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High venous pressures and associated hepatic congestion are important drivers for Fontan-associated liver disease. The prognostic significance of hepatomegaly as a marker of congestion however is not well defined and is further explored in this research study.
Fontan patients who have had liver ultrasound scans were identified from the Prince Sultan Cardiac Centre Fontan Database and had their anatomic, surgical, clinical histories abstracted from the electronic medical records following institutional ethics approval. Liver volumes were determined retrospectively from reviewing individual US images, and these, divided into tertiles, were analysed in the context of the predefined endpoints of (i) Primary – death or heart or liver transplantation, or (ii) Secondary – combined endpoint of death, transplantation, arrhythmia, or protein-losing enteropathy.
Mean indexed liver volumes for the entire cohort (n = 199) were 1065.1 ± 312.1 ml/m2, range 387 to 2071 ml/m2. Patients with the largest liver volumes (highest tertile) were less likely to have a functioning fenestration compared to those in the lowest tertile 44% versus 56% p = 0.016 and experienced the highest burden of mortality and heart or heart–liver transplantation, p = 0.016, and were more likely to reach the composite endpoint of death, protein-losing enteropathy, arrhythmia, or transplantation, p = 0.010. Liver volumes had an overall predictive accuracy for the combined outcome of 61% (CI 53%, 67%, p = 0.009).
Liver volumetry may serve as a potentially important congestion biomarker for adverse outcomes after the Fontan operation.
Background: There are uncertainties regarding the optimal management of acutely symptomatic carotid stenosis (“hot carotids”). We sought to explore the approaches of stroke physicians to anti-thrombotic management, imaging, and revascularization in patients with “hot carotids”. Methods: We used a qualitative descriptive methodology to examine decision-making approaches of physicians regarding the management of hot carotids. We conducted semi-structured interviews with 22 stroke physicians from various specialties in 16 centers across 4 continents. Results: Important themes regarding anti-thrombotic included limitations of existing clinical trial evidence, competing physician preferences, antiplatelet therapy while awaiting revascularization and various regional differences. Timely imaging availability, breadth of information gained, and surgeon/interventionalist preferences were important themes influencing the choice of imaging modality. The choice of revascularization intervention was influenced by healthcare system factors such as use of multidisciplinary review and operating room/angiography suite availability, and patient factors like age and infarct size. Many themes related to uncertainties in the management of hot carotids were also discussed. Conclusions: Our study revealed themes that are important to international stroke experts. We highlight common and divergent practices while underscoring important areas of clinical equipoise and uncertainty. Teams designing international carotid trials may wish to accommodate identified variations in practice patterns and areas of uncertainty.
Antimicrobial resistance (AMR) is a global priority with significant clinical and economic consequences. Multidrug-resistant (MDR) Pseudomonas aeruginosa is one of the major pathogens associated with significant morbidity and mortality. In healthcare settings, the evaluation of prevalence, microbiological characteristics, as well as mechanisms of resistance is of paramount importance to overcome associated challenges.
Consecutive clinical specimens of P. aeruginosa were collected prospectively from 5 acute-care and specialized hospitals between October 2014 and September 2017, including microbiological, clinical characteristics and outcomes. Identification and antimicrobial susceptibility test were performed using the BD Phoenix identification and susceptibility testing system, matrix-assisted laser desorption ionization–time-of-flight mass spectrometry (MALDI-TOF MS), and minimum inhibitory concentration (MIC) test strips. Overall, 78 selected MDR P. aeruginosa isolates were processed for whole-genome sequencing (WGS).
The overall prevalence of MDR P. aeruginosa isolates was 5.9% (525 of 8,892) and showed a decreasing trend; 95% of cases were hospital acquired and 44.8% were from respiratory samples. MDR P. aeruginosa demonstrated >86% resistance to cefepime, ciprofloxacin, meropenem, and piperacillin-tazobactam but 97.5% susceptibility to colistin. WGS revealed 29 different sequence types: 20.5% ST235, 10.3% ST357, 7.7% ST389, and 7.7% ST1284. ST233 was associated with bloodstream infections and increased 30-day mortality. All ST389 isolates were obtained from patients with cystic fibrosis. Encoded exotoxin genes were detected in 96.2% of isolates.
MDR P. aeruginosa isolated from clinical specimens from Qatar has significant resistance to most agents, with a decreasing trend that should be explored further. Genomic analysis revealed the dominance of 5 main clonal clusters associated with mortality and bloodstream infections. Microbiological and genomic monitoring of MDR P. aeruginosa has enhanced our understanding of AMR in Qatar.
Background: Whereas the beneficial effect of antiplatelet therapy for recurrent stroke prevention is well-established, uncertainties remain regarding the optimal anti-thrombotic regimen for acutely symptomatic carotid stenosis (“hot carotid”), particularly as patients await revascularization. We sought to explore the approaches of stroke physicians to peri-procedural anti-thrombotic management of patients with “hot carotids”. Methods: We conducted semi-structured interviews regarding “hot carotid” management with purposive sampling of 20 stroke physicians from 14 centres in North America, Europe, Asia, and Australia. We identified key themes using conventional qualitative content analysis. Results: Important themes revealed from our discussion included limitations of existing clinical trial evidence, competing surgeon versus neurologist/internist preferences, and single vs dual antiplatelet therapy (DAPT) while awaiting revascularization. Areas of uncertainty included the management of stroke while on aspirin, implications of non-stenotic features of carotid disease (intraluminal thrombus, plaque morphology), the role of newer anti-platelet agents or anticoagulants, platelet aggregation testing, and how soon to start DAPT. Conclusions: Our qualitative analysis revealed themes that were important to stakeholders in stroke care. Teams designing international trials will have to accommodate identified variations in anti-thrombotic practice patterns and take into consideration areas of uncertainty, such as newer anti-thrombotic agents, and the implication of non-stenotic features of carotid disease.
Background: Evidence informing the choice between endarterectomy and stenting for acutely symptomatic carotid stenosis (“hot carotid”) is dated, and uncertainties remain regarding the optimal imaging modality. We sought to explore the thoughts of stroke physicians regarding the perioperative management of patients with acute symptomatic carotid stenosis. Methods: We conducted semi-structured interviews regarding “hot carotid” management with purposive sampling of 20 stroke physicians from 14 centres in North America, Europe, Asia, and Australia. We identified key themes using conventional qualitative content analysis. Results: Timely imaging availability, breadth of information gained, and surgeon/interventionalist preference emerged as important themes informing the choice of imaging modality. Multidisciplinary decision making, operating room/angiography suite availability, and implications of patient age and infarct size were important themes related to the choice of revascularization. Areas of uncertainty included utility of carotid plaque imaging, timing of revascularization, and the role of intervention with borderline stenosis or intraluminal thrombus. Conclusions: Our qualitative analysis revealed themes that were important to stroke experts. Teams designing international trials will have to accommodate identified variations in practice patterns and take into consideration areas of uncertainty, such as timing of revascularization, imaging of carotid plaque and non-stenotic features of carotid disease (intraluminal thrombus, plaque morphology).
Background: Patients with acutely symptomatic carotid stenosis (“hot carotid”) have high up-front risk of recurrent strokes. Uncertainties remain regarding optimal anti-thrombotic management, particularly while awaiting revascularization with endarterectomy or stenting (CEA/CAS). Methods: We administered a worldwide electronic survey through Neurology: Clinical Practice. Respondents chose their preferred antithrombotic regimen (1) in a general case of acutely symptomatic carotid stenosis, (2) if the patient was already on aspirin, or (3) had associated intraluminal thrombus(ILT). Responses among different groups were compared using multivariable logistic regression. Results: We received 668 responses from 71 countries. Most respondents favoured CEA(69.1%) over CAS, an aspirin-containing regimen(88.5%), and a clopidogrel-containing regimen(64.4%) if already on aspirin. Monotherapy was favoured by 54.4-70.6% across scenarios. The preferred dual therapy was low-dose aspirin(75-100mg) plus clopidogrel(22.2%), or high-dose aspirin(160-325mg) plus clopidogrel if already on aspirin(12.2%). Respondents favouring CAS more often chose ≥2 agents (adjusted odds-ratio[aOR] vs CEA: 2.00, 95%CI 1.36-2.95,p=0.001) or clopidogrel-containing regimens (aOR:1.77,1.16-2.70,p=0.008). Respondents from Europe less commonly chose multiple agents (aOR vs United States/Canada: 0.57,0.35–0.93,p=0.023) while those from Asia more often favored multi-agent regimens (aOR:1.95,1.11–3.43,p=0.020). Conclusions: Our results highlight the heterogeneous anti-thrombotic management of hot carotids. Future trials should likely include high-dose aspirin monotherapy or low-dose aspirin/clopidogrel dual-therapy as a comparator arm to stimulate enrolment.
Our objective was to compare care-seeking patterns in Mosul, Iraq, in 2018, 1 y after Islamic State of Iraq and Syria (ISIS) control, with findings from neighborhoods that had been sampled in 2017
For this multi-stage randomized cluster household survey, we created one cluster in each of 20 neighborhoods randomly selected from the 40 neighborhoods in the 2016/17 survey; 12 in east Mosul, 8 in west Mosul. In each, 30 households were interviewed beginning at a randomly selected start house. Questions were derived from the 2016/2017 post-ISIS survey.
We interviewed the head of household or senior female in 600 households containing 3375 persons. One year after ISIS, some household demographic shifts had occurred. Diarrhea in children during the past 2 wk decreased from 50.1% to 7.5% (P < 0.001); however, cough/difficulty breathing increased from 15.5% to 33.6% (P < 0.01). Among adults, care-seeking for noncommunicable diseases increased from 22.3% to 43.5% (P < 0.001). Emotional and psychological complaints common in the previous survey were now nearly absent. Pregnancy complications diminished from 65.2% to 15.4% (P < 0.001).
Communicable diseases predominated among children and noncommunicable diseases among adults. Access to health care substantially improved, although barriers remained. Satisfaction with services was mixed, with dissatisfaction expressed about testing, medicine access, and costs, but the work of health providers was rated highly.
To analyze the evacuation preparedness of hospitals within the European Union (EU).
This study consisted of 2 steps. In the first step, a systematic review of the subject matter, according to the PRISMA flow diagram, was performed. Using Scopus (Elsevier, Amsterdam, Netherlands), PubMed (National Library of Medicine, Bethesda, MD), and Gothenburg University´s search engine, 11 questions were extracted from the review and were sent to representatives from 15 European Union (EU)- and non-EU countries.
The findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the EU or other non-EU countries in this study. A major shortcoming revealed by this study is the lack of awareness of the untoward consequences of medical decision-making during an evacuation. Some countries did not respond to the questions due to the lack of relevant guidelines, instructions, or time.
Hospitals are exposed to internal and external incidents and require an adequate evacuation plan. Despite many publications, reports, and conclusions on successful and unsuccessful evacuation, there is still no common guide for evacuation, and many hospitals lack the proper preparedness. There is a need for a multinational collaboration, specifically within the EU, to establish such an evacuation planning or guideline to be used mutually within the union and the international community.
The Iron Age (c. 1300–600 BC) of South-eastern Arabia is characterised by rapid expansion of settlement. Social structures formed over the previous millennia, however, persisted and were reinforced through the development of collective funerary monuments. A recently discovered tomb of Late Bronze to Early Iron Age date at Dibbā al-Bayah in the Sultanate of Oman has yielded a range of artefacts that illuminate the nature and extent of the long-distance contacts of the local community. Seemingly selected not only for their exotic appeal, but also for their apotropaic function, these objects testify to a deep cross-cultural knowledge extending across the wider region during this crucial period in Arabian prehistory.
Reports of psychiatric morbidity associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection tend to be limited by geography and patients’ clinical status. Representative samples are needed to inform service planning and research.
To describe the psychiatric morbidity associated with SARS-CoV-2 infection (confirmed by real-time polymerase chain reaction) in referrals to a consultation-liaison psychiatry service in Qatar.
Retrospective review of 50 consecutive referrals.
Most patients were male. Median age was 39.5 years. Thirty-one patients were symptomatic (upper respiratory tract symptoms or pneumonia) for coronavirus disease 2019 (COVID-19) and 19 were asymptomatic (no characteristic physical symptoms of COVID-19 infection). Seventeen patients (34%) had a past psychiatric history including eight with bipolar I disorder or psychosis, all of whom relapsed. Thirty patients (60%) had physical comorbidity. The principal psychiatric diagnoses made by the consultation-liaison team were delirium (n = 13), psychosis (n = 9), acute stress reaction (n = 8), anxiety disorder (n = 8), depression (n = 8) and mania (n = 8). Delirium was confined to the COVID-19 symptomatic group (the exception being one asymptomatic patient with concurrent physical illness). The other psychiatric diagnoses spanned the symptomatic and asymptomatic patients with COVID. One patient with COVID-19 pneumonia experienced an ischaemic stroke. Approximately half the patients with mania and psychosis had no past psychiatric history. Three patients self-harmed. The commonest psychiatric symptoms were sleep disturbance (70%), anxiety (64%), agitation (50%), depressed mood (42%) and irritability (36%).
A wide range of psychiatric morbidity is associated with SARS-CoV-2 infection and is seen in symptomatic and asymptomatic individuals. Cases of psychosis and mania represented relapses in people with schizophrenia and bipolar disorder and also new onset cases.
A retrospective study was done on admissions of Somatoform Disorder in Mosul Psychiatric Unit for five years period. Two hundred seventy five patients were admitted during that period 224 women and 51 men. Majority of men came from Urban areas compared to 58% of women. Single status were over represented 55% compared to 34% married. 82% of the singles, 90% of widows and 83% of divorced were women. It also showed that there were two seasonal peaks of admissions in January and July. Hysterical pseudo-fits were the most frequent diagnosis. There were no significant change in the number of yearly admissions apart from the first year. The proportion of hysterical disorders compared to total psychiatric disorders admissions was 7.4%.
were consistent with national studies but showed higher figures to neighbouring countries. It was consistent with figures in United Kingdom before 1950.
When patients feel spiritually supported by staff, we find increased use of hospice and reduced use of aggressive treatments at end of life, yet substantial barriers to staff spiritual care provision still exist. We aimed to study these barriers in a new cultural context and analyzed a new subgroup with “unrealized potential” for improved spiritual care provision: those who are positively inclined toward spiritual care yet do not themselves provide it.
We distributed the Religion and Spirituality in Cancer Care Study via the Middle East Cancer Consortium to physicians and nurses caring for advanced cancer patients. Survey items included how often spiritual care should be provided, how often respondents themselves provide it, and perceived barriers to spiritual care provision.
We had 770 respondents (40% physicians, 60% nurses) from 14 Middle Eastern countries. The results showed that 82% of respondents think staff should provide spiritual care at least occasionally, but 44% provide spiritual care less often than they think they should. In multivariable analysis of respondents who valued spiritual care yet did not themselves provide it to their most recent patients, predictors included low personal sense of being spiritual (p < 0.001) and not having received training (p = 0.02; only 22% received training). How “developed” a country is negatively predicted spiritual care provision (p < 0.001). Self-perceived barriers were quite similar across cultures.
Significance of results
Despite relatively high levels of spiritual care provision, we see a gap between desirability and actual provision. Seeing oneself as not spiritual or only slightly spiritual is a key factor demonstrably associated with not providing spiritual care. Efforts to increase spiritual care provision should target those in favor of spiritual care provision, promoting training that helps participants consider their own spirituality and the role that it plays in their personal and professional lives.
Purpose: We measured anterior cerebral artery (ACA)-middle cerebral artery (MCA) and posterior cerebral artery (PCA)-MCA pial filling on single-phase computed tomography angiograms (sCTAs) in acute ischemic stroke and correlate with the CTA-based Massachusetts General Hospital (MGH) and digital subtraction angiography (DSA)-based American Society of Interventional and Therapeutic Neuroradiology (ASITN) score. Methods: Patients with acute stroke and M1 MCA±intracranial internal carotid artery occlusion on baseline CTA were included. Baseline sCTA was assessed for phase of image acquisition. An evaluator assessed collaterals using the Calgary Collateral (CC) Score (measures pial arterial filling in ACA-MCA and PCA-MCA regions separately), the CTA-based MGH score, and on DSA using the ASITN score. Infarct volumes were measured on 24- to 48-hour magnetic resonance imaging/ computed tomography. Results: Of 106 patients, baseline sCTA was acquired in early arterial phase in 9.9%, peak arterial in 50.7%, equilibrium in 32.4%, early venous in 5.6%, and late venous in 1.4%. Variance in ACA-MCA collaterals explained only 32% of variance in PCA-MCA collaterals on the CC score (Spearman’s correlation coefficient rho [rho]=0.56). Correlation between ACA-MCA collaterals and the MGH score was strong (rho=0.8); correlation between PCA-MCA collaterals and this score was modest (rho=0.54). Correlation between ACA-MCA collaterals and the ASITN score was modest (n=53, rho=0.43); and correlation between PCA-MCA collaterals and ASITN score was poor (rho=0.33). Of the CTA-based scores, the CC Score (Akaike [AIC] 1022) was better at predicting follow-up infarct volumes than was the MGH score (AIC 1029). Conclusion: Collateral assessments in acute ischemic stroke are best done using CTA with temporal resolution and by assessing regional variability. ACA-MCA and MCA-PCA collaterals should be evaluated separately.
Undergraduate medical education requires ongoing improvement in order to keep pace with the changing demands of twenty-first century medical practice. Problem-based learning is increasingly being adopted in medical schools worldwide. We review its application in the specialty of ENT, and we present our experience of using this approach combined with more traditional methods.
We introduced problem-based learning techniques into the ENT course taught to fifth-year medical students at Al-Ahsa College of Medicine, King Faisal University, Saudi Arabia. As a result, the teaching schedule included both clinical and theoretical activities. Six clinical teaching days were allowed for history-taking, examination techniques and clinical scenario discussion. Case scenarios were discussed in small group teaching sessions. Conventional methods were employed to teach audiology and ENT radiology (one three-hour session each); a three-hour simulation laboratory session and three-hour student presentation were also scheduled. In addition, students attended out-patient clinics for three days, and used multimedia facilities to learn about various otolaryngology diseases (in another three-hour session). This input was supplemented with didactic teaching in the form of 16 instructional lectures per semester (one hour per week).
From our teaching experience, we believe that the application of problem-based learning to ENT teaching has resulted in a substantial increase in students' knowledge. Furthermore, students have given encouraging feedback on their experience of combined problem-based learning and conventional teaching methods.
Computer-based medical simulation has recently been adopted as a new method of medical education. This paper reviews the uses of medical simulation within the ENT specialty, and reports how such simulation is used in Al-Ahsa College of Medicine, Saudi Arabia.
We review our use of a simulation laboratory in ENT training. Students are taught ENT anatomy using physical models, ear diseases using physical models, and ENT examination by watching video recordings, and are taught the principles of common ENT surgery using a computerised mannequin (for laryngoscopy and bronchoscopy). A haptic temporal bone surgery simulator is used for mastoidectomy and functional endoscopic sinus surgery training, and a mannequin for cricothyrotomy and tracheotomy training.
The use of such simulation methods has greatly improved our students' perception and comprehension.
The authors identify natural bitumen on stone implements dating to 70 000 BP. It is proposed that this represents residue from hafting, taking the practice back a further 30 000 years from the date previously noted and published in Nature. The bitumen was tracked to a source 40km away, using gas chromatography-mass spectrometry and carbon isotopes.
Patients on chronic haemodialysis experience a wide range of physical and psychological stresses. The specific sources of stress include: loss or threatened loss of possessions; relationship problems (e.g. staff–patient relationships, changed roles within the family); restrictions related to physical health status and the dialysis regimen; loss of body function and impaired body image; increased dependency and aggression; the threat of death; impairment of vocational function and financial security; and decreased participation in leisure, social and community activities (Phipps & Turkington, 2001). A review of psychological maladjustment in patients on haemodialysis found that about 55% exhibited significant emotional distress, a prevalence three to five times that found in the general population (Aghanwa & Morakinyo, 1997). The present study aimed to ascertain the prevalence of psychiatric morbidity among patients attending a renal dialysis unit in Mosul, Iraq.
A new species of Chalinula (Haplosclerida: Chalinidae), C. saudiensis, is described from the coral reefs of the Red Sea off Jeddah. The new species is remarkable in its vivid blue colour and its bioactivity. Its description includes cytological features in transmission electron microscopy.
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