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Background: Allograft artery-infected pseudoaneurysm (PA) represents a rare but life-threatening complication of kidney transplantation (KT). A review of the literature, showed that nearly all these cases ended resulted in graft loss. We presented a case of post-KT-infected external iliac artery anastomotic PA successfully managed by endovascular stenting with graft preservation. Additionally, we reviewed the pertinent literature., Method: In this article, we described a hypertensive, 47-year-old man who presented 1 month post-cadaveric KT with acute kidney injury and gram-negative bacteremia secondary to a large infectious anastomotic PA of the external iliac artery., Results: Because of favorable anatomy, successful arterial angio-stent fixation of the main renal artery PA, sparing the lower polar artery, was performed after 1 week of antibiotic and fungal coverage., Conclusion: Patient was discharged after 2 weeks with functioning graft. Graft function was stable after 3 months., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Scientists have emerged with innovative research on non-human primates showing that the booster dose of the COVID-19 vaccine increases neutralizing antibody levels against all variants. The current cross-sectional survey was designed to evaluate the knowledge, perception, and acceptance of the booster dose of the COVID-19 vaccine among the patients visiting the various dental clinics in Aseer region, Kingdom of Saudi Arabia. A total of 609 dental patients were selected from various dental clinics by a simple random probability sampling method. The questionnaire was designed in multiple languages and categorized as demographic information, knowledge, perception, and acceptance of participants to a booster dose. An anonymous, self-administered, closed-ended online, and paper-based questionnaire was used to assess the above parameters. In the current survey, the majority of the participants were Saudis (80.8%) with an age mean of 37.7 ± 8.7 years. About 68.6% (418 out of 609) of participants had poor knowledge about the booster dose. Significant differences in the levels of knowledge were found in relation to gender, area of residency, education, nationality, and occupation. The distribution of level of perception of booster dose differs significantly among participants of different marital statuses and nationalities. Hesitation to booster was reported more in the rural than in the urban population. Despite a low level of knowledge, a higher level of good perception and acceptance of booster doses were reported among the studied population.

Pharmacists deliver pharmaceutical care in many different healthcare settings and are well-placed to support the prevention of stroke. However, their role and impact in this area is ill-defined. This systematic review aims to explore the pharmacists’ role in stroke prevention. Nine databases were searched for studies reporting pharmacist interventions in the management of primary and secondary ischaemic stroke prevention. Study quality was evaluated through Cochrane Risk of Bias and Joanna Briggs Institute (JBI) appraisal tools where possible. A narrative review was conducted and meta-analysis performed for studies with comparable outcomes. Of the 834 initial articles, 31 met inclusion criteria. Study designs were varied and included controlled trials, observational studies, audit reports and conference abstracts. Seven studies addressed the pharmacists’ role in primary prevention and 24 in secondary prevention. Pharmacist interventions reported were diverse and often multifactorial. Overall, 20 studies reported significant improvement in outcomes. Meta-analysis showed pharmacist interventions in emergency care significantly improved the odds of achieving thrombolytic therapy door to needle (DTN) times ≤45 min, odds ratio: 2.69 (95% confidence interval (CI): 1.95−3.72); p < 0.001. The pharmacists’ role is varied and spans the stroke treatment pathway, with the potential for a positive impact on a range of health-related outcomes.

The potential of the surface dielectric barrier discharge technique (SDBD) was evaluated to decontaminate the date palm fruit. Preliminary investigations emphasized that Aspergillus niger fungus was predominant in most date samples as a post-harvest infestation. The influence of SDBD techniques on the viability of A. niger isolated from date varieties was investigated and documented. Physical and chemical characterizations of treated dates were assessed, and statistical correlation coefficients were calculated and elucidated. A 4 log 10 reduction of A. niger radial growth was observed at 3 min exposure/15 days of incubation. Simultaneous reductions in pH, water activity, and moisture content of treated dates were observed when compared to untreated dates. Statistical analysis showed a positive correlation between physical and chemical variables with the viability of A. niger in treated samples. Therefore, we believe that SDBD treatment will be a promising technique for decontaminating date fruits from attacked fungi, which will positively impact sustainable food security and consumer health., (© 2022. The Author(s).)

Importance: Helmet noninvasive ventilation has been used in patients with COVID-19 with the premise that helmet interface is more effective than mask interface in delivering prolonged treatments with high positive airway pressure, but data about its effectiveness are limited., Objective: To evaluate whether helmet noninvasive ventilation compared with usual respiratory support reduces mortality in patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia., Design, Setting, and Participants: This was a multicenter, pragmatic, randomized clinical trial that was conducted in 8 sites in Saudi Arabia and Kuwait between February 8, 2021, and November 16, 2021. Adult patients with acute hypoxemic respiratory failure (n = 320) due to suspected or confirmed COVID-19 were included. The final follow-up date for the primary outcome was December 14, 2021., Interventions: Patients were randomized to receive helmet noninvasive ventilation (n = 159) or usual respiratory support (n = 161), which included mask noninvasive ventilation, high-flow nasal oxygen, and standard oxygen., Main Outcomes and Measures: The primary outcome was 28-day all-cause mortality. There were 12 prespecified secondary outcomes, including endotracheal intubation, barotrauma, skin pressure injury, and serious adverse events., Results: Among 322 patients who were randomized, 320 were included in the primary analysis, all of whom completed the trial. Median age was 58 years, and 187 were men (58.4%). Within 28 days, 43 of 159 patients (27.0%) died in the helmet noninvasive ventilation group compared with 42 of 161 (26.1%) in the usual respiratory support group (risk difference, 1.0% [95% CI, -8.7% to 10.6%]; relative risk, 1.04 [95% CI, 0.72-1.49]; P = .85). Within 28 days, 75 of 159 patients (47.2%) required endotracheal intubation in the helmet noninvasive ventilation group compared with 81 of 161 (50.3%) in the usual respiratory support group (risk difference, -3.1% [95% CI, -14.1% to 7.8%]; relative risk, 0.94 [95% CI, 0.75-1.17]). There were no significant differences between the 2 groups in any of the prespecified secondary end points. Barotrauma occurred in 30 of 159 patients (18.9%) in the helmet noninvasive ventilation group and 25 of 161 (15.5%) in the usual respiratory support group. Skin pressure injury occurred in 5 of 159 patients (3.1%) in the helmet noninvasive ventilation group and 10 of 161 (6.2%) in the usual respiratory support group. There were 2 serious adverse events in the helmet noninvasive ventilation group and 1 in the usual respiratory support group., Conclusions and Relevance: Results of this study suggest that helmet noninvasive ventilation did not significantly reduce 28-day mortality compared with usual respiratory support among patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia. However, interpretation of the findings is limited by imprecision in the effect estimate, which does not exclude potentially clinically important benefit or harm., Trial Registration: ClinicalTrials.gov Identifier: NCT04477668.

Background: There is a growing literature on guidelines regarding Ramadan fasting for chronic kidney disease (CKD) patients. However, most studies only consider the impact of fasting on renal function. This study additionally aims to assess factors influencing Ramadan fasting in patients with CKD., Method: This is a prospective before and after cohort study. CKD patients were counseled regarding fasting and followed-up post-Ramadan for renal function status, actual fasting behavior, and other relevant outcomes., Results: Of the 360 patients who attended the pre-Ramadan consultation, 306 were reachable after Ramadan of whom 55.3% were female. Of these 306 67.1% reported that they had fasted, 4.9% had attempted to fast but stopped, and 28% did not fast at all. Of these 74 has a post-fasting kidney test. Of the patients, 68.1% had stage 3A CKD, 21.7% had stage 3B, 7.9% stage 4, and only 2% stage 5. Of those who fasted, 11.1% had a drop in Glomerular Filtration Rate (eGFR) of 20% or more. Those who did not fast (16.7%) presented a similar drop. Conversely, among the few who attempted to fast and had to stop, half showed a drop in eGFR of more than 20%. In linear regression, fasting was not associated with post-Ramadan eGFR, when controlling for age and baseline eGRF. There were 17 (5.6%) significant events, including one death. More significant events occurred among the group who fasted some of Ramadan days, 26.7% of the subjects experienced an adverse event-while 4.7% of the group who did not fast had a significant adverse event compared to 4.4% among those who fasted all Ramadan., Conclusion: Fasting was not a significant determining factor in renal function deterioration in the study's population, nor did it have any significant association with adverse events., (© 2022. The Author(s).)

Objective: The coronavirus disease (COVID-19) pandemic has disrupted healthcare systems worldwide, resulting in decreased and delayed hospital visits of patients with non-COVID-19-related acute emergencies. We evaluated the impact of the COVID-19 pandemic on the presentation and outcomes of patients with non-COVID-19-related medical and surgical emergencies. Method: All non-COVID-19-related patients hospitalized through emergency departments in three tertiary care hospitals in Saudi Arabia and Bahrain in June and July 2020 were enrolled and categorized into delayed and non-delayed groups (presentation ≥/=24 or <24 h after onset of symptom). Primary outcome was the prevalence and cause of delayed presentation; secondary outcomes included comparative 28-day clinical outcomes (i.e., 28-day mortality, intensive care unit (ICU) admission, invasive mechanical ventilation, and acute surgical interventions). Mean, median, and IQR were used to calculate the primary outcomes and inferential statistics including chi-square/Fisher exact test, t-test where appropriate were used for comparisons. Stepwise multivariate regression analysis was performed to identify the factors associated with delay in seeking medical attention. Results: In total, 24,129 patients visited emergency departments during the study period, compared to 48,734 patients in the year 2019. Of the 256 hospitalized patients with non-COVID-19-related diagnoses, 134 (52%) had delayed presentation. Fear of COVID-19 and curfew-related restrictions represented 46 (34%) and 25 (19%) of the reasons for delay. The 28-day mortality rates were significantly higher among delayed patients vs. non-delayed patients (n = 14, 10.4% vs. n = 3, 2.5%, OR: 4.628 (CI: 1.296−16.520), p = 0.038). Conclusion: More than half of hospitalized patients with non-COVID-19-related diagnoses had delayed presentation to the ED where mortality was found to be significantly higher in this group. Fear of COVID-19 and curfew restrictions were the main reasons for delaying hospital visit.

Background: Paediatric out-of-hospital cardiac arrest (OHCA) results in high mortality and poor neurological outcomes. We conducted this study to describe and compare the effects of pre-hospital airway management on survival outcomes for paediatric OHCA in the Asia-pacific region., Methods: We performed a retrospective analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data from January 2009 to June 2018. PAROS is a prospective, observational, multi-centre cohort study from eleven countries. The primary outcomes were one-month survival and survival with favourable neurological status, defined as Cerebral Performance Category1 or 2. We performed multivariate analyses of the unmatched and propensity matched cohort., Results: We included 3131 patients less than 18 years in the study. 2679 (85.6%) children received bag-valve-mask (BVM) ventilations, 81 (2.6%) endotracheal intubations (ETI) and 371 (11.8%) supraglottic airways (SGA). 792 patients underwent propensity score matching. In the matched cohort, advanced airway management (AAM: SGA and ETI) when compared with BVM group was associated with decreased one-month survival [AAM: 28/396 (7.1%) versus BVM: 55/396 (13.9%); adjusted odds ratio (aOR), 0.46 (95% CI, 0.29 - 0.75); p = 0.002] and survival with favourable neurological status [AAM: 8/396 (2.0%) versus BVM: 31/396 (7.8%); aOR, 0.22 (95% CI, 0.10 - 0.50); p < 0.001]. For SGA group, we observed less 1-month survival [SGA: 24/337 (7.1%) versus BVM: 52/337 (15.4%); aOR, 0.41 (95 %CI, 0.25-0.69), p = 0.001] and survival with favourable neurological status., Conclusion: In children with OHCA in the Asia-Pacific region, pre-hospital AAM was associated with decreased one-month survival and less favourable neurological status., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: MEH Ong reports funding from the Zoll Medical Corporation for a study involving mechanical cardiopulmonary resuscitation devices; grants from the Laerdal Foundation, Laerdal Medical, and Ramsey Social Justice Foundation for funding of the Pan-Asian Resuscitation Outcomes Study; an advisory relationship with Global Healthcare SG, a commercial entity that manufactures cooling devices; and funding from Laerdal Medical on an observation program to their Community CPR training Centre Research Program in Norway. MEH Ong has a licensing agreement and patent filed (Application no: 13/047,348) with ZOLL Medical Corporation for a study titled “Method of predicting acute cardiopulmonary events and survivability of a patient. He is also the co-founder and scientific advisor of TIIM Healthcare, a commercial entity which develops real-time prediction and risk stratification solutions at triage. All other authors have no conflict of interest to declare., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Cataracts are the main cause of visual impairment among the aging population, with a high impact on patients' quality of life. It has been suggested that the antioxidant carotenoids lutein and zeaxanthin may play a role in cataract prevention. Recently, significant evidence has associated abnormal glucose metabolism with an increased likelihood of the development of cataracts., Aim: The current study aims to assess the relationship between nutrition and cataracts among adults in the Aseer Region, Saudi Arabia., Methods: A retrospective study was conducted targeting all accessible patients diagnosed with cataracts at Aseer Central Hospital during the period from August 8, 2019, to March 3, 2021, and at Khamis Mushayt General Hospital during the period from June 11, 2018, to March 3, 2021. Data were collected using a pre-structured data collection sheet that covered patients' socio-demographic data, including age, gender, education, work type, and marital status. Also, the type of cataract diagnosed for the study patients was recorded with associated risk factors of cataracts, including chronic diseases, trauma, eye surgery, and family history. The last section covered patients' dietary habits and frequency of dietary intake.  Results: A total of 140 patients with cataracts who fulfilled the inclusion criteria were included in the study. Patients' ages ranged from 21 to 65 years, with a mean age of 54.2 ± 12.9 years old. Additionally, 12.1% of the study patients were smokers, 44.3% were diagnosed with hypertension, and 45% were diabetic, which was type 1 diabetes mellitus (T1DM) among 36.5% and type 2 diabetes mellitus (T2DM) among 52.4%. A family history of congenital cataracts was reported among 12.9%, and 12.9% had a history of eye trauma. Moreover, 37.1% of the study patients had vegetables once per week. Eating fruits or having juice was reported as once per week among 40% of the study patients and three times per week among 20%. Finally, 31.4% take nutritional supplements or vitamins., Conclusion: There is currently an inquiry to endorse or exclude a specific diet or dietary intake that may reduce or even prevent the development and progression of cataracts. It appears beneficial for people to have some antioxidants in their daily food., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Aldhabaan et al.)

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., (© 2022. The Author(s).)

Background: Dispatcher-assisted CPR (DA-CPR) has the potential to deliver early bystander CPR (BCPR) and improve out-of-hospital cardiac arrest (OHCA) survival. This study in the Asia-Pacific evaluated the impact of a DA-CPR program on BCPR rates and survival., Methods: This was a three-arm, prospective, multi-national, population-based, community-level, implementation trial. Cases between January 2009 and June 2018 from the Pan-Asian Resuscitation Outcomes Study were included. Sites either implemented a comprehensive (with quality improvement tool) or a basic DA-CPR package, or served as controls. Primary outcome was survival-to-discharge/30th day post-arrest. Secondary outcomes were BCPR and favorable neurological outcome. A before-after comparison was made within each country; this before-after change was then compared across the three groups using logistic regression., Results: 170,687 cases were analyzed. Before-after comparison showed that survival to discharge was higher in the 'implementation' period in all three groups: comprehensive odds ratio (OR) 1.09, 95% confidence interval (CI; [1.0-1.19]); basic OR 1.14, 95% CI (1.08-1.2); and control OR 1.25, 95% CI (1.02-1.53). Comparing between groups, the comprehensive group had significantly higher change in BCPR (comprehensive vs control ratio of OR 1.86, 95% CI [1.66-2.09]; basic vs control ratio of OR 0.94, 95% CI [0.85-1.05]; and comprehensive vs basic ratio of OR 1.97, 95% CI [1.87-2.08]) and survival with favorable neurological outcome (comprehensive vs basic ratio of OR 1.2, 95% CI [1.04-1.39])., Conclusion: We evaluated the impact of a DA-CPR program across heterogeneous EMS systems and demonstrated that a comprehensive DA-CPR program had the most impact on BCPR and favorable neurological outcome., Competing Interests: Declaration of Competing Interest MEH Ong reports funding from the Zoll Medical Corporation for a study involving mechanical cardiopulmonary resuscitation devices; grants from the Laerdal Foundation, Laerdal Medical, and Ramsey Social Justice Foundation for funding of the Pan-Asian Resuscitation Outcomes Study; an advisory relationship with Global Healthcare SG, a commercial entity that manufactures cooling devices; and funding from Laerdal Medical on an observation program to their Community CPR raining Centre Research Program in Norway. MEH Ong has a licensing agreement and patent filed (Application no: 13/047,348) with ZOLL Medical Corporation for a study titled “Method of predicting acute cardiopulmonary events and survivability of a patient. He is also the co-founder and scientific advisor of TIIM Healthcare, a commercial entity which develops real-time prediction and risk stratification solutions at triage. All other authors have no conflict of interest to declare., (Copyright © 2021 Elsevier B.V. All rights reserved.)

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., (© 2021. The Author(s).)

During the COVID-19 pandemic, many positive shifts have been observed in the ecosystem, with a significant decrease in the greenhouse gas emissions and air pollution. On the other hand, there were unavoidable negative shifts due to a surge in demand for plastic products such as food and groceries' delivery packaging, single-use plastics, medical and personal protective equipment to prevent transmission of COVID-19. Plastic pollution can be considered as a key environmental issue in world due to the huge footprints of plastics on natural ecosystems and public health. Herein, we presented an overview on the rise of plastic pollution during the COVID-19 pandemic. The potential sources of plastic waste during COVID-19 with its negative effects on the environment such as marine ecosystems and the global economics are highlighted. We also suggested some strategies and recommendations to tackle plastic leakages by applying feedstock recycling, sterilization, and with the use of biodegradable plastics that have become a sustainable alternative to fossil fuel plastics. Also, the importance of elevating public awareness and some recommendations to mitigate plastic generated during the pandemic has been addressed as well., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Introduction: The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) had caused an increased burden on healthcare organizations. Thus, a new strategy is needed to ensure all COVID-19 positive cases appropriately followed up , to receive the proper medical and psychological support, and to comply with the isolation guidelines. Here, we describe the characteristics and outcome of COVID-19 patients who were managed at home. In addition, we describe the differences between asymptomatic and those with mild symptoms., Materials and Methods: This is descriptive study of all COVID-19 positive cases who were monitored utilizing the home care concept., Results: During the study period from June 8 to October 18, 2020, there was a total of 5368 COVID-19 patients who were referred to the home isolation/monitoring program. Of those, 2397 (45%) were female and 2971 (55%) were male. Of the total cases, 295 (5%) required hospital admission, 45 (1%) were admitted to zone 2 (an intermediate care facility), and the majority 5028 (94%) were continued in the home monitoring program till recovery. Of the total cases, 3137 (59%) were asymptomatic and the remaining 41% were symptomatic. Asymptomatic patients in comparison to symptomatic patients showed significant differences in relation to mean age (+ SD) of 31.5 (+ 18.6) and 46.45 (+ 17.1), respectively (P < 0.001)), gender, being healthcare workers, and the presence of significant medical conditions. However, a logistic regression analysis showed that only age and the presence of diabetes mellitus were associated with the presence of symptoms. The mean age (±SD) of those who required hospital admission was higher than those who were continued in home monitoring or cared for in zone 2., Conclusion: The utilization of home monitoring program was effective and safe in patients who were either asymptomatic or had mild symptoms., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives: To reveal the mechanisms behind the dual effects of Crataegus aronia (C. aronia) aqueous extract on platelet aggregation by focusing on function, regulation, expression, and signaling of platelets P 2 Y 12 receptors., Methods: Adult male Wistar rats (120 ± 10 g) were classified as control received the vehicle, C. aronia (200 mg/kg), and C. aronia (2,000 mg/kg)-treated rats. After treatments for consecutive 7 days, hematological and molecular experiments were conducted to detect alterations in platelet aggregation, thromboxane B2 (THXB2) and intracellular reactive oxygen species (ROS) content; protein levels of P 2 Y 12 , p-Akt, cyclic adenosine monophosphate (cAMP), phosphorylated vasodilator-stimulated-phosphoprotein (p-VASP), nuclear factor κB (NF-κB), P-selectin, and etc. in platelets were determined by Western blot; mRNA expressions of P 2 Y 12 and some inflammatory markers were determined by real-time polymerase chain reaction., Results: At a concentration of 200 mg/kg, C. aronia inhibited platelet aggregation through multiple interconnected mechanisms including downregulation P 2 Y 12 synthesis and expression, stimulating intracellular cAMP levels and protein levels of p-VASP, inhibiting platelets THXB2 release and protein levels of P-selectin. Also, it inhibited platelets level of ROS and of NF-κB, a major signaling pathway that stimulates the expression of P 2 Y 12 and THXA2 synthesis. Opposite findings were seen in platelets of rats received C. aronia at a concentration of 2,000 mg/kg. Interestingly, co-administration of N-acetylcysteine prevented all hematological and molecular alterations exerted by the high dose of the extract and inhibited platelet aggregation., Conclusion: Oral administration of C. aronia at low dose inhibits platelet aggregation by reducing THXB2 release, expression of P-selectin and activating cAMP and Akt signaling through two major mechanisms including downregulation of P 2 Y 12 and inhibition of ROS-induced activation of NF-κB, an effect that is observed to be in the opposite direction with its high dose., (© 2020. The Chinese Journal of Integrated Traditional and Western Medicine Press and Springer-Verlag GmbH Germany, part of Springer Nature.)

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV- 2) emerged in Wuhan City, China. The SARS-CoV-2 crossed borders and quickly transformed into a "Public health emergency of international concern". Countries around the globe are in the race to achieve herd immunity. We describe the steps taken by Saudi Arabia to achieve this goal., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Non-invasive ventilation (NIV) delivered by helmet has been used for respiratory support of patients with acute hypoxaemic respiratory failure due to COVID-19 pneumonia. The aim of this study was to compare helmet NIV with usual care versus usual care alone to reduce mortality., Methods and Analysis: This is a multicentre, pragmatic, parallel randomised controlled trial that compares helmet NIV with usual care to usual care alone in a 1:1 ratio. A total of 320 patients will be enrolled in this study. The primary outcome is 28-day all-cause mortality. The primary outcome will be compared between the two study groups in the intention-to-treat and per-protocol cohorts. An interim analysis will be conducted for both safety and effectiveness., Ethics and Dissemination: Approvals are obtained from the institutional review boards of each participating institution. Our findings will be published in peer-reviewed journals and presented at relevant conferences and meetings., Trial Registration Number: NCT04477668., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: This study aimed to estimate the prevalence of bone fractures and analyze their associated risk factors in people with and without type 2 diabetes (T2D) in Saudi Arabia., Methods: This study was conducted among 1188 people (581 type 2 diabetes) in Prince Sultan Military Medical City, Riyadh, Saudi Arabia. In addition to the demographic variables, glycated hemoglobin (HbA1c), creatinine, estimated glomerular filtration rate (eGFR), use of teriparatide, presence of rheumatoid arthritis, presence of chronic obstructive pulmonary disease (COPD), Bone mineral density (BMD), Trabecular Bone Score (TBS) and Fracture Risk using the Fracture Risk Assessment Tool (FRAX) were also collected., Results: There were 1188 people (mean age 66.5 ± 8.7yrs) included in this study, of which 1068 (89.9%) were female, and 120 (10.1%) were male. A total of 112 (9.4%) individuals had a fracture history. Female, use of teriparatide, TBS (partially degraded and degraded), FRAX with TBS (MOF), and FRAX with TBS (Hip fx) were identified as independent risk factors for fracture in the whole study population. Teriparatide use and FRAX with TBS (MOF) were observed as independent risk factors for fracture in the non-diabetic population, whereas age, creatinine, eGFR, teriparatide, osteopenia, osteoporosis, TBS (partially degraded, degraded), FRAX with TBS (MOF), FRAX with TBS (Hip fx) were determined as independent risk factors for fracture among patients with diabetes., Conclusion: Patients with T2D were observed to have a higher risk for fractures. The findings of the study highlight the requirement for fracture prevention strategies in patients with diabetes., Competing Interests: Declaration of competing interest Authors have no conflict of interest and the work was not supported or funded by any drug company., (Copyright © 2021. Published by Elsevier Ltd.)

Introduction: The emergence of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) had resulted in an unpresented global pandemic. In the initial events, the Kingdom of Saudi Arabia implemented mandatory quarantine of returning travelers in order to contain COVID-19 cases., Materials and Methods: This is a longitudinal study of the arriving travelers to Quarantine facilities and the prevalence of positive SARS-CoV-2 as detected by RT-PCR., Results: During the study period, there was a total of 1928 returning travelers with 1273 (66%) males. The age range was 28 days-69 years. Of all the travelers, 23 (1.2%) tested positive for SARS-CoV-2. Of the first swab, 14/1928 (0.7%) tested positive. The positivity rate was 0.63% and 0.92% among males and females, respectively (P = 0.57). The second swab was positive in 9 (0.5%) of the other 1914 who were initially negative with a positivity rate of 0.39% and 0.62% among males and females, respectively (P = 0.49). There was no statistical difference in the positivity rates between first and second swab (P = 0.4). Of all travelers, 40 (n = 26, 1.3%) were admitted from the quarantine facility to the hospital due to COVID-19 related positive results or development of symptoms such as fever, cough, and respiratory symptoms; and 14 (0.7%) were admitted due to non-COVID-19 related illness., Conclusion: This study showed the efforts put for facility quarantine and that such activity yielded a lower incidence of positive cases. There was a need to have a backup healthcare facility to accommodate those developing a medical need for evaluation and admission for non-COVID-19 related illnesses., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this in vitro laboratory study was to gauge the nanomechanical properties of the tooth enamel surface using home and in-office bleaching products., Methods: Thirty-six extracted lower lateral incisor teeth (sound and without caries, cracks or restorations) were selected. A silicone mould was used to affix the samples in resin after cutting away the roots. Next, the samples were indiscriminately divided into three treatment groups, i.e., 12 teeth in each study group (control, Opalescence Home, and Opalescence Boost), and treated according to their respective group procedures. Surface topography, nano-indentation, and visual analyses were performed. Data were examined statistically using one-way analysis of variance (p < 0.05)., Results: Both experimental bleaching products enhanced the surface roughness when compared to the samples in the control group. However, the control and Opalescence Boost groups showed insignificant differences. The lowest mean nanohardness (GPa) was observed in the Opalescence Boost group (1.56 GPa ± 0.68 GPa). In contrast, the highest mean nanohardness (GPa) was perceived in the control group (3.53 GPa ± 1.06 GPa). The modulus of elasticity was highly affected using Opalescence Boost (182.63 GPa ± 109.13 GPa) when compared to Control (322.69 GPa ± 168.24 GPa). On visual examination, pronounced roughness was observed in both the Opalescence Home and Opalescence Boost groups., Conclusion: Both teeth whitening products damaged the enamel surface either by roughening the tooth surface or by affecting the nanomechanical properties. Therefore, teeth whitening products may be used, but with great caution., Competing Interests: All the authors of this laboratory study declare no conflict of interest, (© 2019 The Authors.)

Introduction: The main goal of a critical care response team (CCRT) is to quickly assess and transfer, if required, rapidly deteriorating patients to an intensive care unit (ICU) to prevent cardiopulmonary arrest, stabilize patients' condition, and help in optimizing the care provided by the primary team. The objective of this study was to investigate the correlation between early intervention by CCRT and the outcome of oncology patients., Materials and Methods: This is a retrospective cohort study conducted at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. KAMC is a tertiary care facility with 1200-bed capacity. The study compared oncology patients to nononcology patients., Results: Over 4 years, a total number of 4941 patients were reviewed, of which 172 were oncology patients. The average age of patients in the oncology group was 48.8 ± 20.7, while the average age for nononcology was 52.8 ± 21.2 ( P = 0.016). The average Acute Physiology and Chronic Health Evaluation II score on admission for oncology patients was higher than that for the nononcology group (27.8 ± 8.9 vs. 23.6 ± 9.3, respectively). Lower ICU mortality was seen after CCRT implementation (38.8% vs. 62.7%). The average duration of hospital stay and ICU stay increased after CCRT implementation (37.34 vs. 29.31 and 11.93 vs. 8.9, respectively)., Conclusion: In this study, we identified that early intervention by implementing CCRT had a significant impact in reducing ICU mortality for oncology and nononcology patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 International Journal of Critical Illness and Injury Science.)

Objectives: The outcomes of liver transplantation may vary according to socioeconomic factors such as insurance coverage. The aim of this study was to assess the association between the type of insurance payer and outcomes of liver transplant candidates and recipients in the United States., Study Design: This was a retrospective cohort study of a national database., Methods: The US Scientific Registry of Transplant Recipients was used to select adults (≥18 years) wait-listed for liver transplantation in the United States (2001-2017); patients were followed until March 2018., Results: There were 177,862 liver transplant candidates with payer and outcomes data: The mean (SD) age was 54.1 (10.4) years, 64% were male, 39% had chronic hepatitis C with or without alcoholic liver disease (ALD), 19% had ALD alone, 17% had nonalcoholic steatohepatitis, and 16% had hepatocellular carcinoma. Fifty-nine percent were primarily covered by private insurance, 21% by Medicare, and 16% by Medicaid. After listing, 56% eventually received transplants (mean wait time of 229 days) and 22% dropped off the list. In multivariate analysis, adjusted for demographic and clinical factors, being covered by Medicare (odds ratio [OR], 0.81; 95% CI, 0.78-0.84) or Medicaid (OR, 0.76; 95% CI, 0.73-0.79) was independently associated with a lower chance of receiving a transplant (reference: private insurance). Posttransplant mortality was 11.6% at 1 year, 20.1% at 3 years, 26.8% at 5 years, and 41.6% at 10 years. Having Medicare (adjusted hazard ratio [aHR], 1.24; 95% CI, 1.17-1.31) or Medicaid (aHR, 1.14; 95% CI, 1.06-1.21) was independently associated with higher posttransplant mortality (P <.001) but not with the risk of graft loss (P >.05)., Conclusions: Liver transplant candidates covered by Medicare or Medicaid have poorer wait-list outcomes and higher posttransplant mortality.

Aims: To identify and evaluate clinical pharmacology (CP) online curricular (e-Learning) resources that are internationally available for medical students., Methods: Literature searches of Medline, EMBASE and ERIC databases and an online survey of faculty members of international English language medical schools, were used to identify CP e-Learning resources. Resources that were accessible online in English and aimed to improve the quality of prescribing specific medications were then evaluated using a summary percentage score for comprehensiveness, usability and quality, and for content suitability., Results: Our literature searches and survey of 252 faculty (40.7% response rate) in 219 medical schools identified 22 and 59 resources respectively. After screening and removing duplicates, 8 eligible resources remained for evaluation. Mean total score was 53% (standard deviation = 13). The Australian National Prescribing Curriculum, ranked highest with a score of 77%, based primarily on very good ratings for usability, quality and suitable content., Conclusion: Using a novel method and evaluation metric to identify, classify, and rate English language CP e-Learning resources, the National Prescribing Curriculum was the highest ranked open access resource. Future work is required to implement and evaluate its effectiveness on prescribing competence., (© 2019 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Introduction: Social media continues to grow in size, and popularity, The prevalence of social networking continues to develop and will likely play an increasing role in all aspects of society and business, including in healthcare services. This rapid growth has directly influenced healthcare professionals in the clinical setting., Aim: To assess the perceptions and usage of SM (SM) by OSs (OS) in Jeddah, Saudi Arabia, and its impact on their profession, and to evaluate their level of awareness of the potential risks on their practice., Methods: Quantitative: A cross-sectional survey was distributed to practicing OSs in 15 healthcare centers in Jeddah, Saudi Arabia (μ=323) using convenience sampling. Data was analyzed using SPSS. Qualitative: Eight OSs were recruited by purposive and snowball sampling and interviewed using a semi-structured approach. Data was analyzed using thematic content analysis., Results: The Quantitative survey revealed that 165 OSs participated (RR=51%). OSs who use SM partly or entirely for professional purposes represent 53.7% (n=87). The remaining OSs were excluded. Virtually 90% were 40 years old or younger. Residents were less likely to reply to medical questions on SM (p=0.035). It was found that 74.7% of OSs use SM daily. The most commonly used platform was Twitter (75.9%), with Instagram and Snapchat being significantly more used by younger OSs (p= 0.013 and 0.003, respectively). The results of the Qualitative interviews revealed four themes: Guidelines, Ethics and Professionalism; Usage and Perceptions; Doctor-Patient Relationship; Quality of Online Content., Conclusion: OSs' perceptions and usage were generally cautious. The major concerns were patient confidentiality, along with ethical and legal consequences. The need to contribute to quality online content was evident. Lack of formal guidelines was a continuous theme. The development of national guidelines on SM use in the orthopaedic profession is recommended., Competing Interests: There are no conflicts of interest.

Hydrolytic enzyme production by thermophilic bacteria isolated from hot springs in the southern region of Saudi Arabia was investigated. The physical and chemical properties of the hot springs prove to be an important environment for hydrolytic-enzyme-producing thermophilic bacteria. Eighty-four bacterial isolates were obtained from three hot springs: Al-Majardah, Al-Khubah and Al-Ardah. Screening of the isolates for enzyme production indicated that 78 isolates showed activity for one or more enzymes. Molecular identification and phylogenic analysis of selected promising isolates confirmed the identity of the isolates as Bacillus aerius, Bacillus licheniformis and Bacillus sonorensis , which have potential to produce the target enzymes α-amylase, protease and lipase, respectively. Optimization of hydrolytic enzyme production by bacterial strains was investigated using kitchen waste as a cheap carbon energy source. Maximum enzyme production was achieved after 72 hours of incubation at the beginning of the stationary phase of growth. Enzyme production was dependent on the initial pH value in the range of pH 7.5-8.5 and an optimal incubation temperature of between 55-60°C. Enzyme production increased gradually in proportion to the kitchen waste concentration; whereas maximum lipase production was gained at 5.0% (w/v) kitchen waste, 7.0% (w/v) of waste was optimal for both α-amylase and protease productivity. The results indicated that hot springs in Saudi Arabia are a substantial source of thermophilic bacteria producing industrially important enzymes using cheap and unexploited waste., Competing Interests: Conflict of interest: Authors state no conflict of interest, (© 2018 Sulaiman Alrumman et al., published by De Gruyter.)

This cohort study included 36 eyes of 21 patients with high myopia treated with angle supported phakic intraocular lens (pIOL). Endothelial cell density (ECD) at baseline, 6mo and 3y were 3017±296, 2775±265 and 2558±299 cells/mm 2 respectively. ECD loss at 6mo was 7.2% and annual ECD loss was 3% over 36mo. Corrected distance visual acuity at 36mo was 0.4 logMAR or better in 32 (88.9%) eyes. Intraocular pressure did not change ( P =0.9). No eyes developed cataract, retinal detachment or pupillary distortion. Angle supported pIOL gives good visual outcome. Endothelial cell loss should be monitored.

Background and objectives : Subclinical hypothyroidism is an asymptomatic condition with normal thyroxin and raised thyroid stimulating hormone (TSH) level. The objective of the study was to determine the prevalence of subclinical hypothyroidism in primary health care (PHC) settings in Riyadh and explore the relationship of TSH level with age, gender, family history, body mass index, and co-morbid conditions. Subjects and methods : A cross-sectional study of adult visitors to nine satellites PHC clinics in military housing in Riyadh was carried out. TSH concentration and free T4 levels were measured. Data were collected by nurses and physicians during routine clinical practice in primary care. Descriptive analysis was performed on all variables in study, and relationships were explored using chi-square, t -test, analysis of variance, and linear regression. Results : A total of 340 out of 394 participants in the study gave blood samples. Subclinical hyperthyroidism was identified in 2.1% ( p  = .001) and subclinical hypothyroidism in 10.3% ( p  = .001) of the PHC visitors. TSH levels were found to be significantly higher ( p  = .047) in elderly population of ≥60 years and those with family history of thyroid disease. Non-significant upward trends were noted in TSH levels with hyperlipidemia and increasing blood pressure. No overt hyperthyroidism or hypothyroidism was found in our study sample. Conclusion : Subclinical hypothyroidism has a prevalence of 10% of adults visiting PHC's. TSH levels are higher in the elderly, which warrants screening of those aged 60 years and above., Competing Interests: The authors have nothing to disclose and/or declare any possible conflict of interest regarding the article, organizational or/and professional affiliations.

Background: Compliance with the clinical practice guidelines of sepsis management has been low. The objective of our study was to describe the results of implementing a multifaceted intervention including an electronic alert (e-alert) with a sepsis response team (SRT) on the outcome of patients with sepsis and septic shock presenting to the emergency department., Methods: This was a pre-post two-phased implementation study that consisted of a pre-intervention phase (January 01, 2011-September 24, 2012), intervention phase I (multifaceted intervention including e-alert, from September 25, 2012-March 03, 2013) and intervention phase II when SRT was added (March 04, 2013-October 30, 2013) in a 900-bed tertiary-care academic hospital. We recorded baseline characteristics and processes of care in adult patients presenting with sepsis or septic shock. The primary outcome measures were hospital mortality. Secondary outcomes were the need for mechanical ventilation and length of stay in the intensive unit and in the hospital., Results: After implementing the multifaceted intervention including e-alert and SRT, cases were identified with less severe clinical and laboratory abnormalities and the processes of care improved. When adjusted to propensity score, the interventions were associated with reduction in hospital mortality [for intervention phase II compared to pre-intervention: adjusted odds ratio (aOR) 0.71, 95% CI 0.58-0.85, p = 0.003], reduction in the need for mechanical ventilation (aOR 0.45, 95% CI 0.37-0.55, p < 0.0001) and reduction in ICU LOS and hospital LOS for all patients as well as ICU LOS for survivors., Conclusions: Implementing a multifaceted intervention including sepsis e-alert with SRT was associated with earlier identification of sepsis, increase in compliance with sepsis resuscitation bundle and reduction in the need for mechanical ventilation and reduction in hospital mortality and LOS.

Background: The demand for critical care beds is increasing out of proportion to bed availability. As a result, some critically ill patients are kept in the Emergency Department (ED boarding) awaiting bed availability. The aim of our study is to examine the impact of boarding in the ED on the outcome of patients admitted to the Intensive Care Unit(ICU)., Methods: This was a retrospective analysis of ICU data collected prospectively at King Abdulaziz Medical City, Riyadh from ED between January 2010 and December 2012 and all patients admitted during this time were evaluated for their duration of boarding. Patients were stratified into three groups according to the duration of boarding from ED. Those admitted less than 6 h were classified as Group I, between 6 and 24 h, Group II and more than 24 h as Group III. We carried out multivariate analysis to examine the independent association of boarding time with the outcome adjusting for variables like age, sex, APACHE, Mechanical ventilation, Creatinine, Platelets, INR., Results: During the study period, 940 patients were admitted from the ED to ICU, amongst whom 227 (25%) were admitted to ICU within 6 h, 358 (39%) within 6-24 h and 355 (38%) after 24 h. Patients admitted to ICU within 6 h were younger [48.7 ± 22.2(group I) years, 50.6 ± 22.6 (group II), 58.2 ± 20.9 (group III) (P = 0.04)]with less mechanical ventilation duration[5.9 ± 8.9 days (Group I), 6.5 ± 8.1 (Group II) and 10.6 ± 10.5 (Group III), P = 0.04]. There was a significant increase in hospital mortality [51(22.5), 104(29.1), 132(37.2), P = 0.0006) and the ICU length of stay(LOS) [9.55 days (Group I), 9.8 (Group II) and 10.6 (Group III), (P = 0.002)] with increase in boarding duration. In addition, the delay in admission was an independent risk factor for ICU mortality(OR for group III vs group I is 1.90, P = 0.04) and hospital mortality(OR for group III vs Group I is 2.09, P = 0.007)., Conclusion: Boarding in the ED is associated with higher mortality. This data highlights the importance of this phenomenon and suggests the need for urgent measures to reduce boarding and to improve patient flow.

Background: Complications following immediate breast reconstruction can have significant consequences for the delivery of postoperative chemotherapy and radiation therapy. Identifying patients at higher risk of complications would ensure that immediate breast reconstruction does not compromise oncologic treatment. The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is an online tool in the public domain that offers individualized preoperative risk prediction for a wide range of surgical procedures, including alloplastic breast reconstruction. This study evaluates the usefulness of this tool in patients undergoing immediate breast reconstruction with tissue expanders at a single institution., Methods: Details of 278 patients who underwent immediate breast reconstruction with tissue expander placement were entered into the calculator to determine the predicted complication rate. This was compared to the rate of observed complications on chart review. The predictive model was evaluated for calibration and discrimination using the statistical measures used in the original development of the calculator., Results: The predicted rate of complications (5.2 percent) was significantly lower that the observed rate (16.2 percent; p < 0.01). The Hosmer-Lemeshow test confirmed lack of fit of the model. The C statistic was 0.62 and the Brier score was 0.173, indicating that the model had poor predictive power and could not discriminate between those who were at risk for complications and those who were not., Conclusions: The American College of Surgeons National Surgical Quality Improvement Program universal Surgical Risk Calculator underestimated the proportion of patients that would develop complications in this cohort. In addition, it was unable to effectively identify individual patients at increased risk, suggesting that this tool would not make a useful contribution to preoperative decision-making in this patient group.

We explored the feasibility of collecting convalescent plasma for passive immunotherapy of Middle East respiratory syndrome coronavirus (MERS-CoV) infection by using ELISA to screen serum samples from 443 potential plasma donors: 196 patients with suspected or laboratory-confirmed MERS-CoV infection, 230 healthcare workers, and 17 household contacts exposed to MERS-CoV. ELISA-reactive samples were further tested by indirect fluorescent antibody and microneutralization assays. Of the 443 tested samples, 12 (2.7%) had a reactive ELISA result, and 9 of the 12 had reactive indirect fluorescent antibody and microneutralization assay titers. Undertaking clinical trials of convalescent plasma for passive immunotherapy of MERS-CoV infection may be feasible, but such trials would be challenging because of the small pool of potential donors with sufficiently high antibody titers. Alternative strategies to identify convalescent plasma donors with adequate antibody titers should be explored, including the sampling of serum from patients with more severe disease and sampling at earlier points during illness.

As of September 30, 2015, a total of 1589 laboratory-confirmed cases of infection with the Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported to the World Health Organization (WHO). At present there is no effective specific therapy against MERS-CoV. The use of convalescent plasma (CP) has been suggested as a potential therapy based on existing evidence from other viral infections. We aim to study the feasibility of CP therapy as well as its safety and clinical and laboratory effects in critically ill patients with MERS-CoV infection. We will also examine the pharmacokinetics of the MERS-CoV antibody response and viral load over the course of MERS-CoV infection. This study will inform a future randomized controlled trial that will examine the efficacy of CP therapy for MERS-CoV infection. In the CP collection phase, potential donors will be tested by the enzyme linked immunosorbent assay (ELISA) and the indirect fluorescent antibody (IFA) techniques for the presence of anti-MERS-CoV antibodies. Subjects with anti-MERS-CoV IFA titer of ≥1:160 and no clinical or laboratory evidence of MERS-CoV infection will be screened for eligibility for plasma donation according to standard donation criteria. In the CP therapy phase, 20 consecutive critically ill patients admitted to intensive care unit with laboratory-confirmed MERS-CoV infection will be enrolled and each will receive 2 units of CP. Post enrollment, patients will be followed for clinical and laboratory outcomes that include anti-MERS-CoV antibodies and viral load. This protocol was developed collaboratively by King Abdullah International Medical Research Center (KAIMRC), Gulf Cooperation Council (GCC) Infection Control Center Group and the World Health Organization-International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC-WHO) MERS-CoV Working Group. It was approved in June 2014 by the Ministry of the National Guard Health Affairs Institutional Review Board (IRB). A data safety monitoring board (DSMB) was formulated. The study is registered at http://www.clinicaltrials.gov (NCT02190799).

A young female presented with pneumonitis and worsened acute respiratory distress syndrome (ARDS) failed all the conservative ventilator management, was managed with extra corporeal life support technology, and was successfully discharged.

The current study evaluates the ultra high performance liquid chromatography (UHPLC) method for the quantification of talinolol in lipid-based formulations. A simple, rapid, reliable and precise reversed phase UHPLC method has been developed and validated according to the regulatory guidelines, which was composed of isocratic mobile phase; acetonitrile and phosphate buffer saline (pH 4.5) with a flow rate of 0.4 mL/min, and column HSS C18 (2.1 x 50 mm, 1.8 μm). The detection was carried out at 245 nm. The developed UHPLC method was found to be rapid (1.8 min run time), selective with high resolution of talinolol peak (0.88 min) from different lipid matrices and highly sensitive (limit of detection and lower limit of quantification were 0.14 ppm and 0.5 ppm, respectively). The linearity, accuracy and precision were determined as acceptable over the concentration range of 0.5-100 ppm for talinolol. The results showed that the proposed UHPLC method can be used for the estimation of talinolol in lipid-based formulation by indicating its purity and stability with no interference of excipients or related substances of active pharmaceutical ingredient.

Due to individual variations in radiosensitivity, biomarkers are needed to tailor radiation treatment to cancer patients. Since single nucleotide polymorphisms (SNPs) are frequent in human, we hypothesized that SNPs in genes that mitigate the radiation response are associated with radiotoxicity, in particular late complications to radiotherapy and could be used as genetic biomarkers for radiation sensitivity. A total of 155 patients with nasopharyngeal cancer were included in the study. Normal tissue fibrosis was scored using RTOG/EORTC grading system. Eleven candidate genes (ATM, XRCC1, XRCC3, XRCC4, XRCC5, PRKDC, LIG4, TP53, HDM2, CDKN1A, TGFB1) were selected for their presumed influence on radiosensitivity. Forty-five SNPs (12 primary and 33 neighboring) were genotyped by direct sequencing of genomic DNA. Patients with severe fibrosis (cases, G3-4, n = 48) were compared to controls (G0-2, n = 107). Results showed statistically significant (P < 0.05) association with radiation complications for six SNPs (ATM G/A rs1801516, HDM2 promoter T/G rs2279744 and T/A rs1196333, XRCC1 G/A rs25487, XRCC5 T/C rs1051677 and TGFB1 C/T rs1800469). We conclude that these six SNPs are candidate genetic biomarkers for radiosensitivity in our patients that have cumulative effects as patients with severe fibrosis harbored significantly higher number of risk alleles than the controls (P < 0.001). Larger cohort, independent replication of these findings and genome-wide association studies are required to confirm these results in order for SNPs to be used as biomarkers to individualize radiotherapy on genetic basis.

Introduction: The clinical significance of elevation of lactate levels within the reference range is not well studied. The objective of this study was to determine the best cutoff threshold for serum lactate within the reference range (0.01 to 2.00 mM) that best discriminated between survivors and nonsurvivors of critical illness and to examine the association between relative hyperlactatemia (lactate above the identified threshold) and mortality., Methods: This was a retrospective cohort study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care academic center. Youden index was calculated to identify the best lactate cutoff threshold that discriminated between survivors and nonsurvivors. Patients with lactate above the identified threshold were defined as having relative hyperlactatemia. Multivariate logistic regression, adjusting for baseline variables, was performed to determine the relationship between the above two ranges of lactate levels and mortality. In addition, a test of interaction was performed to assess the effect of selected subgroups on the association between relative hyperlactatemia and hospital mortality., Results: During the study period, 2,157 patients were included in the study with mean lactate of 1.3 ± 0.4 mM, age of 55.1 ± 20.3 years, and acute physiology and chronic health evaluation (APACHE) II score of 22.1 ± 8.2. Vasopressors were required in 42.4%. Lactate of 1.35 mM was found to be the best cutoff threshold for the whole cohort. Relative hyperlactatemia was associated with increased hospital mortality (adjusted odds ratio (aOR), 1.60, 95% confidence interval (CI) 1.29 to 1.98), and ICU mortality (aOR, 1.66; 95% CI, 1.26 to 2.17) compared with a lactate level of 0.01 to 1.35 mM. This association was consistent among all examined subgroups., Conclusions: Relative hyperlactatemia (lactate of 1.36 to 2.00 mM) within the first 24 hours of ICU admission is an independent predictor of hospital and ICU mortality in critically ill patients.

Objective: We aim to evaluate the outcome of flexible ureterorenoscopy (F-URS) with holmium laser in treating renal diverticular stone as a minimal invasive option., Patients and Methods: We reviewed retrospectively the records of 45 patients who underwent F-URS using holmium laser from 2004 to 2011 for symptomatic renal diverticular stone. The presenting symptoms were renal colic, urinary tract infection or hematuria. The F-URS used after the Shock Wave Lithotripsy (SWL) failure in 30 (66.7 %) patients. The repeated treatment by F-URS was carried out twice for four patients; in three patients, it was correlated to the size of the stone and it was because of failure to identify the diverticulum in one patient. The follow up visit range were between 4 to 6 weeks with plain radiograph (KUB) and renal ultrasound or non-contrast CT scan (NCCT)., Results: Of our data, there were 45 patients, 22 women and 23 men (mean age of 46.3 years, range 18-72). We found 28 patients (62.2 %) who had stone free (SF), 10 patients (22.2 %) with clinically insignificant residual fragments (less than 3mm in size) and residual fragments (RF) in seven patients (15.6 %). Success rate was considered as stone free or insignificant residual fragment, which was obtained in 38 patients (84.4 %). The symptom-free was in 42 patients (93.3 %)., Conclusion: In our experience, F-URS using holmium laser was very effective minimally-invasive technique that could be the best option for the treatment of renal diverticular stone especially for those who resist the treatment with the SWL. It showed an excellent stone clearance rate, minimal morbidity rate and brief hospital stay., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Pheochromocytoma during pregnancy is extremely rare. Its clinical manifestation includes hypertension with various clinical presentations, possibly resembling those of pregnancy-induced hypertension. The real challenge for clinicians is differentiating pheochromocytoma from other causes of hypertension (preeclampsia, gestational hypertension, and pre-existing or essential hypertension), from other cause of pulmonary edema (preeclampsia, peripartum cardiomyopathy, stress or Takotsubo cardiomyopathy, pre-existing cardiac disease [mitral stenosis], and high doses betamimetics), and from other causes of cardiovascular collapse (pulmonary embolism, and amniotic fluid embolism). Although, several cases of pheochromocytoma during pregnancy have been published, fetal and maternal mortalities due to undiagnosed cases are still reported. We report a case of a patient whose delivery by cesarean section was complicated by severe hemodynamic instability resulting in a cardiac arrest. Later on, pheochromocytoma was suspected based on computed tomography (CT) scan findings. Diagnosis was confirmed with special biochemical investigations that showed markedly elevated catecholamines in urine and metanephrines in serum, and later by histopathology of the excised left adrenal mass. This case illustrates the difficulty of diagnosing pheochromocytoma in pregnancy and raises the awareness to when this rare disease should be suspected.

A 16-year-old male adolescent who presented with vomiting and headache and in the emergency department had a loss of consciousness, was discovered to have a large mass compressing the brainstem. CT scan showed two adjacent mass lesions. Digital subtraction angiography (DSA) revealed a giant aneurysm in the posterior medial choroidal artery, subsequently embolized with Guglielmi detachable coils (GDCs). Ten GDCs were used to embolize the aneurysm and the distal aspect of its parent artery. Postembolization DSA confirmed complete embolization of the aneurysm. Endovasular embolization of giant aneurysms in the medial posterior choroidal artery with GDCs is technically feasible and represents a successful therapeutic option. In unruptured giant intracranial aneurysms, simultaneous packing of the aneurysm with coils and occlusion of the distal parent artery can have a good outcome.

Unlabelled: What's known on the subject? and What does the study add? Stone density on non-contrast computed tomography (NCCT) is reported to be a prognosis factor for extracorporeal shockwave lithotripsy (ESWL). In this prospective study, we determined that a 970 HU threshold of stone density is a very specific and sensitive threshold beyond which the likelihood to be rendered stone free is poor. Thus, NCCT evaluation of stone density before ESWL may useful to identify which patients should be offered alternative treatment to optimise their outcome., Objective: • To evaluate the usefulness of measuring urinary calculi attenuation values by non-contrast computed tomography (NCCT) for predicting the outcome of treatment by extracorporeal shockwave lithotripsy (ESWL)., Patients and Methods: • We prospectively evaluated 50 patients with urinary calculi of 5-22 mm undergoing ESWL. • All patients had NCCT at 120 kV and 100 mA on a spiral CT scanner. Patient age, sex, body mass index, stone laterality, stone size, stone attenuation values (Hounsfield units [HU]), stone location, and presence of JJ stent were studied as potential predictors. • The outcome was evaluated 4 weeks after the ESWL session by NCCT. • ESWL success was defined as patients being stone-free (SF) or with remaining stone fragments of <4 mm, which were considered as clinically insignificant residual fragments (CIRF)., Results: • Our survey concluded that 26 patients (52%) were SF, 12 (24%) had CIRF and 12 (24%) had residual fragment on NCCT after a one ESWL treatment. • Stones of patients who became SF or had CIRF had a lower density compared with stones in patients with residual fragments [mean (sd) 715 (260) vs 1196 (171) HU, P < 0.001]. • The Youden Index showed that a stone density of 970 HU represented the most sensitive (100%) and specific (81%) point on the receiver-operating characteristic curve. • The stone-free rate for stones of <970 HU was 96% vs 38% for stones of ≥ 970 HU (P < 0.001). A linear relationship between the calculus density and the success rate of ESWL was identified., Conclusion: • The use of NCCT to determine the attenuation values of urinary calculi before ESWL helps to predict treatment outcome, and, consequently, could be helpful in planning alternative treatment for patients with a likelihood of a poor outcome from ESWL., (© 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.)

Introduction: Patient care and safety is the main goal and mission of any health care provider. We surveyed nurses in the wards and obtained their feedback about the quality of care delivered by the Critical Care Response Team (CCRT)., Methods: Our hospital has 900 beds. A self-administered survey was given onsite to all ward nurses. Survey items were identified, discussed, reviewed, piloted, and finalized over a 3-month period in a focus group discussion format during three CCRT core group meetings. Responses were anonymous and collected by the nurses onsite., Results: The total number of returned and analyzed surveys was 274 (98.6%). Ninety-seven percent agreed that CCRT staff arrived in a timely manner. Ninety-four percent reported that CCRT staff helped in managing sick patients and ∼70% reported that it strengthened team dynamics. Only 50% of the nurses felt CCRT staff improved competence at the bedside. The overall satisfaction was 100%; none of the nurses were dissatisfied with the team., Conclusion: The CCRT helped manage sick patients in the wards. However, CRRT staff should remember to involve and communicate with the team initiator and the patient's physician to optimize patient health care.

Objectives: We aim to assess the outcome of the flexible ureterorenoscopy (F-URS) with holmium laser in treating horseshoe kidney (HSK) stones., Patients and Methods: We reviewed retrospectively the records of 18 patients with HSK stone (18 renal units) who underwent F-URS using holmium laser from December 2004 to October 2009. The mean age was 37.7±6.9 years. The F-URS used after the extracorporeal shock wave lithotripsy (ESWL) failure in eight patients (44.4%) and four patients (22.2%) had PCNL failure. The follow up visit range were between 4 and 6 weeks with plain radiograph (KUB) and renal ultrasound or non contrast computed tomography scan (NCCT). Success rate was defined as stone free or residual fragment less than 3 mm. Use of auxiliary procedures like ESWL were considered as treatment failure., Results: Eighteen patients, three females and 15 males with mean age was 37.7±6.9 years with HSK calculi underwent ureteroscopic management. The presenting symptoms were renal colic, urinary tract infection or hematuria. We found different HSK stone location (11 mixed calyceal, three mixed pelvic and calyceal and four pelvic). The average stone burden was 15.5±7.3 mm and the mean operative time was 112±9.4 minutes. All over procedures were 27, with mean average of 1.5 procedures per patient. The success rate was 89%., Conclusion: The F-URS with holmium laser is an efficient minimal invasive procedure in treating HSK stones., (Copyright © 2010. Published by Elsevier Masson SAS.)

Objectives: To assess the outcome of flexible ureterorenoscopy (F-URS) with the holmium laser in treating stones in the horseshoe kidney (HSK)., Methods: We retrospectively reviewed the records of 17 patients with a HSK stone (17 renal units) who had undergone F-URS with the holmium laser from December 2004 to May 2009. The presenting symptoms were renal colic, urinary tract infection, or hematuria. F-URS was used in as an alternative after the failure of shock wave lithotripsy in 8 patients (47%) and percutaneous nephrolithotomy failure in 4 patients (23.5%). Follow-up examination was performed after 4-6 weeks with plain radiography and either renal ultrasonography or noncontrast computed tomography. Success was defined as stone-free status or residual fragments <3 mm. The use of auxiliary procedures was considered to indicate treatment failure., Results: A total of 17 patients were included in the present study (3 females and 14 males). Their age was 16-52 years (mean age ± SD 34.7 ± 6.3). The HSK stone location was 7 mixed caliceal, 3 mixed pelvic and caliceal, and 7 pelvic. The average stone burden was 16 mm (range 7-35). The overall number of procedures was 25 (mean 1.5 procedures/patient). Of the 17 patients, 15 (88.2%) were rendered stone free., Conclusions: The results of our study have shown that F-URS with the holmium laser is an efficient minimal invasive procedure for treating HSK stones., (Copyright © 2010 Elsevier Inc. All rights reserved.)