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Introduction: Development of veins of head and neck is complex. Variations in the venous architecture of head and neck includes persistence or complete obliteration of communication between Internal Jugular Vein (IJV) and External Jugular Vein (EJV) and also partial obliteration in EJV. Knowledge of variations in venous architecture is beneficial to avoid injuries to these veins during interventions like EJV cannulation for diagnostic and therapeutic purposes. Aim: To study the variations in the venous architecture of the neck in the cadavers. Materials and Methods: This descriptive cross-sectional study was conducted in the Department of Anatomy, Calcutta National Medical College, Kolkata, West Bengal, India during December 2017 to December 2019. Total 26 specimens of both male and female cadavers were dissected, and variations in the venous architecture was noted, also each variation was explained in the light of embryology. Results: Retromandibular Vein (RMV) was found to be undivided in all 10 of the variations found in the eight male and two female cadavers. EJV was found to be absent in one specimen among 26 dissected. Communication between IJV and EJV was found in one specimen. In another specimen, EJV was found to be draining into IJV which can be embryologically seen as a communication between IJV and EJV while the caudal part of EJV had degenerated. Conclusion: Undivided RMV, particularly absent posterior division is not very uncommon in male and female in this ethnicity. Absence of common facial vein was more common in male as compared to female. Persistent communication between EJV and IJV were also more in male. Moreover occurrence of facial vein drainage into EJV was also remarkably high.

Introduction: Morphologic and morphometric evaluation of mandible is clinically important. Considering the close relationship of lingula with neurovascular structures entering through mandibular foramen, lingula is often used as an important bony landmark during oral and maxillofacial surgical approach and inferior alveolar nerve block anaesthesia. Inadequate anatomical knowledge may result various intra operative complications like haemorrhge, fractures and nerve injury. Also, structural variations of lingula followed by inaccurate localization of mandibular foramen have been implicated as causative factor for unsuccessful inferior alveolar nerve block anaesthesia. Aim: To determine morphological and morphometric variations related to lingula of mandible in localizing mandibular foramen and to compare the results with similar type of osteological studies performed earlier on different population group. Materials and Methods: The study was performed on 36 adult dry human mandibles on both sides to categorize lingula according to its various shapes and determine the location of lingula based on surrounding mandibular landmarks by using Vernier caliper as 5 distances from tip of lingula as follows: i) to anterior border of ramus of mandible; ii) to posterior border of ramus of mandible; iii) to centre of mandibular notch; iv) to the alveolar socket of second molar tooth; and v) to the base of mandible. The present study also indicated bilingual distance between tips of lingula of both sides. Data collected were analyzed statistically. Results: The most common shape of lingula was observed as triangular (51.39%) followed by truncated (23.61%), then nodular (20.83%) and assimilated (4.17%) as least prevalent type. The average distances of tip of lingula from anterior and posterior borders of ramus of mandible were 18.21±1.50 mm and 16.33±1.21 mm respectively. On average, the tip of lingula was situated at 18.17±1.51 mm, 33.40±2.11 mm and 32.07±2.68 mm from mandibular notch, second molar tooth and base of the mandible respectively. The average bilingual distance between lingula of both sides was observed as 73.35±3.94 mm. Conclusion: Considering morphologic and morphometric variations of lingula as of great clinical importance in the field of surgery involving mandibular ramus, present study may be helpful by adding important information about localization of mandibular foramen with respect to variations of lingula.

The knowledge of branches of superior mesenteric artery important for Surgeon and radiologists who deals abdominal diseases. Superior mesenteric artery is second ventral branch of abdominal aorta which arises from 1 cm below coelic trunk, opposite L1 vertebrae and supplies lower portion of duodenum, whole jejunum, ileum caecum, appendix, ascending colon and major portion transverse colon. Actually it is the artery for derivates of midgut. [1] Superior mesenteric artery gives inferior pancreatic duodenal artery, middle colic artery, right colic artery and ileo colic artery from its right concave side some ileo-jejunal artery from convex left side. Usually middle colic artery arises from superior mesenteric artery at the lower border of pancreas and immediately enters the root of transverse mesocolon and divides into right and left branch. The right branch anastomose with ascending branch of right colic artery near right colic flexure and left anastomose with ascending branch of left colic. Here we present a case of absence of mid colic artery from superior mesenteric artery and right colic artery shows some extra branches from its proximal part which supplies transverse colon.

Introduction: Reconstruction of stature from human skeletal remains has long been considered as an important medico legal challenge. In absence of other bones like cranium or pelvis, anatomical knowledge of long bone even when only a fragment of it becomes available may help to meet that challenge through a series of estimation of length of long bone first and then reconstruction of stature of the unidentified individual. Aim: To determine length of different segments of humerus and then reconstruction of total length of humerus, in West Bengal population using standard regression formula. Materials and Methods: A total of 60 adult dry humerii, 30 belonging to right and 30 of left side of unknown age and sex were taken. Each bone was divided into five segments (H1, H2, H3, H4 and H5) by taking predetermined points on it. Such five parameters along with total length of humerus were measured to the nearest millimetre. The values were presented as mean±SD in mm separately for each side. The proportion of each segment to the total length was also calculated. Simple linear regression (p < 0.01) was used to correlate the length of each segment with total length. Later on, when multiple regressions were used to estimate total length, incorporation of variables was made through stepwise regression. Results: The average total length of humerus on right side was 307.13±17.99 and on left side 297.77±19.78. The mean lengths of five segments, namely H1, H2, H3, H4 and H5 were 6.11±0.80, 34.07±1.44, 18.76±2.00, 16.22±2.13 and 32.51±2.70 mm on right and 6.03±0.73, 33.10±1.95, 18.12±1.68, 15.99±1.82 and 31.96±1.32 mm on left humerii respectively. When multiple linear regression was used, H2 alone contributing 65% and 76% showed significant changes in estimating total length of humerus in case of right and left sides respectively. Conclusion: The present study revealed prediction of total length of humerus from detailed estimation of different segments of humerus among West Bengal population which may be treated in future as an useful reference not only for anatomists, forensic experts and archaeologists but also for orthopaedic surgeons undertaking reconstructive surgery for proximal and distal humeral fractures.

Introduction: The middle ear ossicles form a semi rigid chain in the middle of the ear for conduction and amplification of sound waves from the tympanic membrane to the inner ear. Although, our knowledge of the ear ossicles dates back to the 15th century, and various studies have been carried out on their morphometry, morphology, anomalies, embryology, function and structure throughout the world, information about the morphology of middle ear ossicles is meagre in Indian subjects. Aim: To find out the morphological variations of middle ear ossicles of right and left sides. Materials and Methods: In the present study, the middle ear ossicles were bilaterally dissected out from the temporal bones obtained from 26 cadaveric heads from the Department of Anatomy under a surgical oto-microscope with micro instruments. Morphological variations were studied under the magnification of the operating microscope. Attempt was also made to evaluate the clinical implications related to such variants and compare the results with those observations made in other parts of India and abroad. Age variation was not considered as the ossicles reach their full size at birth. Results: It was observed that the stapes was the most variable and the incus as the most stable ossicle so far as morphological variations are concerned. Malleus presented variations in the free ends of manubrium, lateral process and anterior process. Variation in morphology of stapes did not follow any fixed pattern. Conclusion: It is expected that this work may also inspire many others to continue temporal bone dissection with a view to gather more ossicles which might be preserved in ossicular banks by following proper sterilization methods for future use as homografts in ossiculoplasty. These harvested ossicles may be used to replace eroded middle ear ossicles as an alternative to manufactured prosthesis.

In the present work, Mg-4Al-xNd (x = 0, 1, 4 wt.%) alloys were prepared by a stir casting method, and the effect of the addition of Neodymium (Nd) as-cast and of heat-treated microstructures was studied. The addition of 1 wt.% Nd preferentially formed the Al2Nd phase and completely suppressed the formation of the intermetallic Mg17Al12 (γ) phase, which was initially present in the base alloy (Mg-4Al alloys). On increasing the Nd percentage from 1 to 4 wt.% in the base alloy, two intermetallic phases, Al2Nd and Al11Nd3, were observed in the microstructure, as higher levels of Nd led to a peritectic reaction between Al and the Al2Nd phase, and part of the Al2Nd transformed into the Al11Nd3 phase. The hardness of the as-cast alloy increased with the Nd content. Thus, the hardness increased from 57.1 ± 4.1 Hv of Mg-4Al to 66.5 ± 2.6 Hv of Mg-4Al-4Nd. It was also found that solutionizing and isothermal aging of alloys containing Nd at 180 °C for 96 h led to the size reduction of Al- and Nd-containing intermetallics without altering their morphologies. Further, it was found that Nd does not have any effect on the aging kinetics of the alloys because all of the alloys with and without Nd attained peak hardness at 24 h of aging time.

Background: The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication., Methods: This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death., Results: We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001)., Conclusions: C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality., Trial Registration: this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021)., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Since the SARS-CoV-2 pandemic emerged, antimicrobial stewardship (AS) activities need to be diverted into COVID-19 management., Methods: In order to assess the impact of COVID-19 on AS activities, we analyzed changes in antibiotic consumption in moderate-to-severe COVID-19 patients admitted to four units in a tertiary-care hospital across three COVID-19 waves. The AS program was introduced at the hospital in 2018. During the first wave, COVID-19 forced the complete withdrawal of hospital AS activities. In the second wave, antibiotic guidance calibration for COVID-19 patients was implemented in all units, with enhanced stewardship activities in Units 1, 2, and 3 (intervention units). In a controlled before and after study, antimicrobial usage during the three waves of the COVID-19 pandemic was compared to the 12-month prepandemic unit (Unit 4 acted as the control). Antibiotic consumption data were analyzed as the overall consumption, stratified by the World Health Organization AWaRe classification, and expressed as defined-daily-dose (DDD) and days-of-therapy (DOT) per 1000 patient-day (PD)., Results: In the first wave, the overall normalized DOT in units 2-4 significantly exceeded the 2019 level (2019: 587 DOT/1000 PD ± 42.6; Unit 2: 836 ± 77.1; Unit 3: 684 ± 122.3; Unit 4: 872, ± 162.6; p < 0.05). After the introduction of AS activities, consumption decreased in the intervention units to a significantly lower level when compared to 2019 (Unit 1: 498 DOT/1000 PD ± 49; Unit 2: 232 ± 95.7; Unit 3: 382 ± 96.9; p < 0.05). Antimicrobial stewardship activities resulted in a decreased amount of total antibiotic consumption over time and positively affected the watch class and piperacillin-tazobactam use in the involved units., Conclusions: During a pandemic, the implementation of calibrated AS activities represents a sound investment in avoiding inappropriate antibiotic therapy.

Scope: Despite the large availability of vaccines, coronavirus disease 2019 (COVID-19), induced by severe acute respiratory syndrome coronavirus 2, continues to be a major threat for health-care providers and fragile people. A number of options are now available for outpatients with mild-to-moderate COVID-19 at the risk of disease progression for the prevention of deaths or hospitalization., Methods: A European Society of Clinical Microbiology and Infectious Diseases COVID-19 guidelines task force was established by the European Society of Clinical Microbiology and Infectious Diseases Executive Committee. A small group was established, half appointed by the chair and the remaining selected based on an open call. Each panel met virtually once a week. For all decisions, a simple majority vote was used. A long list of clinical questions using the population, intervention, comparison, outcome format was developed at the beginning of the process. For each population, intervention, comparison, outcome, two panel members performed a literature search, with a third panelist involved in case of inconsistent results. Voting was based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach., Recommendations: In this update, we focus on anti-viral agents, monoclonal antibodies (mAbs) and other treatment options proposed for patients with mild or moderate COVID-19 who are at the risk of hospitalization or death. Although the use of anti-virals is recommended, especially nirmatrelvir/ritonavir and remdesivir or, alternatively, molnupirarvir, the administration of mAbs against the spike protein strictly depends on circulating variants or the ability to test timely for variants and sub-variants. At the time of writing (April-June 2022), the only active mAb was tixagevimab/cilgavimab given the predominance of the Omicron BA.2, BA.3, BA.4 and BA.5 sub-lineages in Europe. However, considering that the epidemiological scenario is extremely dynamic, constant monitoring of variants of concern is mandatory., (Copyright © 2022 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: Antibiotic stewardship (AS) is a cornerstone of the fight against antimicrobial resistance; however, evidence on the best practice to improve antibiotic prescription in various hospital settings is still scarce. This study aimed to measure the efficacy of a non-restrictive AS intervention in the internal medicine area of a tertiary-care hospital across a 3-year period., Methods: The intervention comprised a 3-month 'intensive phase' based on education and guidelines provision, followed by 9 months of audits and feedback activities. The primary outcome was the overall antibiotic consumption measured as days of therapy (DOTs) and defined daily doses (DDDs). Secondary outcomes were carbapenem and fluoroquinolone consumption, all-cause in-hospital mortality, length of stay, incidence of Clostridioides difficile and carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSIs). All outcomes were measured in the intervention wards comparing the pre-phase with the post-phase using an interrupted time-series model., Results: A total of 145 337 patient days (PDs) and 14 159 admissions were included in the analysis. The intervention was associated with reduced DOTs*1000PDs (-162.2/P = 0.005) and DDDs*1000PDs (-183.6/P ≤ 0.001). A sustained decrease in ward-related antibiotic consumption was also detected during the post-intervention phase and in the carbapenem/fluoroquinolone classes. The intervention was associated with an immediate reduction in length of stay (-1.72 days/P < 0.001) and all-cause mortality (-3.71 deaths*100 admissions/P = 0.002), with a decreasing trend over time. Rates of Clostridioides difficile infections and CRE-BSIs were not significantly impacted by the intervention., Conclusions: The AS intervention was effective and safe in decreasing antibiotic consumption and length of stay in the internal medicine area. Enabling prescribers to judicious use of antimicrobials through active participation in AS initiatives is key to reach sustained results over time., (Copyright © 2022 Elsevier Ltd and International Society of Antimicrobial Chemotherapy. All rights reserved.)

Objectives: We sought to evaluate the incidence of 28-day hospital readmission in a tertiary hospital in Oman and identify potential factors associated with increased risk of hospital readmission., Methods: We conducted a retrospective study of all adult patients (≥ 18 years) admitted under the care of the General Internal Medicine unit from 1 June to 31 December 2020 at Sultan Qaboos University Hospital. Elective admissions and COVID-19 infection-related admission were excluded from the study., Results: There were 200 patients admitted during the study period. The mean age was 58.6±19.3 years, and 106 (53.0%) patients were males. Forty-eight (24.0%) patients had unplanned readmission within 28-days after discharge from the hospital. Patients with 28 days unplanned readmission were older (66.6 vs. 56.0 years, p < 0.001) and had a longer length of hospital stay (6.0 vs. 4.0 days, p < 0.001). Also, hypertension (77.1% vs. 55.3%, p = 0.007), diabetes mellitus (64.6% vs. 48.0%, p = 0.045), and comorbidity (≥ 3 comorbidities, [43.8% vs. 23.8%, p = 0.005]) were more prevalent in the unplanned readmission group. Patients with poor functional status (43.7% vs. 26.3%, p < 0.001), requiring feeding tube (25.0% vs. 5.3%, p < 0.001), and with polypharmacy (75.0% vs. 50.0%, p = 0.003) were at increased risk of readmission., Conclusions: 28-day hospital readmission is prevalent in our health care setting. Old age, polypharmacy, comorbidities, and poor functional status were associated with an increased risk of hospital readmission. Therefore, evidence-based interventions must be implemented in our health care system to minimize the risk of hospital readmission., (The OMJ is Published Bimonthly and Copyrighted 2022 by the OMSB.)

Objectives: This study aimed to evaluate the prevalence and clinical significance of elevated peripheral blood eosinophil (PBE) counts in hospitalised patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in Oman. An elevated PBE count during AECOPD is a potential predictor of treatment responsiveness and future exacerbation risk., Methods: This single-centre retrospective study included all patients with AECOPD who were admitted to Sultan Qaboos University Hospital, Muscat, Oman, between January 2017 and July 2019. The patients were classified as having eosinophilic or non-eosinophilic AECOPD based on blood eosinophil counts. An elevated eosinophil count was defined as a blood eosinophil count >0.3 × 10 9 cells/L on admission. The length of hospital stay, use of oral and inhaled steroids, number of readmissions in a year and use of mechanical ventilation on admission were compared between the eosinophilic and non-eosinophilic AECOPD groups., Results: Of the 102 patients included in the study, 42.2% had eosinophilic AECOPD. The eosinophilic AECOPD group had a reduced length of hospital stay ( P = 0.02) but an increased risk of readmission in a year ( P = 0.04). Most patients in both groups were treated with inhaled and oral steroids. The need for mechanical ventilation did not differ between the groups., Conclusion: Eosinophilia is highly prevalent in patients with AECOPD and is associated with a reduced length of hospital stay but an increased risk of readmission in a year. It can be used as a surrogate marker to predict the health outcomes of patients with AECOPD and select treatment options., Competing Interests: CONFLICT OF INTEREST The authors declare no conflicts of interest., (© Copyright 2022, Sultan Qaboos University Medical Journal, All Rights Reserved.)

Background: International travel has been recognized as a risk factor contributing to the spread of antimicrobial resistance (AMR). However, tools focused on AMR in the context of international travel and designed to guide decision-making are limited. We aimed at developing an evidence-based educational tool targeting both healthcare professionals (HCPs) and international travellers to help prevent the spread of AMR., Methods: A literature review on 12 antimicrobial-resistant bacteria (ARB) listed as critical and high tiers in the WHO Pathogen Priority List covering four key areas was carried out: AMR surveillance data; epidemiological studies reporting ARB prevalence data on carriage in returning travellers; guidance documents reporting indications on screening for ARB in returning travellers and recommendations for ARB prevention for the public. The evidence, catalogued at country-level, provided the content for a series of visualizations that allow assessment of the risk of AMR acquisition through travel., Results: Up to January 2021, the database includes data on: (i) AMR surveillance for 2.018.241 isolates from 86 countries; (ii) ARB prevalence of carriage from 11.679 international travellers and (iii) 15 guidance documents published by major public health agencies. The evidence allowed the development of a consultation scheme for the evaluation of risk factors, prevalence of carriage, proportion and recommendations for screening of AMR. For the public, pre-travel practical measures to minimize the risk of transmission were framed., Conclusions: This easy-to-use, annually updated, freely accessible AMR travel tool (https://epi-net.eu/travel-tool/overview/), is the first of its kind to be developed. For HCPs, it can provide a valuable resource for teaching and a repository that facilitates a stepwise assessment of the risk of AMR spread and strengthen implementation of optimized infection control measures. Similarly, for travellers, the tool has the potential to raise awareness of AMR and outlines preventive measures that reduce the risk of AMR acquisition and spread., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society of Travel Medicine.)

BACKGROUND Left ventricular thrombus (LVT) is a complication of left ventricular dysfunction and myocardial infarction (MI) and is associated with systemic thromboembolism. Two-dimensional transthoracic echocardiography (TTE) is considered the first-line diagnostic tool for detection of LVT. Vitamin K antagonists (VKA) targeting an international normalized ratio (INR) from 2 to 3 are the only approved treatments by the Food and Drug Administration (FDA). New emerging observational data support the use of direct oral anticoagulants (DOACs) as an alternative therapeutic option; however, their safety and efficacy have not been assessed in a good-quality randomized controlled trial. CASE REPORT Here, we present a case of a 43-year-old man diagnosed with human immunodeficiency virus (HIV)-associated dilated cardiomyopathy complicated with an LVT. He was treated with rivaroxaban for 9 consecutive months with no interruption of therapy at any point in time; however, he presented to the emergency department with symptoms of decompensated heart failure. A follow-up TTE demonstrated a significant increase in the size of his LVT. This case questions the efficacy of using factor Xa inhibitor (rivaroxaban) as an alternative option for LVT treatment. CONCLUSIONS This case demonstrates a failure of rivaroxaban in treating LVT in a patient with HIV-associated dilated cardiomyopathy. Good-quality randomized clinical trials or prospective studies are required to establish the efficacy and safety of DOACs for LVT treatment as an alternative to VKA.

Background: In long-term care facilities (LTCFs) residents often receive inappropriate antibiotic treatment and infection prevention and control practices are frequently inadequate, thus favouring acquisition of MDR organisms. There is increasing evidence in the literature describing antimicrobial stewardship (AMS) activities in LTCFs, but practical guidance on how surveillance data should be linked with AMS activities in this setting is lacking. To bridge this gap, the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks joined their efforts to provide practical guidance for linking surveillance data with AMS activities., Materials and Methods: Considering the three main topics [AMS leadership and accountability, antimicrobial usage (AMU) and AMS, and antimicrobial resistance (AMR) and AMS], a literature review was performed and a list of target actions was developed. Consensus on target actions was reached through a RAND-modified Delphi process involving 40 experts from 18 countries and different professional backgrounds adopting a One Health approach., Results: From the 25 documents identified, 25 target actions were retrieved and proposed for expert evaluation. The consensus process produced a practical checklist including 23 target actions, differentiating between essential and desirable targets according to clinical relevance and feasibility. Flexible proposals for AMS team composition and leadership were provided, with a strong emphasis on the need for well-defined and adequately supported roles and responsibilities. Specific antimicrobial classes, AMU metrics, pathogens and resistance patterns to be monitored are addressed. Effective reporting strategies are described., Conclusions: The proposed checklist represents a practical tool to support local AMS teams across a wide range of care delivery organization and availability of resources., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.)

Background: Antimicrobial surveillance and antimicrobial stewardship (AMS) are essential pillars in the fight against antimicrobial resistance (AMR), but practical guidance on how surveillance data should be linked to AMS activities is lacking. This issue is particularly complex in the hospital setting due to structural heterogeneity of hospital facilities and services. The JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks have joined efforts to formulate a set of target actions for linking surveillance data with AMS activities., Methods: A scoping review of the literature was carried out addressing research questions on three areas: (i) AMS leadership and accountability; (ii) antimicrobial usage and AMS; (iii) AMR and AMS. Consensus on the target actions was reached through a RAND-modified Delphi process involving over 40 experts in different fields from 18 countries., Results: Evidence was retrieved from 51 documents. Initially 38 targets were proposed, differentiated as essential or desirable according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for 32 targets. Following a second consultation, 27 targets were approved, 11 were deleted and 4 were suggested for rephrasing, leading to a final approved list of 34 target actions in the form of a practical checklist., Conclusions: This White Paper provides a pragmatic and flexible tool to guide the development of calibrated hospital-surveillance-based AMS interventions. The strength of this tool is that it is a comprehensive perspective that takes into account the hospital patient case-mix and the related epidemiology, which ultimately drives antimicrobial usage, and the feasibility in low-resource settings., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.)

Background: The outpatient setting is a key scenario for the implementation of antimicrobial stewardship (AMS) activities, considering that overconsumption of antibiotics occurs mainly outside hospitals. This publication is the result of a joint initiative by the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks, which is aimed at formulating a set of target actions for linking surveillance data with AMS activities in the outpatient setting., Methods: A scoping review of the literature was carried out in three research areas: AMS leadership and accountability; antimicrobial usage and AMS; antimicrobial resistance and AMS. Consensus on the actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine or public health, from 18 low-, middle- and high-income countries., Results: Evidence was retrieved from 38 documents, and an initial 25 target actions were proposed, differentiating between essential or desirable targets according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for all targets. Further to a second review, 6 statements were re-considered and 3 were deleted, leading to a final list of 22 target actions in the form of a practical checklist., Conclusions: This White Paper is a pragmatic and flexible tool to guide the development of calibrated surveillance-based AMS interventions specific to the outpatient setting, which is characterized by substantial inter- and intra-country variability in the organization of healthcare structures, maintaining a global perspective and taking into account the feasibility of the target actions in low-resource settings., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.)

G-protein-coupled receptors (GPCRs) are membrane-bound proteins, which are responsible for the detection of extracellular stimuli and the origination of intracellular responses. Both glucagon and glucagon-like peptide-1 (GLP-1) receptors belong to G protein-coupled receptor (GPCR) superfamily. Along with insulin, glucagon and GLP-1 are critical hormones for maintaining normal serum glucose within the human body. Glucagon generally plays its role in the liver through cyclic adenosine monophosphate (cAMP), where it compensates for the action of insulin. GLP-1 is secreted by the L-cells of the small intestine to stimulate insulin secretion and inhibit glucagon action. Despite extensive research efforts and the multiple approaches adopted, the glycemic control in the case of type-2 diabetes mellitus remains a major challenge. Therefore, a deep understanding of the structure-function relationship of these receptors will have great implications for future therapies in order to maintain a normal glucose level for an extended period of time. The antagonists of glucagon receptors that can effectively block the hepatic glucose production, as a result of glucagon action, are highly desirable for the tuning of the hyperglycemic state in type 2 diabetes mellitus. In the same manner, GLP-1R agonists act as important treatment modalities, thanks to their multiple anti-diabetic actions to attain normal glucose levels. In this review article, the structural diversity of glucagon and GLP-1 receptors along with their signaling pathways, site-directed mutations and significance in drug discovery against type-2 diabetes are illustrated. Moreover, the promising non-peptide antagonists of glucagon receptor and agonists of GLP-1 receptor, for the management of diabetes are presented with elaboration on the structure-activity relationship (SAR)., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

This work was aimed to explore the potential effect of hyaluronic acid (HA) initial concentration (7.0 - 14.0 % w/v) on cross-linking efficiency of HA hydrogels cross-linked with 1,4-butanediol diglycidyl ether (BDDE). The results revealed that the hydrogel prepared at 10.0 % HA concentration exhibited a slower degradation rate, a lower swelling ability and more regular porosity than those prepared at either lower or higher HA concentration. After four days incubating with hyaluronidase, the content of NAG (N-acetyl glucosamine) remaining in the 10.0 HA hydrogel was 25.1±1.9 % with respect to the total NAG content found in the original mass. In contrast, the hydrogels prepared at 7.0 % and 14.0 % HA concentration showed a less remaining content of NAG equaled to approximately 15.9±5.4 % and 19.5±2.6 % respectively. On the other hand, the swelling ability of tested hydrogels was steadily decreased with the increase of HA initial concentration until the 10.0 % HA hydrogel and then showed an opposite trend. Based on this finding, the 10.0 % HA hydrogel exhibited the lowest swelling ratio which was observed at 129±3.2 g/g in distilled water and at 116±2.4 g/g in phosphate buffer saline (PBS). The SEM images showed various morphologies within the entire range of tested hydrogels. However, the hydrogel prepared at 10.0 % HA concentration was more homogenous and appeared with narrower pore-size distribution ranged in diameter from less than 50 μm to approximately 300 μm. Finally, the effect of HA initial concentration was investigated by FTIR which confirmed that the 10.0 % HA hydrogel was subject to a greater loss of (- OH) at 3343 cm-1 than other hydrogels except the 11.0 % HA hydrogel. This phenomenon was probably attributed to the formation of pendants that allowed the 11.0 % HA hydrogel to appear with a lower peak intensity than the 10.0 % HA hydrogel in the FTIR spectra. In conclusion, the HA initial concentration plays a crucial role in determining the cross-linking efficiency of HA hydrogels cross-linked with BDDE.

Regardless of various strategies reported for cross-linking hyaluronic acid (HA) with 1,4-butanediol diglycidyl ether (BDDE), seeking new strategies that enhance cross-linking efficiency with a low level of cross-linker is essential. In this work, we studied the influence of mixing approach on two cross-linked BDDE-HA hydrogels prepared by two different mixing approaches; the large-batch mixing approach in which the hydrogel quantities were all mixed as a single lump in one container (hydrogel 1), and the small-batches mixing approach in which the hydrogel quantities were divided into smaller batches, mixed separately at various HA/BDDE ratios then combined in one reaction mixture (hydrogel 2). The result showed that the cross-linking reaction was mixing process-dependent. Degradation tests proved that, in relation to hydrogel 1, hydrogel 2 was more stable, and exhibited a higher resistance towards hyaluronidase activity. The swelling ratio of hydrogel 1 was significantly higher than that of hydrogel 2 in distilled water; however, in phosphate buffer saline, both hydrogels showed no significant difference. SEM images demonstrated that hydrogel 2 composite showed a denser network structure and smaller pore-size than hydrogel 1. In comparison to native HA, the occurrence of chemical modification in the cross-linked hydrogels was confirmed by FTIR and NMR distinctive peaks. These peaks also provided evidence that hydrogel 2 exhibited a higher degree of modification than hydrogel 1. In conclusion, the small-batches mixing approach proved to be more effective than large-batch mixing in promoting HA-HA entanglement and increasing the probability of BDDE molecules for binding with HA chains., (Copyright © 2016 Elsevier B.V. All rights reserved.)