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Introduction Impulsivity in adolescents has been largely studied as it is frequently observed in that phase. However, the relationship between impulsivity and emotion regulation has been rarely explored. Objectives Our study aimed to assess impulsivity and emotional regulation in medical students as well as to explore the link between them. Methods This was a descriptive and analytical cross-sectional study conducted from September to December 2017, among first and second year students of the medical school of Sfax who were aged between 18 and 19 years. We collected sociodemographic as well as clinical data of the participants. “Barratt Impulsivity Scale” (BIS) and “Difficulties in Emotion Regulation Scale” (DERS) were used to assess impulsivity and emotion regulation respectively. Results One hundred students were included in our study, with a mean age of 18 years and a sex ratio of 0.81. Among them, 62% were smokers with an average consumption of 19.6 packets year. Alcohol and cannabis use was reported by 9% and 5% of the students respectively. The mean impulsivity score on the Barratt scale was 66.78 ± 9.44 with scores ranging from 40 to 112. Among our participants, 25% had a high level of impulsivity (score > 72). Unplanned impulsivity was the dimension with the highest mean score (23.74±4.64). Our results showed that impulsivity was significantly associated with the male gender (p=0.002) and smoking (p

Introduction trauma affects not the child but the whole family. how would the parents’ reaction to trauma influence the child’s resilience capacities? Objectives study the mental health status of parents of children consulting the trauma and resilience unit. Methods Descriptive and retrospective study of 20 consultants in the trauma and resilience unit at Mongi Slim hospital between January and April 2022. The evaluation of depressive symptoms in children was made by Children's Depression Inventory (CDI). The Hamilton Depression and Anxiety Scales were used to assess anxiety and depressive symptomatology in the parents of the consultants. Results The mean age of the children was 10.46±3.24. The traumatic event was related to an assault in 75% of cases, 45% of which were intrafamilial, road accident and death of a relative in 10% respectively, 5% domestic violence. Five consultants had a CDI score ≥8 and 15 had a score >10. Only parents of children with a CDI score>19 had moderate to severe symptoms according to hamilton scales. The diagnosis of adjustment disorder was made in 45% of cases, post-traumatic stress disorder 20%, acute stress disorder 10% other 15% Conclusions The parents’ reaction to the tragedy would play a modulating role on the children’s resilience capacities. less anxious and depressed parents would help their child build his/her coping mecanisms. Disclosure of Interest None Declared

Introduction Forensic psychiatry is a specific field of practice in child psychiatry where skills are applied for legal purposes and the expert is faced with certain difficulties. Objectives Our objective was to determine the characteristics of the forensic procedure and the clinical profile of the consultants. Methods Cross-sectional and retrospective descriptive study concerning patients consulting the child psychiatry department of Mongi Slim Hospital between January 2018 and December 2019 in the context of a forensic expertise, excluding administrative expertise. Telephone interviews were carried out for the medicolegal follow-up. Results The average age was 9 [+/- 3.1] years and the sex ratio was 0.97. The majority of the requests for expertise came from the specialised unit for violence against women and children (40%). The expert’s task was to carry out a child psychiatric examination in 44% of cases and to establish credibility in 6.8% of cases. Apart from 3 cases of perpetrators, the requests concerned victims of physical (40.1%), sexual (38.6%) and psychological (21.3%) aggression. The assault had taken place within the family in 52% of cases and the alleged aggressor was the father in 36%. The average time between the incident and the request for an expert opinion was significantly longer in cases of sexual assault (p =0.01). The physical assaults concerned more boys (p = 0.05) while those of a sexual nature concerned female children (p=0.005). Victims of sexual aggression showed more sexualised behaviour (p

Introduction Children exposed to trauma present particular clinical features, therefore this population requires specific care and support. Objectives Study the clinical features and care modalities of children consulting Trauma & Resilience Unit. Methods It is a retrospective descriptive study of children consulting Trauma & Resilience unit at the child psychiatry department of Mongi Slim Hospital in Tunis (Tunisia) between January and April 2022. We collected data concerning the course of clinical features and care modalities with help of an exploitation form. Statistical analyses were performed by SPSS26. Results Our study included 66 patients. The sex ratio was 1. The mean age was 10.46 ± 3.24 years. The main symptoms initially presented were hypervigilance in preschoolers (p=0.02), avoidance behaviors in school-age children (p

Herbal tea is a mainstay dosage form in practically all systems of traditional medicine and widely used in modern alternative and complementary medicine. Incorporating botanical extracts into herbal tea formulations is of vital interest to manufacturers as it allows for the use of herbal ingredients that would otherwise not be suitable for the dosage form, for instance, dosing requirements, solubility in water, sensory constraints etc. Furthermore, reducing the amount of ingredients in a formula increases compliance with dosing recommendations and thus therapeutic benefit. However, formulating with botanical extracts comes with challenges, ranging from sourcing ingredients of appropriate quality, developing suitable methods for quality control with combinations of (herbal) ingredients, processing constraints such as hygroscopicity, solubility, dispersibility, homogeneity of distribution, and packaging machinability, all the way to stability required for hot-water infusion. We report on experiences with overcoming such challenges in a set of examples and provide guidance to the extract industry on how to tap into the bagged tea sector with better suited or tailor-made solutions for the formulator.

Background: Sports nutrition is an impactful component to sports performance. The purpose of the current study was to investigate the sports nutrition knowledge of National Collegiate Athletic Association collegiate athletes and assess self-reported perceived requirements for energy and macronutrient intake. A secondary aim was to evaluate the awareness of physical and emotional perceptions associated with mindful eating., Methods: Participants included NCAA Division I (DI, n  = 45), II (DII, n  = 31), and III (DIII, n  = 47) athletes. Athletes completed a validated questionnaire designed to assess sports nutrition knowledge and were asked questions about their perceived dietary energy and macronutrient requirements. Daily energy intake values were calculated using a recommended relative energy intake value of 40, 50, and 60 kcal/kg/day for low, moderate, and high activity levels, respectively. Carbohydrate recommendations were calculated using 4, 6, and 8 g/kg/day, protein recommendations were calculated using relative intakes of 1.4, 1.6, and 1.8 g/kg/day, and fat recommendations were calculated from a relative percentage of total predicted daily energy requirements, equating to 15, 25, and 30% of daily energy. Additionally, athletes completed a questionnaire to assess mindfulness regarding eating habits., Results: Overall, athletes answered 45.5 ± 13.5% of questions correctly on the nutrition questionnaire with significant differences observed between male (48.6 ± 13.6%) and female athletes (43.6 ± 13.2%; p  = 0.044), as well as significant differences observed between DI athlete scores (38.8 ± 14.1%) and DII athletes (47.7 ± 11.4%; p  = 0.002), and DI athletes and DIII athletes (51.71 ± 11.83%; p  =  <0.001). All athletes significantly ( p  < 0.001) underestimated daily energy intake requirements (female, 2,112 ± 575 kcal/day; male, 3,283 ± 538 kcal/day). The mindfulness eating habits total score was significantly higher in male athletes (65.1 ± 6.5) compared to female athletes (60.9 ± 9.5; p  = 0.009)., Conclusions: Division I, II, and III collegiate athletes have poor sports nutrition knowledge, with Division I athletes having exhibited lower scores compared to Division II and III athletes on the sports nutrition knowledge questionnaire. Athletes from all levels of collegiate sports underestimated their energy and macronutrient requirements. Differences in mindful eating habits among female and male athletes were also evident.

Abstract: Willingham, BD, Daou, M, VanArsdale, J, Thomas, M, and Saracino, PG. Energy availability in female collegiate beach volleyball athletes. J Strength Cond Res 38(11): 1941-1950, 2024-Low energy availability (LEA) is a present risk for many female athletes. Yet, the literature on LEA is often reliant on single, short-term, snapshots, which may not be reflective of the chronic energy balance surrounding female athletes in sport. Therefore, the purpose of this study was to establish the current prevalence of LEA in female collegiate beach volleyball athletes during the preseason and across the competitive season. One-way repeated measures analysis of variance was used to compare measures of EA (i.e., dietary intake, activity energy expenditure [EE], body composition) and EE (i.e., resting metabolic rate and thermic effect of feeding) at 4 timepoints-once in the preseason (i.e., Fall), and 3 times across the 10-week competitive season in Spring (i.e., week 1, week 5, and week 9). Significance was set at p ≤ 0.05. Although mean EA was in the subclinical zone (i.e., 30-45 kcal·kg FFM-1·d-1) at each timepoint, the prevalence of LEA for individuals was 30.8% in the preseason, 37.5% at week 1, 25.0% at week 5, and 62.5% at week 9. Further, carbohydrate intake was below the recommended range for power athletes at each timepoint, suggesting that female beach volleyball athletes with LEA may benefit from increasing carbohydrate intake. Despite no statistical differences in body mass across the season (p = 0.577), there was a trend for increasing fat-free mass (p = 0.062) as the season progressed. Importantly, LEA is not a team-wide condition but an individual one. Therefore, approaches to mitigate LEA should be individualized., (Copyright © 2024 National Strength and Conditioning Association.)

Background: Antimicrobial resistance (AMR) is a global threat to public health. Misuse or overuse of antimicrobials contributes to the emergence of AMR. Data on antimicrobial prescribing represent the cornerstone for guiding antimicrobial stewardship strategies. This study aimed to assess the use, indications, classification, and quality indicators of antimicrobials prescribed to patients in four tertiary hospitals in Niger., Methods: This cross-sectional study used the methodology for Global Point Prevalence Surveys in tertiary hospitals between January and April 2024. Hospital records of all inpatients on admission at 08:00 hours on a specific day were reviewed for antimicrobial use during the survey., Results: The overall prevalence of antibiotic use across hospitals was 54.5% ( n  = 470/862), ranging between 66.2% ( n  = 149/234) and 44.3% ( n  = 183/258). Most antibiotics used were antibacterials (89.0%, n  = 637). Third-generation cephalosporins (48.2%, 307/637), imidazole derivatives (14.7%, 105/716), penicillins with extended spectrum (9.6%, 69/716), and fluoroquinolones (6.1%, 44/716) were the most commonly prescribed classes of antibiotics. Most antibiotics (84.9%, n  = 608) were prescribed to treat community-acquired infections, while surgical prophylaxis accounted for 6.4% ( n  = 47/716). Most antibiotics (96.1%; n  = 688/716) were used empirically, and less than a quarter (20.7%) of antibiotics prescribed had a documented stop/review date recorded. Only, 4.2% ( n  = 31/716) of prescribed antibiotics had cultures and susceptibility testing requested., Conclusion: This study shows that antibiotic prescription rates are high in tertiary hospitals, with relatively high use of third-generation cephalosporins. Most antibiotics were empirically used and not guided by culture and susceptibility testing. These results could be the subject of key interventions for hospital antibiotic stewardship strategies in Niger., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Introduction: Neurological disorders (ND) have a high incidence in sub-Saharan Africa (SSA). In this region, systemic challenges of conventional medicine (CM) and cultural beliefs have contributed to a large utilization of traditional medicine (TM). Yet, data on TM and those who use it in the treatment of ND in SSA are scarce. Here, we systematically analyze its role as a therapy modality for ND in Mali, the socio-demographic characteristics of its users, and propose next steps to optimize the dual usages of TM and CM for patients with ND., Methods: We conducted a questionnaire study in two phases. In phase one, patients with ND answered questions on their usage of and attitudes towards TM. In phase two, the TM therapists who provided care to the patients in phase one answered questions regarding their own practices for treating ND. Patients were recruited from the country's two university neurology departments., Results: 3,534 of the 4,532 patients seen in the Departments of Neurology in 2019 met the inclusion criteria. Among these 3,534 patients, 2,430 (68.8%) had previously consulted TM for their present ND. Patients over 60 years of age most often used TM (83.1%). By education, illiterate patients utilized TM the most (85.5%) while those with more than a secondary education used TM the least (48.6%). An income greater than the minimum guaranteed salary was associated with decreased use of traditional medicine (OR 0.29, CI 0.25-0.35, p < 0.001). Among those using TM, it was overwhelmingly thought to be more effective than CM (84.6%). Linking illness to supernatural causes and believing TM therapists had a better understanding of illnesses were the most common reasons patients used traditional medicine (82.3% and 80.5%, respectively). We then interviewed 171 TM therapists who had provided care to the patients in phase one. These providers most commonly "sometimes" (62.6%) referred patients to CM and 4.1% never had. A majority of TM providers (62.6%) believed collaboration with CM could be improved by having doctor "take into account" our existence., Conclusion: Our work shows that TM plays a central role in the provision of care for patients with ND in SSA with certain cohorts using it at higher rates. Future development of treatment of ND in SSA will require optimizing TM with CM and needs buy-in from all stakeholders including conventional medicine clinicians, traditional medicine therapists, researchers, politicians, and most importantly, patients., (© 2024. The Author(s).)

Background . Macrolide-induced resistance to clindamycin is a well-described mechanism leading to treatment failure. Herein, we determined the frequency and associated factors of inducible clindamycin resistance in Gram-positive cocci in a tertiary care hospital. Methods . A cross-sectional descriptive study was carried out between January and December 2022. d-tests were performed as recommended by EUCAST 2021 guidelines on 100 non-duplicate clinical isolates of Gram-positive cocci to determine the prevalence of methicillin resistance and inducible clindamycin resistance among the collected isolates. Results . Of the 100 Gram-positive cocci isolates, 56 (56.0%), 17 (17.0%) and 27 (27.0%) were respectively coagulase-negative staphylococci, Staphylococcus aureus and Streptococcus spp. Among Streptococcus spp., Group D Streptococci (15.0%) were the most isolated. Methicillin-resistant Staphylococcus aureus (MRSA) represented nine (53.0%) of the S. aureus isolates. Constitutive (cMLSb) and inducible clindamycin resistance (iMLSb) phenotypes were detected in 36 (36.0%) and 14 (14.0 %) of the isolates, respectively. S. aureus exhibited 38.4% of cMLSb and 13.7% of iMLSb. The result of multivariate analysis showed that age groups, gender, type of samples, provenance, and bacteria, were not significantly associated with Gram-positive cocci iMLSb phenotype. Conclusion . The study reported for the first time a high prevalence of inducible resistance of Gram-positive cocci strains to clindamycin in Niger Republic. This suggests the urgent need for the implementation of regular screening of these isolates and the wise use of clindamycin in clinical practice., Competing Interests: The authors declare that they have no conflict of interest., (Copyright © 2024 The Authors.)

Rationale/objectives: Despite plausible pathophysiological mechanisms, research is needed to confirm the relationship between sleep, circadian rhythm and delirium in patients admitted to the intensive care unit (ICU). The objective of this review is to summarise existing studies promoting, in whole or in part, the normalisation of sleep and circadian biology and their impact on the incidence, prevalence, duration and/or severity of delirium in ICU., Methods: A sensitive search of electronic databases and conference proceedings was completed in March 2023. Inclusion criteria were English-language studies of any design that evaluated in-ICU non-pharmacological, pharmacological or mixed intervention strategies for promoting sleep or circadian biology and their association with delirium, as assessed at least daily. Data were extracted and independently verified., Results: Of 7886 citations, we included 50 articles. Commonly evaluated interventions include care bundles (n=20), regulation or administration of light therapy (n=5), eye masks and/or earplugs (n=5), one nursing care-focused intervention and pharmacological intervention (eg, melatonin and ramelteon; n=19). The association between these interventions and incident delirium or severity of delirium was mixed. As multiple interventions were incorporated in included studies of care bundles and given that there was variable reporting of compliance with individual elements, identifying which components might have an impact on delirium is challenging., Conclusions: This scoping review summarises the existing literature as it relates to ICU sleep and circadian disruption (SCD) and delirium in ICU. Further studies are needed to better understand the role of ICU SCD promotion interventions in delirium mitigation., Competing Interests: Competing interests: MPK is a member of Serca LLC (no conflict with this review)., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose of Review: To review replicated and highlight novel studies of sleep in children and adults with episodic and chronic migraine., Recent Findings: Attack-related sleep symptoms are most common in the prodrome and may represent early activation of the hypothalamus rather than migraine triggers. Interictally, patients with migraine report poor sleep quality and high rates of insomnia symptoms. Cognitive behavioral therapy for insomnia in adults and adolescents with chronic migraine and comorbid insomnia results in significant improvement on their headache burden. Thus far, objective studies report that migraine per se is a not associated with sleep apnea. At the present time, there is minimal evidence that migraine is under circadian influence. The current body of evidence suggests that the insomnia symptoms and poor sleep quality commonly reported by patients with migraine are not attack-related but occur interictally and are a marker of worsening disease. The development of clinical guidelines to approach sleep symptoms and expansion of CBT-I trials in those with episodic migraine would be clinically valuable., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Our recent studies have shown headache disorders to be very common in the central and western sub-Saharan countries of Benin and Cameroon. Here we report headache in nearby Mali, a strife-torn country that differs topographically, culturally, politically and economically. The purposes were to estimate headache-attributed burden and need for headache care., Methods: We used cluster-random sampling in seven of Mali's eleven regions to obtain a nationally representative sample. During unannounced household visits by trained interviewers, one randomly selected adult member (18-65 years) from each household was interviewed using the structured HARDSHIP questionnaire, with enquiries into headache in the last year and, additionally, headache yesterday (HY). Headache on ≥ 15 days/month (H15+) was diagnosed as probable medication-overuse headache (pMOH) when associated with acute medication use on ≥ 15 days/month, and as "other H15+" when not. Episodic headache (on < 15 days/month) was recorded as such and not further diagnosed. Burden was assessed as impaired participation (days lost from paid and household work, and from leisure activity). Need for headache care was defined by criteria for expectation of benefit., Results: Data collection coincided with the SARS-CoV-2 pandemic. The participating proportion was nonetheless extremely high (99.4%). The observed 1-year prevalence of any headache was 90.9%. Age- and gender-adjusted estimates were 86.3% for episodic headache, 1.4% for pMOH and 3.1% for other H15+. HY was reported by 16.8% with a mean duration of 8.7 h. Overall mean headache frequency was 3.5 days/month. Participants with pMOH lost more days from paid (8.8 days/3 months) and household work (10.3 days/3 months) than those with other H15+ (3.1 and 2.8 days/3 months) or episodic headache (1.2 and 0.9 days/3 months). At population level, 3.6-5.8% of all time was spent with headache, which led to a 3.6% decrease in all activity (impaired participation). Almost a quarter (23.4%) of Mali's adult population need headache care., Conclusion: Headache is very common in Mali, as in its near neighbours, Benin and Cameroon, and associated with substantial losses of health and productivity. Need for headache care is high - a challenge for a low-income country - but lost productivity probably translates into lost gross domestic product., (© 2024. The Author(s).)

This paper introduces a novel application of the laser speckle technique in dentistry, focusing on assessing the efficiency of dental excavation methods used to remove decayed tooth structure. The aim is to evaluate the efficiency of two chemo-mechanical agents and the high-speed drill using the laser speckle technique, which offers objective, non-invasive, and real-time evaluation capabilities. Extracted human primary molars with active occlusal carious lesions were sectioned into three parts, with each part allocated to one of three groups: Group 1 (Brix3000 ® ), Group 2 (Papacarie DUO ® ), and Group 3 (High-speed drill mechanical caries removal). Caries removal was performed using the designated agent or method for each group. After caries excavation, speckle imaging using a 632.8 nm laser was conducted. Additionally, SEM was used to acquire micro-photographs of the surface morphology of the treated samples. The findings reveal insights into the comparative efficiency of the three dental excavation agents and methods using the laser speckle technique. The speckle parameters extracted from speckle patterns generated by treated teeth provide valuable information for evaluating the performance of the excavation methods. The scanning electron microscopy images also offer detailed visual evidence to support the analysis. This paper demonstrates the potential of the laser speckle technique for assessing the efficiency of dental excavation methods. The objective, non-invasive, and real-time evaluation provided offers advantages over subjective visual assessment and manual measurements., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Surveillance methods of circulating antibiotic resistance genes (ARGs) are of utmost importance in order to tackle what has been described as one of the greatest threats to humanity in the 21st century. In order to be effective, these methods have to be accurate, quickly deployable, and scalable. In this study, we compare metagenomic shotgun sequencing (TruSeq DNA sequencing) of wastewater samples with a state-of-the-art PCR-based method (Resistomap HT-qPCR) on four wastewater samples that were taken from hospital, industrial, urban and rural areas. ARGs that confer resistance to 11 antibiotic classes have been identified in these wastewater samples using both methods, with the most abundant observed classes of ARGs conferring resistance to aminoglycoside, multidrug-resistance (MDR), macrolide-lincosamide-streptogramin B (MLSB), tetracycline and beta-lactams. In comparing the methods, we observed a strong correlation of relative abundance of ARGs obtained by the two tested methods for the majority of antibiotic classes. Finally, we investigated the source of discrepancies in the results obtained by the two methods. This analysis revealed that false negatives were more likely to occur in qPCR due to mutated primer target sites, whereas ARGs with incomplete or low coverage were not detected by the sequencing method due to the parameters set in the bioinformatics pipeline. Indeed, despite the good correlation between the methods, each has its advantages and disadvantages which are also discussed here. By using both methods together, a more robust ARG surveillance program can be established. Overall, the work described here can aid wastewater treatment plants that plan on implementing an ARG surveillance program., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Daw Elbait et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Glioblastoma (GBM) has poor prognosis due to ineffective agents and poor delivery methods. MicroRNAs (miRs) have been explored as novel therapeutics for GBM, but the optimal miRs and the ideal delivery strategy remain unresolved. In this study, we sought to identify the most effective pan-subtype anti-GBM miRs and to develop an improved delivery system for these miRs., Methods: We conducted an unbiased screen of over 600 miRs against 7 glioma stem cell (GSC) lines representing all GBM subtypes to identify a set of pan-subtype-specific anti-GBM miRs and then used available TCGA GBM patient outcomes and miR expression data to hone in on miRs that were most likely to be clinically effective. To enhance delivery and expression of the miRs, we generated a polycistronic plasmid encoding 3 miRs (pPolymiR) and used HEK293T cells as biofactories to package pPolymiR into engineered exosomes (eExos) that incorporate viral proteins (Gag/VSVg) in their structure (eExos+pPolymiR) to enhance function., Results: Our stepwise screen identified miR-124-2, miR-135a-2, and let-7i as the most effective miRs across all GBM subtypes with clinical relevance. Delivery of eExos+pPolymiR resulted in high expression of all 3 miRs in GSCs, and significantly decreased GSC proliferation in vitro. eExos+pPolymiR prolonged survival of GSC-bearing mice in vivo when compared with eExos carrying each of the miRs individually or as a cocktail., Conclusion: eExos+pPolymiR, which includes a pan-subtype anti-glioma-specific miR combination encoded in a polycistronic plasmid and a novel exosome delivery platform, represents a new and potentially powerful anti-GBM therapeutic., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Non-compliance in the drafting of examination bulletins makes it difficult to perform them and interpret the results. With the aim of continuously improving laboratory services and guaranteeing the quality of urine cytobacteriological examination (ECBU) results, we initiated this study to evaluate non-compliance in the drafting of ECBU reports., Materials and Methods: This was a retrospective descriptive cross-sectional study which focused on non-compliance in the drafting of ECBU reports analysed in the laboratory from January to December 2022., Results: During the study period, we collected 383 non-compliant ECBU reports out of 672, with a frequency of 56.99%. Non-compliances were related to age (2.68%), profession (24.40%), clinical information (6.70%) and residence (52.08%). The majority of non-compliant reports came from the medicine (35.51%) and urology (25.85%) departments., Conclusion: The high frequency of non-compliance is a cause for concern and is of concern to all prescribers in this hospital., Competing Interests: The authors declare that they have no competing interests., (© 2024 The Authors.)

Tuberous Sclerosis Complex (TSC) is caused by TSC1 or TSC2 mutations, leading to hyperactivation of mechanistic target of rapamycin complex 1 (mTORC1) and lesions  in multiple organs including lung (lymphangioleiomyomatosis) and kidney (angiomyolipoma and renal cell carcinoma). Previously, we found that TFEB is constitutively active in TSC. Here, we generated two mouse models of TSC in which kidney pathology is the primary phenotype. Knockout of TFEB rescues kidney pathology and overall survival, indicating that TFEB is the primary driver of renal disease in TSC. Importantly, increased mTORC1 activity in the TSC2 knockout kidneys is normalized by TFEB knockout. In TSC2-deficient cells, Rheb knockdown or Rapamycin treatment paradoxically increases TFEB phosphorylation at the mTORC1-sites and relocalizes TFEB from nucleus to cytoplasm. In mice, Rapamycin treatment normalizes lysosomal gene expression, similar to TFEB knockout, suggesting that Rapamycin's benefit in TSC is TFEB-dependent. These results change the view of the mechanisms of mTORC1 hyperactivation in TSC and may lead to therapeutic avenues., (© 2024. The Author(s).)

Wastewater-based epidemiology (WBE) demonstrates an efficient tool to monitor and predict SARS-CoV-2 community distribution. Many countries across the world have adopted the technique, however, most of these studies were conducted for a short duration with a limited sampling size. In this study, long-term reliability and quantification of wastewater SARS-CoV-2 surveillance is reported via analyzing 16,858 samples collected from 453 different locations across the United Arab Emirates (UAE) from May 2020 to June 2022. The collected composite samples were first incubated at 60 °C followed by filtration, concentration, and then RNA extraction using commercially available kits. The extracted RNA was then analyzed by one-step RT-qPCR and RT-ddPCR, and the data was compared to the reported clinical cases. The average positivity rate in the wastewater samples was found to be 60.61 % (8.41-96.77 %), however, the positivity rate obtained from the RT-ddPCR was significantly higher than the RT-qPCR suggesting higher sensitivity of RT-ddPCR. Time-lagged correlation analysis indicated an increase in positive cases in the wastewater samples when the clinical positive cases declined suggesting that wastewater data are highly affected by the unreported asymptomatic, pre-symptomatic and recovering individuals. The weekly SARS-CoV-2 viral count in the wastewater samples are positively correlated with the diagnosed new clinical cases throughout the studied period and the studied locations. Viral count in wastewater peaked approximately one to two weeks prior to the peaks appearing in active clinical cases indicating that wastewater viral concentrations are effective in predicting clinical cases. Overall, this study further confirms the long-term sensitivity and robust approach of WBE to detect trends in SARS-CoV-2 spread and helps contribute to pandemic management., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: This scoping review aimed to describe the scope of commercially available virtual reality (VR) healthcare applications for mainstream head-mounted displays (HMD)s., Methods: A search was conducted during late April and early May 2022 over five major VR app stores using "health," "healthcare," "medicine," and "medical" as keywords. Apps were screened based on their title and description sections. Metadata collected included: title, description, release date, price (free or paid), multilingual support, VR app store availability, and HMD support., Results: The search yielded 1995 apps, out of which 60 met the inclusion criteria. The analysis showed that the number of healthcare VR apps has been steadily increasing since 2016, but no developer has released more than two apps so far. Most of the reviewed apps can run on HTC Vive, Oculus Quest, and Valve Index. Thirty-four (56.7%) apps had a free version, and 12 (20%) apps were multilingual, i.e., supported languages other than English. The reviewed apps fell into eight major themes: life science education (3D anatomy, physiology and pathology, biochemistry, and genetics); rehabilitation (physical, mental, and phobia therapy); public health training (safety, life-saving skills, and management); medical training (surgical and patient simulators); role-playing as a patient; 3D medical imagery viewing; children's health; and online health communities., Conclusions: Although commercial healthcare VR is still in its early phases, end-users can already access a broad range of healthcare VR apps on mainstream HMDs. Further research is needed to assess the usefulness and usability of existing apps., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background and Objectives: Lebanon has one of the highest incidence rates of bladder cancer (BC) in the world. In 2019, Lebanon's economy collapsed which majorly impacted healthcare costs and coverage. This study assesses the overall direct costs of urothelial BC in Lebanon, from the perspective of public and private third-party payers (TPP) and households, and evaluates the impact of the economic collapse on these costs., Methods: This was a quantitative, incidence-based cost-of-illness study, conducted using a macro-costing approach. Costs of medical procedures were obtained from the records of various TPPs and the Ministry of Public Health. We modeled the clinical management processes for each stage of BC, and conducted probabilistic sensitivity analyses to estimate and compare the cost of each stage, pre-and post-collapse, and for each payer category., Results: Before the collapse, the total annual cost of BC in Lebanon was estimated at LBP 19,676,494,000 (USD 13,117,662). Post-collapse, the total annual cost of BC in Lebanon increased by 768% and was estimated at LBP 170,727,187,000 (USD 7,422,921). TPP payments increased by 61% whereas out-of-pocket (OOP) payments increased by 2,745% resulting in a decrease in TPP coverage to only 17% of total costs., Conclusion: Our study shows that BC in Lebanon constitutes a significant economic burden costing 0.32% of total health expenditures. The economic collapse induced an increase of 768% in the total annual cost, and a catastrophic increase in OOP payments., (© 2023. The Author(s).)

Objective: Having learners practice a motor skill with the expectation of teaching it (versus an expectation of being tested on it) has been revealed to enhance skill learning. However, this improvement in skill performance is lost when the skill must be performed under psychological pressure due to 'choking under pressure.' The present study investigated whether this choking effect is caused by an accrual of declarative knowledge during skill practice and could be prevented if a technique (analogy instructions) to minimize the accrual of declarative knowledge during practice is employed., Design: We used a 2 (Expectation: teach/test) x 2 (Instructions: analogy/explicit) x 2 (Posttest: low-pressure/high-pressure) mixed-factor design, with repeated measures on the last factor., Methods: One-hundred fifty-six participants were quasi-randomly assigned (based on sex) to one of four groups. Participants in the teach/analogy and teach/explicit groups practiced golf putting with the expectation of teaching putting to another participant, and analogy instructions or explicit instructions, respectively. Participants in the test/analogy and test/explicit groups practiced golf putting with the expectation of being tested on their putting, and analogy instructions or explicit instructions, respectively. The next day all participants completed low- and high-pressure putting posttests, with their putting accuracy serving as the dependent variable., Results: We observed an Expectation x Instructions × Posttest interaction, such that a main effect of expectation was found in the low-pressure posttest, with the teach group exhibiting superior accuracy, and an Expectation × Instructions interaction was revealed for the high-pressure posttest. This interaction resulted from the teach group showing greater accuracy than the test group exclusively when receiving analogy instructions., Conclusion: Results show that participants who practiced with the expectation of teaching exhibited superior learning and indicate that they choked under pressure likely due to their accrual of declarative knowledge during practice, since the choking effect was prevented by having them practice with analogy instructions. Accordingly, having learners practice with the expectation of teaching and techniques that minimize the accrual of declarative knowledge is recommended., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Host immunity has been suggested to clear drug-resistant parasites in malaria-endemic settings. However, the immunogenetic mechanisms involved in parasite clearance are poorly understood. Characterizing the host's immunity and genes involved in controlling the parasitic infection can inform the development of blood-stage malaria vaccines. This study investigates host regulatory cytokines and immunogenomic factors associated with the clearance of Plasmodium falciparum carrying a chloroquine resistance genotype. Biological samples from participants of previous drug efficacy trials conducted in two Malian localities were retrieved. The P. falciparum chloroquine resistance transporter (Pfcrt) gene was genotyped using parasite DNA. Children carrying parasites with the mutant allele (Pfcrt-76T) were classified based on their ability to clear their parasites. The levels of the different cytokines were measured in serum. The polymorphisms of specific human genes involved in malaria susceptibility were genotyped using human DNA. The prevalence of the Pfcrt-76T was significantly higher in Kolle than in Bandiagara (81.6 % vs 38.6 %, p < 10 -6 ). The prevalence of children who cleared their mutant parasites was significantly higher in Bandiagara than in Kolle (82.2 % vs 67.4 %, p < 0.05). The genotyping of host genes revealed that IFN-γ -874 T and TNF-α -308A alleles were positively associated with parasite clearance. Cytokine profiling revealed that IFN-γ level was positively associated with parasite clearance (p = 0.04). This study highlights the role of host's immunity and immunogenetic factors to clear resistant parasites, suggesting further characterization of these polymorphisms may help to develop novel approaches to antiparasitic treatment strategies., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Background: Citrullinemia type 1 (CTLN1) is a rare autosomal recessive disease caused by argininosuccinate synthetase (ASS) deficiency. Manifestations vary from the acute neonatal or "classic" form to a milder, late-onset, or "unconventional" form. To date, more than 93 variants in the ASS1 gene located on chromosome 9q43.11 (OMIM #215700) are reportedly responsible for CTLN1. Their incidence and distribution vary according to geographic origins and ethnicity, and a correlation, although not clearly delineated, has been established between the genotype and the phenotype of the disease. Though, in the Middle East, national descriptions of CTLN1 are still lacking., Methods: A total of ten unrelated Middle Eastern families, five Lebanese, two Syrians, and three Iraqis with citrullinemia index cases, were included in this study. Upon informed consent, DNA was extracted from the whole blood of the index patients as well as their parents and siblings. Genetic analysis was carried out by Sanger sequencing of the ASS1 gene., Results: Seven different variants were identified. Two novel variants, c.286C>A (p.(Pro96Thr), RNA not analyzed) in exon 5 and deletion c.685&#95;688+6del(p.(Lys229Glyfs*4), RNA not analyzed) in exon 10, were found in one Lebanese and one Syrian family, respectively, and were correlated with early-onset and severe clinical presentation. Five other known variants: c.535T>C (p.(Trp179Arg), RNA not analyzed) in exon 8, c.787G>A (p.(Val263Met), RNA not analyzed) in exon 12, c.847G>A (p.(Glu283Lys), RNA not analyzed) in exon 13, c.910C>T (p.(Arg304Trp), RNA not analyzed) in exon 13, and c.1168G>A (p.(Gly390Arg), RNA not analyzed) in exon 15, were found in Lebanese, Syrian, and Iraqi families, and were associated with diverse clinical presentations., Conclusion: Two novel variants and five known variants were found in a total of ten unrelated Middle Eastern families., (© 2022 The Authors. Molecular Genetics & Genomic Medicine published by Wiley Periodicals LLC.)

Aim: This study evaluated the color aging of two computer aided design/computer aided manufacturing (CAD/CAM) provisional materials of different compositions (polymethyl methacrylate and composite resin) after exposure to thermal aging and immersion in coffee for 3, 6, and 12 intraoral months., Setting and Design: The current in vitro study was conducted from September to December 2021 at the Craniofacial laboratory at the Saint Joseph University in Beirut, Lebanon., Materials and Methods: The shades of 2.0 mm thick, 10.0 mm in diameter disk shaped specimens of VITA CAD Temp ® and Ceramill ® TEMP were measured using the VITA Linearguide 3D MASTER ® and a conversion table to extract the CIE LFNx01aFNx01bFNx01 values on a white background (n = 30)., Statistical Analysis Used: The color differences ΔE at 3, 6, and 12 months were calculated and analyzed by repeated measures ANOVA followed by Bonferroni multiple comparisons, univariate analyses, and one sample t tests., Results: The mean ΔE T1/T0 , ΔE T2/T0 , and ΔE T3/T0 values were significantly higher than the cutoff values for acceptability and perceptibility for the VITA CAD Temp ® and the Ceramill ® TEMP groups. In addition, the increase in ΔE overtime was significantly greater in the Ceramill ® TEMP group compared to the VITA CAD Temp ® group., Conclusions: The Ceramill ® TEMP changed color more and faster than the VITA CAD Temp ® . In addition, whether at 3, 6, or 12 months, the color variations of both materials are not only perceptible but also unacceptable compared to the initial shade., Competing Interests: None

Background: The aim of this study was to evaluate the color stability and the surface roughness of a bulk-fill composite flow (SDR® Plus) by comparison to an ORMOCER-based composite (Ceram.x® Universal SphereTEC™) in order to confirm the validity of using SDR® Plus in the anterior region and to allow the prediction of its long-term results., Material and Methods: 35 composite specimens of the same shade (A2), thickness (2mm) and shape of both types of composite were prepared. The specimens were cured and polished according to the manufacturer's instructions. The initial shade of the specimens was measured using a calibrated EasyShade spectrophotometer. The initial surface roughness of the specimens was measured by AFM. Afterwards, the specimens were subjected to an accelerated aging procedure through thermo-cycling, a coffee stain challenge and brushing to simulate two years in the oral environment. The shade and surface roughness of the specimens were measured again after the accelerated aging procedure., Results: The mean ΔE was significantly larger than 3.368 in Ceram.x® group (- p -value<0.001) and SDR® Plus group (- p -value<0.001). The mean surface roughness has significantly increased for both groups after aging with no significant difference between the two groups. It however remained clinically acceptable., Conclusions: SDR® Plus and Ceram.x® showed similar surface roughness when subjected to the same testing conditions. Concerning the color stability, both composites displayed noticeable discoloration, with higher ΔE values registered for Ceram.x®. Key words: Composite resins, spectrophotometry, atomic force microscopy, dental material, resin-based material., Competing Interests: Conflicts of interest The authors declare that they have no conflicts of interest., (Copyright: © 2023 Medicina Oral S.L.)

Aims: The aim of the present in vitro study was to compare the effectiveness of passive ultrasonic irrigation (PUI), sonic irrigation, and mechanic dynamic activation on the removal of debris and smear layer from primary mandibular second molars during pulpectomy., Materials and Methods: Mesial roots of 48 primary mandibular second molars were prepared with an R-motion 21 mm file (30/0.04) (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland), irrigated with 1% sodium hypochlorite (NaOCl) and 17% ethylenediaminetetraacetic acid (EDTA), and divided into four groups ( n = 24 canals) according to the final irrigation activation technique: control group without activation, PUI with Ultra-X (Eighteeth, Changzhou, China), mechanical activation with XP-endo Finisher (FKG), and sonic irrigation with EQ-S (Meta Biomed, Chungcheongbuk-do, Korea). The roots were split longitudinally and analyzed using scanning electron microscopy (SEM). The presence of debris and smear layer was assessed using a 5-grade scoring scale with 200× and 1000× magnification, respectively. The Kruskal-Wallis and Friedman tests were used for data analysis., Results: The activation of the irrigant significantly improved debris and smear layer removal ( p < 0.001). There was no significant difference between Ultra-X, XP-endo Finisher, and EQ-S ( p > 0.05). No activation technique was able to completely eliminate debris and smear layer from the root canals of primary mandibular second molars., Conclusions: During pediatric pulpectomy, the irrigation protocol must include activation of the irrigation solutions using either ultrasonic, sonic, or mechanical activation techniques to enhance the removal of debris and smear layer for a better prognosis., Clinical Significance: During root canal treatment on primary teeth, the clinician must incorporate an activation technique in the irrigation protocol to enhance the removal of debris and smear layer and increase the success of the treatment.

Purpose: Neurocritical care patients are at risk of stress-induced gastrointestinal ulceration. We performed a systematic review and meta-analysis of stress ulcer prophylaxis (SUP) in critically ill adults admitted with a primary neurologic injury., Materials and Methods: We included randomized controlled trials (RCTs) comparing SUP with histamine-2-receptor antagonists (H2RAs) or proton pump inhibitors (PPIs) to placebo/no prophylaxis, as well as to each other. The primary outcome was in-ICU gastrointestinal bleeding (GIB). Predefined secondary outcomes were all-cause 30-day mortality, ICU length of stay (LOS), nosocomial pneumonia, and other complications., Results: We identified 14 relevant trials enrolling 1036 neurocritical care patients; 11 trials enrolling 930 patients were included in the meta-analysis. H2RAs resulted in a lower incidence of GIB as compared to placebo or no prophylaxis (Risk ratio [RR] 0.42, 95% CI 0.30-0.58; p < 0.001); PPIs with a lower risk of GIB compared to placebo/no prophylaxis (RR 0.37, 95% CI 0.23-0.59; p < 0.001). No significant difference was observed in GIB comparing PPIs with H2RAs (RR 0.53, 95% CI 0.26-1.06; p = 0.07; I 2 = 0%)., Conclusions: In neurocritical care patients, the overall high or unclear risk of bias of individual trials, the low event rates, and modest sample sizes preclude strong clinical inferences about the utility of SUP., Competing Interests: Declaration of Competing Interest The authors have no conflict of interests to report relevant to this study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Coronavirus disease 2019 (COVID-19) was first identified in respiratory samples and was found to commonly cause cough and pneumonia. However, non-respiratory symptoms including gastrointestinal disorders are also present and a big proportion of patients test positive for the virus in stools for a prolonged period. In this cross-sectional study, we investigated viral load trends in stools and nasopharyngeal swabs and their correlation with multiple demographic and clinical factors. The study included 211 laboratory-confirmed cases suffering from a mild form of the disease and completing their isolation period at a non-hospital center in the United Arab Emirates. Demographic and clinical information was collected by standardized questionnaire and from the medical records of the patient. Of the 211 participants, 25% tested negative in both sample types at the time of this study and 53% of the remaining patients had detectable viral RNA in their stools. A positive fecal viral test was associated with male gender, diarrhea as a symptom, and hospitalization during infection. A positive correlation was also observed between a delayed onset of symptoms and a positive stool test. Viral load in stools positively correlated with, being overweight, exercising, taking antibiotics in the last 3 months and blood type O. The viral load in nasopharyngeal swabs, on the other hand, was higher for blood type A, and rhesus positive (Rh factor). Regression analysis showed no correlation between the viral loads measured in stool and nasopharyngeal samples in any given patient. The results of this work highlight the factors associated with a higher viral count in each sample. It also shows the importance of stool sample analysis for the follow-up and diagnosis of recovering COVID-19 patients., Competing Interests: The authors have declared that no competing interests exist.

Objective: This study investigated the effect of dentin surface treatment with the erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser on the bond strength of zirconia to dentin. Background data: Although it is well-known that resin cement (RC) provides adequate bond strength of zirconia restorations to the tooth structure, many clinicians were not convinced in bonding reliability to zirconia materials. So, they preferred cementing their crowns with glass-ionomer cement (GIC). Pretreating the dentin surface is recommended to improve the adhesion of crowns cemented with GIC or RC. Recently, the Er,Cr:YSGG laser has been widely used for a cavity preparation, conditioning the tooth structure. However, there is not enough research on the bond strength of zirconia crowns cemented on a Er,Cr:YSGG laser-treated dentin. Methods: Forty-eight molars were cut horizontally at the crest of curvature. The flat dentin surface of 24 molars was left untreated, whereas the dentin surface of the other half was treated using an Er,Cr:YSGG laser 2.78 μm (4.5 W, 8.18 J/cm 2 , 90 mJ, 60 μs, 50 Hz, 60% air and 80% water). In addition, 48 plates of zirconia were prepared to be cemented with GIC or RC on the dentin surface. So, the molars were divided into four groups as follows: GIC+untreated dentin; GIC+treated dentin; RC+untreated dentin; and RC+treated dentin. All the specimens were subjected to shear bond strength test. The mode of failure was determined and additional samples were prepared to evaluate the cement-dentin interface using a scanning electron microscope. Data were analyzed with two-way analysis of variance accompanied by univariate analyses. Results: The bond strength of zirconia cemented with GIC or bonded with RC significantly increased on a Er,Cr:YSGG laser-treated dentin surface ( p  < 0.05). Conclusions: Dentin preconditioning with an Er,Cr:YSGG laser significantly improved the bond strength of zirconia plates to dentin as compared with untreated dentin.

Introduction: Sepsis is a common, life-threatening syndrome of physiologic, pathologic, and biochemical abnormalities that are caused by infection and propagated by a dysregulated immune response. In 2017, the estimated annual incidence of sepsis around the world was 508 cases per 100,000 (95% confidence interval [CI], 422-612 cases per 100,000), however, reported incidence rates vary significantly by country. A scoping review will identify knowledge gaps by systematically investigating the incidence of sepsis., Methods and Analysis: This scoping review will be guided by the updated JBI (formerly Joanna Briggs Institute) methodology. We will search the following electronic databases: MEDLINE, EMBASE, CINAHL, and Cochrane Database of Systematic Reviews/Central Register of Controlled Trials. In addition, we will search websites of trial and study registries. We will review titles and abstracts of potentially eligible studies and then full-texts by two independent reviewers. We will include any study that is focused on the incidence of sepsis or septic shock in any population. Data will be abstracted independently using pre-piloted data extraction forms, and we will present results according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews., Ethics and Dissemination: The results of this review will be used to create a publicly available indexed and searchable electronic registry of existing sepsis research relating to incidence in neonates, children, and adults. With input from stakeholders, we will identify the implications of study findings for policy, practice, and research. Ethics approval was not required given this study reports on existing literature., (© 2022. The Author(s).)

The Lebanese healthcare system has been facing major challenges due to an unprecedented financial crisis, socio-political instability, and the COVID-19 pandemic. This study aims to examine the impact of overlapping major crises on care continuity and to propose IT-based solutions to address current challenges and build future resilience. To this end, we adopted a participatory action research approach and conducted a two-phase qualitative study - six semi-structured interviews followed by three future workshops with local stakeholders including physicians and interns practicing in Lebanon. Through the interviews, we identified the primary consequences of the crises and the ways they impacted the continuity of care. We also identified adaptation mechanisms used by physicians and patients to ensure continuity of care. Through the future workshops, we identified various IT-based solutions that could be implemented to tackle existing challenges and support local adaptation attempts.

α-glucosidase inhibitors represent an important class of type 2 antidiabetic drugs and they act by lowering postprandial hyperglycemia. Today, only three synthetic inhibitors exist on the market, and there is a need for novel, natural and more efficient molecules exhibiting this activity. In this study, we investigated the ability of Tamarix nilotica ethanolic and aqueous shoot extracts, as well as methanolic fractions prepared from aqueous crude extracts to inhibit α-glucosidase. Both, 50% ethanol and aqueous extracts inhibited α-glucosidase in a concentration-dependent manner, with IC50 values of 12.5 μg/mL and 24.8 μg/mL, respectively. Importantly, α-glucosidase inhibitory activity observed in the T. nilotica crude extracts was considerably higher than pure acarbose (IC50 = 151.1 μg/mL), the most highly prescribed α-glucosidase inhibitor on the market. When T. nilotica crude extracts were fractionated using methanol, enhanced α-glucosidase inhibitory activity was observed in general, with the highest observed α-glucosidase inhibitory activity in the 30% methanol fraction (IC50 = 5.21 μg/mL). Kinetic studies further revealed a competitive reversible mechanism of inhibition by the plant extract. The phytochemical profiles of 50% ethanol extracts, aqueous extracts, and the methanolic fractions were investigated and compared using a metabolomics approach. Statistical analysis revealed significant differences in the contents of the crude extracts and fractions and potentially identified the molecules that were most responsible for these observed variations. Higher α-glucosidase inhibitory activity was associated with an enrichment of terpenoids, fatty acids, and flavonoids. Among the identified molecules, active compounds with known α-glucosidase inhibitory activity were detected, including unsaturated fatty acids, triterpenoids, and flavonoid glycosides. These results put forward T. nilotica as a therapeutic plant for type 2 diabetes and a source of α-glucosidase inhibitors., Competing Interests: The authors have declared that no competing interests exist.

To develop Best Practice Guidelines (BPG) for the use of Telehealth in Rheumatology in the Arab region, to identify the main barriers and facilitators of telehealth, and to provide rheumatologists with a practical toolkit for the implementation of telehealth. Guidelines were drafted by a core steering committee from the Arab League of Associations for Rheumatology (ArLAR) after performing a literature search. A multidisciplinary task force (TF), including 18 rheumatologists, 2 patients, and 2 regulators from 15 Arab countries, assessed the BPG using 3 rounds of anonymous online voting by modified Delphi process. The statements were included in the final BPG without further voting if ≥ 80% of TF members indicated high agreement. The voting on barriers and facilitators was performed through one voting round. The toolkit was developed based on available literature and discussions during the Delphi rounds. Four General Principles and twelve Statements were formulated. A teleconsultation was specifically defined for the purpose of these guidelines. The concept of choice in telehealth was highlighted, emphasizing patient confidentiality, medical information security, rheumatologist's clinical judgment, and local jurisdictional regulations. The top barrier for telehealth was the concern about the quality of care. The toolkit emphasized technical aspects of teleconsultation and proposed a triage system. The ArLAR BPG provide rheumatologists with a series of strategies about the most reliable, productive, and rational approaches to apply telehealth., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)