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Tarek Mohammed Hegazi,* Abdulaziz Mohammad AlSharydah,* Iba Alfawaz, Afnan Fahad Al-Muhanna, Sarah Yousef Faisal Diagnostic and Interventional Radiology Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar City, Eastern Province, Saudi Arabia*These authors contributed equally to this workCorrespondence: Tarek Mohammed Hegazi, Chairperson of the Radiology Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Khobar City, Eastern Province, Saudi Arabia, Tel +966-0138966877 (EXT: 2007), Email tarek.hegazi@gmail.comPurpose: To evaluate the impact of using computational data management resources and analytical software on radiation doses in mammography and radiography during the COVID-19 pandemic, develop departmental diagnostic reference levels (DRLs), and describe achievable doses (ADs) for mammography and radiography based on measured dose parameters.Patients and Methods: This ambispective cohort study enrolled 795 and 12,115 patients who underwent mammography and radiography, respectively, at the King Fahd Hospital of the University, Al-Khobar City, Saudi Arabia between May 25 and November 4, 2021. Demographic data were acquired from patients’ electronic medical charts. Data on mammographic and radiographic dose determinants were acquired from the data management software. Based on the time when the data management software was operational in the institute, the study was divided into the pre-implementation and post-implementation phases. Continuous and categorical variables were compared between the two phases using an unpaired t-test and the chi-square test.Results: The median accumulated average glandular dose (AGD; a mammographic dose determinant) in the post-implementation phase was three-fold higher than that in the pre-implementation phase. The average mammographic exposure time in the post-implementation phase was 16.3 ms shorter than that in the pre-implementation phase. Furthermore, the median values of the dose area product ([DAP], a radiographic dose determinant) were 9.72 and 19.4 cGycm2 in the pre-implementation and post-implementation phases, respectively.Conclusion: Although the data management software used in this study helped reduce the radiation exposure time by 16.3 ms in mammography, its impact on the mean accumulated AGD was unfavorable. Similarly, radiographic exposure indices, including DAP, tube voltage, tube current, and exposure time, were not significantly different after the data management software was implemented. Close monitoring of patient radiation doses in mammography and radiography, and dose reduction will become possible if imaging facilities use DRLs and ADs via automated systems.Keywords: average glandular dose, entrance skin dose, dose area product, radiograph, mammogram

Abstract Background Large-scale gut microbiome sequencing has revealed key links between microbiome dysfunction and metabolic diseases such as type 2 diabetes (T2D). To date, these efforts have largely focused on Western populations, with few studies assessing T2D microbiota associations in Middle Eastern communities where T2D prevalence is now over 20%. We analyzed the composition of stool 16S rRNA from 461 T2D and 119 non-T2D participants from the Eastern Province of Saudi Arabia. We quantified the abundance of microbial communities to examine any significant differences between subpopulations of samples based on diabetes status and glucose level. Results In this study we performed the largest microbiome study ever conducted in Saudi Arabia, as well as the first-ever characterization of gut microbiota T2D versus non-T2D in this population. We observed overall positive enrichment within diabetics compared to healthy individuals and amongst diabetic participants; those with high glucose levels exhibited slightly more positive enrichment compared to those at lower risk of fasting hyperglycemia. In particular, the genus Firmicutes was upregulated in diabetic individuals compared to non-diabetic individuals, and T2D was associated with an elevated Firmicutes/Bacteroidetes ratio, consistent with previous findings. Conclusion Based on diabetes status and glucose levels of Saudi participants, relatively stable differences in stool composition were perceived by differential abundance and alpha diversity measures. However, community level differences are evident in the Saudi population between T2D and non-T2D individuals, and diversity patterns appear to vary from well-characterized microbiota from Western cohorts. Comparing overlapping and varying patterns in gut microbiota with other studies is critical to assessing novel treatment options in light of a rapidly growing T2D health epidemic in the region. As a rapidly emerging chronic condition in Saudi Arabia and the Middle East, T2D burdens have grown more quickly and affect larger proportions of the population than any other global region, making a regional reference T2D-microbiome dataset critical to understanding the nuances of disease development on a global scale.

Although states and international institutions have developed elaborate sets of laws and regulations to oversee the legal movement of oil, significant amounts of oil are moved out of controlled channels every year with considerable financial, political and security ramifications. Despite their salience for global political economy, scholarly analyses of uncontrolled oil movements are recent and scant. This paper aims to facilitate systematic analysis of uncontrolled oil movements around the globe by presenting a novel categorization. Our categorization relates the incentives of players involved, either as states or nonstate actors, to the capabilities these players possess when moving uncontrolled oil, either as buyers or sellers.Brief case analyses demonstrate that incentives of actors and capabilities they possess exhibit considerable variance. The nonstate actors we examine predominantly take advantage of arbitrage opportunities that borders and/or lapses in political authority create. States engaging in uncontrolled movement of oil in our cases, on the other hand, are rather motivated by an immediate need to create revenue or secure oil supplies for their economy or military. The state and nonstate actors in our analysis also tend to differ with respect to the reactions they give to changes in political and economic landscape. Nonstate actors emerge as agile actors that are quick to seize opportunities due to lapses in authority and more readily adapt to countermeasures. States can move oil at a larger scale due to their command over capital intensive equipment; however, they are more vulnerable to international scrutiny and coercive countermeasures. The insights from our analysis motivate further comparative, data-based research to identify causal processes leading to various forms of uncontrolled oil movements.

Objective To assess whether the risk of cardiovascular complications of covid-19 differ between the sexes and to determine whether any sex differences in risk are reduced in individuals with pre-existing cardiovascular disease.Design Registry based observational study.Setting 74 hospitals across 13 countries (eight European) participating in CAPACITY-COVID (Cardiac complicAtions in Patients With SARS Corona vIrus 2 regisTrY), from March 2020 to May 2021Participants All adults (aged ≥18 years), predominantly European, admitted to hospital with highly suspected covid-19 disease or covid-19 disease confirmed by positive laboratory test results (n=11 167 patients).Main outcome measures Any cardiovascular complication during admission to hospital. Secondary outcomes were in-hospital mortality and individual cardiovascular complications with ≥20 events for each sex. Logistic regression was used to examine sex differences in the risk of cardiovascular outcomes, overall and grouped by pre-existing cardiovascular disease.Results Of 11 167 adults (median age 68 years, 40% female participants) included, 3423 (36% of whom were female participants) had pre-existing cardiovascular disease. In both sexes, the most common cardiovascular complications were supraventricular tachycardias (4% of female participants, 6% of male participants), pulmonary embolism (3% and 5%), and heart failure (decompensated or de novo) (2% in both sexes). After adjusting for age, ethnic group, pre-existing cardiovascular disease, and risk factors for cardiovascular disease, female individuals were less likely than male individuals to have a cardiovascular complication (odds ratio 0.72, 95% confidence interval 0.64 to 0.80) or die (0.65, 0.59 to 0.72). Differences between the sexes were not modified by pre-existing cardiovascular disease; for the primary outcome, the female-to-male ratio of the odds ratio in those without, compared with those with, pre-existing cardiovascular disease was 0.84 (0.67 to 1.07).Conclusions In patients admitted to hospital for covid-19, female participants were less likely than male participants to have a cardiovascular complication. The differences between the sexes could not be attributed to the lower prevalence of pre-existing cardiovascular disease in female individuals. The reasons for this advantage in female individuals requires further research.

Abstract Background Adenomyoepithelioma of the breast is an uncommon subtype of breast neoplasm that occurs in adults over a wide age range but most commonly in middle-aged and older adults. It usually presents as a solitary palpable mass or is detected on breast radiographic images. Histologically, it is a biphasic tumor with proliferation of both the epithelial and myoepithelial components of the glands, with variable types of tissue metaplasia. Case presentation A 64-year-old Saudi woman who underwent regular breast screening (mammogram) presented to our hospital following radiographic detection of a suspicious grouped microcalcification in the upper outer quadrant of her right breast on the mammogram. A wide local excision of the right breast lump was performed. Following histopathological examination of the breast lump, the final diagnosis was breast adenomyoepithelioma with mucoepidermoid/divergent differentiation, with no evidence of malignancy. About two years after the operation, a clinical follow-up conducted outside our hospital showed the development of ductal carcinoma in situ in the same breast. Conclusion Although the prognosis and the plan of treatment remains the same, our case highlights the complexities in making an accurate diagnosis between the various types of metaplasia within adenomyoepithelioma on one hand and the presence of mucoepidermoid differentiation in adenomyoepithelioma on the other.

Abstract Biomarkers to identify ICU COVID-19 patients at high risk for mortality are urgently needed for therapeutic care and management. Here we found plasma levels of the glycolysis byproduct methylglyoxal (MG) were 4.4-fold higher in ICU patients upon admission that later died (n = 33), and 1.7-fold higher in ICU patients that survived (n = 32),compared to uninfected controls (n = 30). The increased MG in patients that died correlated inversely with the levels of the MG-degrading enzyme glyoxalase-1 (r 2 = − 0.50), and its co-factor glutathione (r 2 = − 0.63), and positively with monocytes (r 2 = 0.29). The inflammation markers, SSAO (r 2 = 0.52), TNF-α (r 2 = 0.41), IL-1β (r 2 = 0.25), CRP (r 2 = 0.26) also correlated positively with MG. Logistic regression analysis provides evidence of a significant relationship between the elevated MG upon admission into ICU and death (P

Objectives: Following the release of an informational bulletin, Roche Diagnostics adopted a more restrictive hemolysis index (100 HI) for the release of serum lipase results on all Cobas systems. This study aimed to evaluate the interference threshold for serum lipase hemolysis on Cobas C501/311/701/Integra 400 systems using a total allowable error set by the Royal College of Pathologists of Australasia (RCPA). Methods: To assess the influence of hemolysis on lipase, the parameter was quantified in serum pools spiked with escalating concentrations of a hemolysis interferent. The lipase assay was performed using the colorimetric lipase method (LIPC), and the HI was determined by absorbance measurements of diluted samples in accordance with the system protocol. Results: The Cobas Integra 400 and Cobas C311 showed the greatest interference of lipase with hemolysis (≤300 HI). The Cobas C501 and C701 demonstrated less sensitivity to hemolysis (≤1300 HI). Conclusion: The results of this study demonstrate that interference limits may vary between different Roche systems, even when the same reagent is used. Our study indicated that the lipase hemolysis threshold (100 HI) currently set by the manufacturer was excessively restrictive. This finding highlights the necessity of verifying manufacturers' information bulletins to provide better medical care. [ABSTRACT FROM AUTHOR]

Simple Summary: Breast Cancer (BC) is an important disease causing death of many women worldwide. Here the relationship between gastroenteral microbionta and metabolism in the context of BC is investigated and described in detail. The interrelation between BC, metabolite abnormalities and reprogramming, and micronenvironment is described. All information about the various mechanisms by which these bacterial residents may influence disease initiation, progression, and treatment response is collected and summarized. We will see that gut-based biomarkers, and synergy between conventional therapies and microbiome interventions, together will soon be able to open-up new gates for breast cancer therapy. Breast cancer (BC), a major cause of death among women worldwide, has traditionally been linked to genetic and environmental factors. However, emerging research highlights the gut microbiome's significant role in shaping BC development, progression, and treatment outcomes. This review explores the intricate relationship between the gut microbiota and the breast tumor microenvironment, emphasizing how these microbes influence immune responses, inflammation, and metabolic pathways. Certain bacterial species in the gut either contribute to or hinder BC progression by producing metabolites that affect hormone metabolism, immune system pathways, and cellular signaling. An imbalance in gut bacteria, known as dysbiosis, has been associated with a heightened risk of BC, with metabolites like short-chain fatty acids (SCFAs) and enzymes such as β-glucuronidase playing key roles in this process. Additionally, the gut microbiota can impact the effectiveness of chemotherapy, as certain bacteria can degrade drugs like gemcitabine and irinotecan, leading to reduced treatment efficacy. Understanding the complex interactions between gut bacteria and BC may pave the way for innovative treatment approaches, including personalized microbiome-targeted therapies, such as probiotics and fecal microbiota transplants, offering new hope for more effective prevention, diagnosis, and treatment of BC. [ABSTRACT FROM AUTHOR]

We synthesized a novel compound library featuring a spirooxindole core structure combined with various heterocycles, including benzofuran, benzothiophene, and thiophene scaffolds. Evaluation using MTT assays against HepG2, 4T1, and MDA‐MB‐231 cells revealed the most potent candidate, spirooxindole hybrid 5c, with an IC50 of 5 ± 0.6 µM against HepG2, inducing G2/M phase cell cycle arrest, inhibition of the wound healing, and induction of ROS. Selected spirooxindole conjugates exhibited significant inhibitory potential against MDM2, with KD values ranging from 0.0531 to 16.8 µM. Notably, the salt of spirooxindole analogue 5q demonstrated the highest inhibitory activity at KD = 53.1 nM. Molecular docking studies revealed excellent accommodation of the designed compounds within the MDM2 receptor. All compounds displayed favorable ADME profiles, suggesting their potential as lead compounds for further optimization. [ABSTRACT FROM AUTHOR]

This study examines the challenges faced by informal housing in Damascus, Syria; and its impact on sustainable development. The study categorizes and characterizes these informal settlements, exploring their origins and governmental policies aimed at their rehabilitation. Despite the Syrian government's strategies for sustainable urban development, the findings reveal that these initiatives remain largely theoretical, with slow implementation hindering progress towards sustainability. This study emphasizes the need for well-defined timelines and actionable plans to achieve desired improvements in these areas.

Mostly, urine is devoid of bacteria, viruses, and fungi, making it sterile. However, an infection may arise when minuscule organisms, mostly bacteria from the digestive system, attach to the urethral opening and proliferate, leading to infections. This research seeks to identify the B-lactam genes responsible for antibiotic resistance in Klebsiella pneumoniae linked with infections, as well as their resistance to treatments. This inquiry specifically focuses on this aspect. The primary focus of the study was identifying bacterial isolates by established diagnostic methods. The secondary objective was to assess the resistance and sensitivity of antibiotics. Lastly, the study used the Polymerase Chain Reaction (PCR) method to ascertain the presence of the blaCTX-M and blaTEM genes. Within the period from November 2022 to June 2023, a 540 clinical samples were gathered from patients with urinary tract infections at Al-Hakim General Hospital, Al-Sadr City Hospital, Al-Furate Al-Awsat Hospital, and Al-Zahra Maternity and Children in AL-Najaf governorate. A total of 120 samples were found to be tainted with Klebsiella pneumoniae. This study assessed the sensitivity of the test using the disk diffusion method. The findings indicated that Klebsiella pneumoniae exhibited high levels of resistance to a road scope of antibiotics, namely Ampicillin/sulbactam, Ampicillin, and Ticarcillin/Clavulanic acid. Additionally, some isolates showed resistance to Cefotaxime. The experiment yielded diverse outcomes for the quinolone, aminoglycoside, and macrolide groups. Among the 120 samples that were examined, 87 of them showed positive results for K. pneumoniae when the PCR technique was used to detect the presence of the blaCTX-M gene. On the other hand, 36 samples tested positive for K. pneumoniae when the blaTEM gene was used. The specimens were obtained from the urine of individuals diagnosed with urinary tract infections.

COVID-19 pandemic disease continues to spread over all countries. There is increasing evidence that the SARA-COV-2 virus can cause damage to both the peripheral and central nervous systems through either direct or indirect mechanisms, potentially leading to long-term neurological effects. Рrolonged COVID can cause clinical symptoms such as anxiety, depression, fatigue, brain fog with cognitive dysfunction and memory problems. Brain fog, a colloquial term for cognitive Impairment (CI) , has emerged as a significant long-term neurological complication following COVID-19 infection. Recently, several studies have indicated that these cognitive symptoms can persist for months to over a year post-infection, affecting the quality of life of survivors. This article reviews the mechanisms of coronavirus invasion of the brain and how brain fog occurs after long-term Covid disease.

The present study aimed to isolate and diagnose Staphylococcus Aureus (S. aureus) from clinical specimens of patients infected with urinary tract infections and evaluate the bacteria’s resistance to antimicrobial agents. Additionally, it attempted to study the existence of the clumping factor A (clfA) gene. This study took place in Najaf province, Iraq, from December 2020 to April 2021 and included 40 clinical specimens taken from urine. In order to make an initial diagnosis of S. aureus isolates, microscopic evaluation was used in conjunction with culture and biochemical features. The automatic final diagnostic provided by the VITEK-2 compact system (bioMérieux, France) was utilized, which had a significant advantage. The results showed that 27 (67.5%) isolates gave positive results for S. aureus, 2 (5%) isolates for Streptococcus pyogenes, 6 (15%) isolates for Lactobacillus, and 5 (12.5%) for Escherichia coli. Antibiotic sensitivity test was conducted by disk diffusion methods, in which the isolates showed high resistance to ceftriaxone, as well as erythromycin, and they showed sensitivity to vancomycin, gentamicin, amikacin, and ciprofloxacin. The findings led to a concluding remark that all of the S. aureus isolates were clfA gene positive.

Every Door Direct Mail (EDDM) is a service of the United States Postal Service (USPS) that delivers non-addressed mail to all postal customers on designated mailing routes. Primarily used for marketing, we describe EDDM’s efficacy as a research tool for remotely recruiting a representative convenience sample of rural Appalachian households for a longitudinal survey-based health study. In June 2020, recruitment postcards were sent via EDDM to all residential addresses (n = 31,201) within an 18 ZIP code region of Southeastern Ohio. Adults were invited to complete a survey online via QR code or to call for a mailed survey. Respondent demographic characteristics were generated using SPSS and compared with the region’s 2019 U.S. Census Bureau statistics. A total of 841 households responded to the invitation, reflecting a response rate higher than marketing estimates (2.7 % vs 2 %). Compared to Census data, a greater proportion of respondents were female (74 % vs 51 %), and highly educated (64 % vs 36 % college graduates); a comparable proportion were non-Hispanic (99 % vs 98 %), white (90 % vs 91 %), and had ≥ 1 adult in the household (1.7 ± 0.9); and a lower proportion had a household income < $50 k (47 % vs 54 %). The median age was higher (56 vs 30 years), and 29 % were retirees. EDDM was a viable method for remote recruitment of a rural geographically-based sample. Further work is needed to explore its efficacy in recruiting representative samples in other contexts and to inform best practices for its use.

Over the past five years, several studies have reported deposition and retention of gadolinium in the brain after administration of gadolinium-based contrast agents (GBCAs) during radiological procedures. Patients with renal insufficiency cannot filter gadolinium efficiently; however, gadolinium is also retained in the brain of some adults and pediatrics with no renal impairment. In the literature, data is mostly available from retrospective magnetic resonance imaging (MRI) studies, where gadolinium deposition may be indirectly measured by evaluating changes in T1 signal intensity in the brain tissues, particularly in the deep gray matter such as the dentate nucleus and/or globus pallidus. Many pathological studies have reported a direct correlation between T1 signal changes and gadolinium deposition in human and animal autopsy specimens, which raised concerns on the use of GBCAs, particularly with linear chelators. The association between gadolinium accumulation and occurrence of physical and neurological side effects or neurotoxic damage has not yet been conclusively demonstrated. Studies have also observed that gadolinium is deposited in the extracranial tissues, such as the liver, skin, and bone, of patients with normal kidney function. This narrative review describes the effects of different types of GBCAs in relation to gadolinium deposition, evaluates current evidence on gadolinium deposition in various tissues of the human body, and summarizes the current recommendations regarding the use of GBCAs.

Abdulaziz Al-Sharydah,1 Abdulrahman Al-Abdulwahhab,1 Sari Al-Suhibani,1 Afnan Al-Muhanna,1 Abdullah Abohimed,2 Abdulmonem AlSharidah,3 Faisal Alabbas3 1Diagnostic and Interventional Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Al-Khobar City, Eastern Province, Saudi Arabia; 2Department of Medical Imaging, Ministry of National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia; 3College of Medicine, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Al-Khobar City, Eastern Province, Saudi ArabiaCorrespondence: Abdulrahman Al-AbdulwahhabDiagnostic and Interventional Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, P.O. Box: 31952 (4398), Al-Khobar City, Eastern Province, Saudi ArabiaTel +966502333711Email ahAbdulwahab@iau.edu.saPurpose: Basilar artery tip aneurysms can have fatal consequences and poor prognostic outcomes in case of rupture. We investigated the standard parameters used to evaluate aneurysmal morphology to predict aneurysm rupture.Patients and Methods: We measured the differences between ruptured and unruptured basilar bifurcation aneurysms in terms of morphological features, including aneurysm size, size ratio, aneurysm height, perpendicular height, aneurysm width, bottleneck ratio, aspect ratio, and present daughter domes, using 3D angiography.Results: Among 34 patients, 21 (61.8%) and 13 (38.2%) had ruptured and unruptured basilar tip aneurysms, respectively. In the ruptured group, the mean aneurysm size, and aspect, size, and bottleneck ratios were 6.8 ± 1.9 mm, 3.2 ± 1.0, 2.3 ± 0.5, and 2.2 ± 0.4, respectively, compared to 4.5 ± 1.5 mm, 4.4 ± 2.0, 1.6 ± 0.4, and 2.7 ± 0.7, respectively, in the non-ruptured group. Univariate analysis showed a larger aneurysmal cross-sectional diameter (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.5– 5.392; p

Breast cancer is a primary cause of human deaths among gynecological cancers around the globe. Though it can occur in both genders, it is far more common in women. It is a disease in which the patient’s body cells in the breast start growing abnormally. It has various kinds (e.g., invasive ductal carcinoma, invasive lobular carcinoma, medullary, and mucinous), which depend on which cells in the breast turn into cancer. Traditional manual methods used to detect breast cancer are not only time consuming but may also be expensive due to the shortage of experts, especially in developing countries. To contribute to this concern, this study proposed a cost-effective and efficient scheme called AMAN. It is based on deep learning techniques to diagnose breast cancer in its initial stages using X-ray mammograms. This system classifies breast cancer into two stages. In the first stage, it uses a well-trained deep learning model (Xception) while extracting the most crucial features from the patient’s X-ray mammographs. The Xception is a pertained model that is well retrained by this study on the new breast cancer data using the transfer learning approach. In the second stage, it involves the gradient boost scheme to classify the clinical data using a specified set of characteristics. Notably, the experimental results of the proposed scheme are satisfactory. It attained an accuracy, an area under the curve (AUC), and recall of 87%, 95%, and 86%, respectively, for the mammography classification. For the clinical data classification, it achieved an AUC of 97% and a balanced accuracy of 92%. Following these results, the proposed model can be utilized to detect and classify this disease in the relevant patients with high confidence.

Introduction: Verification and validation of analytical methods are crucial aspects of quality assurance in a laboratory. This study aimed to develop a risk analysis and assessment tool to streamline the process of identifying so-called 'sentinel' tests. Materials and methods: The Roche Cobas 8000 systems were evaluated to analyze 83 serum analytes, including routine chemistry, immunoassays, and therapeutic drugs. A failure mode and effects analysis were conducted to produce an analytic risk rating. This was achieved by multiplying the scores for Sigma metrics, the score for potential damage extent, and the score for environmental factors. Each test was assigned a typical risk priority number (RPN). Tests with an RPN of ≤9 were rated as low risk and ranked as 'B'. Tests with an RPN of >10 were considered high risk and graded as 'A'. Results: Regarding the Cobas C701/ISE, 17 of 54 methods were rated as 'A' and subject to a systematic method review process. A total of 37 methods were assigned a rank of 'B' and hence were eligible for a selective verification process. Concerning the Cobas E801, 10 out of 29 methods were classified as 'A' and, therefore, require a systematic verification process. A further nineteen methods were assigned a rank of 'B' and hence eligible for a select verification. Conclusions: This study demonstrated the high effectiveness of the risk analysis and assessment model developed to identify sentinel tests in the lean management of the verification/validation process. [ABSTRACT FROM AUTHOR]

Primary breast carcinoma with neuroendocrine features is an uncommon presentation of mammary cancers. The authors present a case of a rapidly growing breast mass that raised many differential diagnoses. The diagnosis in this case was challenging. Extensive clinical assessment, radiological imaging, nuclear scans, pathological evaluations, and series of multidisciplinary meetings were utilized to reach the diagnosis of neuroendocrine breast carcinoma.

The development of renewable energy is often treated as a purely positive outcome for the world, without consideration of the challenges that come with implementation at scale, which will inevitably follow with the process of a global energy transition. Studies on the political process of the transition to a world of renewables are scarce. This article provides a review on the geopolitical, institutional, and technological aspects of the development of renewable energy sources, including transportation and delivery of energy across national borders. At scale internationally, renewable energy will present many of the same issues as other mature sources of energy. Security, export interdependence, and the availability of source materials will all become increasingly important concerns.

Abstract Background To mitigate the risk of stent thrombosis, patients treated by percutaneous coronary intervention (PCI) are administered dual anti-platelet therapy comprising aspirin and a platelet P2Y12 receptor inhibitor. Clopidogrel is a prodrug requiring activation by the cytochrome P450 enzyme, CYP2C19. In Saudi Arabia, it has been reported that approximately 26% of the population carries CYP2C19*2 and/or *3 loss-of-function polymorphisms in addition to a high prevalence of CVD. Methods This prospective (April 2013–December 2020) parallel assignment clinical trial focuses on ST-Elevation Myocardial Infarction (STEMI) patient outcomes. The clinical trial includes 1500 STEMI patients from two hospitals in the Eastern Province of Saudi Arabia. Patients are assigned to one of two groups; the control arm receives conventional therapy with clopidogrel, while in the active arm the Spartan RX CYP2C19 assay is used to determine the *2 genotype. Carriers of a CYP2C19*2 loss-of-function allele receive prasugrel or ticagrelor, while non-carriers are treated with clopidogrel. Follow-up is one year after primary PCI. The primary end point is the number of patients who develop an adverse major cardiovascular event, including recurrent MI, non-fatal stroke, cardiovascular death, or major bleeding one year after PCI. Discussion The risk of stent thrombosis in PCI patients is usually reduced by dual anti-platelet therapy, comprising aspirin and a P2Y12 inhibitor, such as clopidogrel. However, clopidogrel requires activation by the cytochrome P450 enzyme, CYP2C19. Approximately 20% of the population are unable to activate clopidogrel as they possess the CYP2C19*2 loss-of function (LoF) allele. The primary goal of this trial is to study the benefits of treating only those patients that cannot activate clopidogrel with an alternative that has shown to be a more effective platelet inhibitor and does not require bioactivation by the cytochrome P450 enzyme. We expect an improvement in net clinical benefit outcome in the active arm patients, thus supporting pharmacogenetic testing in PCI patients post STEMI. Trial registration Trial registration name is “Bedside Testing of CYP2C19 Gene for Treatment of Patients with PCI with Antiplatelet Therapy” (number NCT01823185 ) retrospectively registered with clinicaltrials.gov on April 4, 2013. This trial is currently at the patient recruitment stage.