Expert Group Opinion Research Articles

Nitrosamines in antihypertеnsives, metformin and ranitidine as cofactors for melanoma and development of other cancers. Expert group opinion

Nitrosamines in antihypertеnsives, metformin and ranitidine as cofactors for melanoma and development of other cancers. Expert group opinion

Pre and Posttransplant Vaccination for Solid Organ Transplant Recipient and in South Asia - Expert Group Opinion

Infections are common after solid organ transplantation (SOT) and are an important cause of significant morbidity and mortality. Many of these infections can be prevented or their severity reduced by vaccination in pre and posttransplantation period. It is better to complete the vaccination before transplantation as protection and seroconversion is better, and live vaccines are mostly contraindicated after SOT. Live vaccines should be given at least 4 weeks before transplantation but killed vaccines can be given up to 2 weeks before the planned transplantation. Vaccination for some diseases which are endemic in South Asia should be given, along with usual vaccinations. Serological monitoring is required for some vaccines to check their efficacy. Similarly, some vaccines are recommended for SOT recipients traveling to various endemic regions.

Expert Group Opinion for Diagnosis and Management of Fungal Infections in Solid Organ Transplant Recipients in South Asia

Fungal infections, are common in solid organ transplant (SOT) récipients in South Asia. Invasive fungal infections (IFI) are the third-most common cause of infections in SOT recipients in South Asia after urinary tract infection and tuberculosis and are a significant cause of morbidity and mortality in this population. There are multiple factors, which lead to poor outcomes of these patients, i.e., lack of awareness, inadequate training of physicians, poor laboratory support to diagnose these infections, and sometimes nonavailability of appropriate antifungal agents to treat these infections. Among the IFI in India, invasive candidiasis is the most common followed by mucormycosis, invasive aspergillosis, and cryptococcosis. There is an increasing prevalence of azole resistance and multi-drug resistance among candida infections in South Asia. There are drug interactions of azoles with tacrolimus, cyclosporine, and everolimus and this must be kept in mind when treating various fungal infections. Another challenge is, how to screen and treat the donors and recipients before accepting them for transplant and subsequent management of transplant recipients. The most common endemic mycoses in the Asia-Pacific region are histoplasmosis caused by Histoplasma capsulatum, talaromycosis caused by Talaromyces marneffei and sporotrichosis caused by Sporothrix schenckii. The endemic fungal infections should be kept in the differential diagnosis of pyrexia of unknown origin in transplant recipients. Finally, the outcomes of these patients can be improved by increasing awareness among transplant physicians, better and wider availability of diagnostic facilities, and appropriate use of antifungal agents to treat these infections.

Evaluation and Management of Tuberculosis in Solid Organ Transplant Recipients

Both tubercular and non-tubercular mycobacterial infections are common in South Asia. These are important pathogens in solid organ transplant recipients and hence prevention (when possible), prompt diagnosis, and early and optimum treatment is critical to reduce morbidity and prevent mortality. This article reviews available data to portray a possible approach to evaluation and management of mycobacterial infections in South Asian solid organ transplant recipients.

Expert Group Opinion for Urinary Tract Infection in Solid Organ Transplant Recipients in South Asia

Urinary tract infection (UTI) is one of the common infections in solid organ transplant recipients and the most common infection in kidney transplant recipients. UTI in the early posttransplant period is associated with significant morbidity and graft dysfunction. Female gender, advanced age, presence of urinary tract abnormalities, and diabetes mellitus are some of the risk factors for UTI. The emergence of multi-drug resistant bacteria has made the treatment difficult and one needs to be aware of the local antibiotic resistance pattern when treating empirically. These patients should be treated adequately and those with recurrent UTI would need long-term prophylaxis. Asymptomatic bacteriuria should only be treated if it occurs within the first 2–3 months of transplant, otherwise, it can lead to the emergence of the resistant organism without any benefit. To reduce the risk of UTI after transplant, the Foley's catheter should be removed within 3–5 days, DJ stent should be removed within 2–3 weeks and the recipient should be kept on routine prophylaxis for 6 months.

Endemic Viral Disease - Expert Group Opinion for Solid Organ Transplant Recipients in South Asia – Dengue, Chikungunya, Zika, Rabies, Japanese Encephalitis, and Nipah Virus

South Asia is endemic to many virus infections such as arboviruses such as dengue virus, chikungunya virus, Zika virus, Japanese encephalitis (JE) virus, and rabies virus. Arbovirus infections present as fever, rash, arthralgia, myalgia, etc., Although transmission of these viruses has rarely been reported in organ transplants, in the endemic season, there is a possibility as the donor might be in an incubation period. Donor deferral for at least 30 days is advised in any donor with confirmed or suspected cases of arboviral infection. Rabies and JE can cause encephalitis and remain undiagnosed many times, so donors with unknown etiology of encephalitis should be excluded from donation. Nipah virus is an emerging virus, which is reported mainly from Bangladesh, Siliguri, and Kerala in India, however, no case of donor-derived infection has been reported yet.

Expert Group Opinion for Diagnosis and Management Viral Hepatitis in Solid Organ Transplant Recipients in South Asia

Viral hepatitis is endemic in the South Asia region and is mainly caused by four hepatotropic viruses: hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis E virus (HEV). South Asia region consists of developing countries and HAV and HEV infections are common because of poor sanitary conditions and hygiene practices. HAV and HEV are transmitted person-to-person by fecal[FIGURE DASH]oral route. HBV and HCV are transmitted via permucosal or percutaneous exposure. It is important to know the impact of these viral infections in the setting of transplantation including evaluation and management in pre, peri, and posttransplant periods. This review summarizes the epidemiology, preventive practices, and advisory for travelers to these endemic regions. Furthermore, recommendations for screening donors and recipients in transplant settings are discussed.

Expert Group Opinion for Endemic Bacterial Infections in South Asia in Solid Organ Transplant Recipients - Typhoid, Paratyphoid, Leptospirosis, Scrub Typhus, and Melioidosis

Typhoid, paratyphoid, leptospirosis, scrub typhus, and melioidosis are some of the common bacterial infections which are endemic in the region of South Asia. Typhoid and paratyphoid cause enteric fever which is a common cause of fever in the general population in this region. It is caused by Salmonella through contaminated food and water. Enteric fever is one of the most common causes of fever in travelers in this region. Leptospirosis is a zoonotic disease caused by Leptospira and occurs due to direct contact with animals like or through abraded skin after the monsoon in the endemic area. Fever and jaundice are the most common presentations. Scrub typhus is caused by mite Orientia tsutsugamushi and it has now emerged as one of the most common causes of pyrexia in this region. Melioidosis is an uncommon infection caused by the bacteria Burkholderia pseudomalle, which is endemic in some regions of South Asia and is usually seen in immunocompromised individuals. Melioidosis is often called great mimicker due to a variety of clinical manifestations which might confuse it with other diseases. All these infections can cause fever or other systemic complications involving various organs in transplant recipients, so they should be kept as part of differential diagnosis of pyrexia in transplant recipients. There are no recommendations to screen for these infections in transplant candidates or donors, however, transplant candidates or donors with fever should be investigated for these infections and transplant should be deferred until full recovery and for some time thereafter.

Cryptosporidium Infection in Solid Organ Transplant Recipients in South Asia - Expert Group Opinion for Diagnosis and Management

Cryptosporidium is a protozoan ubiquitous in natural water sources worldwide. It is a common intestinal pathogen that frequently causes gastroenteritis syndrome. It is mainly transmitted from person to person via the fecal-oral route, sexual transmission, and possibly through respiratory secretions. After an incubation period of a few days to 2 weeks, it presents as an asymptomatic oocyst passer to clinically evident profuse and prolonged diarrhea, associated with nausea, vomiting, abdominal pain, and fever. The extraintestinal manifestations may occur in the form of respiratory tract disease, pancreatitis, cholangitis, rarely sclerosing cholangitis, and urinary tract infection. Stool microscopy examination for identifying oocysts is the mainstay diagnostic tool. The association with cancer is new evolving paradigm with cryptosporidium infection. Nitazoxanide is the treatment of choice. However, paromomycin in combination with other antiparasitic agents, such as macrolides (azithromycin, spiramycin), and nitazoxanide may be a more effective option in case of no response.

Expert Group Opinion for Respiratory Infections in Solid Organ Transplant Recipients in South Asia

Respiratory infections are among the most common and serious infections after solid organ transplantation (SOT). Infections within a month after transplant are usually donor-derived or bacterial infections related to surgical infections or ventilator associated. Infections between 1–6 months after SOT are mostly opportunistic due to various viruses, or fungal infections. After 6 months of transplantation usually community acquired infections predominate, however it is not uncommon to find opportunistic fungal and viral infections in this period. The signs and symptoms of these infections are often mitigated in SOT recipients, so a high index of suspicion is required along with microbiological or tissue diagnosis early in the course to timely treat these infections. Thorough screening for common infections and endemic infections is required in donor and recipients before transplantation to reduce the risk of infections in posttransplant period. Finally, a longer duration of treatment and prophylaxis is required for adequately treat these infections and prevent the relapse.

Endemic Parasitic Disease - Expert Group Opinion for South Asia for Solid-Organ Transplantation − Leishmaniasis, Malaria, Toxoplasmosis, Filariasis, and Strongyloidiasis

Although parasitic infections including malaria, leishmania, and toxoplasmosis contribute to a significant burden of the morbidity and mortality of global populations, they remain woefully understudied in solid-organ transplantation with recommendations mainly based on expert opinions. This paradox is due to the fact that the geographic prevalence of most of these infections is restricted to the developing world where priorities of care are different due to economic constraints. Limited availability of transplant programs where parasitic infections are endemic, challenges in diagnosis, re-activation or recrudescence of latent infections which may present at a later date, the lesser impact of these infections in the immune-suppressed host and limited availability of drugs used in the treatment of some of these infections may influence therapeutic interventions. In the Indian sub-continent, malaria, visceral leishmaniasis (VL), filariasis, strongyloidiasis, and toxoplasmosis are endemic. India contributes to 4% of the total global burden of cases of malaria and has the highest number of cases among the South Asian countries. VL is restricted to Bihar and West Bengal in India and liposomal amphotericin, the drug of choice is still prohibitively expensive. The impact of toxoplasmosis, filariasis, and strongyloidiasis in solid-organ transplant is still limited compared to other infections. Challenges are mainly related to donor screening and exclusion as applying western recommendations to these endemic infections may not be practical. Early diagnosis and appropriate therapy improve outcomes.

Diarrhea in Solid Organ Transplant Recipients in the South Asian Region - Expert Group Opinion for Diagnosis and Management

Diarrhea after solid organ transplantation is a common problem. Posttransplant diarrhea can lead to dehydration, weight loss, graft dysfunction, frequent hospitalization and increased mortality. Posttransplant diarrhea is seen in 20%–25% of patients within 2 years of transplantation and it can be both due to infections and the drugs. The most common cause of drug causing diarrhea is mycophenolate mofetil, and tacrolimus. The common infective causes of diarrhea in posttransplant recipients include viral infections (norovirus, sapovirus, cytomegalovirus [CMV]), bacterial infections (Salmonella, Clostridium difficile, Aeromonas, Campylobactor, Enterotoxigenic, and Enterohemorrhagic Escherichia coli) and parasitic infections (Cryptosporidium, Giardia lamblia, Microsporidia Cyclospora, Strongyloidiasis etc.). Because of overall poor hygienic conditions, infective diarrhea is common in South Asian region. Since most cases of acute diarrhea are infective, and many with viral etiologies, conservative management using oral rehydration solution, antidiarrheal drugs, and where appropriate, a short course of antibiotics helps in the resolution of most cases. A detailed evaluation should be performed in patients with chronic diarrhea, recurrent diarrhea, and those with graft dysfunction. The evaluation of diarrhea should include stool microscopy for ova and cysts, special stains for opportunistic parasitic infection, and molecular diagnostic tools like multiplex Polymerase chain reaction. Colonoscopic and upper gastrointestinal endoscopic examination with biopsies are required to investigate for CMV infection, malabsorption syndrome, inflammatory bowel diseases and posttransplant lymphoproliferative disorder. Although the causes of diarrhea are numerous, an algorithmic approach should be followed both for the diagnosis and the treatment of diarrhea in an organ transplant recipient.

Supplier selection by integrated IFDEMATEL-IFTOPSIS Method: A case study of automotive supply industry

Selecting the best supplier emerges as a crucial subject for all sectors to achieve long term collaborations in supply chains. This study object to select the most suitable supplier for a company engage in activities in the automotive supply industry. For this purpose, a five-stage Intuitionistic Fuzzy Multi-Criteria Decision Making (IFMCDM) model is conducted. Firstly, decision criteria are defined by literature research and expert group opinions. Secondly, the importance weights of these criteria are obtained by IF Decision Making Trial and Evaluation Laboratory (IFDEMATEL). Followingly, the most suitable supplier is assessed by IF Technique for Order Preference by Similarity to Ideal Solution (IFTOPSIS). In the fourth stage, Sensitivity Analysis is utilized to analyze the effect of differentiation in criterion. Lastly, a comparative analysis is carried out. The results of the study has pointed that “Price” is the most important criterion in supplier selection and “Supplier 4” is the best alternative for this case. Main contribution of this study is to integrate IFDEMATEL-IFTOPSIS method for the first time in automotive supplier selection literature and propose a specific decision framework. In addition, proposed model is found robust and valid.

An expert opinion of the Association of Cardiovascular Interventions and the Working Group on Cardiovascular Pharmacotherapy of the Polish Cardiac Society related to the place of prasugrel in the prevention of cardiovascular events in patients with acute coronary syndromes.

Based on many randomized clinical trials, it can be concluded that dual antiplatelet therapy is one of the best-studied treatments in the field of cardiovascular medicine. For many years prasugrel and ticagrelor have been preferred inhibitors of the platelet P2Y12 receptor in patients with acute coronary syndromes. These drugs enable faster, stronger, and more consistent inhibition of platelets and lead to better clinical outcomes than clopidogrel. The following document is an expert group opinion summarizing the latest knowledge in the field of antiplatelet therapy in the prevention of cardiovascular events in patients with acute coronary syndromes, with a special focus on prasugrel.

The importance of protein sources to support muscle anabolism in cancer: An expert group opinion

This opinion paper presents a short review of the potential impact of protein on muscle anabolism in cancer, which is associated with better patient outcomes. Protein source is a topic of interest for patients and clinicians, partly due to recent emphasis on the supposed non-beneficial effect of proteins; therefore, misconceptions involving animal-based (e.g., meat, fish, dairy) and plant-based (e.g., legumes) proteins in cancer are acknowledged and addressed. Although the optimal dietary amino acid composition to support muscle health in cancer is yet to be established, animal-based proteins have a composition that offers superior anabolic potential, compared to plant-derived proteins. Thus, animal-based foods should represent the majority (i.e., ≥65%) of protein intake during active cancer treatment. A diet rich in plant-derived proteins may support muscle anabolism in cancer, albeit requiring a larger quantity of protein to fulfill the optimal amino acid intake. We caution that translating dietary recommendations for cancer prevention to cancer treatment may be inadequate to support the pro-inflammatory and catabolic nature of the disease. We further caution against initiating an exclusively plant-based (i.e., vegan) diet upon a diagnosis of cancer, given the presence of elevated protein requirements and risk of inadequate protein intake to support muscle anabolism. Amino acid combination and the long-term sustainability of a dietary pattern void of animal-based foods requires careful and laborious management of protein intake for patients with cancer. Ultimately, a dietary amino acid composition that promotes muscle anabolism is optimally obtained through combination of animal- and plant-based protein sources.

هیچ شواهد علمی برای القای خاصیت مغناطیسی در محل تزریق واکسن کووید ۱۹ وجود ندارد: نظرات خبرگان

Objective: Following rumors circulating in cyberspace and among the public about the creation of magnetic properties at the injection site of the Covid-19 vaccine, the issue was investigated by a team of relevant experts and specialists. Expert Group opinion: There is no scientific evidence for the effect of the Covid-19 vaccine on the magnetization of the vaccine site. The spread of rumors in the community is due to ignorance of the subject of magnetic behavior. However, it is necessary to provide the accurate information to the community to address their concerns. Conflict of Interest: None of the authors has any conflict of interest to disclose. Ethical publication statement: We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. How to cite this article: Arshi Sh. There is no Scientific Evidence for Magnetization of the COVID-19 Vaccination Site: Expert Opinions. Salāmat-i ijtimāī (Community Health). 2021; 8(2):349-350. DOI: http://doi.org/10.22037/ch.v8i2.31472. --------------------------------------------------------------------------------------------------------------------------------------------------- [This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License]

Recommendations for rheumatologists on pharmacological management during the COVID-19 health emergency: Expert group opinion

Coronavirus 2019 (COVID-19) is an unexpected pandemic that has caused a state of emergency, as well as generating drastic changes in clinical care protocols. Some drugs commonly used in rheumatoid arthritis, systemic lupus erythematosus, and other systemic autoimmune diseases have been described for its treatment. Therefore, there is an imminent risk of shortages. The aim of this narrative review and expert opinion is to present general recommendations on the clinical and administrative management of outpatients with autoimmune or systemic inflammatory disease, in the context of the COVID-19 pandemic.

Pain in Women: A Perspective Review on a Relevant Clinical Issue that Deserves Prioritization.

IntroductionGender equity and gender medicine are opportunities not to be missed, and this Expert Group Opinion Paper on pain in women aims to review the treatment of pain conditions mainly affecting women, as well as the fundamental aspects of the different clinical response to drug treatment between the genders, and what can be done for gender-specific rehabilitation.MethodsPerspective review.ResultsGenotypic and phenotypic differences in pain between the sexes are conditioned by anatomical, physiological, neural, hormonal, psychological, social, and cultural factors, such as the response to pharmacological treatment to control pain. The examination of these factors shows that women are affected by pain diseases more frequently and severely than men and that they report pain more frequently and with a lower pain threshold than men. Some forms of pain are inherently related to gender differences, such as pain related to the genitourinary system. However, other forms of chronic pain are seen more frequently in women than men, such as migraine, rheumatological, and musculoskeletal pain, in particular fibromyalgia.DiscussionResearch is needed into the pathophysiological basis for gender differences in the generation of acute pain and maintenance of chronic pain, including the factors that put women at higher risk for developing chronic pain. In addition, different specialties need to collaborate to develop gender-related diagnostic and therapeutic guidelines, and healthcare professionals need to upskill themselves in the appropriate management of pain using existing diagnostic tools and therapeutic options.

A Practitioner's Toolkit for Insulin Motivation in Adults with Type 1 and Type 2 Diabetes Mellitus: Evidence-Based Recommendations from an International Expert Panel.

AimTo develop an evidence-based expert group opinion on the role of insulin motivation to overcome insulin distress during different stages of insulin therapy and to propose a practitioner’s toolkit for insulin motivation in the management of diabetes mellitus (DM).BackgroundInsulin distress, an emotional response of the patient to the suggested use of insulin, acts as a major barrier to insulin therapy in the management of DM. Addressing patient-, physician- and drug-related factors is important to overcome insulin distress. Strengthening of communication between physicians and patients with diabetes and enhancing the patients' coping skills are prerequisites to create a sense of comfort with the use of insulin. Insulin motivation is key to achieving targeted goals in diabetes care. A group of endocrinologists came together at an international meeting held in India to develop tool kits that would aid a practitioner in implementing insulin motivation strategies at different stages of the journey through insulin therapy, including pre-initiation, initiation, titration and intensification. During the meeting, emphasis was placed on the challenges and limitations faced by both physicians and patients with diabetes during each stage of the journey through insulinization.Review ResultsAfter review of evidence and discussions, the expert group provided recommendations on strategies for improved insulin acceptance, empowering behavior change in patients with DM, approaches for motivating patients to initiate and maintain insulin therapy and best practices for insulin motivation at the pre-initiation, initiation, titration and intensification stages of insulin therapy.ConclusionsIn the management of DM, bringing in positive behavioral change by motivating the patient to improve treatment adherence helps overcome insulin distress and achieve treatment goals.

Utility of Precision Medicine in the Management of Diabetes: Expert Opinion from an International Panel.

AimThe primary objective of this review is to develop a practice-based expert group opinion on the role of precision medicine with a specific focus on sulfonylureas (SUs) in diabetes management.BackgroundThe clinical etiology, presentation and complications of diabetes vary from one patient to another, making the management of the disease challenging. The pre-eminent feature of diabetes mellitus (DM) are chronically elevated blood glucose concentrations; however, in clinical practice, the exclusion of autoimmunity, pregnancy, pancreatic disease or injury and rare genetic forms of diabetes is crucial. Within this framework, precision medicine provides unique insights into the risk factors and natural history of DM. Precision medicine goes beyond genomics and encompasses patient-centered care, molecular technologies and data sharing. Precision medicine has evolved in the field of diabetology. It has helped improve the efficacy of SUs, a class of drugs, which have been effectively used in the management of diabetes mellitus for decades, and it has enabled the expansion of SUs use in diabetes patients with genetic mutations.Review ResultsAfter due discussions, the expert group analyzed studies that focused on the use of SUs in diabetes patients with genomic variations and rare mutations. The expert group opined that SUs are important glucose-lowering drugs and that precision medicine helps in improving the efficacy of SUs by matching them to those patients who will benefit most.ConclusionPrecision medicine opens new vistas for the effective use of SUs in unexpected patient populations, such as those with genetic mutations.