Faisal Masud

Emergence and diversification of dengue 2 cosmopolitan genotype in Pakistan, 2011.

Major dengue epidemics have been observed in the Indian subcontinent since the 1980s and have occurred with increased hospitalizations and mortality. In 2011, the first major epidemic of dengue occurred in Lahore, the second largest city in Pakistan, and resulted in 21,685 confirmed cases and 350 deaths. To investigate the possible viral causes for the increased epidemic activity, we determined the predominant serotype and characterized the viruses genetically. Of 50 patients carefully selected as probable dengue fever or dengue hemorrhagic fever, 34 were positive by virologic testing (i.e. PCR and/or virus isolation). DENV-2 was detected in 32 patients and DENV-1 in two. A total of 24 partial and three full DENV genomes were sequenced. Phylogenetic analyses of the capsid (C), pre-membrane (prM), and envelope genes comprising 2500 nucleotides in length indicated that all DENV-2 isolates in Pakistan since 2007 form a monophyletic lineage that is endemic in the country. These viruses were all of the cosmopolitan genotype (IV) and most closely related to viruses isolated in India and Sri Lanka in the past two decades. Phylogenetic analyses of data currently available in GenBank suggest that the Cosmopolitan genotype has diverged into two geographically distinct sub-lineages: sub-lineage IV-a has only been observed in Southeast Asia, China and Oceania, while IV-b is prevalent in the Indian subcontinent. These results highlight the increased diversity of dengue viruses as they spread geographically within the region.

Reductions in Sepsis Mortality and Costs After Design and Implementation of a Nurse-Based Early Recognition and Response Program

BACKGROUND Sepsis is a leading cause of death, but evidence suggests that early recognition and prompt intervention can save lives. In 2005 Houston Methodist Hospital prioritized sepsis detection and management in its ICU. In late 2007, because of marginal effects on sepsis death rates, the focus shifted to designing a program that would be readily used by nurses and ensure early recognition of patients showing signs suspicious for sepsis, as well as the institution of prompt, evidence-based interventions to diagnose and treat it. METHODS The intervention had four components: organizational commitment and data-based leadership; development and integration of an early sepsis screening tool into the electronic health record; creation of screening and response protocols; and education and training of nurses. Twice-daily screening of patients on targeted units was conducted by bedside nurses; nurse practitioners initiated definitive treatment as indicated. Evaluation focused on extent of implementation, trends in inpatient mortality, and, for Medicare beneficiaries, a before-after (2008-2011) comparison of outcomes and costs. A federal grant in 2012 enabled expansion of the program. RESULTS By year 3 (2011) 33% of inpatients were screened (56,190 screens in 9,718 unique patients), up from 10% in year 1 (2009). Inpatient sepsis-associated death rates decreased from 29.7% in the preimplementation period (2006-2008) to 21.1% after implementation (2009-2014). Death rates and hospital costs for Medicare beneficiaries decreased from preimplementation levels without a compensatory increase in discharges to postacute care. CONCLUSION This program has been associated with lower inpatient death rates and costs. Further testing of the robustness and exportability of the program is under way.

Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type.

Objective:To establish a baseline for the incidence of sepsis by severity and presence on admission in acute care hospital settings before implementation of a broad sepsis screening and response initiative. Methods:A retrospective cohort study using hospital discharge abstracts of 5672 patients, aged 18 years and above, with sepsis-associated stays between February 2012 and January 2013 at an academic medical center and 5 community hospitals in Texas. Results:Sepsis was present on admission in almost 85% of cases and acquired in-hospital in the remainder. The overall inpatient death rate was 17.2%, but was higher in hospital-acquired sepsis (38.6%, medical; 29.2%, surgical) and Stages 2 (17.6%) and 3 (36.4%) compared with Stage 1 (5.9%). Patients treated at the academic medical center had a higher death rate (22.5% vs. 15.1%, P<0.001) and were more costly (

Tibial tenderness identifies secondary hyperparathyroidism responding to high-dose vitamin D in Pakistani women.

68,050±184,541 vs.

The Sepsis Early Recognition and Response Initiative (SERRI).

19,498±31,506, P<0.001) versus community hospitals. Conclusions:Greater emphasis is needed on public awareness of sepsis and the detection of sepsis in the prehospitalization and early hospitalization period. Hospital characteristics and case mix should be accounted for in cross-hospital comparisons of sepsis outcomes and costs.

Phenotypic and metabolic dichotomy in obesity: clinical, biochemical and immunological correlates of metabolically divergent obese phenotypes in healthy South Asian adults

OBJECTIVE To assess the utility of anterior tibial tenderness (ATT) measured by visual analogue scoring (VAS) as a clinical diagnostic tool for vitamin D deficiency in a high-risk population of Pakistani women. METHODS ATT was measured by VAS in 75 premenopausal women age 17 to 56 years (mean, 41.3 years) with generalized aches and pains and calcium <11 mg/dL (normal, 8 to 11 mg/dL) who were seen at a tertiary care center in Lahore, Pakistan. This was followed by administration of 1.8 million units of vitamin D3 in divided doses. ATT, vitamin D, and parathyroid hormone (PTH) levels were checked before and after the injections. Correlation between ATT, vitamin D, and PTH, as well as changes in ATT, vitamin D, and PTH following supplementation were determined. RESULTS Pre-intervention average calcium and vitamin D were 9.3 mg/dL (range, 8 to 10.3 mg/dL) and 12.1 ng/mL (range, 1.5 to 32.6 ng/mL), respectively. Seventy-four percent of the participants (53/75) had vitamin D deficiency and elevated PTH (>60 pg/mL). Mean PTH was 81.6 pg/mL (range, 29.1 to 370 pg/mL). Changes in ATT correlated strongly (r = 0.422; P = .013) with changes in PTH. Following supplementation, there was significant improvement in ATT (P<.01) and vitamin D level (P<.01), with a decrease in PTH level (P<.01). CONCLUSION ATT is a valid clinical diagnostic measure of vitamin D deficiency in South Asian women.

Vitamin D levels for optimum bone health

Duration of Initiative 48 months and currently ongoing. Setting The Houston Methodist Hospital System and affiliated hospitals (3 facilities with 2 hospital-run skilled nursing facilities in and around Houston), St. Josephs Regional Health Center (1 acute care hospital and 2 skilled nursing facilities in Bryan, Texas), Hospital Corporation of America (2 acute care facilities in Houston, 1 acute care facility in McAllen, Texas [Rio Grande Valley]), Kindred Healthcare (2 long term acute care facilities in Houston), Select Medical Specialty Hospitals (2 long term acute care facilities in Houston). Whom This Should Concern Hospital administrators, quality and safety officers, performance improvement and patient safety professionals, clinic managers, infection control and prevention staff, and other physicians, nurses, and clinical staff.

Association of metabolic factors with dengue viral infection on admission triage which predict its clinical course during Lahore dengue epidemic

INTRODUCTION Metabolic heterogeneity among obese individuals is thought to translate into variations in cardiovascular risk. Identifying obese people with an unfavourable metabolic profile may allow preventive strategies to be targeted at high-risk groups. This study aimed to identify clinical, biochemical and immunological differences between insulin-sensitive and insulin-resistant obese subgroups, to understand the population-specific pathophysiological basis of the adverse cardiovascular risk profile in the latter group. METHODS Cardiovascular risk indicators, including anthropometric parameters, blood pressure, acanthosis nigricans area, and related biochemical, endocrine and inflammatory markers, were determined in 255 healthy South Asian volunteers aged 18-45 years, with a 2:1 ratio of obese/overweight to normal-weight individuals. Lifetime atherosclerotic cardiovascular disease (ASCVD) risk was also calculated. RESULTS Body mass index (BMI) and insulin sensitivity-based tertiles independently showed incremental trends in waist-hip ratio, skinfold thickness, acanthosis nigricans area, blood pressure, serum lipids, hepatic enzymes, adipokines, inflammatory markers and ten-year ASCVD risk. The anthropometric, biochemical and inflammatory parameters of obese insulin-sensitive and obese insulin-resistant groups differed significantly. Extreme group analysis after excluding the middle tertiles of both insulin resistance and BMI also showed significant difference in anthropometric indicators of cardiovascular risk and estimated lifetime ASCVD risk between the two obese subgroups. CONCLUSION Obese insulin-sensitive individuals had a favourable metabolic profile compared to the obese insulin-resistant group. The most consistent discriminative factor between these phenotypic classes was anthropometric parameters, which underscores the importance of clinical parameters as cardiovascular risk indicators in obesity.