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Mohamad-Hani Temsah,1,2,* Noura Abouammoh,2,3,* Ayman Al-Eyadhy,1,2 Yazed AlRuthia,4,5 Marwah Hassounah,3 Fahad Alsohime,1,2 Ali Alhaboob,1,2 Mohammed Almazyad,1,2 Majed Alabdulhafid,1,2 Fadi Aljamaan,2,6 Khalid Alhasan,1,2 Amr Jamal2,3,7 1Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia; 3Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 4Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; 5Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; 6Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 7Evidence-Based Health Care & Knowledge Translation Research Chair, King Saud University, Riyadh, Saudi Arabia*These authors contributed equally to this workCorrespondence: Amr Jamal Email amrjamal@ksu.edu.saBackground: Several factors influence patients’ length of stay (LOS) in pediatric intensive care units (PICUs). This study explored the factors and cost associated with long LOS among pediatric patient population across various PICUs and pediatric surgical cardiac intensive care units (SCICUs).Methods: This is a multi-center concurrent mixed-methods study that was conducted in different PICUs and SCICUs in Riyadh, Saudi Arabia. The units’ leaders were qualitatively interviewed to explore the potential factors contributing to long LOSs in PICUs and SCICUs, and deductive content analysis was used. Microcosting was utilized to estimate the inpatient costs for a sample of long-stay patients (LSPs) and the potential cost savings if those patients were transferred to step-down care units (SDUs) for those who stayed ≥ 60 days.Results: Ten (90%) leaders of PICUs and SCICUs who were invited had participated. Changing the admission criteria, patient transfer to SDUs, family engagement in the decision-making process, and adopting a national do-not-resuscitate (DNR) policy were factors contributing to short LOSs. On the other hand, administrative constraints, staff avoidance of code status decisions, lack of palliative care resources, and complex patient characteristics were factors associated with long LOSs. The mean inpatient cost per patient was SAR 3.63 million (USD 0.97 million), and the total cost for the 48 patients was SAR 172.95 million (USD 46.12 million).Conclusion: If the recommendation to transfer LSPs after a 60-day PICU stay to SDUs is taken, the estimated cost savings among this sample of patients alone can be as high as SAR 109.47 million (USD 29.19 million). Therefore, future studies should examine the factors contributing to long LOSs in PICUs and SCICUs as well as the effectiveness of different policies aimed at improving the resource allocation and management using more robust study designs and diverse patient population.Keywords: pediatric critical care, long-stay patients, cost of long-stay patients, content analysis

Mohamad-Hani Temsah,1,2,* Noura Abouammoh,1,3,* Ahmed Ashry,2 Ayman Al-Eyadhy,1,2 Ali Alhaboob,1,2 Fahad Alsohime,1,2 Mohammed Almazyad,1,2 Majed Alabdulhafid,1,2 Reem Temsah,4 Fadi Aljamaan,1,5 Amr Jamal,1,3,6 Rabih Halwani,7,8 Khalid Alhasan,1,2 Jaffar A Al-Tawfiq,9– 11 Mazin Barry1,12 1College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Pediatric Intensive Care Unit, Department of Pediatrics, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia; 3Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia; 4College of Pharmacy, Alfaisal University, Riyadh, Saudi Arabia; 5Critical Care Department, King Saud University Medical City, Riyadh, Saudi Arabia; 6Evidence-Based Health Care & Knowledge Translation Research Chair, King Saud University, Riyadh, Saudi Arabia; 7Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates; 8Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates; 9Specialty Internal Medicine and Quality Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; 10Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; 11Infectious Disease Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 12Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, King Saud University and King Saud University Medical City, Riyadh, Saudi Arabia*These authors contributed equally to this workCorrespondence: Amr Jamal Email amrjamal@ksu.edu.saObjective: A key measure to mitigate coronavirus disease 2019 (COVID-19) has been social distancing. Incorporating video-conferencing applications in the patient handover process between healthcare workers can enhance social distancing while maintaining handover elements. This study describes pediatric intensive care unit (PICU) physicians’ experience using an online video-conferencing application for handover during the COVID-19 pandemic.Design: Qualitative content analysis.Setting: PICU at a university hospital in Riyadh, Saudi Arabia.Subjects: PICU Physicians.Interventions: Due to the pandemic, the hospital’s PICU used Zoom® as a remote conferencing application instead of a face-to-face handover. Following institutional review board approval, data were collected over two weeks (1 Jul 2020 to 14 Jul 2020).Measurements: An online survey was conducted using open-ended questions to capture demographic data and the perceived efficacy of remote handovers. Thematic framework analysis process included open coding, creating categories, and abstraction.Main Results: All 37 PICU physicians who participated in the handover completed the survey. The participants comprised six attendings, nine specialists, and 22 residents. While 20 (54.1%) physicians reported attending 1– 5 Zoom handovers by the time of the study, some (n. 6, 16.2%) had more than ten virtual handovers. They had variable previous teleconferencing experiences. Most physicians (78.4%) were comfortable conducting a remote handover. Most found that Situation–Background–Assessment–Recommendation handover elements were properly achieved through this remote handover process. The perceived advantages of online handover included fewer interruptions, time efficiency, and facilitation of social distancing. The perceived disadvantages were the paucity of nonverbal communication and teaching during virtual meetings.Conclusion: Video-conferencing applications for online handovers could supplement traditional face-to-face intensive care unit patient handover during outbreaks of infectious diseases. The use of video streaming and more emphasis on teaching should be encouraged to optimize the users’ experience.Keywords: COVID-19, PICU, physicians, physical distancing, zoom for remote handover, tele-ICU

Introduction: The variable clinical course of chronic lymphocytic leukemia (CLL) and the lack of consensus on follow-up and treatment strategies have necessitated a prognostic model for identifying high-risk patients at the time of diagnosis., Methods: We involved a retrospective analysis of demographic and clinical characteristics of 212 patients diagnosed with Binet stage A CLL and thus eligible for risk stratification by both the International Prognostic Score for Early-stage CLL (IPS-E) and the alternative IPS-E (AIPS-E). We evaluated the applicability of these prognostic indices in our young, Middle Eastern cohort (median age 59 at diagnosis)., Results: During the study period with a median follow-up of 3.5 years, 67 patients (32 %) experienced progression to first treatment and cumulative incidence of treatment was 13 % at 1 year and 28 % at 3 years after diagnosis. Sixty-nine (51 % of the 136 with a known value) patients harbored an unmutated immunoglobulin heavy chain gene (IGHV) and 21 (10 %) an 11q or 17p deletion with 11 % lacking FISH results. For each early-stage CLL prognostic index, more patients were identified as high-risk for disease progression (51 % of 124 patients evaluable for IPS-E; 42 % of 109 patients evaluable for AIPS-E) than intermediate-risk and low-risk. Multivariable models involving the IPS-E and AIPS-E components revealed that unmutated IGHV and elevated absolute lymphocyte count were significant predictors of earlier treatment requirement. Both prognostic scores were discriminative of time to first treatment (log-rank p < 0.001; c-statistics of 0.74 for IPS-E and 0.69 for AIPS-E)., Conclusion: Although clarity on clinical behavior with regard to initiation of treatment remains elusive, IPS-E and AIPS-E are valuable tools for identifying high-risk patients.

This study presents a novel approach to enhance expert panel discussions in a medical conference through the use of ChatGPT-4 (Generative Pre-trained Transformer version 4), a recently launched powerful artificial intelligence (AI) language model. We report on ChatGPT-4's ability to optimize and summarize the medical conference panel recommendations of the first Pan-Arab Pediatric Palliative Critical Care Hybrid Conference, held in Riyadh, Saudi Arabia. ChatGPT-4 was incorporated into the discussions in two sequential phases: first, scenarios were optimized by the AI model to stimulate in-depth conversations; second, the model identified, summarized, and contrasted key themes from the panel and audience discussions. The results suggest that ChatGPT-4 effectively facilitated complex do-not-resuscitate (DNR) conflict resolution by summarizing key themes such as effective communication, collaboration, patient and family-centered care, trust, and ethical considerations. The inclusion of ChatGPT-4 in pediatric palliative care panel discussions demonstrated potential benefits for enhancing critical thinking among medical professionals. Further research is warranted to validate and broaden these insights across various settings and cultures., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Almazyad et al.)

Objectives: We aimed to describe Familial Hemophagocytic Lymphohistiocytosis (F-HLH) patients' clinical features, intensive care courses, and outcomes., Methods: Multi-center retrospective cohort study of pediatric patients diagnosed with F-HLH from 2015 to 2020 in five tertiary centers in Saudi Arabia. Patients were classified as F-HLH based on their genetic confirmation of known mutation or on their clinical criteria, which include a constellation of abnormalities, early disease onset, recurrent HLH in the absence of other causes, or a family history of HLH., Results: Fifty-eight patients (28 male, 30 female), with a mean age of 21.0 ± 33.9 months, were included. The most common principal diagnosis was hematological or immune dysfunction (39.7%), followed by cardiovascular dysfunction in 13 (22.4%) patients. Fever was the most common clinical presentation in 27.6%, followed by convulsions (13.8%) and bleeding (13.8%). There were 20 patients (34.5%) who had splenomegaly, and more than 70% of patients had hyperferritinemia >500 mg/dl, hypertriglyceridemia >150 mg/dl and hemophagocytosis in bone marrow biopsy. Compared to deceased patients 18 (31%), survivors had significantly lower PT ( p  = 041), bilirubin level of <34.2 mmol/L ( p  = 0.042), higher serum triglyceride level ( p  = 0.036), and lesser bleeding within the initial 6 h of admission ( p  = 0.004). Risk factors for mortality included requirements of higher levels of hemodynamic (61.1% vs. 17.5%, p  = 0.001) and respiratory (88.9% vs. 37.5%, p  < 0.001) support, and positive fungal cultures ( p  = 0.046)., Conclusions: Familial HLH still represents a challenge in the pediatric critical care setting. Earlier diagnosis and prompt initiation of appropriate treatment could improve F-HLH survival., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Alsohime, Temsah, Alotaibi, Alhalabi, AlEnezy, Yousef, Alzaydi, Inany, Al-Eyadhy, Almazyad, Alharbi, Alsoqati, Andijani, Ghazal, Masri, Doussouki, Butt, Alshehri, Alsatrawi, Macarambon, Hasan and Alsultan.)

Objectives: To measure the prevalence of viral infections, length of stay (LOS), and outcome in children admitted to the pediatric intensive care unit (PICU) during the period preceding the COVID-19 pandemic in a MERS-CoV endemic country., Methods: A retrospective chart review of children 0-14 years old admitted to PICU with a viral infection., Results: Of 1736 patients, 164 patients (9.45%) had a positive viral infection. The annual prevalence trended downward over a three-year period, from 11.7% to 7.3%. The median PICU LOS was 11.6 days. Viral infections were responsible for 1904.4 (21.94%) PICU patient-days. Mechanical ventilation was used in 91.5% of patients, including noninvasive and invasive modes. Comorbidities were significantly associated with intubation (P-value = 0.025). Patients infected with multiple viruses had median pediatric index of mortality 2 (PIM 2) scores of 4, as compared to 1 for patients with single virus infections (p < 0.001), and a median PICU LOS of 12 days, compared to 4 in the single-virus group (p < 0.001). Overall, mortality associated with viral infections in PICU was 7 (4.3%). Patients with viral infections having multiple organ failure were significantly more likely to die in the PICU (p = 0.001)., Conclusion: Viral infections are responsible for one-fifth of PICU patient-days, with a high demand for mechanical ventilation. Patients with multiple viral infections had longer LOS, and higher PIM 2 scores. The downward trend in the yearly rate of PICU admissions for viral infections between the end of the MERS-CoV outbreak and the start of the COVID-19 pandemic may suggest viral interference that warrants further investigations., Competing Interests: Declaration of competing interest Authors have no conflict of interest to declare., (Copyright © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Herpes zoster (HZ) is caused by reactivation of the latent varicella zoster virus (VZV) following decline in cell-mediated immunity. All over the world, in the past couple of years, the Corona Virus 2019 (COVID-19) has emerged as a viral cause of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection. Based on the current limited evidence, co-infection of COVID-19 with VZV or reactivation of VZV after COVID-19 vaccination has been sporadically reported. All patients diagnosed with HZ, in Farwaniya Hospital in Kuwait, from March 2020 to July 2021, having either (A) a positive COVID-19 polymerase chain reaction (PCR) test, or (B) been vaccinated against SARS-CoV-2 were enrolled in the study. All patients' demographic information, medical history, laboratory findings, and vaccination status was documented. All statistical analyses were performed using SPSS Statistics version 21.0 software. Twelve cases infected with COVID-19 with a positive PCR (group 1) and five cases vaccinated against SARS-CoV-2 (group 2) were documented. Out of the 12 COVID-19 infected patients (group 1), only two patients (16.67%) required hospitalization, while the remaining 10 patients had mild/moderate lymphopenia. Furthermore, amongst the 12 positive COVID-19 cases, four patients with HZ were diagnosed within the first week of COVID-19, while the remaining eight cases were diagnosed within 8 weeks of COVID-19. Thoracic segments were affected in five cases (41.67%), cervical in one case (8.33%), cranial in two cases (16.67%), lumbar in three cases (25%) and sacral in one case (8.33%). In group 2, three patients presented with HZ within 4 weeks of having received the first dose of the vaccine and two patients after the second dose. Blood investigations for all five vaccinated patients did not show any abnormalities. Cervical segments were affected in two patients (40%), and cranial, thoracic, and lumbar segment in the remaining patients respectively (20%). Experts must be aware of the probable increased risk of HZ during the COVID 19 pandemic. We propose appropriate curative and preventive measures against HZ infection, including a systematic follow-up of these patients to ensure that they stick to extreme safety measures till the diagnosis of COVID-19 is omitted., (© 2022 Wiley Periodicals LLC.)

Background: Safeguarding children and adolescents from unintentional injuries is a significant concern for parents and caregivers. With them staying more at home during the coronavirus disease 2019 pandemic, more educational tools and valid educational programs are warranted to improve parental knowledge and awareness about childhood and adolescences' safety. This study aims to explore the effectiveness of childhood and adolescence safety campaigns on parents' knowledge and attitude toward preventable injuries., Methods: This was a pre-post experimental study, in which the predesigned assessments were used as an evaluation tool before and after attending a childhood and adolescence safety campaign. The pre-post assessment question included questions to evaluate the socio-demographic status, followed by knowledge questions in line with the current childhood and adolescence safety campaign. The outcomes of interest were assessed before and after attending the campaign's stations., Results: Three hundred eight parents volunteered to participate in this study. Their knowledge score improved from 36.2 [standard deviation (SD) 17.7] to 79.3 (SD 15.6) after attending the Campaign (t value = 34.6, P < .001). Both, perceptions on the preventability of accidents and the parents' perceived usefulness of educational campaigns showed improvements, with (t value = 6.3, P < .001) and (t value = 3.097, P < .001), respectively., Conclusion: The educational childhood and adolescence safety campaign for caregivers in Saudi Arabia resulted in a significant increase in the overall knowledge and attitudes toward childhood and adolescence's safety. As children and adolescents are currently staying at home more, additional educational tools and programs are warranted to promote safe practices among parents and caregivers., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Acute myeloid leukemia (AML) is a hematological malignancy that arises from the clonal proliferation of immature myeloid cells. Although the number of AML cases has dramatically increased worldwide, information on its prevalence and incidence in Kuwait is lacking. This study reports the incidence of AML and patient demographics in the country from 2014 to 2020, based on the 2016 WHO classification of AML., Subjects and Methods: Data on patients with AML, including acute promyelocytic leukemia (APL), were collected from a clinical cohort with 281 cases analyzed in this study., Results: The overall median age of the population was 47 years with a 1.1:1 male-to-female ratio. Over the study period, the incidence of AML demonstrated a general increasing trend, with the highest and lowest overall incidence occurring in 2018 and 2015, respectively. The frequency of APL in our cohort was 8.9%. Regarding the 2017 European LeukemiaNet (ELN) risk stratification of patients with AML, 37%, 46%, and 17% of patients had a favorable, intermediate, and adverse risk, respectively. A total of 57% of cases achieved complete remission post-induction, and the median overall survival was 37 months., Conclusion: Our study may help predict the future trends of AML in Kuwait to help improve clinical management and patient outcomes., (© 2022 The Author(s). Published by S. Karger AG, Basel.)

Objectives: To identify the causes, modes, and timing of death in a tertiary pediatric intensive care unit (PICU)., Methods: This is a retrospective data analysis of patients older than 48 hours and younger than 15 years who died in the PICU over a 5-year period from January 2012 until December 2016 at a tertiary hospital in Riyadh, Saudi Arabia., Results: There were 101 deaths out of 2295 admissions, representing average crude mortality rate of 4.4%. Sepsis was the most common cause of death in 31 patients (30.7%), followed by lower respiratory tract infections in 19 (18.8%), and cardiac diseases in 12 (11.9%). Failed cardiopulmonary resuscitation was the most common mode of death in 51 patients (50.5%), followed by withholding life-sustaining treatment in 43 (42.6%), and brain death in 7 (6.9%). Although more deaths occurred during after hours (n=70; 69.3%), there was no significant correlation between mode of death and working hours vs. after hours ( p >0.05). Among the cohort, 63 patients (62.4%) had an infection-attributed mortality, of which 43 (68.3%) were bacterial, 14 (22.2%) were viral, and 10 (15.9%) were fungal., Conclusion: Infections remain a significant cause of death in the PICU. Further improvement of prevention programs and early therapy of severe infections could lower pediatric mortality. This report highlights the need for enhancing palliative care programs. The low rate of brain death diagnoses warrants further investigation., (Copyright: © Saudi Medical Journal.)

Objective: To determine the value and perspectives of intensive care unit (ICU) healthcare professionals (HCPs) and families about the Glass Door (GD) decal team communication tool., Design: Quality improvement methodology was used to design, test and implement the GD. Uptake was measured through audit. Impact was assessed through mixed methodology (survey of ICU HCPs (n=96) and semi-structured interviews of HCPs (n=10) and families (n=7))., Setting: Eighteen bed, closed, mixed medical-surgical-cardiac ICU in a tertiary care, university-affiliated, paediatric hospital., Population: Interdisciplinary ICU HCPs and families of children admitted to the ICU., Intervention: A transparent template (the GD) applied to the outside of ICU patients' doors with sections for HCPs names, physiological goals and planned tests and treatments for the day. Medical staff completed the GD in rounds (AM and PM) and any HCP caring for the patient updated it throughout the day., Measurements and Main Results: After 3 months, 96% of 613 doors were employed of which 99% respected confidentiality. ICU HCPs reported improved understanding of the patient's plan (84% today vs 59% pre-GD, p<0.001) and sense that families were up-to-date (79% today vs 46% pre-GD, p<0.001). Based on semi-structured interviews, the GD promoted a shared understanding of the plan contributing to care continuity. The GD reassured families the team is working together and fostered family engagement in the care. Routine family experience surveys showed no change in families' sense of privacy during admission; families denied the GD's anticipated compromise of confidentiality., Conclusions: The GD decal communication tool, visible on the patient's door, improved ICU HCPs' perceived knowledge of their patient's plan. The GD improved the shared mental model, facilitated teaching and information transfer and fostered family engagement. Challenges included knowing the rules for use and consistent application. Concerns initially raised by HCPs about confidentiality were denied by families., 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.)

Understanding the factors affecting survival and modifying the preventable factors may improve patient outcomes following cardiopulmonary resuscitation (CPR). The aim of this study was to assess the prevalence and outcomes of cardiac arrest and CPR events in a tertiary pediatric intensive care unit (PICU). Outcomes of interest were the return of spontaneous circulation (ROSC) lasting more than 20 minutes, survival for 24 hours post-CPR, and survival to hospital discharge. We analyzed data from the PICU CPR registry from January 1, 2011 to January 1, 2018. All patients who underwent at least 2 minutes of CPR in the PICU were included. CPR was administered in 65 PICU instances, with a prevalence of 1.85%. The mean patient age was 32.7 months. ROSC occurred in 38 (58.5%) patients, 30 (46.2%) achieved 24-hour survival, and 21 (32.3%) survived to hospital discharge. Younger age ( p  < 0.018), respiratory cause ( p  < 0.001), bradycardia ( p  < 0.018), and short duration of CPR ( p  < 0.001) were associated with better outcomes, while sodium bicarbonate, norepinephrine, and vasopressin were associated with worse outcome ( p  < 0.009). The off-hour CPR had no impact on the outcome. The patients' cumulative predicted survival declined by an average of 8.7% for an additional 1 minute duration of CPR ( p  = 0.001). The study concludes that the duration of CPR, therefore, remains one of the crucial factors determining CPR outcomes and needs to be considered in parallel with the guideline emphasis on CPR quality. The lower survival rate post-ROSC needs careful consideration during parental counseling. Better anticipation and prevention of CPR remain ongoing challenges., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Philadelphia-negative myeloproliferative neoplasms (MPNs) are a group of hematopoietic stem cell disorders that include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). This study examines the driver mutations among patients with MPNs in Kuwait., Patients and Methods: This study was a retrospective review of 942 MPN cases with a driver mutation from July 2007 to June 2019 to examine their demographic, clinical, and laboratory attributes., Results: The annual incidence of MPNs is 1.6 per 100,000 persons, and ET is the most common subtype. The median age of our cohort was 55 years, and the patients were predominantly male. We found that the most frequent gene mutation of MPNs in our cohort was the JAK2V617F mutation, which was present in 90% of cases, followed by the CALR exon 9, MPLW515L/K, and JAK2 exon 12 mutations. In our cohort, thrombotic events were observed in 18.7% of cases., Conclusion: Although Philadelphia-negative MPNs are rare hematologic malignancies, thrombosis is a relatively common initial presentation. The JAK2V617F mutation was the driver mutation in the majority of patients with MPN., (Copyright © 2021. Published by Elsevier Inc.)

Background: Characteristics of critical Severe Acute Respiratory Syndrome-related Coronavirus 2 (SARS-CoV-2) infection in children is not well understood. This study described the clinical characteristics of children admitted to intensive care units (ICU) and explored factors associated with the need for invasive ventilation or mortality., Methods: A multicenter, retrospective, cohort study was conducted over eight medical centers, including all patients younger than 18 years of age and admitted to the ICU due to a direct consequence of coronavirus disease 2019 (COVID-19). Patients who were admitted to the ICU for any alternate reason and tested positive for SARS-CoV-2 by screening test, and patients who were admitted due to multi-inflammatory syndrome in children, were excluded. Demographic, laboratory, imaging, and clinical data were collected. Descriptive statistics were used to compare survivors and non-survivors. Fine and Gray's hazard model was used to estimate the association between clinical variables and ICU death., Results: During the study period, 25 pediatric COVID-19 patients received care in the ICUs. The median age was 2.78 years (IQR 0.21-8.51), and 60% were male. Only three patients were reported to be previously healthy at admission. Nine (36%) patients required invasive mechanical ventilation, including two were on extracorporeal membrane oxygenation. Four (16%) patients died during ICU care. In univariate analysis, the presence of comorbidity (HR 0.0001; 95%CI 0.00001-0.00016), platelets count (HR 0.99; 95% CI 0.98-0.99), elevated procalcitonin (HR 1.05; 95%CI 1.016-1.09), and circulatory compromise (HR 16.34; 95%CI 1.99-134.35), all at the time of ICU admission, were associated with in-ICU mortality., Conclusion: Our findings suggest that children admitted to the ICU with SARS-CoV-2 infection, generally, have a favorable outcome. Low platelets count, elevated procalcitonin, presence of comorbidity, and shock at the time of ICU admission were associated with death. This study may shed more light on the disease dynamics of critical pediatric COVID-19., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: The coronavirus disease (COVID-19) pandemic is an international public health threat. This study aimed to evaluate COVID-19-related knowledge, preventive behaviors, and risk perception among Saudi Arabian medical students and interns., Materials and Methods: This cross-sectional study was conducted among fourth- and fifth-year medical students and interns between June and August 2020 at three colleges of medicine in Qassim Region, Saudi Arabia. A previously validated questionnaire was distributed as an online survey., Results: The total mean knowledge score was 12.5/15 points; 83.9% achieved a high score. The mean score of self-reported preventive behavior was 8.40; 94.1% achieved a high score. The overall mean risk perception score was 5.34/8 points; 31.6% achieved a high score., Conclusion: Medical students assessed in this study displayed sufficient knowledge and preventive behaviors regarding the COVID-19 pandemic and an average level of risk perception. Lower scores by younger medical students suggest that they must improve their COVID-19 knowledge and risk perception, as they are a potential source of health information in their communities.

The epidemiology, genetics, and thrombosis risk of MPNs among Arabs are largely unknown. This may be attributed to scarce epidemiological data, particularly from our region. Our study included 381 Kuwaiti nationals with Ph-negative MPNs and a confirmed driver mutation involving JAK2 (exon 12 14), CALR, or MPL. This first regional study examines the demographics, clinical parameters, and thrombosis-related attributes of the participants. This study reported a median age of 58 years, with females and males representing 54.9% and 45.1%, respectively. ET was the most frequent subtype of Ph-negative MPNs in our population, accounting for 52.0% of the cases, followed by PV, found in 34.6% of the participants, and PMF, found in 8.4% of participants. The crude annual cumulative incidence of Ph-negative MPNs in Kuwait ranged from 0.674 to 3.177 per 100,000 population across the study period. The most common driver mutation was JAK2V617F, with a frequency of 89.5%. At diagnosis, 19.2% of the patients presented with unexplained thrombosis, and almost half were of arterial origins. Males were more likely to present with arterial thrombosis than females (61.5% vs. 35.3%), whereas venous thrombotic events were more common in females than in males (47.1% vs. 17.9%; p-value = 0.025). Ph-negative MPNs in Kuwait are rare; however, thrombosis is a frequent complication, being documented in up to 19.2% of cases at presentation, more commonly at arterial sites. These findings call for thorough evaluation of patients with unexplained derangements in their hematological parameters during follow-ups., (© 2020 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Context: Diabetes-related retinopathy (DR), the most common complication of diabetes mellitus (DM), is a severe and preventable cause of visual loss and blindness that has been reported to be the fourth leading cause of blindness among four million cases globally., Aims: This study aimed to evaluate the knowledge, attitudes, and practices of fourth- and fifth-year medical students concerning patients with DR., Methods and Materials: This cross-sectional descriptive study was conducted at a College of Medicine in Saudi Arabia, in November 2018, and comprised 153 fourth- and fifth-year medical students of both sexes. Participants were required to complete a previously validated hard copy questionnaire., Results: In total, > 50% of participants showed good knowledge of DR (poor participant knowledge, n = 65, 42.5%). We found 16 (10.5%) participants had poor attitudes to DR compared to 137 (89.5%) of participants with good attitudes, and 32 (20.9%) participants showed poor practices compared to 121 (79.1%) participants showing good practices. There was a statistically significant difference between the sexes and the level of practice ( P = 0.021)., Conclusions: More than 50% of participants in our study showed good knowledge concerning DR, with excellent attitudes and practices. Moreover, participants' age was identified as a significant factor affecting practice regarding DR. More targeted education is required to improve their knowledge base in regard to DR. Medical faculties have a significant role in the education of medical students to ensure greater awareness of DR., Competing Interests: There are no conflicts of interest., (Copyright: © Journal of Family Medicine and Primary Care.)

Dorsal dimelia is a form of duplication along the dorsoventral axis of the developing limb. Previous authors reporting on this rare entity have stated that the essential feature of the deformity is the presence of double or circumferential nail at the tip of the finger and that the aetiology is probably related to a mutation of Engrailed-1 (En-1). In this paper we report on two cases to demonstrate that the deformity in humans may be fully or partially expressed, with or without the double nail deformity, respectively. We also reviewed reported cases in humans and experimental animals and searched our two cases for candidate causative genes within the En-1 pathway.