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BackgroundAcute intoxication with central nervous system (CNS) xenobiotics is an increasing global problem. Predicting the prognosis of acute toxic exposure among patients can significantly alter the morbidity and mortality. The present study outlined the early risk predictors among patients diagnosed with acute exposure to CNS xenobiotics and endorsed bedside nomograms for identifying patients requiring intensive care unit (ICU) admission and those at risk of poor prognosis or death.MethodsThis study is a 6-year retrospective cohort study conducted among patients presented with acute exposure to CNS xenobiotics.ResultsA total of 143 patients’ records were included, where (36.4%) were admitted to the ICU, and a significant proportion of which was due to exposure to alcohols, sedative hypnotics, psychotropic, and antidepressants (P = 0.021). ICU admission was associated with significantly lower blood pressure, pH, and HCO3 levels and higher random blood glucose (RBG), serum urea, and creatinine levels (P ConclusionThe proposed nomograms yielded significant straightforward and reliable prognostic outcomes predictors in acute exposure to CNS xenobiotics.

This study aims to identify the impact of supply chain management practices on the operational performance of five-star hotels operating in Jordan. A special questionnaire was designed and distributed to marketing, procurement and inventory managers. The results show that the level of supply chain management practices (customer relations, supplier relations and internal processes) and the level of operational performance (flexibility, quality and time) were generally high, with a statistically significant positive relationship between these practices and operational performance in all dimensions, except for relations with suppliers and time. Furthermore, there were no statistically significant differences in the hotels’ responses due to age and spread degree.

Implantable bioelectrodes have the potential to advance neural sensing and muscle stimulation, mainly in patients with peripheral nerve injuries. They function as the transducer at the interface between the damaged nerve and the muscle which is controlled by that nerve. This work reports the fabrication and characterization of novel, low-cost, flexible bioelectrodes based on polyaniline (PANI) and supported with silicone polymer. The fabricated electrodes were evaluated for their electrical and mechanical characteristics. PANI was used as the main transducer component in this fabrication. The characterization methods included electrical conductivity, capacitive behavior, long-term electrical impedance, and mechanical evaluation. The results of the fabricated PANI-silicone-based samples displayed a bulk impedance of 0.6 kΩ with an impedance of 1.6 kΩ at the frequency of 1 kHz. Furthermore, the bioelectrodes showed a charge storage capacity range from 0.0730 to 4.3124 C/cm2. The samples were stable when subjected to cyclic voltammetry tests. The bioelectrodes revealed very flexible mechanical properties as observed from the value of Young’s modulus (in the order of MPa) which was less than that of skin. Hence, the PANI-based bioelectrodes reported herein showed promising electrochemical characteristics with high flexibility.

Background Cardiogenic shock is associated with substantial morbidity and mortality. Although inotropic support is a mainstay of medical therapy for cardiogenic shock, little evidence exis...

COVID-19 brought telemedicine to the forefront of clinical cardiology. We aimed to examine the extent of trainees' involvement in and comfort with telemedicine practices in Canada with the use of a web-based self-administered survey. Eighty-six trainees from 12 training programs completed the survey (65% response rate). Results showed that before COVID-19, 39 trainees (45%) had telemedicine exposure, compared with 67 (78%) after COVID-19 (P < 0.001). However, only 44 trainees (51%) reported being comfortable or very comfortable with the use of telemedicine. Of the 67 trainees who were involved in telemedicine, 4 (6%) had full supervision during virtual visits, 13 (19%) had partial supervision, and 50 (75%) had minimal or no supervision. Importantly, 67 trainees (78%) expressed the need for telemedicine-specific training and 64 (74%) were willing to have their virtual visits recorded for the purpose of evaluation and feedback. Furthermore, 47 (55%) felt strongly or very strongly positive about incorporating telemedicine into their future practice. The main perceived barriers to telemedicine use were concerns about patients' engagement, fear of weakening the patient-physician relationship, and unfamiliarity with telemedicine technology. These barriers, together with training in virtual physical examination skills and medicolegal aspects of telemedicine, are addressed in several established internal medicine telemedicine curricula that could be adapted by cardiology programs. In conclusion, while the degree of telemedicine involvement since COVID-19 was high, the trainees' comfort level with telemedicine practice remains suboptimal likely due to lack of training and inadequate staff supervision. Therefore, a cardiology telemedicine curriculum is needed to ensure that trainees are equipped to embrace telemedicine in cardiovascular clinical care.

Transthoracic echocardiography is the standard of care in anatomic and functional cardiovascular assessment; however, focused cardiac ultrasound (FoCUS) performed with portable ultrasound equipment is increasingly being used as an adjunct to comprehensive history and physical examination. FoCUS assessments, unlike formal echocardiography, are intended to assist physicians in answering explicit clinical questions with a narrow differential diagnosis in real time. Over the past decade, a growing body of literature has repeatedly shown the value that FoCUS adds to clinical evaluation. Specifically, FoCUS improves point-of-care diagnostic accuracy, which in turn modifies treatment plans, decreases time to diagnosis, and reduces resource utilization. Although less robust, there is also evidence showing improvement in clinical outcomes. Based on this evidence, clinicians, training programs, and clinical societies have embraced FoCUS as a tool to complement bedside patient evaluation. Herein, we review the evidence for FoCUS in clinical practice, specifically evaluating the diagnostic accuracy, the impact on clinical decision-making, and the effect on clinical outcomes.

Myocardial blood flow (MBF) quantification by Rubidium-82 positron emission tomography (PET) has shown promise for cardiac allograft vasculopathy (CAV) surveillance and risk stratification post heart transplantation. The objective was to determine the prognostic value of serial PET performed early post transplantation. Heart transplant (HT) recipients at the University of Ottawa Heart Institute with 2 PET examinations (PET1 = baseline, PET2 = follow-up) within 6 years of transplant were included in the study. Evaluation of PET flow quantification included stress MBF, coronary vascular resistance (CVR), and myocardial flow reserve (MFR). The primary composite outcome was all-cause death, re-transplant, myocardial infarction, revascularization, allograft dysfunction, cardiac allograft vasculopathy (CAV), or heart failure hospitalization. A total of 121 patients were evaluated (79% male, mean age 56 ± 11 years) with consecutive scans performed at mean 1.4 ± 0.7 and 2.6 ± 1.0 years post HT for PET1 and PET2, respectively. Over a mean follow-up of 3.0 (IQR 1.8, 4.6) years, 26 (22%) patients developed the primary outcome: 1 death, 11 new or progressive angiographic CAV, 2 percutaneous coronary interventions, 12 allograft dysfunction. Unadjusted Cox analysis showed a significant reduction in event-free survival in patients with PET1 stress MBF 76 (HR: 2.19, 95% CI 0.87-5.51 P = 0.045). There was no association between MFR and outcomes. Low-stress MBF and persistent increased CVR on serial PET imaging early post HT are associated with adverse cardiovascular outcomes. Early post-transplant and longitudinal assessment by PET may identify at-risk patients for increased surveillance post HT.

Background While an assessment of the right ventricular (RV) size remains challenging, the entire RV is can be imaged on coronary computed tomography angiography (CCTA) studies. With prospective ECG-triggering, the RV end diastolic volume (RVEDV) cannot be measured; however, the RV mid-diastolic volume (RVMDV) can still be measured accurately from routine CCTA data sets. The objective of this study is to establish normal reference values for RVMDV. Methods Right ventricular mid-diastolic volumes were measured in 4855 consecutive patients undergoing prospectively ECG-triggered coronary CTA. All patients with known cardiac or pulmonary disease (coronary artery disease, myocardial infarction, revascularization, heart failure, pulmonary hypertension, congenital heart disease, valvular heart disease, atrial fibrillation, implantable cardiac defibrillator implantation, cardiac transplant, or cardiac surgery) or smoking history (3313 patients) were excluded. Results 1542 patients were analyzed (mean age 56.4 ± 11.1 years, mean BSA 1.96 ± 0.26 and 47% male). The mean RVMDV for men and women was 168.6 ± 37.6 mL and 117.6 ± 26.4 mL, respectively. Mean BSA-indexed RVMDV was 80.0 ± 15.3 mL/m2 and 64.1 ± 12.2 mL/m2 for men and women, respectively. The presence of hypertension and diabetes did not have an impact on these values. RVMDV and BSA-indexed RVMDV were lower in women and in older individuals. Conclusion Normal reference ranges for RVMDV were established using prospectively ECG-triggered coronary CTA studies. This data can be used to identify patients with abnormal RV volumes and potentially RV dysfunction, adding incremental diagnostic value to routine CCTA studies.

Purpose To design a checklist in order to reduce the frequency of reconstructive preventable errors (PE) performed by undergraduate dental students at McGill University. Materials and methods The most common PE occurring at a university dental clinic were identified by three reviewers analyzing the refunded cases, and used to create a preliminary checklist. This checklist was then validated by a panel of dental educators to produce a finalized 20-item checklist. The 20-question checklist was then submitted to students in a cross-sectional survey-based study to evaluate its relevance to undergraduate clinical education needs. Results As many as 81% of students reported to have forgotten at least one item of the checklist during care of their last patient, and the most forgotten checklist items corresponded to the pretreatment stage. The students also reported that 17 of the 20 items in the checklist were relevant to a considerable extent or highly relevant. Conclusion Common PE identified in the undergraduate clinic could be used to create a checklist of relevant items designed to reduce errors made by students and practitioners performing prosthodontic and reconstructive treatments. However, further studies are required to evaluate the implementation and efficiency of the checklist.

The suboptimal implementation of guideline-directed medical therapy (GDMT) for heart failure (HF) patients has been linked with poor clinical outcomes. Little is known about the potential role of cardiology residency training programs in improving trainees' (ie, future cardiologists') ability to utilize GDMT.In this survey-based study, we examined the degree of exposure to ambulatory HF patient management among cardiology trainees in Canada. All cardiology residency program directors (n = 15; 100% response rate) completed our survey.Although 9 programs (60%) mandated ≥ 3 ambulatory cardiology rotations, only 3 (20%) required ≥ 2 ambulatory HF rotations. When HF rotations were provided, only 7 programs (47%) offered moderate or higher exposure to ambulatory nontransplant HF patients (defined as ≥ 5 clinics/rotations). This element was independent of program- and institution-specific characteristics. All institutions had a multidisciplinary HF clinic, and the majority (13 [87%]) had access to an inpatient HF service, a consultative HF service, and/or a specialist pharmacist. Furthermore, 13 program directors (87%) agreed on the importance of adopting HF training curriculum and their program's readiness to implement such a module.The current state of HF training among cardiology residencies is suboptimal and in need of improvement. Most programs have access to a HF clinic, a specialist pharmacist, or an inpatient consultative service, which would facilitate adoption of a HF management curriculum that focuses on practical and experiential aspects of GDMT optimization. This program, which is under development, will be offered to training programs nationwide, to enable trainees to manage this growing and increasingly complex patient population.Une mise en application sous-optimale des traitements médicaux recommandés dans les lignes directrices (TMRLD) dans les cas de patients atteints d’insuffisance cardiaque (IC) a été associée à des issues cliniques défavorables. On en sait peu sur le rôle éventuel des programmes de résidence en cardiologie sur l’amélioration des capacités des stagiaires (c.-à-d. des futurs cardiologues) à mettre en œuvre les TMRLD.Notre étude s’appuyant sur un sondage a permis d’examiner le niveau d’exposition des stagiaires en cardiologie au Canada à la prise en charge des patients ambulatoires atteints d’IC. La direction de tous les programmes de résidence en cardiologie (n = 15; taux de réponse de 100 %) a participé à notre sondage.Alors que neuf programmes (60 %) exigeaient ≥ trois stages en cardiologie ambulatoire, seulement trois d’entre eux (20 %) exigeaient ≥ deux stages en IC ambulatoire. Parmi les programmes offrant des stages en IC, seulement sept (47 %) offraient une exposition modérée à élevée à des patients ambulatoires atteints d’IC et n’ayant pas reçu de greffe (cette exposition était établie à cinq cliniques par stage ou plus); le niveau d’exposition à ces patients ne dépendait pas des caractéristiques du programme ou de l’établissement. Dans tous les établissements, une clinique multidisciplinaire spécialisée en IC était présente, et la majorité d’entre eux (13 [87 %]) bénéficiaient également d’un service pour les patients hospitalisés atteints d’IC, d’un service de consultation en IC et/ou de la présence d’un pharmacien spécialisé. De plus, la direction de 13 programmes (87 %) se disait en accord avec l’importance d’adopter un curriculum de formation portant sur l’IC et considérait que leur programme était prêt à intégrer un tel module.L’état actuel de la formation en IC dans les programmes de résidence en cardiologie n’est pas optimal, et des améliorations sont nécessaires. La plupart des programmes ont accès à une clinique en IC, un pharmacien spécialisé ou un service de consultation pour les patients hospitalisés, ce qui pourrait faciliter l’adoption d’un curriculum de prise en charge de l’IC portant sur l’expérience concrète de l’optimisation des TMRLD. Ce module, qui est en cours d’élaboration, sera offert à tous les programmes de formation à travers le Canada, pour permettre aux stagiaires de mieux prendre en charge cette population de patients qui gagne en nombre et en complexité.

Recently, digital techniques have revolutionized the production of partial removable dental prostheses (PRDPs). This chapter reviews current systems for PRDP production, how they are done in clinical practice, advantages and limitations, and current literature regarding their clinical performance. Currently, several digital techniques are available in the market for PRDP production including subtractive and additive techniques. Subtractive milling technique is mainly effective for non-metal PRDP, whereas additive techniques are used mainly in metal PRDP. Digital techniques expand the range of materials that can be utilized for PRDP production, including new polymers (PEEK), and facilitate previously difficult procedures such as casting titanium PRDP, which can be produced more easily with digital methods. This review shows that available evidence suggests that these techniques have promising clinical results. Laser sintering resulted in higher patient’s satisfaction compared to conventional PRDP. However, long-term clinical trials are recommended to explore the long-term effects of these techniques. Moreover, this review showed the lack of evidence on the clinical performance of non-metal partial removable dental prostheses.Other Information Published in: Clinical Dentistry Reviewed License: https://creativecommons.org/licenses/by/4.0See article on publisher's website: http://dx.doi.org/10.1007/s41894-020-00074-y

OBJECTIVE: The aim of this study was to investigate the prevalence of metabolic syndrome (MS) among dentists in Riyadh, Saudi Arabia. The study also explored the causes of occupational stress among the participating dentists. MATERIALS & METHODS: The participants included a conveniently selected sample of dentists (N = 126; Males = 65; Females = 61). The participants’ anthropometric measurements/blood sample analysis were carried out and they completed a self-administered questionnaire. Data analysis included demographics, gender/age wise comparison using SPSS (p 0.05) were observed for cholesterol, triglycerides and HDL. However, significant difference (p = 0.00) was found for the fasting glucose level (Males = 5.69±1.49; Females = 4.94±0.42). Overall mean scoring (3.00±1.11) for the stress showed that the participants fall into the average/moderate level of stress category (Males = 3.16±1.02; Females = 2.83±1.08). Almost two third (68.26%) of the participant’s responded that they were under some kind of stress. CONCLUSIONS: MS was found to be less frequent among the dentists working in the city of Riyadh. Overall, the dentists were under moderate level of occupational stress, with male dentists being more prone to work related stress.

Major advances in ultrasound technology over the past decade have increased the affordability and accuracy of modern ultrasonography equipment. Moreover, miniaturization of this technology has led to the creation of portable, standalone units, referred to as “pocket” ultrasounds, that physicians

Introduction: Cardiogenic shock (CS) is associated with significant morbidity and mortality. Although inotropic support is a mainstay of medical therapy for CS, little evidence exists to guide the selection of inotropic agents in clinical practice. Methods: In this double blind randomized controlled trial, we assigned patients with SCAI class B to E shock to either milrinone or dobutamine for inotropic support. Therapy was titrated based on clinical, biochemical and hemodynamic response as evaluated by the treating physician. The primary outcome was a combined endpoint of in hospital mortality, non-fatal MI, stroke, new initiation of renal replacement therapy (RRT), need for MCS or cardiac transplant, or cardiac arrest with successful resuscitation. Secondary outcomes included individual components of the primary outcome. Results: Among 192 participants, there was no significant difference in the primary outcome, occurring in 49% (47 of 96) of patients in the milrinone arm and 54% (52 of 96) patients in the dobutamine group (RR 0.90, 95% CI of 0.69-1.19, p-value = 0.47). There were also no differences in important secondary outcomes between milrinone and dobutamine, including in-hospital mortality 37% (35 of 96) vs 43% (41 of 96) (RR 0.85, 95% CI 0.60-1.21, p-value = 0.38) or need for RRT 22% (21 of 96) vs 17% (16 of 96) (RR 1.31, 95% CI 0.73-2.36, p-value = 0.36). Conclusions: In this randomized clinical trial of milrinone and dobutamine in CS, there was no difference in the primary composite outcome or in important secondary outcomes. The selection of inotropic agent could reasonably be based on physician comfort, cost and individual response to therapy.

Implantable bioelectrodes have the potential to advance neural sensing and muscle stimulation in peripheral nerve injuries. The current emerging prostheses rely on the use of metals to assist the nerve recovery process, which is often slow. The implantable electrode works as a bridge between the proximal end of the injured peripheral nerve and the respective muscle. Current electrodes suffer from several drawbacks including the high cost, high interfacial impedance, and stiffness, hence, damaging the body soft tissue. This paper discusses the fabrication and characterization of a novel, low-cost, flexible bioelectrodes based on silicone, and polyaniline (PANI). This work synthesized and characterized three types of implantable electrodes based on their electrochemical and mechanical properties; where PANI and silicone were varied. The electrode samples were fabricated and characterized for their conductivity, capacitive behavior and their mechanical properties. The PANI based samples displayed a bulk impedance of 10.7 kΩ with an impedance of 1.3 MΩ at the frequency of 1 kHz; furthermore, it had a modulus of elasticity of 0.1468 MPa. The results for the silicone with PANI showed promising electrochemical and mechanical characteristics with flexible and ductile properties when compared with the values reported in the literature.

Along with its heavy toll of morbidity and mortality, the coronavirus disease 2019 (COVID-19) pandemic exposed several limitations of the current global research response. The slow and inefficient process of carrying out traditional randomized clinical trials led regulatory authorities to hastily approve treatments and tests without sufficient evidence of safety and efficacy.We here outline issues with the current research platform, summarize shortcomings of traditional randomized clinical trials particularly apparent at the time of pandemics, and highlight the advantages of pragmatic clinical trials as an alternative to rapidly generate the needed clinical evidence. We further discuss barriers and challenges to pragmatic clinical trials implementation and explore opportunities for research institutions and regulatory authorities to facilitate widespread adoption of this vital research tool.As a subsequent wave of COVID-19, and/or another epidemic, are all but inevitable in our lifetime, we must ensure that our research infrastructure is conducive to carrying out pragmatic clinical trials to expeditiously generate the needed evidence and blunt the epidemic’s toll on human lives and livelihoods.

Transthoracic echocardiography is the standard of care in anatomic and functional cardiovascular assessment; however, focused cardiac ultrasound (FoCUS) performed with portable ultrasound equipment is increasingly being used as an adjunct to comprehensive history and physical examination. FoCUS assessments, unlike formal echocardiography, are intended to assist physicians in answering explicit clinical questions with a narrow differential diagnosis in real time. Over the past decade, a growing body of literature has repeatedly shown the value that FoCUS adds to clinical evaluation. Specifically, FoCUS improves point-of-care diagnostic accuracy, which in turn modifies treatment plans, decreases time to diagnosis, and reduces resource utilization. Although less robust, there is also evidence showing improvement in clinical outcomes. Based on this evidence, clinicians, training programs, and clinical societies have embraced FoCUS as a tool to complement bedside patient evaluation. Herein, we review the evidence for FoCUS in clinical practice, specifically evaluating the diagnostic accuracy, the impact on clinical decision-making, and the effect on clinical outcomes.

Myocardial blood flow (MBF) quantification by Rubidium-82 positron emission tomography (PET) has shown promise for cardiac allograft vasculopathy (CAV) surveillance and risk stratification post heart transplantation. The objective was to determine the prognostic value of serial PET performed early post transplantation.Heart transplant (HT) recipients at the University of Ottawa Heart Institute with 2 PET examinations (PET1 = baseline, PET2 = follow-up) within 6 years of transplant were included in the study. Evaluation of PET flow quantification included stress MBF, coronary vascular resistance (CVR), and myocardial flow reserve (MFR). The primary composite outcome was all-cause death, re-transplant, myocardial infarction, revascularization, allograft dysfunction, cardiac allograft vasculopathy (CAV), or heart failure hospitalization. A total of 121 patients were evaluated (79% male, mean age 56 ± 11 years) with consecutive scans performed at mean 1.4 ± 0.7 and 2.6 ± 1.0 years post HT for PET1 and PET2, respectively. Over a mean follow-up of 3.0 (IQR 1.8, 4.6) years, 26 (22%) patients developed the primary outcome: 1 death, 11 new or progressive angiographic CAV, 2 percutaneous coronary interventions, 12 allograft dysfunction. Unadjusted Cox analysis showed a significant reduction in event-free survival in patients with PET1 stress MBF 2.1 (HR: 2.43, 95% CI 1.11-5.29 P = 0.047) and persistent abnormal PET1 to PET2 CVR 76 (HR: 2.19, 95% CI 0.87-5.51 P = 0.045). There was no association between MFR and outcomes.Low-stress MBF and persistent increased CVR on serial PET imaging early post HT are associated with adverse cardiovascular outcomes. Early post-transplant and longitudinal assessment by PET may identify at-risk patients for increased surveillance post HT.

More than 3 decades ago, Wyngaarden and Gill first warned of the challenges facing physician-scientists in their seminal papers "The Clinical Investigator as an Endangered Species" and "The End of the Physician-Scientist." In the years since these papers were published, there has been expansion of stage I-II preclinical research focusing on discovery and exploratory studies. Expansion has often come at the expense of physician-scientists whose traditional role has been to bridge the gap between early preclinical research (stage I-II) and clinical trials (stage IV). Consequently, a paradigm shift has occurred, and increasing pressure has been placed on physician-scientists to choose between clinical practice and fundamental research. This shift is particularly concerning in the field of cardiovascular medicine, where the ubiquitous nature and clinical significance of cardiovascular disease make the role of the translational scientist essential. The challenges facing academic cardiologists have then further been amplified by the necessity not only to maintain clinical competence but also to maintain competence in highly technical fields with rapidly advancing technology. Potential solutions to these problems include increasing support from postgraduate training programs, increased participation of trainees in physician-scientist development programs, and recognition of the pivotal role physician-scientists play in translational research by funding agencies. Although the physician-scientist remains an endangered species, multifaceted solutions with a focus on collaboration among institutions, training programs, and funding agencies have the potential to maximize efficiency in biomedical research and successfully translate scientific discoveries from bench to bedside.

Objectives: Mitigating the gastrointestinal (GI) bleeding risks of dual antiplatelet therapy (DAPT) is a common clinical concern. While proton pump inhibitors (PPIs) remain the most effective therapy, their adverse events warrant considering alternatives, including Histamine 2 receptor antagonists (H2RAs). Methods: We searched for randomized controlled trials in MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials, published from 1980 to 2016. After screening, 10 trials were eligible. We compared PPIs to H2RAs in patients on DAPT in terms of 2 clinical and one laboratory outcomes; GI complications, major adverse cardiovascular events (MACE) and high on-treatment platelet reactivity (HTPR). Clinical and statistical inter-study heterogeneity was low for all 3 outcomes (I2 = 0%, p > 0.05 for all). Results: Fixed effects meta-analysis suggested that PPIs were superior to H2RAs in preventing GI complications (OR 0.28, 95% CI 0.17–0.48) but with higher risk of HTPR (OR 1.28, 95% CI 1.030–1.60) though without a higher incidence of MACE (OR 0.99, 95% CI 0.55–1.77). Conclusions: PPIs are superior to H2RAs for gastroprotection in patients on DAPT. However, PPIs are associated with HTPR, with no significant difference demonstrated in MACE. Based on currently available data, the use of PPIs may be warranted in selected patients on DAPT deemed at risk for GI complications.

Fusion is known as a developmental anomaly described by the union of two neighbouring teeth. The worldwide prevalence of bilaterally fused teeth in the primary dentition is about 0.02% which is considered very rare. Only few cases of bilateral fusion have been reported in Indian population. This paper presents a rare case of three-year-old boy with bilateral fusion of primary mandibular lateral incisors and canine teeth. Treatment consisted of pit and fissure sealants and topical fluoride application. To conclude, fused primary teeth are considered as harmless asymptomatic abnormality.

Cardiac allograft vasculopathy (CAV) limits long-term survival after heart transplantation. Non-invasive evaluation is challenging, and currently, there is no validated biomarker for CAV diagnosis or prognostication. To identify potential candidate CAV biomarkers, we utilized the Slow Off-rate Modified Aptamer (SOMAscan) assay, which evaluates over 1000 serum proteins, including many relevant to biological pathways in CAV. We evaluated three heart transplant patient groups according to angiographic ISHLT CAV grade: CAV1-2 (mild-moderate CAV), CAV3 (severe CAV), and CAV0 (normal control). SOMAscan assays were performed and proteins quantitated. Comparisons of proteins between study groups were performed using one-way ANOVA (false discovery rate q-value < 0.10). Thirty-one patients (12 mild-moderate CAV, 9 severe CAV, 10 controls) were included: 81% male, median age 57 years and median 1.1 years post-transplant. Compared to controls, patients with mild-moderate CAV had similar characteristics, while patients with severe CAV had longer time from transplant and increased allosensitization. Statistical/bioinformatics analysis identified 14 novel biomarkers for CAV, including 4 specific for mild-moderate CAV. These proteins demonstrated important actions including apoptosis, inflammation, and platelet/coagulation activation. Upon preliminary receiver operating characteristics curve analysis, our protein biomarkers showed moderate-to-high discriminative ability for CAV (area under curve: 0.72 to 0.94). These candidate biomarkers are being validated in prospective studies.

Purpose To identify laypersons' most preferred tooth shade as a function of observer and patient factors, namely patients' skin shade and observers' socio-demographics. Materials and methods Two online surveys using computer-designed perioral images with different shades of the skin and teeth were distributed to participants in Montreal (Canada) and San Francisco (USA). The first survey (n = 120) was designed to assess public preferences of tooth shade value, hue and chroma as a function of the skin color of the perioral image (model), and the demographic characteristics of the observer. The first survey included 6 sets of 9 identical perioral images. A different skin shade (from very dark to very light) was used for each set of images, and each set of images presented teeth with different tooth shades which included three different levels of value (2M1, 3M1, 4M1), hue (3L1.5, 3M1, 3R1.5), and chroma (3M1, 3M2, 3M3) of the Vita 3D Master shade guide. Participants were asked to choose their preferred image for each category (value, hue, chroma) within each set of skin shades. A second survey was performed to pinpoint the tooth shade that is preferred the most by the general public. In this survey, images with four tooth shades (1M1, 2M1, 3M1, 4M1) and 6 skin shades were distributed (n = 70). Ordinal logistic regression was used to identify significant predictors of preferred tooth shades. Results Most of the participants preferred teeth with the highest value (54%), a neutral hue (59%) and the lowest chroma (89%). About 75% of the participants preferred 1M1 the lightest tooth shade over other shades regardless of their demographics or skin color of the model. Among the observer-related variable, age was the most significant predictor of people preferred tooth shade (p = 0.019). Conclusion This study showed that there are common preferences in terms of tooth shade value, hue and chroma among participants regardless of demographic variables and facial skin shades. This data could guide dentists for tooth shade selection in the clinical practice.

Background Incorporating focused cardiac ultrasonography (FoCUS) into clinical examination could improve the diagnostic yield of bedside patient evaluation. Purpose To compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation. Data Sources English-language searches of MEDLINE, Embase, and Web of Science from 1 January 1990 to 23 May 2019 and review of reference citations. Study Selection Eligible studies were done in patients having cardiovascular evaluation; compared FoCUS-assisted clinical assessment versus clinical assessment alone for the diagnosis of left ventricular systolic dysfunction, aortic or mitral valve disease, or pericardial effusion; and used transthoracic echocardiography as the reference standard. Data Extraction Three study investigators independently abstracted data and assessed study quality. Data Synthesis Nine studies were included in the meta-analysis. The sensitivity of clinical assessment for diagnosing left ventricular dysfunction (left ventricular ejection fraction

Radiation safety has been at the center of interest of both researchers and healthcare institutions. This review will summarize and shed light on the various techniques adapted to reduce staff exposure to ionizing radiation (IR) in the field of cardiac imaging. In the last years, with the advance of awareness and the development of new technologies, there have been several tools and techniques adapted. The breakthrough of several technologies to lower radiation dose and shorten the duration of diagnostic tests associated with IR, the use of protection devices by staff members, and mostly the awareness of exposure to IR are the hallmark of these advances. Using all these measures has led to a significant decrease in staff exposure to IR. Reducing staff exposure to meet the “As Low As Reasonably Achievable” principle is feasible. This review introduces the most important strategies applied in cardiac imaging.

Background Strip root perforation requires meticulous diagnosis and may compromise the prognosis, if left undiscovered. It is a common reason for endodontic failure. Strip perforations, usually seen in the mid-section of a curved canal, may result from excessive instrumentation. Radiographic detection of strip perforations may be challenging. Objective The aim of this study was to compare the sensitivity, specificity, and accuracy of digital periapical (PA) radiography compared with cone beam computed tomography (CBCT) in detecting simulated perforation in filled and unfilled canals in extracted teeth. Materials and Methods After obtaining institutional review board approval, canals of 30 extracted mandibular molar teeth were prepared. Mesial roots of the 15 study teeth were perforated, and all canals were filled in the 15 study and 15 control teeth. The teeth were mounted in simulated D-3 bone. All teeth were imaged by using CBCT and triangulated PA radiography before and after obturation. Discontinuity seen near the furcations was considered perforation. Receiver operating characteristic (ROC) analysis was used to show sensitivity, specificity, and accuracy. Analysis of variance (ANOVA) was used to compare the results, and the kappa statistic for interobserver agreement. Results Az values for CBCT before and after obturation were 0.941 and 0.873, respectively, and for PA radiography, the values were 0.640 and 0.776, respectively (P Discussion CBCT is more reliable than PA radiography for the detection of perforations, especially in unfilled canals. The accuracy of CBCT decreased after filling because of artifact formation. Accurate diagnosis of perforations in unfilled canals using PA radiography is limited.

Digital technology such as computer-aided design/computer-aided manufacture (CAD/CAM) is rapidly expanding and transforming dentistry at an unprecedented pace. CAD/CAM technology in dentistry can be classified as either “subtractive” or “additive” manufacturing methods. Subtractive manufacturing method includes machining and milling (CAM) and laser ablation technologies, while additive manufacturing method includes 3D printing and laser melting technologies. Different materials (polymers, metals, and ceramics) and equipment are commercially available for various dental applications such as custom trays, surgical guides, temporary or definite fixed or removable dental prostheses, and orthodontic or maxillofacial appliances. This chapter reviews the main systems including production processes, dental applications, available materials and equipment, and advantages and limitations of the technology.

Recently, digital techniques have revolutionized the production of partial removable dental prostheses (PRDPs). This chapter reviews current systems for PRDP production, how they are done in clinical practice, its advantages and limitations, and current literature regarding their clinical performance. Currently, several digital techniques are available in the market for PRDP production including subtractive and additive techniques. Subtractive milling technique is mainly effective for nonmetal PRDP. Digital techniques expand the range of materials that can be utilized for PRDP production, including new polymers (PEEK), and facilitate previously difficult procedure such as casting titanium PRDP, which can be produced digitally more easily. This review shows that available evidence suggests that these techniques have promising clinical results. Laser-sintering resulted in higher patient satisfaction compared to conventional technique. However, long-term clinical trials are recommended to explore the long-term effects of these techniques. Moreover, this review showed the lack of evidence on the clinical performance of nonmetal partial removable dental prostheses.

OBJECTIVES We sought to describe the safety and efficacy outcomes of patients on warfarin presenting with ST-elevation myocardial infarction (STEMI). BACKGROUND Limited data exist on the outcomes and optimal management of STEMI patients on warfarin undergoing primary percutaneous coronary intervention (PCI). METHODS Baseline characteristics and outcomes were prospectively collected for 2,390 consecutive STEMI patients referred for primary PCI. Patients were stratified based on warfarin use at baseline. The primary safety endpoint was the rate of in-hospital bleeding (a composite of major bleeding or minor bleeding) according to the thrombolysis in myocardial infarction (TIMI) classification. Efficacy endpoints included major adverse cardiovascular events (MACE), defined as death, myocardial infarction, or stroke, as well as intracranial bleeding, cardiogenic shock, and length of stay. Multiple logistic regression was used to determine if warfarin was independently associated with bleeding and MACE. RESULTS Warfarin patients (n = 59 vs. n = 2,331) were significantly older (73.2 years vs. 61.7 years; P

Background: Chest pain is a frequent cause for emergency department (ED) presentation and is associated with significant costs. A pathway for expedited outpatient stress testing and follow-up for low risk chest pain patients in the ED was established in our institution. We present patients’ demographics and evaluate the efficacy, safety and overall performance of this quality improvement (QI) initiative. Methods: All patients referred to the program were retrospectively identified from the first year of experience. Rates of MACE and readmissions were determined at both 30 and 60 days of follow-up. Average time to testing and clinic assessment were measured. Rates of Cardiology consultations and admissions for chest pain were determined before and after program implementation. Results and discussion: A total of 425 patients were identified who were referred to the program. Forty patients were excluded from analysis as they failed to attend or declined testing, were inappropriately referred, or were lost to follow-up. Patient characteristics, outcome data, and adverse events are shown in table 1. A rate of over 75% stress testing within 5 days of ED visit and 68% of clinic visit within 6 weeks of a positive test was observed. Trends towards a reduction in admissions and consultations occurred in the year following program implementation(Figure 1). Conclusion: This local program for rapid out-patient testing for low risk chest pain patients in the ED is feasible, safe, and effective. Lack of patient adherence to follow-up is a concern with this out-patient approach. Improving time to stress testing and clinic waiting times have been identified as institutional priorities on the basis of this QI project.

More than 3 decades ago, Wyngaarden and Gill first warned of the challenges facing physician-scientists in their seminal papers "The Clinical Investigator as an Endangered Species" and "The End of the Physician-Scientist." In the years since these papers were published, there has been expansion of stage I-II preclinical research focusing on discovery and exploratory studies. Expansion has often come at the expense of physician-scientists whose traditional role has been to bridge the gap between early preclinical research (stage I-II) and clinical trials (stage IV). Consequently, a paradigm shift has occurred, and increasing pressure has been placed on physician-scientists to choose between clinical practice and fundamental research. This shift is particularly concerning in the field of cardiovascular medicine, where the ubiquitous nature and clinical significance of cardiovascular disease make the role of the translational scientist essential. The challenges facing academic cardiologists have then further been amplified by the necessity not only to maintain clinical competence but also to maintain competence in highly technical fields with rapidly advancing technology. Potential solutions to these problems include increasing support from postgraduate training programs, increased participation of trainees in physician-scientist development programs, and recognition of the pivotal role physician-scientists play in translational research by funding agencies. Although the physician-scientist remains an endangered species, multifaceted solutions with a focus on collaboration among institutions, training programs, and funding agencies have the potential to maximize efficiency in biomedical research and successfully translate scientific discoveries from bench to bedside.

Objectives Work-related stress, a significant problem among medical residents, has an unknown effect on non-clinical healthcare workers. This study aimed to compare work-related stress, potential risk factors, and stress-coping strategies at a tertiary care hospital in the KSA. Methods This case-control study measured work-related stress using a 14-question perceived stress scale (PSS-14), and stress-coping strategies were probed using a 28-item brief coping scale (BCS-28). Results One hundred and forty-seven participants (49 residents and 98 administrative employees), aged 27.9 ± 4.0 years, completed the questionnaire. After adjusting the results for socio-demographic and clinical characteristics, the average PSS-14 was found to be significantly higher among residents than among administrative employees (27.65 ± 9.39 vs. 25.09 ± 10.06, p = 0.026). The PSS-14 was significantly associated with the female sex, major medical illnesses, psychiatric disorders, facing stressors and maladaptive stress-coping strategies. The serum cortisol and lipids levels of both groups were similar and were not associated with stress. Overall, the residents had lower adaptive stress-coping strategies. Similar maladaptive stress-coping strategies were recorded in residents and administrative employees. Conclusion Residents perceived higher work-related stress than administrative employees, which is unexplained by differences in socio-demographic and clinical characteristics. Focused stress-management training programs are needed for all healthcare workers, especially residents.

Objective: To assess and compare the level of knowledge and attitude toward basic life support among bachelor of dental surgery clinical students (third-, fourth-, and fifth-year dental students), dental interns, postgraduate students and faculty in the Dental College at King Saud University, Riyadh, Saudi Arabia. Material and methods: A previously validated self-select questionnaire was randomly distributed to the participants. The structured questionnaires consist of demographic data, knowledge and attitude of the participants related to basic life support. Results: 454 participants completed the surveys with response rate of 77.85%. The mean knowledge score for the participants was 5.99 with a median score of six. A highly statistically significant difference was detected among the different academic groups (analysis of variance ANOVA; F=9.756, P

PURPOSE: Self-medication is common worldwide. However, the prevalence of sale of prescription medications without prescription and the quality of assessment and counselling provided by community pharmacists to cardiac patients is unknown. We sought to determine the prevalence of prescription medication sales and explore how pharmacists assess and counsel patients with acute cardiac conditions. METHODS: Six hundred community pharmacies in the two largest cities in Saudi Arabia were selected. Two simulated clients presented either an acute coronary syndrome (ACS) scenario or an acute heart failure (AHF) scenario to the pharmacists. Descriptive statistics and regression models were used to analyse and present the collected data. RESULTS: Of 600 pharmacies, 379 (63.2%) sold various prescription medications to simulated patients without prescription. Assessment and counselling provided by pharmacists were inadequate. Almost a quarter of pharmacists did not ask simulated patients any questions; 52% asked one or two questions; and only 24% asked three or more questions. Only 28 pharmacists (4.7%) inquired about drug allergies; 48.5% instructed simulated patients on the dosage and frequency of the sold medications; 21.6% provided instruction on treatment duration; and 19.4% gave instructions on dose, frequency, and duration of treatment. Compared to AHF, ACS simulated patients were more likely to be asked about other symptoms and comorbidities (59.7% vs. 48.7%, p = 0.007 and 46.3% vs. 37.3%, p = 0.005, respectively) and were more likely to be advised to go to hospital (70.3% vs. 56.3%, p < 0.001). CONCLUSIONS: The sale of prescription medications by community pharmacists to simulated cardiac patients without prescription is very common; assessment and counselling qualities are suboptimal.

We determine the impact of an educational awareness campaign on the level of knowledge and the attitude of the Saudi population in Riyadh, Saudi Arabia in an attempt to improve the awareness and reduce the social stigma associated with epilepsy.The Saudi Epilepsy Society organized a citywide awareness campaign in 2013. A survey consisting of 11 questions pertaining to epilepsy awareness was distributed to Saudi citizens living in Riyadh, aged 15 years and above, in malls, health clubs, mosques, universities, and schools during that campaign. The same questionnaire was administered before and after the awareness campaign to the same individuals on the same day to assess the impact of the campaign (n=2118).The epilepsy awareness campaign significantly raised the general knowledge about epilepsy: 1519 before vs. 1944 after (P0.001) would allow their children to interact with an individual who had epilepsy; 1567 before vs. 688 after (P0.001) would not want their children to marry an individual with epilepsy. Eight hundred twenty six before vs. 47 after (P0.001) thought that epilepsy is untreatable. Regarding the causes of epilepsy, 1663 before vs. 896 after (P0.001) believed that epilepsy is caused by supernatural powers, and 1224 before vs. 1874 after (P0.001) chose brain disease as a cause of epilepsy.These findings suggest that epilepsy awareness campaigns can close knowledge gaps. A long-term reevaluation may be needed to assess awareness sustainability.

Statement of problem The effect of the surface treatment of zirconium oxide posts on their push-out bond strength is controversial. Purpose The purpose of this study was to compare the effects of 2 surface treatments on the bond strength of zirconium oxide posts cemented with different cements and to assess the failure mode. Material and methods Seventy extracted human teeth were divided into 7 groups (n=10). Custom zirconium oxide posts (Cercon; Degudent) were fabricated for 6 groups. Posts in 3 groups were airborne-particle abraded (A). Posts in the other 3 groups were tribochemical silica coated (T). Three cements were used. Zinc phosphate cement was used to cement the zirconium oxide posts in groups AZ and TZ, RelyX ARC cement was used in groups ARA and TRA, and RelyX Unicem cement was used in groups ARU and TRU. Group C contained custom metal posts cemented with zinc phosphate cement. Specimens were horizontally sectioned into 3 sections and subjected to a push-out test. A mixed model analysis of variance, 1-way ANOVA, and the Tukey multiple comparison tests were used for statistical analysis. Results The highest push-out bond strength was recorded for Group ARU (21.03 MPa), and the lowest was recorded for Group ARA (7.57 MPa). No significant difference in push-out bond strength was found among the different surface treatments and root regions ( P >.05). The type of cement had a significant effect on the push-out bond strength of zirconium oxide posts ( P =.049). RelyX Unicem cement recorded (19.57 ±8.83 MPa) significantly higher push-out bond strength compared with zinc phosphate (9.95 ±6.31 MPa) and RelyX ARC cements (9.39 ±5.45 MPa). Adhesive failure at the post-cement interface was recorded for 75% of the posts cemented with zinc phosphate and RelyX ARC cements, while mixed failure was recorded for 75% of the posts cemented with RelyX Unicem cement. Conclusions The type of cement used resulted in a statistically significant difference in the push-out bond strength of zirconium oxide posts, while both the surface treatment and root region resulted in no statistically significant effect after artificial aging. RelyX Unicem cement had significantly higher push-out bond strength than did zinc phosphate and RelyX ARC cements.

Purpose Women comprise 1 in 4 of all heart transplant (HT) recipients. Sex/gender differences affect cardiovascular disease burden and outcomes with important potential to impact patient care. As an initial step towards developing personalized therapy, we evaluated differences in HT clinical characteristics and outcomes between men and women. Methods A retrospective review was performed of consecutive adult patients who underwent HT at the University of Ottawa Heart Institute (Ontario, Canada) between 2012 and 2016. We determined patient characteristics in women and men at transplant and outcomes post transplant including death, graft function, rejection, infection and hospitalization. Results A total of 121 HT patients were evaluated: 29 (24%) female, mean age 53.6±12.3 years, 39 (32%) for ischemic cardiomyopathy (Table). Compared to men, women had lower body mass index, increased donor-recipient sex mismatch, and higher sensitization. There were no differences in the use or dose of induction or maintenance immunotherapy, however, women received a higher mean dose of Valganciclovir for cytomegalovirus (CMV) prophylaxis: 12.1±4.1 vs. 9.5±4.2 mg/kg/day, p=0.05. Over a mean follow-up of 3.0±1.9 years, there were 12 (10%) deaths, and no difference in survival or graft function between men and women. Compared to men, women had significantly higher rates of infection (62% vs. 41%, p=0.05) and hospitalization for infection (31% vs. 13%, p=0.03). Leukopenia (white cell count Conclusion Clinical characteristics and short-term outcomes post HT differ among women and men. Prospective evaluation and long-term follow-up of larger cohorts are needed to determine strategies to improve care in women following HT.

Objectives: Main objectives of the present study were to develop a baseline information about dental students' perception of their educational environment at the College of Dentistry, King Saud University (KSU) in Riyadh; and to investigate the role of four different variables on the students' perception. Methods: Dundee Ready Education Environment Measure (DREEM) questionnaire was distributed among 497 undergraduate dental students, in the second week of the first semester of the academic year, from second year students to interns studying in the College of Dentistry of King Saud University (KSU). Results: Response rate was 60.73%. Mean for the total DREEM scores was 108.42/200. DREEM subscales mean were above 50% of the total score. DREEM overall score showed no significant statistical difference among the four variables investigated, except the academic year, where the second year students scored significantly higher (118.36 ± 15.8) compared to the interns (105 ± 21.3). Conclusion: Students’ perception of educational environment in the KSU College of Dentistry was satisfactory. However, several weak areas were identified which need some attention and consideration. Keywords: Educational environment, DREEM, Perception, Dental students

Background Gubernaculum dentis (GD) is an anatomic structure, described in the literature as an eruption pathway from the dental follicle to the gingiva for permanent teeth.1 This is the first reported case of a GD associated with a transmigrating canine.2 Clinical and Radiologic Findings A 60-year-old female of Indian origin presented for evaluation for implant placement to replace a clinically missing lower canine tooth. Her medical history was unremarkable. Cone beam computed tomography (CBCT) of the mandible was performed, and the image demonstrated the presence of a corticated tract of low density, contiguous with the dental follicle of the horizontally displaced and impacted mandibular left canine. The tract extended from the pericoronal space around the impacted tooth toward the alveolar crest. The structure measured 2 cm long and 2 mm wide. Differential or Definitive Interpretation On the basis of the clinical and radiographic findings, this structure was diagnosed as GD and had to be differentiated from bone trabeculae, medullary spaces, neurovascular bundles, or sinus tracts. Because this is considered a normal anatomic structure, no biopsy was indicated.1 Discussion Histologically, GD consists of a fibrous band running in the bony channel that connects the pericoronal follicular tissue of the successional tooth with the overlying gingiva. Typically, GD opens on the alveolar bone crest behind the deciduous teeth. Radiographically, GD appears as a corticated tract of low density, contiguous with the dental follicle of an unerupted tooth on CBCT.3 It would be difficult to visualize the very thin and round radiolucent structures with a diameter of only 1 to 3 mm on 2-dimensional radiographs. In addition, the structure lies in the spongy bone of the maxilla and the mandible. Therefore, GD has not received adequate attention in dental fields, including oral and maxillofacial radiology.

Clinical data regarding newly introduced laser-sintered removable partial dentures (RPDs) are needed before this technique can be recommended. Currently, only a few clinical reports have been published, with no clinical studies.This clinical trial compared short-term satisfaction in patients wearing RPDs fabricated with conventional or computer-aided design and computer-aided manufacturing (CAD-CAM) laser-sintering technology.Twelve participants with partial edentulism were enrolled in this pilot crossover double-blinded clinical trial. Participants were randomly assigned to wear cast or CAD-CAM laser-sintered RPDs for alternate periods of 30 days. The outcome of interest was patient satisfaction as measured using the McGill Denture Satisfaction Instrument. Assessments was conducted at 1, 2, and 4 weeks. The participant's preference in regard to the type of prosthesis was assessed at the final evaluation. The linear mixed effects regression models for repeated measures were used to analyze the data, using the intention-to-treat principle. To assess the robustness of potential, incomplete adherence, sensitivity analyses were conducted.Statistically significant differences were found in patients' satisfaction between the 2 methods of RPD fabrication. Participants were significantly more satisfied with laser-sintered prostheses than cast prostheses in regard to general satisfaction, ability to speak, ability to clean, comfort, ability to masticate, masticatory efficiency, and oral condition (P.05). At the end of the study, 5 participants preferred the laser-sintered, 1 preferred the cast RPD, and 3 had no preference.The use of CAD-CAM laser-sintering technology in the fabrication of removable partial dentures may lead to better outcomes in terms of patient satisfaction in the short term. The conclusion from this pilot study requires confirmation by a larger randomized controlled trial.ClinicalTrials.gov. A study about patient satisfaction with laser-sintered removable partial dentures; NCT02769715.

Vasoplegia occurs in up to 16% of patients who undergo heart transplantation (HT) and is associated with significant morbidity and mortality. We present a case of a 61-year-old man with ischemic cardiomyopathy receiving sacubitril/valsartan (Entresto; Novartis, Cambridge, MA) who developed profound hypotension after HT. He was treated with intravenous methylene blue and high-dose vasopressors, but developed acute kidney injury requiring dialysis and a prolonged stay in the intensive care unit. This case supports a potent vasodilatory effect of sacubitril/valsartan, and if confirmed by other studies, might warrant consideration for withholding treatment while awaiting HT, particularly in patients with risk factors for vasoplegia.

Providing care to hospitalized patients may be associated with stress, reduced quality of life, and even psychiatric disorders. This case-control study aimed to compare the level of stress (using the 14-question perceived stress scale (PSS-14), potential risk factors, and stress-coping strategies (using the 28-item brief coping scale (BCS-28) between two convenient samples of patients’ companions (56) and administrative employees (98) working in a tertiary care hospital in Saudi Arabia. The average PSS-14 was slightly higher in companions than administrative employees (27.4 ± 9.9 vs. 25.1 ± 10.1, p=0.179). After stratifying by gender, the difference in males (but not females) was marginally significant in the unadjusted comparison and significant in the adjusted comparison. Companions had similar scores of adaptive stress-coping strategies but higher scores of maladaptive stress-coping strategies compared with administrative employees. This was especially apparent in the denial and self-distraction strategies. PSS-14 in all participants had a moderate significant positive correlation with maladaptive stress-coping strategies. Companions exhibited a gender-specific slight increase in the level of stress and adopted more maladaptive stresscoping strategies compared with administrative employees. There were no group differences in blood lipids, serum glucose, or cortisol levels.