolism in Medicago truncatula results in increased lipid accumulation in vegetative tissue

Alfalfa (Medicago sativa L.), is the most widely grown perennial forage crop, which is a close relative of the model diploid legume Medicago truncatula. However, use of alfalfa lead to substantial greenhouse gas emissions and economic losses related to inefficiencies in rumen fermentation. The provision of supplemental lipids has been used as a strategy to mitigate these issues, but it is a costly approach. The ability to enhance lipid content within the vegetative tissues of alfalfa would therefore be very advantageous. As such, our aim was to assess and select gene candidates to increase total shoot lipid content in M. truncatula using a virus‐induced gene silencing (VIGS) approach. We targeted gene homologs of the SUGAR‐DEPENDANT 1 (SDP1), ADP‐GLUCOSE‐PYROPHOSPHORYLASE SMALL SUBUNIT 1 (APS1), TRIGALACTOSYLDIACYLGLYCEROL 5 (TGD5) and PEROXISOMAL ABC TRANSPORTER 1 (PXA1) in M. truncatula for silencing. Reduced target transcript levels were confirmed and changes of shoot lipid content and fatty acid composition were measured. Silencing of SDP1, APS1 and PXA1 each resulted in significant increases in shoot total lipid content. Significantly increased proportions of α‐linolenic acid (18:3Δ9cis,12cis,15cis) were observed and stearic acid (18:0) levels significantly decreased in the total acyl lipids extracted from vegetative tissues of each of the M. truncatula silenced plants. In contrast, palmitic acid (16:0) levels were significantly decreased in only SDP1 and PXA1‐silenced plants. Genes of PXA1 and SDP1 would be ideal targets for mutation as a means of improving the quality of alfalfa for increasing feed efficiency and minimizing greenhouse gas emissions from livestock production in the future

Preliminary study on Lampyrids in Kiralakelle nature reserve, Matara District, Southern Sri Lanka; An ecotourism perspective

Lampyrids  or fireflies are one of the ecotourism subjects throughout the world and there is a possibility to use them as a rapidly increasing tourism aspect in Sri Lanka. Previous records have revealed 63 species of fireflies belonging to 24 genera were listed in the country. However, the ecotourism significance of Sri Lankan firefly fauna is poorly studied and never been documented. The aim of the present study was to introduce the existing lampyrid fauna of Kiralakelle nature reserve in ecotourism view point as one of proposed tourism development site in Southern Province, Matara, Sri Lanka.Study carried out throughout year 2010 from 6.00 p.m. to 22.00 p.m. as one sampling in each month. Fireflies were observed using 6 observation points located in two types of landscapes (1-3 points closer to forest patches and 4-6 closer to marshy water filling lands) along the main pathway of the nature reserve. Each point had 2.5 m radius and distance between two points was 250m. Abundance and diversity indices were estimated. Totally, 7 adult firefly species, namely  Luciola cingulata,  L. extricans,  L. melaspis,  L. praeusta  complex, and Asymmetricata humeralis,  Curtos costipennis  and  Lamprigera tenebrosa  were recorded. Genus-  Luciola  was the dominant lampyrid group in nature reserve and the lowest abundance was recorded in genus-Lamprigera  fireflies. While  A. humeralis  was the highly abundant species in nature reserve,  L. extricanswas recorded as the less abundant one. The highest percentage abundance of recorded lampyrids was shown in observation point 1 and the lowest in point 5. The average percentage abundance of lampyrids was high in 1-3 observation points closer to forest patches than others.  L. cingulata, L. praeusta  complex and  A. humeralis were shown their abundance throughout the year in Kiralakelle nature reserve and the other 4 species were recorded as seasonally dominant lampyrids. The highest Shannon Wiener diversity was obtained from observation point 2 (1.554) and the lowest in point 6 (1.240). Records of this  study will be helpful for better understanding of firefly fauna in Kiralakelle nature reserve and provide clear outline of their usability for tourism success. The site  currently has threatened by illegal human activities such as felling, garbage filling,  animal hunting and forests firing. Hence, additional conservation strategies are needed to protect the lampyrid fauna in this nature reserve. Sustainable ecotourism based on lampyrids will be a vital aspect to succeed the night-tourism industry in Kiralakelle nature reserve in future and throughout Sri Lanka as well.Key words: Ecotourism, Kiralakelle nature reserve, Lampyrid

Doctors and nurses perceptions towards the introduction of clinical pharmacy service to the Sri Lankan healthcare system- Experience from a tertiary care hospital

Objectives: To evaluate the rate of acceptance of the clinical pharmacist’s (CP’s) recommendations regarding Drug Related Problems (DRPs) by healthcare team, to determine the quality and quantity of drug information queries directed to the CP and to assess the level of acceptance of clinical pharmacy service (CPS) by other members of the ward staff.Methods: This was a controlled trial conducted in a tertiary care hospital. The control group received standard care. The intervention group received a CPS in addition to the standard care. DRPs were classified according to the adapted PCNE classification system V5.01. The CP discussed the identified potential DRPs with healthcare team. All the drug related questions directed to the CP by healthcare staff were recorded. A staff survey was carried out before and after the study.Results: A total of 270 drug related recommendations were directed to the healthcare team. 83% (P < 0.001) of the recommendations were accepted by doctors and 74% (P < 0.001) were acted upon. 17 medication-related questions were directed to the CP from the team. The perceptions of doctors regarding ward-based CPS were satisfactory at baseline period. At end of study, the majority of doctors were happy to welcome a service from a competent CP. Nurses were resistant to this collaboration.Conclusions: There was high acceptance of CP’s recommendations regarding DRPs by the medical team. Doctors were satisfied with the inclusion of a ward-based pharmacist to the healthcare team. However there is a need to improve liaisons between CP and nursing staff

Learning to self-manage by intelligent monitoring, prediction and intervention

Despite the growing prevalence of multimorbidities, current digital self-management approaches still prioritise single conditions. The future of outof- hospital care requires researchers to expand their horizons; integrated assistive technologies should enable people to live their life well regardless of their chronic conditions. Yet, many of the current digital self-management technologies are not equipped to handle this problem. In this position paper, we suggest the solution for these issues is a model-aware and data-agnostic platform formed on the basis of a tailored self-management plan and three integral concepts - Monitoring (M) multiple information sources to empower Predictions (P) and trigger intelligent Interventions (I). Here we present our ideas for the formation of such a platform, and its potential impact on quality of life for sufferers of chronic conditions

Impact of a ward based clinical pharmacy service on drug-related hospital re-admissions - Evidence from a controlled clinical trial in a tertiary care hospital in Sri Lanka

Objective: To determine the impact of a ward-based clinical pharmacy service on drug related hospital re-admissions.Methods: This was a part of a controlled trial conducted in a tertiary care hospital in Sri Lanka to evaluate the clinical pharmacy service. The control group received the standard care whereas the intervention group received a ward-based pharmacist’s service in addition to the standard care. The pharmacist performed a prospective medications review of patients with chronic non-communicable diseases during their hospital stay and made recommendations to the health care team when appropriate. At discharge reconciliation of discharge prescription was done. Patients were educated about discharge medicines to improve knowledge and compliance. Both groups were followed up monthly for six months to identify drug-related hospital re-admissions.Results: Of 137 drug-related re-admissions, 93 (involving 87/356 patients) were from the control group, and 44 (involving 42/361 patients) were from the intervention group (P < 0.001). Non-compliance was the main reason for re-admissions in the control group and it was significantly higher in the control group (control vs. intervention: 53.8% vs. 34.1%; P = 0.013). Adverse drug reactions were the most common reason for re-admission in the intervention group (23/44; 52.3%). There was a significantly larger percentage of re-admissions in the control group due to unintentional omission of drugs on discharge prescription (control vs. intervention: 17.2% vs. 2.3%; P = 0.012).Conclusion: Ward based clinical pharmacy service was useful to reduce drug related hospital re-admissions in patients with chronic non-communicable diseases. Establishing a ward based clinical pharmacy service is recommended

Upper limb muscle strength and endurance in Chronic Obstructive Pulmonary Disease

Introduction: Skeletal muscle weakness is an overlooked effect of chronic obstructive pulmonarydisease (COPD).Objectives: In this case-control study we compared skeletal muscle strength and endurance of a groupof patients with COPD with a comparable group of healthy volunteers.Methods: Upper limb muscle strength and endurance of 18 males and 12 females from a medical clinicof a tertiary care hospital with diagnosed COPD was measured by a handgrip dynamometer usingprescribed protocol and was compared with muscle strength and endurance of 30 healthy age, genderand body mass index (BMI) matched volunteers. Patients with concomitant severe cardiac, neurologicaland rheumatological conditions were excluded. Data were analyzed using SPSS version 16. Two sampleT-test was used to identify the statistical significance.Results: There was no significant difference in BMI of cases and controls (males mean BMI: cases19.8kgm2, controls 20.4kgm2; p = 0.73; females mean BMI: cases 20.4kgm2, controls 18.6kgm2; p =0.19). Muscle strength and endurance were significantly lower in cases when compared with controls,both in males (mean muscle strength: cases 19.8kg, controls 29.3kg, p<0.001. mean endurance: cases80.6s, controls 190.2s, p<0.001) and females (mean muscle strength; cases 11.8kg, controls 23.3kg,p<0.001, mean endurance: cases 49.3s, controls 111.3s, p<0.001).Conclusions: In this study a population of patients with COPD had significantly lower muscle strengthand endurance. Since muscle weakness contributes to poor ventilation and quality of life, programmesto improve muscle strength and endurance should be considered in the management of COPD

Selection of the solvent and extraction conditions for maximum recovery of antioxidant phenolic compounds from coffee silverskin

The extraction of antioxidant phenolic compounds from coffee silverskin (CS) was studied. Firstly, the effect of different solvents (methanol, ethanol, acetone, and distilled water) on the production of antioxidant extracts was evaluated. All the extracts showed antioxidant activity (FRAP and DPPH assays), but those obtained with methanol and ethanol had significantly higher (p < 0.05) DPPH inhibition than the remaining ones. Due to the lower toxicity, ethanol was selected as extraction solvent, and further experiments were performed in order to define the solvent concentration, solvent/solid ratio, and time to maximize the extraction results. The best condition to produce an extract with high content of phenolic compounds (13 mg gallic acid equivalents/g CS) and antioxidant activity [DPPH = 18.24 μmol Trolox equivalents/g CS and FRAP = 0.83 mmol Fe(II)/g CS] was achieved when using 60 % ethanol in a ratio of 35 ml/g CS, during 30 min at 60–65 °C.This work was supported by the Portuguese Foundation for Science and Technology (FCT). The authors gratefully acknowledge Teresa Conde, student of Biological Engineering, for the help and interest in this work

Semi-automated non-target processing in GC × GC–MS metabolomics analysis: applicability for biomedical studies

Due to the complexity of typical metabolomics samples and the many steps required to obtain quantitative data in GC × GC–MS consisting of deconvolution, peak picking, peak merging, and integration, the unbiased non-target quantification of GC × GC–MS data still poses a major challenge in metabolomics analysis. The feasibility of using commercially available software for non-target processing of GC × GC–MS data was assessed. For this purpose a set of mouse liver samples (24 study samples and five quality control (QC) samples prepared from the study samples) were measured with GC × GC–MS and GC–MS to study the development and progression of insulin resistance, a primary characteristic of diabetes type 2. A total of 170 and 691 peaks were quantified in, respectively, the GC–MS and GC × GC–MS data for all study and QC samples. The quantitative results for the QC samples were compared to assess the quality of semi-automated GC × GC–MS processing compared to targeted GC–MS processing which involved time-consuming manual correction of all wrongly integrated metabolites and was considered as golden standard. The relative standard deviations (RSDs) obtained with GC × GC–MS were somewhat higher than with GC–MS, due to less accurate processing. Still, the biological information in the study samples was preserved and the added value of GC × GC–MS was demonstrated; many additional candidate biomarkers were found with GC × GC–MS compared to GC–MS

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