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This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).

Abstract Background Noninvasive respiratory support is frequently needed for patients with acute hypoxemic respiratory failure due to coronavirus disease 19 (COVID-19). Helmet noninvasive ventilation has multiple advantages over other oxygen support modalities but data about effectiveness are limited. Methods In this multicenter randomized trial of helmet noninvasive ventilation for COVID-19 patients, 320 adult ICU patients (aged ≥14 years or as per local standards) with suspected or confirmed COVID-19 and acute hypoxemic respiratory failure (ratio of arterial oxygen partial pressure to fraction of inspired oxygen < 200 despite supplemental oxygen with a partial/non-rebreathing mask at a flow rate of 10 L/min or higher) will be randomized to helmet noninvasive ventilation with usual care or usual care alone, which may include mask noninvasive ventilation, high-flow nasal oxygen, or standard oxygen therapy. The primary outcome is death from any cause within 28 days after randomization. The trial has 80% power to detect a 15% absolute risk reduction in 28-day mortality from 40 to 25%. The primary outcome will be compared between the helmet and usual care group in the intention-to-treat using the chi-square test. Results will be reported as relative risk and 95% confidence interval. The first patient was enrolled on February 8, 2021. As of August 1, 2021, 252 patients have been enrolled from 7 centers in Saudi Arabia and Kuwait. Discussion We developed a detailed statistical analysis plan to guide the analysis of the Helmet-COVID trial, which is expected to conclude enrollment in November 2021. Trial registration ClinicalTrials.gov NCT04477668 . Registered on July 20, 2020

OBJECTIVES: Patients with traumatic brain injury (TBI) have an increased risk for venous thromboembolism (VTE). The current guidelines recommend pharmacologic prophylaxis, but its timing remains unclear. METHODS: In this retrospective cohort study, patients with moderate-to-severe TBI admitted to a tertiary care intensive care unit between 2016 and 2019 were categorized into two groups according to the timing of pharmacologic prophylaxis: early if prophylaxis was given within 72 h from hospital admission and late if after 72 h. RESULTS: Of the 322 patients in the cohort, 46 (14.3%) did not receive pharmacological prophylaxis, mainly due to early brain death; 152 (47.2%) received early pharmacologic prophylaxis and 124 (38.5%) received late prophylaxis. Predictors of late pharmacologic prophylaxis were lower body mass index, intracerebral hemorrhage (odds ratio [OR], 3.361; 95% confidence interval [CI], 1.269–8.904), hemorrhagic contusion (OR, 3.469; 95% CI, 1.039–11.576), and lower platelet count. VTE was diagnosed in 43 patients on a median of 10 days after trauma (Q1, Q3: 5, 15): 6.6% of the early prophylaxis group and 26.6% of the late group (P < 0.001). On multivariable logistic regression analysis, the predictors of VTE were Acute Physiology and Chronic Health Evaluation II score, subarachnoid hemorrhage, and late versus early pharmacologic prophylaxis (OR, 3.858; 95% CI, 1.687–8.825). The late prophylaxis group had higher rate of tracheostomy, longer duration of mechanical ventilation and stay in the hospital, lower discharge Glasgow coma scale, but similar survival, compared with the early group. CONCLUSIONS: Late prophylaxis (>72 h) was associated with higher VTE rate in patients with moderate-to-severe TBI, but not with higher mortality.

BACKGROUND: Endotracheal tube (ETT) occlusion is a potentially life-threatening event. This study describes a quality improvement project to prevent ETT occlusion in critically ill patients. METHODS: After a cluster of clinically significant ETT occlusion incidents at a tertiary-care intensive care unit (ICU), the root cause analysis suggested that the universal use of heat moisture exchangers (HMEs) was a major cause. Then, we prospectively audited new ETT occlusion incidents after changing our practices to evidence-based active and passive humidification during mechanical ventilation (MV). We also compared the outcomes of affected patients with matched controls. RESULTS: During 100 weeks, 18 incidents of clinically significant ETT occlusion occurred on a median of 7 days after intubation (interquartile range, 4.8–9.5): 8 in the 10 weeks before and 10 in the 90 weeks after changing humidification practices (8.1 vs. 1.0 incidents per 1000 ventilator days, respectively). The incidents were not suspected in 94.4%, the peak airway pressure was >30 cm H2O in only 25%, and 55.6% were being treated for pneumonia when ETT occlusion occurred. Compared with 51 matched controls, ETT occlusion cases had significantly longer MV duration (median of 13.5 vs. 4.0 days; P = 0.002) and ICU stay (median of 26.5 vs. 11.0 days; P = 0.006) and more tracheostomy (55.6% vs. 9.8%; P < 0.001). The hospital mortality was similar in cases and controls. CONCLUSIONS: The rate of ETT occlusion decreased after changing humidification practices from universal HME use to evidence-based active and passive humidification. ETT occlusion was associated with more tracheostomy and a longer duration of MV and ICU stay.

Background: The COVID-19 pandemic has strained ICUs worldwide. To learn from our experience, we described the critical care response to the outbreak. Methods: This is a case study of the response of the Intensive Care Department (75-bed capacity) at a tertiary-care hospital to COVID-19 pandemic, which resulted in a high number of critically ill patients. Results: Between March 1 and July 31, 2020, 822 patients were admitted to the adult non-cardiac ICUs with suspected (72%)/confirmed (38%) COVID-19. At the peak of the surge, 125 critically ill patients with COVID-19 were managed on single day. To accommodate these numbers, the bed capacity of 4 ICUs was increased internally from 58 to 71 beds (+40%) by cohorting 2 patients/room in selected rooms; forty additional ICUs beds were created in 2 general wards; one cardiac ICU was converted to managed non-COVID-19 general ICU patients and one ward was used as a stepdown for COVID-19 patients. To manage respiratory failure, 53 new ICU ventilators, 90 helmets for non-invasive ventilation and 47 high-flow nasal cannula machines were added to the existing capacity. Dedicated medical teams cared for the COVID-19 patients to prevent cross-contamination. The nurse-to-patient and RT-to-patient ratio remained mostly 1:1 and 1:6, respectively. One-hundred-ten ward nurses were up-skilled to care for COVID-19 and other ICU patients using tiered staffing model. Daily executive rounds were conducted to identify patients for transfer and at least 10 beds were made available for new COVID-19 admissions/day. The consumption of PPE increased multiple fold compared with the period preceding the pandemic. Regular family visits were not allowed and families were updated daily by videoconferencing and phone calls. Conclusions: Our ICU response to the COVID-19 pandemic required almost doubling ICU bed capacity and changing multiple aspects of ICU workflow to be able to care for high numbers of affected patients.

Abstract Background It is unclear whether screening for sepsis using an electronic alert in hospitalized ward patients improves outcomes. The objective of the Stepped-wedge Cluster Randomized Trial of Electronic Early Notification of Sepsis in Hospitalized Ward Patients (SCREEN) trial is to evaluate whether an electronic screening for sepsis compared to no screening among hospitalized ward patients reduces all-cause 90-day in-hospital mortality. Methods and design This study is designed as a stepped-wedge cluster randomized trial in which the unit of randomization or cluster is the hospital ward. An electronic alert for sepsis was developed in the electronic medical record (EMR), with the feature of being active (visible to treating team) or masked (inactive in EMR frontend for the treating team but active in the backend of the EMR). Forty-five clusters in 5 hospitals are randomized into 9 sequences of 5 clusters each to receive the intervention (active alert) over 10 periods, 2 months each, the first being the baseline period. Data are extracted from EMR and are compared between the intervention (active alert) and control group (masked alert). During the study period, some of the hospital wards were allocated to manage patients with COVID-19. The primary outcome of all-cause hospital mortality by day 90 will be compared using a generalized linear mixed model with a binary distribution and a log-link function to estimate the relative risk as a measure of effect. We will include two levels of random effects to account for nested clustering within wards and periods and two levels of fixed effects: hospitals and COVID-19 ward status in addition to the intervention. Results will be expressed as relative risk with a 95% confidence interval. Conclusion The SCREEN trial provides an opportunity for a novel trial design and analysis of routinely collected and entered data to evaluate the effectiveness of an intervention (alert) for a common medical problem (sepsis in ward patients). In this statistical analysis plan, we outline details of the planned analyses in advance of trial completion. Prior specification of the statistical methods and outcome analysis will facilitate unbiased analyses of these important clinical data. Trial registration ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019

Abstract Background To evaluate the effect of screening for sepsis using an electronic sepsis alert vs. no alert in hospitalized ward patients on 90-day in-hospital mortality. Methods The SCREEN trial is designed as a stepped-wedge cluster randomized controlled trial. Hospital wards (total of 45 wards, constituting clusters in this design) are randomized to have active alert vs. masked alert, 5 wards at a time, with each 5 wards constituting a sequence. The study consists of ten 2-month periods with a phased introduction of the intervention. In the first period, all wards have a masked alert for 2 months. Afterwards the intervention (alert system) is implemented in a new sequence every 2-month period until the intervention is implemented in all sequences. The intervention includes the implementation of an electronic alert system developed in the hospital electronic medical records based on the quick sequential organ failure assessment (qSOFA). The alert system sends notifications of “possible sepsis alert” to the bedside nurse, charge nurse, and primary medical team and requires an acknowledgment in the health information system from the bedside nurse and physician. The calculated sample size is 65,250. The primary endpoint is in-hospital mortality by 90 days. Discussion The trial started on October 1, 2019, and is expected to complete patient follow-up by the end of October 2021. Trial registration ClinicalTrials.gov NCT04078594 . Registered on September 6, 2019

Fossil fuel is the main source for CO2 emissions that causes global warming. This fact is the starting point for this paper, that consider on three different sources of data: crude oil used to calculate CO2 emissions for Iraq for the period from 1980 to 2018; annual data of total CO2 emissions available from the Carbon Dioxide Information Analysis Center (CDIAC) for Iraq and the world for the period from 1980 to 2014; and CO2 concentrations for Iraq for the period from 2002 to 2006 and for the world for the period from 1980 to 2018. The result is a multifaceted according to the dataset sources. Carbon dioxide emissions calculated from Iraqi crude oil was increased from 1.29 Mt in 2012 to 1.97 Mt in 2018. The world and Iraq CO2 emissions with different slop of average line that was 0.5 for world, 0.003 for Iraq, while increased exponential function from 2008 to 2014 to reach 36 and 0.17 Mt, respectively. The highest value of Iraqi CO2 concentration was 403 ppm in 2016, while the global CO2 concentrations slowly increased with slop line equal to 1.75 ppm per year, from minimum value of 338.6 ppm was in 1980, while maximum value of 407.05 ppm was in 2018, that’s mean no decreased in CO2 concentration unless emissions addressed.

Mohammed A Mamun,1,2 Firoj al Mamun,1,2 Ismail Hosen,1,2 Mahmudul Hasan,1,3 Abidur Rahman,1,3 Ahsanul Mahbub Jubayar,1,3 Zeba Maliha,1,4 Abu Hasnat Abdullah,1,2 Md Abedin Sarker,1,2 Humayun Kabir,1,5 Avijit Sarker Jyoti,6 Mark Mohan Kaggwa,7,8 Md Tajuddin Sikder2 1CHINTA Research Bangladesh, Dhaka, Bangladesh; 2Department of Public Health and Informatics, Jahangirnagar University, Dhaka, Bangladesh; 3Department of Biochemistry and Molecular Biology, University of Rajshahi, Rajshahi, Bangladesh; 4Bangabandhu Sheikh Mujib Medical College, Faridpur, Bangladesh; 5Department of Public Health, North South University, Dhaka, Bangladesh; 6Mugda Medical College, Dhaka, Bangladesh; 7Department of Psychiatry, Mbarara University of Science & Technology, Mbarara, Uganda; 8African Centre for Suicide Prevention and Research, Mbarara, UgandaCorrespondence: Mohammed A Mamun Tel +880 1738592653Email mamunphi46@gmail.comBackground: It is said that psychological stressors have risen during the COVID-19 pandemic, which may contribute to suicidality. A few studies were conducted investigating suicidality amid the first wave of the pandemic in Bangladesh, but none of these studies explored the predictive role of the suicidality-related factors (eg, behavior and health-related variables, COVID-19 risk, fear of COVID-19). Thus, this study aimed to investigate the prevalence of suicidality and the predictive models explaining suicidality variance among Bangladeshi young adults during the second wave of the pandemic.Methods: An online-based cross-sectional survey was conducted during the second wave of the pandemic (between 1 and 13 April 2021; a year after the pandemic’s inception in the country). The survey questionnaire collected information on socio-demographics, behavior and health-related variables, COVID-19 risk, fear of COVID-19, depression, anxiety, and suicidality. A total of 756 data were analyzed (male 59%; mean age 22.24 ± 4.39 years), and hierarchical regression was performed considering suicidality as the dependent variable. A p-value < 0.05 was set to be statistically significant with a 95% of confidence interval.Results: About 8.2% reported having at least suicidal thoughts within the pandemic inception to survey time (one-year suicidal ideation). More specifically, 7.40% had only suicidal ideation, whereas 0.10% planned for suicide, 0.70% attempted suicide. None of the socio-demographic variables was significantly associated with suicidality. Taking drugs, performing less physical activity, poor self-reporting health condition, being comorbid, being at higher COVID-19 risk, having fear of COVID-19 infection, and suffering from depression and anxiety were significantly associated with a higher risk of suicidality. However, the final model including all of the studied variables explained a 17.1% (F=8.245, p< 0.001) variance in terms of suicidality.Conclusion: Although this study reported a lower severity of suicidality than prior Bangladeshi studies conducted during the first wave of the pandemic, a portion of people are still at risk of suicide and they should be given attention.Keywords: COVID-19 suicide, psychological impact, suicide, self-harm, depression, fear of COVID-19, Bangladeshi youths

Although cancer is still one of the most significant global challenges facing public health, the world still lacks complementary approaches that would significantly enhance the efficacy of standard anticancer therapies. One of the essential strategies during cancer treatment is following a healthy diet program. The ketogenic diet (KD) has recently emerged as a metabolic therapy in cancer treatment, targeting cancer cell metabolism rather than a conventional dietary approach. The ketogenic diet (KD), a high-fat and very-low-carbohydrate with adequate amounts of protein, has shown antitumor effects by reducing energy supplies to cells. This low energy supply inhibits tumor growth, explaining the ketogenic diet’s therapeutic mechanisms in cancer treatment. This review highlights the crucial mechanisms that explain the ketogenic diet’s potential antitumor effects, which probably produces an unfavorable metabolic environment for cancer cells and can be used as a promising adjuvant in cancer therapy. Studies discussed in this review provide a solid background for researchers and physicians to design new combination therapies based on KD and conventional therapies.

BackgroundThe cardiovascular complications of Coronavirus Disease 2019 (COVID-19) may be attributed to the hyperinflammatory state leading to increased mortality in patients with COVID-19. HMG-CoA Reductase Inhibitors (statins) are known to have pleiotropic and anti-inflammatory effects and may have antiviral activity along with their cholesterol-lowering activity. Thus, statin therapy is potentially a potent adjuvant therapy in COVID-19 infection. This study investigated the impact of statin use on the clinical outcome of critically ill patients with COVID-19.MethodsA multicenter, retrospective cohort study of all adult critically ill patients with confirmed COVID-19 who were admitted to Intensive Care Units (ICUs) between March 1, 2020, and March 31, 2021. Eligible patients were classified into two groups based on the statin use during ICU stay and were matched with a propensity score based on patient's age and admission APACHE II and SOFA scores. The primary endpoint was in-hospital mortality, while 30 day mortality, ventilator-free days (VFDs) at 30 days, and ICU complications were secondary endpoints.ResultsA total of 1,049 patients were eligible; 502 patients were included after propensity score matching (1:1 ratio). The in-hospital mortality [hazard ratio 0.69 (95% CI 0.54, 0.89), P = 0.004] and 30-day mortality [hazard ratio 0.75 (95% CI 0.58, 0.98), P = 0.03] were significantly lower in patients who received statin therapy on multivariable cox proportional hazards regression analysis. Moreover, patients who received statin therapy had lower odds of hospital-acquired pneumonia [OR 0.48 (95% CI 0.32, 0.69), P < 0.001], lower levels of inflammatory markers on follow-up, and no increased risk of liver injury.ConclusionThe use of statin therapy during ICU stay in critically ill patients with COVID-19 may have a beneficial role and survival benefit with a good safety profile.

BackgroundFrom the earliest times, manna has been widely used as a tasty local sweet or folk medicine. The type of manna being investigated in the present study is called Gaz-alafi, a mixture of insect and Quercus brantii leaves secretions from oak forests in the north of Iraq and west of Iran.MethodsAqueous and ethanol extracts were prepared as decoction. Various phytochemical tests were conducted to analyze manna composition, including total phenolic contents using the Folin-Ciocalteu method and LC-MS. Gallic acid and catechin were detected in both extracts, in addition to tiliroside presence in ethanol extract, which added more value to the phenolic content of ethanol extract. Cytotoxic activities of Gaz alafi were evaluated against breast cancer cell lines and compared to normal cell lines and doxorubicin using the MTT assay. Antimicrobial properties were assessed against Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, Bacillus subtilis, and Candida albicans using the dilution method of the micro-titer plate. Serum levels of IFN-γ, interleukin-2 (IL-2), interleukin-4 (IL-4), and interleukin-10 (IL-10) were measured using ELISA. The effect of extracts on splenocyte proliferation was evaluated using the lymphocytes proliferation assay. Macrophage function was evaluated using the nitro blue tetrazolium assay, whereas pinocytosis was evaluated using the neutral red uptake assay. Ten days after tumor inoculation, changes in tumor size, survival rates, levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and creatinine were measured.ResultsThe growth of cancer cells was inhibited by Gaz alafi ethanol extract. An alteration in IFN- γ, IL-2, and IL-4 levels toward antiproliferation immune response were reported for both extracts. The aqueous extract efficiently stimulated lymphocyte proliferation, phagocytosis, and pinocytosis, followed by the ethanol extracts with moderate activity. After treating the mice with ethanol extracts, a significant reduction in tumor size and several undetected tumors were recorded.ConclusionsGaz alafi extracts (aqueous and ethanol) are promising sources for anticancer and immunostimulatory agents. Further studies are needed to fully identify the chemical composition of Gaz alafi extracts.

Metallic nanowires (MNWs) are of particular interest as transparent electrodes (TEs) in optoelectronic devices due to their outstanding and unique optical, electrical and mechanical capabilities. In present research, we systematically studied the influence of gamma radiations (γ-radiations) on silver nanowires (AgNWs). We irradiated AgNWs with various doses of γ-radiations ranging between 12 kGy and 20 kGy. After irradiation, we studied the structural properties of un-irradiated and γ-irradiated AgNWs via X-ray diffraction (XRD). The XRD analysis of un-irradiated sample confirmed the pure crystalline metallic nature of un-irradiated AgNWs with crystallite size 29.80 nm. The XRD analysis of irradiated samples revealed the face centered cubic (FCC) crystalline structure at all doses of γ-radiations. The crystallite sizes have been observed to be 31.99 nm, 33.94 nm and 32.56 nm for samples irradiated by γ-radiations of doses 12 kGy, 15 kGy and 20 kGy respectively. XRD data was also used to investigate structural factors such as dislocation density and strain in material. Morphological studies were carried out via transmission electron microscopy (TEM). The TEM images revealed that silver nanoparticles (AgNPs) are formed on outer surfaces of AgNWs after γ-irradiation. After γ-irradiation, optical transmittances have been enhanced up to dose 15 kGy which is might be due to formation of NPs on Ag-NWs.

Background Celiac disease (CD) is a chronic autoimmune enteropathy. It results from genetic predisposition and exposure to gluten-containing food. The prevalence and presentation of CD vary among populations. Purpose This study aimed to describe the prevalence and clinical characteristics of CD in children in Bahrain. Methods We retrospectively reviewed the medical records of children diagnosed with CD in the pediatric department, Salmaniya Medical Complex, Bahrain, in 1988–2018. Their clinical, biochemical, serological, and histopathological findings were documented. Adherence to the recommended gluten-free diet (GFD) was assessed. Results Of 86 patients with CD, 67 were included. The CD prevalence was 0.02%. A significant increase in prevalence in the last decade was observed (P

Abstract Each year in Saudi Arabia, the Hajj season represents one of the world’s most significant annual mass gatherings, attracting high proportion of immigrants from different parts of the world in small crowded areas, posing a risk for Tuberculosis (TB) transmission. There is a high potential for TB contact and infection in the workplace as it is transmitted through the air. Most of the studies in Saudi Arabia assessed the TB infection among health care workers. However, the TB incidence rate among other variant occupational groups was not yet determined. This study was conducted to assess the incidence rate of tuberculosis, and determine the risk factors of TB infection among different occupational groups in the Makkah region, Saudi Arabia 2016. A cross-sectional study was carried out based on the secondary data of the patients registered in the Saudi national tuberculosis control and prevention program in 2016. Data were then organized and analyzed for age, gender, nationality, educational level, average monthly wage, average weekly working hours, and occupation of the patients. Occupations were reclassified according to the Saudi Standard Classification of Occupation (SSCO). A total of 1270 cases were included in this study, 300 (23.6%) of them were workers. The incidence rate of TB among workers in the Makkah region was 9 per 100,000 workers compared to 31 per 100,000 persons among the general population in 2016. The TB incidence rate was the highest among occupation of supporting basic engineering with 13 per 100,000 workers in 2016. The highest incidence rate of TB among occupations of supporting basic engineering could be attributed to close contact with the general population in closed spaces for long periods of time, and low socioeconomic status.

Sol–gel technique is utilized to produce the series of ferrite having chemical formula BaYyFe2-yO4 (y = 0.00, 0.02, 0.04, 0.06, 0.08, 0.10). The cubic structure of all the samples have been revealed through X-ray diffraction data. The inclusion of yttrium content among the ferrites beyond 0.06, it will result into development of YFeO3 secondary phase. The lattice parameter of samples upsurges with the substitution of yttrium ions (Y3+). Jump lengths on A & B sites, bond lengths and ionic radii have direct relation with yttrium concentration. The evaluation of electrical parameters reveal that the resistivity, activation energy and bond length increased with the growth of yttrium. Below the Curie temperature, the movement of electrons and holes is main cause of conduction mechanism. But above this temperature, the polaron hopping handle the conduction process. With the addition of yttrium, the saturation magnetization value decreased. Coercivity of samples enlarged with the substitution of yttrium ions. The involvement of yttrium ion in barium ferrite system makes it appropriate for high frequency appliances.

Abstract Objective The aim of this study is to examine the association of hypophosphatemia and hyperphosphatemia on the first day of ICU admission with mortality in septic critically ill patients. Methods In this retrospective cohort study, all adult patients who were admitted to the medical-surgical ICUs between 2014 and 2017 with sepsis or septic shock were categorized as having hypophosphatemia, normophosphatemia and hyperphosphatemia based on day 1 serum phosphate values. We compared the clinical characteristics and outcomes between the three groups. We used multivariate analysis to examine the association of hypophosphatemia and hyperphosphatemia with these outcomes. Results Of the 1422 patients enrolled in the study, 188 (13%) had hypophosphatemia, 865 (61%) normophosphatemia and 369 (26%) had hyperphosphatemia. The patients in the hyperphosphatemia group had significantly lower GCS, higher APACHE II scores, higher serum creatinine, increased use of vasopressors, and required more mechanical ventilation with lower PaO2/FiO2 ratio compared with the other two groups. In addition, the hyperphosphatemia group showed significantly higher ICU and hospital mortality in comparison with the other two groups. Conclusion Hyperphosphatemia and not hypophosphatemia on the first ICU admission day was associated with an increase in the ICU and hospital mortality in septic critically ill patients.

Let be an associative algebra over a field F of any characteristic with involution * and let K=skew(A)={a in A|a*=-a} be its corresponding sub-algebra under the Lie product [a,b]=ab-ba for all a,b in A . If for some finite dimensional vector space over F and * is an adjoint involution with a symmetric non-alternating bilinear form on V , then * is said to be orthogonal. In this paper, Jordan-Lie inner ideals of the orthogonal Lie algebras were defined, considered, studied, and classified. Some examples and results were provided. It is proved that every Jordan-Lie inner ideals of the orthogonal Lie algebras is either eKe* or is a type one point space.

Abstract The quality of a hydrocarbon reservoir is strongly controlled by the depositional and diagenetic facies nature of the given rock. Therefore, building a precise geological/depositional model of the reservoir rock is critical to reducing risks while exploring for petroleum. Ultimate reservoir characterization for constructing an adequate geological model is still challenging due to the in general insufficiency of data; particularly integrating them through combined approaches. In this paper, we integrated seismic geomorphology, sequence stratigraphy, and sedimentology, to efficiently characterize the Upper Miocene, incised-valley fill, Abu Madi Formation at South Mansoura Area (Onshore Nile Delta, Egypt). Abu Madi Formation, in the study area, is a SW-NE trending reservoir fairway consisting of alternative sequences of shales and channel-fill sandstones, of the Messinian age, that were built as a result of the River Nile sediment supply upon the Messinian Salinity Crisis. Hence, it comprises a range of continental to coastal depositional facies. We utilized dataset including seismic data, complete set of well logs, and core samples. We performed seismic attribute analysis, particularly spectral decomposition, over stratal slices to outline the geometry of the incised-valley fill. Moreover, well log analysis was done to distinguish different facies and lithofacies associations, and define their paleo-depositional environments; a preceding further look was given to the well log-based sequence stratigraphic setting as well. Furthermore, mineralogical composition and post-depositional diagenesis were identified performing petrographical analysis of some thin sections adopted from the core samples. A linkage between such approaches, performed in this study, and their impact on reservoir quality determination was aimed to shed light on a successful integrated reservoir characterization, capable of giving a robust insight into the depositional facies, and the associated petroleum potential. The results show that MSC Abu Madi Formation constitutes a third-order depositional sequence of fluvial to estuarine units, infilling the Eonile-canyon, with five sedimentary facies associations; overbank mud, fluvial channel complex, estuarine mud, tidal channels, and tidal bars; trending SW-NE with a Y-shape channel geometry. The fluvial facies association (zone 1 and 3) enriches coarse-grained sandstones, deposited in subaerial setting, with significantly higher reservoir quality, acting as the best reservoir facies of the area. Although the dissolution of detrital components, mainly feldspars, enhanced a secondary porosity, improving reservoir quality of MSC Abu Madi sediments, continental fluvial channel facies represent the main fluid flow conduits, where marine influence is limited.

Neil Hawkes,1,2 Umakant Dave,3 Mesbah Rahman,2,3 Dafydd Richards,3 Mahmud Hasan,4,5 AHM Rowshon,4 Faruque Ahmed,4,6 M Masudur Rahman,6 MG Kibria,6 Phedra Dodds,7 Bethan Hawkes,8 Stuart Goddard,9 Imdadur Rahman,10 Peter Neville,1 Mark Feeney,11 Gareth Jenkins,12 Keith Lloyd,12 Krish Ragunath,13 Cathryn Edwards,2,11 Simon D Taylor-Robinson14 1Department of Gastroenterology, Cwm Taf Morgannwg University Health Board, Llantrisant, South Wales, UK; 2British Society of Gastroenterology Central Office, London, UK; 3Department of Gastroenterology, Swansea Bay University Health Board, Swansea, UK; 4Office of the Central Secretariat, Bangladesh Gastroenterology Society, Dhaka, Bangladesh; 5Office of Central Secretariat, Gastroliver Foundation, Dhaka, Bangladesh; 6Department of Gastroenterology, Sheikh Russel National Gastroliver Institute and Hospital, Dhaka, Bangladesh; 7Department of Endoscopy Nursing, Office of the JAG GRS Team, Powys Health Board, Brecon, UK; 8Office of the Wales Cancer Network Pathway, Welsh Cancer Network, Cardiff, UK; 9Welsh Institute of Minimal Access Therapy, Cardiff MediCentre, Welsh Institute for Minimal Access Therapy, Cardiff University, Cardiff, UK; 10Department of Gastroenterology, Southampton NHS Trust, Southampton, UK; 11Department of Gastroenterology and Liver Medicine, Torbay and South Devon NHS Foundation Trust, Devon, UK; 12Faculty of Health and Life Sciences, Medicine, Swansea University, Swansea, UK; 13Office of the Provost, Faculty of Health Sciences, Bentley Campus, Curtin Medical School, Curtin University, Perth, Western Australia, Australia; 14Department of Surgery and Cancer, Imperial College London, London, UKCorrespondence: Neil Hawkes Email neil.hawkes@wales.nhs.ukAbstract: The British Society of Gastroenterology (BSG) and the Bangladesh Gastroenterology Society (BGS) have collaborated on an endoscopy training programme, which has grown up over the past decade from a small scheme borne out of the ideas of consultant gastroenterologists in Swansea, South Wales (United Kingdom) to improve gastroenterology services in Bangladesh to become a formalised training programme with broad reach. In this article, we document the socioeconomic and historical problems that beset Bangladesh, the current training needs of doctors and how the BSG-BGS collaboration has made inroads into changing outcomes both for gastroenterologists in Bangladesh, but also for the populations they serve.Keywords: endoscopy training, Bangladesh, training programmes, gastroenterology training

Abstract Background Diabetes is a risk factor for infection with coronaviruses. This study describes the demographic, clinical data, and outcomes of critically ill patients with diabetes and Middle East Respiratory Syndrome (MERS). Methods This retrospective cohort study was conducted at 14 hospitals in Saudi Arabia (September 2012–January 2018). We compared the demographic characteristics, underlying medical conditions, presenting symptoms and signs, management and clinical course, and outcomes of critically ill patients with MERS who had diabetes compared to those with no diabetes. Multivariable logistic regression analysis was performed to determine if diabetes was an independent predictor of 90-day mortality. Results Of the 350 critically ill patients with MERS, 171 (48.9%) had diabetes. Patients with diabetes were more likely to be older, and have comorbid conditions, compared to patients with no diabetes. They were more likely to present with respiratory failure requiring intubation, vasopressors, and corticosteroids. The median time to clearance of MERS-CoV RNA was similar (23 days (Q1, Q3: 17, 36) in patients with diabetes and 21.0 days (Q1, Q3: 10, 33) in patients with no diabetes). Mortality at 90 days was higher in patients with diabetes (78.9% versus 54.7%, p

A contrast agent with specific characteristics is essential for high-quality magnetic resonance imaging (MRI). It plays a crucial role in enhancing the visibility of certain tissues and structures, making it imperative for diagnostic procedures. Superparamagnetic iron oxide nanoparticles (SPIONs) have emerged as a promising alternative to traditional contrast agents for MRI due to their non-toxicity and superior magnetic properties. However, a suitable surface coating strategy is needed to produce polymer-coated SPIONs with controllable sizes in order to enhance their stability and biocompatibility. This study presents a novel one-pot synthesis method for the production of highly stable polyvinylpyrrolidone (PVP)-coated SPIONs. By systematically manipulating the physicochemical properties of SPIONs, the effect of different molecular weights of PVP was studied. The results showed that SPIONs coated with PVP with molecular wight 40,000 g/mol (40 K) exhibited a high magnetization (Ms = 48.4 emu/g), an average size distribution (11.61 nm), and excellent stability. The relaxivity of coated and uncoated SPIONs was investigated using MRI images. The results revealed that the (r2/r1) ratio of PVP40K-SPIONs was 72.55, compared to 55.72 for the bare SPIONs, making them a highly promising T2-contrast agent for future development of MRI applications. This study opens new avenues for the development of biocompatible and stable SPIONs for improved medical diagnostic and imaging.

Background: Alagille syndrome (ALGS) is an autosomal dominant disease caused by JAG1 or NOTCH2 mutation. It is diagnosed by the presence of three out of five features: characteristic facies, posterior embryotoxon, peripheral pulmonary stenosis, vertebral defects, and interlobular bile duct paucity. This study aimed to review the prevalence, clinical presentations, diagnosis, treatment, and outcome of patients with ALGS. Materials and Methods: This is a retrospective review of patients with ALGS at the Pediatric Department, Salmaniya Medical Complex, Bahrain, between August 1994 and October 2022. The diagnosis was based on clinical, laboratory, radiological, histopathological, and genetic findings. Results: Five patients were found to have ALGS. The prevalence of ALGS in Bahrain was 1.04 patients per 100,000 (0.001%). Four were Bahraini and three were females. Median birth weight was 2.3 (2.3–2.5) kg. All patients presented at the time of birth with low birth weight, cholestatic jaundice, clay-colored stool, heart murmur, and dysmorphic facial features. All had congenital heart diseases, two had butterfly vertebrae, and one had posterior embryotoxon. All had elevated liver enzymes and normal abdominal ultrasound. Three had positive hepatobiliary iminodiacetic acid scan and one had bile duct paucity in liver biopsy. Three had intraoperative cholangiogram. Four were positive for JAG1 mutation. All received ursodeoxycholic acid and fat-soluble vitamins. Two required liver transplantation. Conclusion: ALGS is a rare disorder in Bahrain. Diagnosis is challenging as the disease can be associated with or misdiagnosed as biliary atresia. Patients with ALGS are at high risk of morbidity either by unnecessary intraoperative cholangiogram or unavoidable liver transplantation.

Introduction. Human rhinovirus (HRV) can lead to a variety of respiratory illnesses; it is also an uncommon cause of community-acquired pneumonia (CAP). We described the characteristics and outcomes of patients hospitalized for CAP due to HRV. Methods. We retrospectively studied consecutive adult patients admitted to King Abdulaziz Medical City-Riyadh with CAP due to HRV between 2016 and 2019. The diagnosis was made by respiratory multiplex PCR within 48 hours of hospitalization. We compared patients requiring ICU admission to those who did not. Results. One-hundred-and-six patients were studied (peak hospitalization between November and January, median age 71.5 years, hypertension 59%, diabetes 50%, and chronic respiratory disease 44.3%); 16 (15.1%) patients required ICU admission. The median pneumonia severity index score (PSI) was 107, with no significant difference between ICU and nonICU patients. ICU patients had a higher prevalence of tachypnea (62.5% vs. 26.7%, p=0.005), hemoptysis (12.5% vs 0%, p=0.001), and lymphopenia (71.4% vs 26.3%, p=0.01). Chest X-ray on presentation showed bilateral infiltrates in 47/101 (46.5%) patients and unilateral infiltrates in 26/101 (25.7%) patients. Systemic corticosteroids were used in 54.7% of patients (the median initial dose was 120 mg of prednisone equivalent and was higher in nonICU patients). Most (69.2%) ICU patients received mechanical ventilation (median duration of 8 days). Bacterial coinfection (6.6%) and superinfection (3.8%) were rare. The overall hospital mortality was 9.4% (higher for ICU patients: 37.5% vs. 4.4%, p

Background and Objectives. Acute bronchiolitis is a common respiratory disease in children. C-reactive protein (CRP) is an indicator of bacterial coinfection. This study is aimed at assessing the frequency of elevated CRP in children with acute bronchiolitis and at comparing the clinical characteristics, laboratory and radiological findings, antibiotics use, and outcome according to CRP levels. Material and Methods. We retrospectively reviewed medical records of children with acute bronchiolitis admitted to Pediatric Department, Salmaniya Medical Complex, Bahrain, in 2019-2020. Demographic, clinical, laboratory and radiological data, and outcomes were collected. Patients with high CRP were compared with those with normal levels. Results. Of 287 patients, 229 (79.2%) were included. 132 (57.6%) were males. Median presentation age was 3.7 (interquartile range (IQR), 1.27-12.33) months. Median CRP level was 10.4 (IQR, 2.8-35.1) mg/L. CRP was high in 167 (72.9%) patients. 17.6% (33/187 patients) had confirmed bacterial coinfection. Respiratory syncytial virus (RSV) was detected in 84 (36.7%) patients. Mean CRP level was higher in RSV-negative compared to RSV-positive patients, 31.3±44.3 versus 21.5±27.7 mg/L, respectively (P=0.042). Respiratory viral serology profile was positive in 34.7% (17/49 patients). 66.9% (107/160 patients) had positive chest X-ray. Antibiotics were used in 78.1% (179/227 patients). Thirteen (5.7%) patients required intensive care, five (2.2%) had surgical intervention, four (1.8%) required endotracheal intubation, and four (1.8%) died. Patients with high CRP were older at presentation (P

Background and Objectives. Jaundice is a common cause of hospital admission in infants presenting within the first month of life. This study is aimed at determining neonatal and maternal risk factors of indirect hyperbilirubinemia, at comparing neonates with risk factors and those without, and at assessing the type of management according to hyperbilirubinemia severity. Material and Methods. In this retrospective cross-sectional study, medical records of neonates with indirect hyperbilirubinemia who were admitted to the Pediatric Department, Salmaniya Medical Complex, Bahrain, between January 2020 and December 2020 were reviewed. Neonatal demographic data, antenatal history, birth weight, feeding type, maternal and neonatal laboratory evaluations, management, and length of hospital stay were collected and compared. Results. Out of 555 records, 404 neonates were included. Among those, 209 (51%) were males and 275 (68.1%) were Bahraini. The median indirect bilirubin level at presentation was 218 (interquartile range, 174-270) μmol/L. ABO incompatibility was the commonest risk factor for neonatal indirect hyperbilirubinemia (n=152, 37.6%) followed by glucose-6-phosphate dehydrogenase (G6PD) deficiency (n=130/400, 32.5%). Age (>25 years) was the commonest maternal risk factor (n=331, 81.9%) followed by cesarean delivery (n=137, 33.9%). Neonates with ABO incompatibility had a significantly higher mean indirect bilirubin level compared to those with other risk factors (234.9±68.5 versus 225±82.2 mmol/L, respectively) (P=0.04). Phototherapy use significantly increased along with the rise of bilirubin level (P

Background and Objectives. Gastrointestinal (GI) endoscopy is a medical field that has been evolving in the last decades. Innovative advances in pediatric endoscopy led to more accurate diagnosis of various GI diseases. This study aimed to assess the appropriateness of endoscopic procedures’ indications and to evaluate the diagnostic and therapeutic yield of pediatric GI endoscopy, considering the limitations to access this facility. Material and Methods. Retrospective, cross-sectional, and analytical chart review was performed for children who underwent GI endoscopy at Salmaniya Medical Complex, Bahrain, from 1995 to 2020. Demographic data, endoscopic indications, and findings were collected and compared. Results. Of 1,111 patients, 1,101 (99.1%) were included in the study. 589 (53.6%) patients were males. Median age at the time of endoscopy was 8 (interquartile range 3, 11) years. 1534 endoscopies were performed (1193 upper GI endoscopies (UGIE) and 341 colonoscopies) in 1296 sessions. The mean number of endoscopies per year was 59±30.9 procedures with 81.4% reduction noted after coronavirus pandemic (P

Remdesivir is a direct-acting inhibitor of SARS-CoV-2 RNA-dependent RNA polymerase that is used to treat severe COVID-19 infections. We report a patient with severe COVID-19 pneumonia who experienced palpitations and syncope two days after starting remdesivir therapy. The QTc interval was prolonged on the Electrocardiogram (ECG) without any significant electrolyte abnormalities or concomitant use of medications with QTc prolongation. Although the cardiac side effects of remdesivir therapy have been well documented, the link between remdesivir therapy and QTc interval prolongation in patients with severe COVID-19 has only been observed in a few cases. Because this arrhythmia has the potential to result in sudden cardiac death, practitioners should be aware of the QTc interval prolongation associated with remdesivir therapy.

Ectopia cordis is a rare type of malformation where the heart is not located normally. It may be partially or completely located outside the thoracic cavity and can be associated with other congenital abnormalities. It results from failure of maturation of midline mesoderm and ventral body formation during embryogenic formation. The exact etiology remains unknown. The literature review reveals the prognosis for infants with ectopia cordis is very poor. Here, we are reporting the first case of a fetus that was prenatally diagnosed with ectopia cordis that was associated with omphalocele documented in our country. Considering the poor prognosis for the fetus, conservative management during the prenatal period was chosen.

Purpose: We report in this article the results of a study conducted on our first year medical students. This study is supposed to serve as an initial general survey of students' knowledge of vector concepts. Our goal here is to get initial insights on students’ misconceptions when about vectors. The results from this study should help plan our next stage of this particular research project. Method: Our test tool was the test of understanding vectors “TUV” first developed by Pablo Barniol and Genaro Zavala in 2014.1 The test was given to a total of 240 students at the beginning of the semester before they were exposed to any vector related instruction (pre-test). Results: We found weak overall performance of our students represented in very low scores in the test (average score 26%). We were also able to determine the major misconceptions held by students by examining their wrong answers for each question. Some of the misconceptions found were: using tip-to-tip method rather than tail-to-tip to add or subtract vectors, the component of a vector (x or y) has a magnitude equal to the vector magnitude, and multiplying a vector with a negative sign doesn't change its direction. Full list of vectors misconceptions is reported in the discussion. Discussion: Results reveal some serious problems in vector concepts understanding that require some attention and careful future planning. Based on the results, we recommended adding a special section on vector concepts to be given to students right at the start of the semester to prepare them better for the course.

Abstract Background Bangladesh, one of the most densely populated countries in the world has been ranked 9th on the Climate Risk Index for 2017: the 10 most affected countries & 7th on the Long-Term Climate Risk Index: the 10 countries most affected from 1998 to 2017. Every year it is afflicted with various climatic disasters including floods, hurricanes and cyclones. Apart from the obvious devastation of lives and property, there is a huge increase in clinical diseases when these disasters occur. Mental health of affected persons after these disasters is a topic that is often neglected by local and national level. Methods A qualitative case study was conducted on perceived need on mental health support & availability of such services in a cyclone affected area in rural Bangladesh. Ten (10) key informant interviews (KIIs) with different stakeholders and ten (10) in-depth interviews (IDIs) with affected people were taken. Findings We found that cyclones had numerous psychosocial impacts on the population including acute stress disorder, sleep disorder, post-traumatic stress disorders (PTSDs), generalized anxiety disorders, suicidal ideation and depression. The survivors had specific needs for receiving support. Children, elderly and women were perceived to be more vulnerable. The government and NGOs had no specific action plans and initiatives to address these issues and support the mental health of affected population. There was a visible gap in finding effective ways to provide affected people with the required mental health & psycho-social services (MHPSS). Conclusion Resilient, responsive and self-sustaining health systems for this vulnerable population are required. Implementation of effective mental health programs and strong mental health policies remain a challenge in Bangladesh where there is a cultural fatalistic acceptance of mental health issues.

Due to the combination of the current conditions of globalization and digitization, the social and economic horizons of the world, and the mixing of technical, economic and societal cultures, many challenges appeared and force referred to modifying the syllabuses and methods of introducing engineering education as a response to changes in student attitudes and low student performance as well as the spread of computers and information technology. In this research we are showing a number of these challenges and some it details to put some of the imbalances with some of the recommendations that would contribute even if it formed a part of the solution, treatment and evaluation.

ترجع هذه النصوص في تاريخها إلى عصر أور الثالثة الذي تميّز بالنّصوص ذات المضامين الاقتصادية وتنوعها، إنّ النصوص مجهولة الموقع الاثري (مصادرة)، وهي موجودة في المتحف العراقي، وبحسب الصيغ التاريخية للنصوص فإنّها ترجع لعهد الملوك أمار سين، و شو سين، وأبي سين، أما المضامين العامة للنصوص فهي (صيغة التسلّم) لمواد مختلفة، والتي جاءت بصيغ مختلفة في أغلب النصوص التي ترجع لعصر أور الثالثة، إذ تمثل شكلاً من أشكال "التسلّم، الحصول، القبول"، وتعتمد على السياق في النص، وعلى كيفية إدراك المتحدث أو الكاتب للحدث. تضمن البحث دراسة لخمسة نصوص من المتحف العراقي (مصادرة) * والتي يعود تاريخها إلى عصر أور الثالثة وجميعها من صنف نصوص "التسلّم" (maḫāru /šu-ba-ti)، وتضمنت تسلّما لمواد مختلفة :(زيت الخنزير، نوع من الجريش، نبات طبي، توابل، ملح الطوب، الشعير).

Intravenous paracetamol is a commonly administered analgesic and antipyretic in inpatient settings. Paracetamol is metabolized by cytochrome P450 (CYP) enzymes followed by conjugating enzymes to mainly glucuronide but to a lesser extent, sulphate metabolites, and oxidative metabolites. Single nucleotide polymorphisms (SNPs) in the CYP enzymes result in modified enzymatic activity. The present study was carried out to evaluate the prevalence of SNPs related to paracetamol metabolism and principal metabolites in critically ill patients, and those with chronic kidney disease. The present study is a cross-sectional study carried out in adults (>21 years) requiring intravenous paracetamol as part of their standard of care. Details regarding their demographics, and renal and liver function tests were collected. Blood was withdrawn for the analysis of paracetamol and their metabolites, and the SNPs of key CYP enzymes. Paracetamol/paracetamol glucuronide (P/PG), paracetamol/paracetamol sulphate (P/PS) and PG/PS were estimated. Acute liver injury (ALI) and renal dysfunction were defined using standard definitions. We observed a significant prevalence of SNPs in CYP1A2*1C, CYP3A4*3, CYP1A2*1K, CYP1A2*6, CYP2D6*10, and CYP2E1*2 amongst the 150 study participants. Those with CYP1A2*6 (CC genotype) were observed with significantly lower PG and PS concentrations, and a higher P/PS ratio; CYP2D6*10 (1/1 genotype) with a significantly lower PG concentration and a higher P/PG ratio; and CYP1A2*1K (CC genotype) was observed with a significantly higher PG/PS ratio. Good predictive accuracies were observed for determining the SNPs with the cut-off concentration of 0.29 μM for PS in determining CYP1A2*1K, 0.39 μM for PG and 0.32 μM for PS in determining CYP1A2*6 genotype, and 0.29 μM for PG in determining the CYP2D6*10 genotype. Patients with renal dysfunction were observed with significantly greater concentrations of paracetamol, PG and P/PS, and PG/PS ratios, with a lower concentration of PS. No significant differences were observed in any of the metabolites or metabolite ratios in patients with ALI. We have elucidated the prevalence of key CYP enzymes involved in acetaminophen metabolism in our population. Alterations in the metabolite concentrations and metabolic ratios were observed with SNPs, and in patients with renal dysfunction. Population toxicokinetic studies elucidating the dose-response relationship are essential to understand the optimized dose in this sub-population.

The purpose of this study was to determine whether administration of the microorganism Eubacterium rectale (E. rectale) could regulate dendritic cell (DC) activation and systemic inflammation in herpes simplex virus type 1-induced Behçet’s disease (BD). E. rectale, butyrate-producing bacteria, was administered to BD mice. Peripheral blood leukocytes (PBL) and lymph node cells were isolated and analyzed by flow cytometry. 16S rRNA metagenomic analysis was performed in the feces of mice to determine the differences in the composition of the microbial population between normal and BD mice. Serum cytokine levels were measured by enzyme-linked immunosorbent assay. The frequency of DC activation marker CD83 positive cells was significantly increased in PBL of BD mice. Frequencies of CD83+ cells were also significantly increased in patients with active BD. 16S rRNA metagenomic analysis revealed different gut microbiota composition between normal and BD mice. The administration of E. rectale to BD mice reduced the frequency of CD83+ cells and significantly increased the frequency of NK1.1+ cells with the improvement of symptoms. The co-administration of colchicine and E. rectale also significantly reduced the frequency of CD83+ cells. Differences in gut microbiota were observed between normal mice and BD mice, and the administration of E. rectale downregulated the frequency of CD83, which was associated with BD deterioration. These data indicate that E. rectale could be a new therapeutic adjuvant for BD management.

Abstract Background In order to set research priorities for reproductive health in the occupied Palestinian territory, it is vital to know what current research has been done in the field of reproductive health. The purpose of this scoping review is to examine the range and nature of reproductive health research in the occupied Palestinian territory and to identify research gaps in the existing literature. Methods We searched four databases: EMBASE, PubMed, CINAHL, and Popline. We included studies that: (i) are published (with an abstract); (ii) relevant to reproductive health; (iii) Palestinians living in Palestine; (iv) participants over the age of 15 years; and (v) restricted to human research. Three independent reviewers screened title and abstracts, and extracted data from included articles. We conducted quantitative and qualitative analyses. Results Of 1025 titles and abstracts screened, 145 articles were included. 52 (36%) articles were conducted in community setting and 34 (24%) were conducted in hospitals. There were 5 (3%) experimental studies. 15 articles had more than one main theme; 160 subthemes overall were identified. The most frequently studied theme was labor and delivery (n = 19; 12%). One article discussed adolescent reproductive health and menopause while no articles discussed men’s reproductive health. Conclusions 91% of the research conducted is observational. The focus of reproductive health research was to understand the topic, community and providers’ perceptions and knowledge. Articles related to the quality of services were limited. It is also important to research the reproductive health of women outside of reproductive age, men, and adolescents.

Background: Nanotechnology can offer the advantages of increasing solubility and bioavailability of delivering drugs like Furosemide. The aim of the current study is to investigate the in vitro and in vivo performance of furosemide nanosuspensions. Methods: Furosemide nanosuspensions were prepared by antisolvent precipitation method using full factorial experimental design. Four factors were employed namely; Stirring time, Injection rate, antisolvent: solvent ratio & stabilizer: drug ratio (at two levels = high & low). The in vitro dissolution experiments were conducted to compare the representative formulation with raw drug powder. The bioavailability of nanosuspension was, also, evaluated in mice as an animal model. Results: Solid state characterization (PXRD, DSC and FESEM) did show physical changes during preparation and optimization of the furosemide nanosuspensions. Individual material attributes showed more significant impact on the average particle size of the nanocrystals compared to process parameters. Two-way interactions between material attributes and process parameters significantly affected nanosuspension particle size distribution. Dissolution rate of furosemide nanosuspemsion was significantly higher than that observed for raw furosemide powder. The in vivo pharmacokinetics parameters of nanosuspension in comparison to pure drug showed significant increase in Cmax and AUC(0-t), about 233% and 266%, respectively. The oral bioavailability of furosemide from nanosuspension was about 2.3 fold higher as compared with the bioavailability from pure drug. Conclusions: Furosemide nanosuspensions prepared using antisolvent precipitation method enhanced the dissolution rate and oral bioavailability compared to raw furosemide powder. Keywords: Furosemide, Nanosuspension, Antisolvent precipitation, Stabilizer, In vitro in vivo assessment