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Fayez Elshaer,1,2 Samih Lawand,3 Mohamed Zeyad,3 Fakhr Al Ayoubi,1 Yassmin Hanfi,3 Abdullah AlQarni1,4 1King Fahad Cardiac Center, Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2National Heart Institute, Cairo, Egypt; 3Dallah Hospital, Riyadh, Saudi Arabia; 4Department of Medicine, University of Bisha, Bisha, Saudi ArabiaCorrespondence: Fayez ElshaerKing Fahad Cardiac Center (KFCC), King Khaled University Hospital (KKUH), King Saud University, Riyadh 7805, Saudi ArabiaTel +4671161Fax +4671158Email felshaer@ksu.edu.saPurpose: This study analyzes the safety and efficacy of LCZ696 (valsartan/sacubitril), a combination of angiotensin II receptor blocker and neprilysin inhibitor (ARNI), in patients with heart failure and preserved ejection fraction (HFpEF).Patients and Methods: An observational pilot study was conducted using a prospective design. A sample of 50 HFpEF patients (27 females and 23 males) was included on LCZ696 (50 mg orally, twice daily), which was then titrated up to a maximum tolerated dose, and followed up in the outpatient clinic. Thirty-seven patients received LCZ696 during hospitalization for decompensated heart failure or before their discharge while same titration was followed for the remaining patients.Results: Patients were classified as New York Heart Association (NYHA) class III (64%), NYHA class IV (22%), and NYHA class II (14%). Diabetes mellitus was found in 74% of patients, while hypertension in 94%. Rapid clinical improvement was found with significant reduction in NYHA class down to NYHA class II (p=0.018). Patients had cleared off the fine basal crackles (specific for the interstitial pulmonary disease) secondary to heart failure (p< 0.001) and improvement or disappearance of edema of the lower limbs (p< 0.001). Heart rate response and jugular venous pressure and NT-pro-BNP were reduced significantly (p-value < 0.001, 0.005, respectively). Echocardiographic criteria for diastolic LV dysfunction (primarily E/A ratio) improved (p=0.001). Serum sodium (NA) levels improved significantly (p=0.015), without worsening renal function or limiting hyperkalemia.Conclusion: LCZ696 (sacubitril/valsartan; ARNI) led to significant clinical improvements in patients with HFpEF. Further, a randomized study is needed to test whether it leads to positive outcomes for a larger sample.Ethical Approval: Project No. E-17-2414, King Saud University, Kingdom of Saudi Arabia.Keywords: impaired diastolic relaxation, left ventricular hypertrophy, LVH, subtle left ventricular systolic dysfunction, ventricular-vascular

The purpose of this paper was first to gain an in-depth understanding of the barriers and facilitators to implementing the BPS model and pain neuroscience education in the current Lebanese physical therapy health care approach and explore its acceptability. A qualitative semi-structured interview using purposive sampling was conducted with eight Lebanese physical therapists practising in different governorates. The transcribed text from the interviews was analyzed using inductive thematic analysis. Two topics were generated and constructed by the researchers: (1) "barriers to the implementation of pain neuroscience education, with subthemes including (a) "current health care approach," (b) "basic curriculum and continuing education," (c) "patients' barriers"; (2) "facilitators to the implementation of pain neuroscience education," with subthemes containing (a) "interest in the BPS model, (b) "therapeutic alliance," and (c) "motivation for future training on BPS approach." The analysis of the results showed that Lebanese physical therapists currently hold a strong biomedical view of chronic pain, assessment, and treatment. However, despite the presence of barriers and challenges, they are aware and open to consider the implementation and future training about the BPS model and pain neuroscience education in their approach. The exploration of potential barriers and facilitators to the bio-psychosocial model and pain neuroscience education implementation may provide an opportunity for better development and design of a culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists. The exploration of barriers and facilitators to the implementation of pain neuroscience education will help to improve pain education and ensure better clinical pain management. The most important barriers were the dominant characteristic of the Lebanese physical therapist's health approach, which is focused on a biomechanically oriented model, and their lack of knowledge to approach chronic pain from a biopsychosocial perspective. [ABSTRACT FROM AUTHOR]

Introduction: Prayer is the most common therapy used in alternative medicine1. The objective of this study was to explore the effect of prayers on endogenous pain modulation, pain intensity, and sensitivity in healthy religious participants. Methods: Two hundred and eight healthy religious participants were enrolled in this study and randomly distributed into two groups, a prayer group (n = 156) and a poem reading or control group (n = 52). Participants from the prayer group were allocated to either an active prayer group (n = 94) receiving an active type of praying or to a passive prayer group (n = 62) receiving a passive type of praying. Pain assessments were performed prior to and following the prayer or poem reading interventions and included pressure pain threshold assessment, conditioned pain modulation, and a numerical pain rating scale for perceived pain intensity. Results: A significant group-by-time interaction for PPT (p = 0.014) indicated post-intervention increases in PPT in the prayer group but not in the poem reading control group. Also, a significant group-by-time interaction for PPT (p = 0.005) indicated that these effects were greater in the active prayer group than in the passive prayer group. Participants experienced a decrease in CPM efficacy (p = 0.030) and an increase in pain intensity (p < 0.001) following the interventions, independent of their group allocation. Discussion: The results showed that prayer, irrespective to type, can positively affect pain sensitivity and intensity, but does not influence endogenous pain inhibition. Process evaluation: Future research should focus on understanding the mechanism behind "prayer induced analgesia". [ABSTRACT FROM AUTHOR]

Introduction: There is growing acknowledgement of the benefits of incorporating a bio-psychosocial model of understanding pain within physical therapist practice1. Consequently this has led to an increasing interest in interventions such Pain neuroscience education (PNE). However, pain management strategies developed by clinicians in one culture may not necessarily be understood, appropriate, or effective in another culture2 Methods: This study is part of a broader research in the development of culturally sensitive pain neuroscience education for the Lebanese population. Therefore, the purpose of this paper is to first gain an in-depth understanding of the Lebanese physiotherapists' perceptions towards the management of chronic low back pain as well as the knowledge regarding PNE. A qualitative one-to-one semi-structured interviews with 10 practicing physical therapists were conducted. The transcribed text from the interviews was analyzed using inductive thematic analysis. Results: Several themes were generated, identified, and constructed by the researchers: (1) physiotherapists use of a biomechanical approach. (2) Poor knowledge about the bio-psychosocial approach or PNE. (3) Barrier and facilitation for the implementation of PNE. Discussion: The preliminary results showed a limited knowledge of the bio-psychosocial approach, or PNE, and that the Lebanese physical therapist use more a biomechanical approach in the treatment and assessment of people with chronic low back pain. Process evaluation: The results showed that training is needed for physiotherapists to deliver a broader model of care, and that future research should focus on developing a culturally sensitive PNE material. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodResultsConclusion\nIMPLICATIONS FOR REHABILITATIONThis paper aims to understand the distinctive biopsychosocial aspects and patient perspectives on chronic low back pain in Lebanon, an Arab country with a unique and rich cultural heritage.Qualitative, semi-structured interviews with 12 Lebanese patients purposefully sampled from various governorates. The interviews included participants from different geographic areas and religions. The data underwent analysis through an inductive thematic approach guided by a bounded relativist ontology, a subjectivist epistemology, and a descriptive phenomenological framework. The coding process was managed by computer-assisted qualitative data analysis software (QSR NVivo version 12.0).The researchers identified and constructed two themes: (1) Chronic low back pain: understanding the impact, coping strategies, and communication patterns in lived experiences within the Lebanese context. This theme sheds light on the complexities of pain management and societal influences in Lebanon. (2) Explanatory model of patients living with chronic low back pain in Lebanon. This theme allowed an exploration of the multifaceted narratives of chronic low back pain.This study found that Lebanese individuals attribute chronic low back pain to biomedical factors despite some recognizing psychosocial elements. It emphasizes the need to educate patients on the biopsychosocial model, facilitate better care, and dispel misconceptions.The exploration of patients’ pain perception may provide an opportunity to better develop and design culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The rehabilitation process should incorporate a balanced biopsychosocial approach, addressing both physical and psychosocial elements of pain, to provide more effective care and outcomes for Lebanese patients who predominantly attribute chronic low back pain to biomedical factors.Lebanese healthcare professionals need to improve communication with Lebanese patients regarding the nature of chronic low back pain, using clear communication to help dispel misconceptions and enhance rehabilitation outcomes.The exploration of patients’ pain perception may provide an opportunity to better develop and design culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The rehabilitation process should incorporate a balanced biopsychosocial approach, addressing both physical and psychosocial elements of pain, to provide more effective care and outcomes for Lebanese patients who predominantly attribute chronic low back pain to biomedical factors.Lebanese healthcare professionals need to improve communication with Lebanese patients regarding the nature of chronic low back pain, using clear communication to help dispel misconceptions and enhance rehabilitation outcomes. [ABSTRACT FROM AUTHOR]

Today, understanding of systematic reviews and meta-analyses and their practical use is essential for who concerned with society's health. Most of the medical reports invoked to these reviews and statements and it is necessary for scientific experts to be familiar with their performing rules and the way of their writing. The basic sciences specialists and clinical professionals study them to keep up the level of their knowledge on the fields of interest.These articles are often seen as the beginning of the developing clinical guidelines for organizations that provide facilities to carry out a research and it is used to verify and justify further investigation. Some of the journals in the field of health adjust their publishing to this direction. Like other researches, Value of the systematic reviews and meta-analyses of the literature is to answer three questions: 1- what has been done? 2- what has been proven? and, 3- how has been it arranged? Systematic review and meta-analysis of basic sciences and clinical medicine could manage the problems of health system and formulate the guidelines for the collection and conclusions of the completed research, which is contributed to a specific subject or question. Guidelines developed at the PRISMA; Preferred Reporting Items for Systematic Reviews and Meta-Analyses, included a checklist and a flow chart. Therefore, the present study aimed to inform the Persian language researchers to publish their writing according to PRISMA statement. [ABSTRACT FROM AUTHOR]

Purpose: To assess the knowledge and attitudes of physicians towards adverse drug reaction (ADR) reporting at King Khalid University Hospital, Riyadh, Saudi Arabia. Method: The study was conducted in King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia over a three-month period (April to June 2014). A self-administered questionnaire was delivered to 116 physicians. The questionnaire comprised of close-ended as well as open-ended questions. Descriptive statistics including, frequency distribution and percentages, were used for both demographic data and various responses to the questions. Results: The response rate was 81.09%. The mean age of the respondents was 33.3 ± 11.49 years. Of the 94 physicians who completed the questionnaire, 88.7% of them didn't know about the National Pharmacovigilance Center. Almost all the physicians (95.7%) were not satisfied by their training in ADRs reporting while half (49.3%) of the respondents thought that only serious ADRs should be reported. Conclusion: There is a need for more educational and training programs for physicians regarding the pharmacovigilance system and ADRs reporting. More research is needed to study the knowledge and attitudes of other healthcare professionals and in various settings. [ABSTRACT FROM AUTHOR]

The implementation of guideline-directed medical therapy (GDMT) in heart failure (HF) has many challenges in real-world clinical practice. The consensus document is written considering the variability of the clinical presentation of HF patients. HF medical therapies need frequent dose adjustment during hospital admission or when patients develop electrolyte imbalance, acute kidney injury, and other acute illnesses. The paper describes clinical scenarios and graphs that will aid the managing physicians in decision-making for HF therapy optimization., Competing Interests: Conflict of interest: None., (© 2024 Saudi Heart Association.)

Objectives: Hospital overload is a persistent occurrence in daily practice. Interventions such as point-of-care testing (POCT) are needed to alleviate the pressure faced by healthcare providers and administrators., Methods: An invited panel of experts from Saudi Arabia was formed under the auspices of the Saudi Heart Association in order to discuss local treatment gaps in the management of patients receiving anticoagulation therapy. This was done in a series of meetings, which resulted in the development of official recommendations for the implementation of POCT for anticoagulation monitoring in the country. Recommendations were based on a comprehensive literature review and international guidelines taking into consideration local clinical practice, clinical gaps, and treatment/testing availabilities., Results: Vitamin K antagonist (VKA)-based anticoagulation therapy requires routine monitoring. POCT is a promising model of care for the monitoring of International Normalized Ratio (INR) in patients receiving oral anticoagulation in terms efficacy, safety and convenience. The availability of POC INR testing should not replace the use of standard laboratory anticoagulation monitoring. However, there are several indications for implementing POCTINR monitoring that was agreed upon by the expert panel. POCT for anticoagulation monitoring should primarily be used in the warfarin (or other VKA) monitoring clinic in order to ensure treatment efficiency, cost-effectiveness of care, patient satisfaction, and quality of life improvement. The expert panel detailed the requirements for the establishment of a warfarin (or other VKA) monitoring clinic in terms of organization, safety, quality control, and other logistic and technical considerations. The limitations of POCT should be recognized and recommendations on best practices should be strictly followed. Core laboratory confirmation should be sought for patients with higher INR results (>4.7) on POCT. Proper training, quality control, and regulatory oversight are also critical for preserving the accuracy and reliability of POCT results., Conclusions: POCT enables more rapid clinical decision-making in the process of diagnosis (rule-in or rule-out), treatment choice and monitoring, and prognosis, as well as operational decision-making and resource utilization. POCT thus can fulfill an important role in clinical practice, particularly for patients receiving VKAs., Competing Interests: Conflict of interest: None declared., (© 2023 Saudi Heart Association.)

Background: The improvement in the clinical care for patients with thrombotic thrombocytopenic purpura (TTP) is evolving, and many efforts are being put to standardize it. Here, we aimed to assess the provided care at a national level and identify deficiencies., Methods: A national Saudi retrospective descriptive study was carried out at six tertiary referral centers and included all patients who underwent therapeutic plasma exchange (TPE) for the diagnosis of TTP between May 2005, and July 2022. Collected information included demographic data, clinical features on presentation, and the results of laboratory investigations at admission and discharge. In addition, the number of TPE sessions, days till the first session of TPE, usage of immunological agents, and clinical outcomes were all collected., Results: One hundred patients were enrolled, predominantly female (56%). The mean age was 36.8 years. At diagnosis, 53% of patients showed neurological involvement. The mean platelet count at presentation was 21 × 10 9 /L. All patients had anemia (mean hematocrit 24.2%). Schistocytes were present in the peripheral blood film of all patients. The mean number of TPE rounds was 13 ± 9.3, and the mean days to start TPE since admission for the first episode was 2.5 days. ADAMTS13 level was measured in 48% of patients and was significantly low in 77% of them. Assessing for clinical TTP scores, 83%, 1000%, 64% of eligible patients had an intermediate/high PLASMIC, FRENCH, and Bentley scores, respectively. Caplacizumab was used on only one patient, and rituximab was administered to 37% of patients. A complete response for the first episode was achieved in 78% of patients. The overall mortality rate was 25%. Neither time to TPE, the use of rituximab or steroid affected survival., Conclusions: Our study shows an excellent response to TPE with a survival rate approximate to the reported international literature. We observed a deficiency in using validated scoring systems in addition to confirming the disease by ADAMTS13 testing. This emphasizes the need for a national registry to facilitate proper diagnosis and management of this rare disorder., (© 2023 Wiley Periodicals LLC.)

Prayer is considered to be the most common therapy used in alternative medicine. This study aimed to explore the effect of prayers on endogenous pain modulation, pain intensity, and sensitivity in healthy religious participants. A total of 208 healthy religious participants were enrolled in this study and randomly distributed into two groups, a prayer group (n = 156) and a poem reading or control group (n = 52). Participants from the prayer group were then selectively allocated using the prayer function scale to either an active prayer group (n = 94) receiving an active type of praying or to a passive prayer group (n = 62) receiving a passive type of praying. Pain assessments were performed before and following the interventions and included pressure pain threshold assessment (PPT), conditioned pain modulation (CPM), and a numerical pain rating scale. A significant group-by-time interaction for PPT (p = 0.014) indicated post-intervention increases in PPT in the prayer group but not in the poem reading control group. Participants experienced a decrease in CPM efficacy (p = 0.030) and a reduction in their NPRS (p < 0.001) following the interventions, independent of their group allocation. The results showed that prayer, irrespective of the type, can positively affect pain sensitivity and intensity, but does not influence endogenous pain inhibition during hot water immersion. Future research should focus on understanding the mechanism behind "prayer-induced analgesia.", (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The burden of cardiovascular diseases is undeniable in local populations, who have high mortality rates and a young age of disease onset. A systematic review of emerging evidence and update of the Saudi Heart Association (SHA) 2019 heart failure (HF) guidelines was therefore undertaken., Methodology: A panel of expert cardiologists reviewed recommendations of the 2019 guidelines following the Saudi Heart Association methodology for guideline recommendations. When needed, the panel provided updated and new recommendations endorsed by the national heart council that are appropriate for clinical practice and local resources in Saudi Arabia., Recommendations and Conclusion: The focused update describes the appropriate use of clinical assessment as well as invasive and non-invasive modalities for the classification and diagnosis of HF. The prevention of HF was emphasized by expanding on both primary and secondary prevention approaches. Pharmacological treatment of HF was supplemented with recommendations on newer therapies, such as SGLT-2 inhibitors. Recommendations were also provided on the management of patients with cardiovascular and non-cardiovascular co-morbidities, with a focus on cardio-oncology and pregnancy. Updated clinical algorithms were included in support of HF management in both the acute and chronic settings. The implementation of this focused update on HF management in clinical practice is expected to lead to improved patient outcomes by providing evidence-based comprehensive guidance for practitioners in Saudi Arabia., Competing Interests: Conflicts of interest None declared., (© 2023 Saudi Heart Association.)

Background: there is limited data on Emergency department (ED) cardiovascular disease (CVD) presentations and outcomes amongst cancer patients., Objectives: The present study aimed to describe the clinical characteristics, prevalence, and clinical outcomes of the most common cardiovascular ED admissions in patients with cancer., Methods: All ED encounters with a primary CVD diagnosis from the US Nationwide Emergency Department Sample between January 2016 to December 2018 were stratified by cancer type as well as metastatic status. Multivariable logistic regression was performed to determine the adjusted odds ratios of in-hospital mortality in different groups., Results: From a total of 20,737,247 ED encounters with a primary CVD diagnosis, cancer was present in 3.4%. In patients with cancer the most common CVDs were DVT/PE (20%), hypertensive heart or kidney disease (14.7%), and AF/flutter (11.2%). The distribution of CVDs varied by cancer type, with AF/flutter most common in patients with lung cancer, AMI most common in patients with prostate cancer, heart failure most common in those with haematological malignancies, and patients with colorectal cancer having the greatest frequency of DVT/PE. Cancer status was independently associated with significantly higher risk of mortality in almost all CVD categories, consistent across all the cancer types, amongst which lung cancer patients had the highest risk of mortality across all CVD categories, except intracranial haemorrhage and hypertensive crisis., Conclusions: Cardiovascular presentations to the ED varied by cancer subtype. Across all cancer subtypes, patients presenting with cardiovascular presentations carried a significantly increased risk of mortality compared to patients with no cancer., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Introduction: One of the challenges of surgery on patients with active SARS-CoV-2(severe acute respiratory syndrome coronavirus 2) infection is the increased risk of postoperative morbidity and mortality., Aim: This study will describe and compare the postoperative morbidity and mortality in asymptomatic patients or those with mild infection with those with severe COVID-19 infection undergoing elective or and emergency surgery., Materials and Methods: This is a retrospective study of 37 COVID 19 patients who had the infection 7 days prior to and 30 days after emergency or elective surgery. Patients were divided to two groups. Group1: the asymptomatic or those with mild infection that is diagnosed just before surgery (14 patients). Group 2: those who were admitted to the hospital because of severe COVID-19 and were operated for COVID-19 related complications (23 patients). Morbidity and mortality of both groups was studied., Results: There was no significant difference in gender between the two groups. There were 5 females (2 in group 1, and 3 in group 2) and 32 males (12 in group 1, and 20 in group 2). Mean age for all patients was 49.8years (38 for group 1 and 57 for group2). Median age for all patients was 50 years (37.5 for group 1 and 57 years for group 2). Sepsis developed in 7 patients (1 patient in group 1 and in 6 patients in group 2). Statistically there was no significant difference in occurrence of sepsis between the two groups. There was a significant difference in the intensive care stay between the two groups (higher in group 2). Four deaths were reported in group 1 and fourteen in group 2. Eighteen out of thirty-seven patients died., Conclusion: Severity of COVID-19 infection will prolong the hospitalization and ICU stay in surgical patients with no significant effect on mortality., Competing Interests: Authors declare that they have no conflicts of interest to disclose., (© 2022 The Authors.)

Background: The biopsychosocial-spiritual model recognizes the impact of religious factors in modulating the experience of pain. Religious beliefs are factors that can influence perceptions, emotions, and behavior, all of which have important implications on health, pain experience, and treatment outcomes., Objectives: The aim of the present study was to identify if and how religious beliefs and attitudes can influence pain intensity, pain interference, pain-related beliefs and cognitions, emotions, and coping among patients with chronic musculoskeletal pain., Study Design: Systematic review., Methods: This systematic review was conducted and reported, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA). An electronic search was conducted in 4 online databases (PubMed, Embase, Web of science, and PsychArticles) and complemented with a hand search (PROSPERO registry: CRD42020161289). Two reviewers independently performed eligibility screening, risk of bias assessment, and data extraction. The risk of bias of the included studies was assessed using the Newcastle Ottawa Scale., Results: Nine cross-sectional studies and one case-control study were included in the review. The methodological quality of the included studies ranged from low to high. The results gathered regarding the association between religiosity and pain intensity, disability, or pain interference were found to be conflicting. Limited evidence suggests that religiosity is positively associated with worse pain-related beliefs and cognitions, worse pain-related emotion, and better pain acceptance. There is insufficient data available to support the claim that religiosity is negatively associated with physical functioning and pain-related self-efficacy in people with chronic musculoskeletal pain., Limitations: The number of included studies was small, with a low level of evidence, and a possible risk of bias., Conclusion: This systematic review shows low evidence and conflicting results for the presence of associations between religiosity and different pain domains such as pain intensity, disability, and pain-related cognitions or emotions in people with chronic musculoskeletal pain.

Background: Heart failure hospitalizations are a major financial cost to healthcare systems. This study aimed to evaluate the costs associated with inpatient hospitalization., Methods: Patients with a primary diagnosis of heart failure during a hospital admission between 2010 and 2014 in the U.S. Nationwide Readmission Database were included. The primary outcome was total cost defined by direct cost of index admission and first readmission within 30-days., Results: A total of 2,645,336 patients with primary heart failure were included in the analysis. The mean ± SD total cost overall was $13,807 ± 24,145; with mean total costs of $15,618 ± 25,264 for patients with 30-day readmission and $11,845 ± 22,710 for patients without a readmission. The comorbidities strongly associated with increased cost were pulmonary circulatory disorder (OR 26.24 95% CI 20.06-34.33), valvular heart disease (OR 25.42 95% CI 20.65-31.28) and bleeding (OR 5.96 95% CI 5.47-6.50). Among hospitalized patients, 12.6% underwent an invasive diagnostic procedure or treatment. The mean cost for patients without invasive care was $10,995. This increased by $129,547, $119,769, $251,110 and $293,575 for receipt of circulatory support, intra-aortic balloon pump, LV assist device and heart transplant. The greatest mean additional cost annually was associated with receipt of coronary angiogram ($26,282 per person for a total of ($728.5 million) and mechanical ventilation ($54,529 per person for a total of $501.7 million)., Conclusion: In conclusion, the costs associated with inpatient heart failure care are significant, and the major contributors to inpatient costs are comorbidities, invasive procedures and readmissions., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction and Importance: Ethmoid sinus foreign body is a rare condition. We describe an unusual case of an intra-ethmoid foreign body that was diagnosed late, we have reported this case to makeover fellow readers aware of the need to carefully examine the patient victim of a road traffic accident and the imaging performed., Case Presentation: A radio-opaque foreign body was detected at CT- scan of a 70- year-old man, who was the victim of a road traffic accident three years previously. The metallic foreign body was removed from the nasal cavity endoscopically without complications., Discussion: The presence of foreign bodies in the paranasal sinuses is extremely rare, especially following a road traffic accident, and has a lower incidence compared to facial injuries. The Symptoms are vague, which Paranasal computed tomography is the examination of choice to locate the foreign body. The best ethmoidal sinus surgical approach is endoscopy., Conclusion: It is important to make a diagnosis and include foreign objects with a recurrence of symptoms especially from an accident on a public road and early removal with extensive debridement results in minimal tissue destruction., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

and importance: this case report aimed at an unusual case of extensive rhinoscleroma with a literature review, We report this case to bring attention to the patients with immunodeficiency problem regardless of presenting symptoms. Case presentation: a 70 -year-old patient with diabetes and hypertension, consulted for chronic median and posterior headaches have not improved with symptomatic treatment. She reported cacosmia without rhinorrhea and right otalgia. The examination of the nasal cavity showed a bleeding lesion on the lateral wall of the nasopharynx. CT-scan of the facial showed tissue lesion on the posterior and lateral walls of the nasopharynx, with infiltration of the parapharyngeal space and bone lysis right edge of the clivus. The biopsy confirmed the diagnosis of rhinoscleroma. The patient started the ciprofloxacin for 3 months, and the evolvement has noticed with the disappearance of the lesion during the first month of treatment. The patient started the ciprofloxacin for 3 months, and the evolvement was noticed with the disappearance of the lesion during the first month of treatment. Cilinical discussion: rhinoscleroma is a chronic and progressive granulomatous disease of the nasal cavities. The diagnosis is confirmed by the search for bacteria and an anatomopathological assessment of MIKULICZ cells. The medical treatment of choice has a high concentration in macrophages such as rifampicin and fluoroquinolone. Conclusion: rhinoscleroma is a granulomatous disease caused by klebsiella rhinoscleromatis, you must think about in front a nasopharyngeal lesion imitating a malignant pathology., Competing Interests: There are no conflicts of interest., (© 2021 The Authors.)

Introduction: Chronic otitis media are still present and often overlooked. Our observation is interesting by the association of double purulent complications of chronic otitis media: paravertebral abscess and lateral sinus thrombosis., Case: We report the case of a 54-year-old man with a long history of NPC, who presented to the hospital with severe right earache, associated with headache and 39°fever. CT scan and MRI assessed a complicated chronic otitis media of the middle ear by thrombophlebitis of the lateral sinus and posterior paravertebral abscess. He was put under antibiotic therapy and cortical mastoidectomy two weeks later. Nearly one-year follow up reveals a satisfactory recovery., Conclusion: The chronic otitis media with effusion deserves careful monitoring. The early diagnosis and adequate treatment of this life-threatening lesion may result in excellent prognosis. Especially for young people in developing countries., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: The majority of cervical wounds are linked to aggressions and attempted autolysis by knives or firearms., Case Presentation: the story is about a 35 -year-old man admitted to the emergency room for a penetrating cervical wound following an accidental fall in the workplace. The extremely long iron bar (concrete)has penetrated its neck on the right side.upon admission, the patient was conscious,hemodynamically and respiratory stable without sensory-motor deficit.Surgical exploration is urgently decided under general anesthesia, from wich the foreign body is successfully removed.A follow -up examination at 4 months was without particularity., Discussion: Penetrating neck injuries caused by objects such as rods or iron bars pose a significantly high risk of serious neurological damage.Penetrating neck injuries can be life-threatening and functional.the extent of the lesions must be assessed precisely before removing the foreign body., Conclusion: we report an exceptional case of a penetrating neck wound caused by a concrete iron bar.treatment should always be multidisciplinary and giving priority to vital structures and function., (© 2021 The Authors.)

Heart failure (HF) is the leading cause of morbidity and mortality worldwide and negatively impacts quality of life, healthcare costs, and longevity. Although data on HF in the Arab population are scarce, recently developed regional registries are a step forward to evaluating the quality of current patient care and providing an overview of the clinical picture. Despite the burden of HF in Saudi Arabia, there are currently no standardized protocols or guidelines for the management of patients with acute or chronic heart failure. Therefore, the Heart Failure Expert Committee, comprising 13 local specialists representing both public and private sectors, has developed guidelines to address the needs and challenges for the diagnosis and treatment of HF in Saudi Arabia. The ultimate aim of these guidelines is to assist healthcare professionals in delivering optimal care and standardized clinical practice across Saudi Arabia.

Atrial fibrillation (AF) is the most common arrhythmia in patients presenting with acute coronary syndrome (ACS). The present study examined the rates and trends of clinical outcomes and management strategies of non-ST-elevation ACS (NSTE-ACS) related hospitalizations in the United States, in patients with concomitant AF compared with those in sinus rhythm (SR). We analyzed the "Nationwide Inpatient Sample" database (2004 to 2014) for patients with a primary discharge diagnosis of NSTE-ACS, and further stratified the cohort on the basis of diagnoses into SR and AF groups. Multivariate analysis was performed to examine the association between AF and major adverse cardiovascular and cerebrovascular events (composite of mortality, stroke, and cardiac complications) and its components. Of 4,668,737 NSTE-ACS hospitalizations, the proportions of SR and AF groups were 82.4% (3,848,202) and 17.6% (820,535), respectively. The incidence of AF increased significantly over time from 16.5% (2004) to 19.3% (2014). The AF group was at a greater risk of adverse outcomes with higher rates and adjusted relative risk (RR) of major adverse cardiovascular and cerebrovascular events (12.9% vs 5.3%; RR 1.74 [1.72, 1.75]), mortality (6.5% vs 3.3%; RR 1.12 [1.11, 1.13]), stroke (2.7% vs 1.5%; RR 1.32 [1.30, 1.34]), and bleeding (14.7% vs 8.8%; RR 1.42 [1.41, 1.43]). Furthermore, the AF group was less likely to receive coronary angiography (47.1% vs 58%) and percutaneous coronary intervention (18.7% vs 32.6%) in comparison to SR (p <0.001 for all outcomes). In conclusion, patients with concomitant AF and NSTE-ACS are less likely to be offered an invasive management strategy for their ACS and are associated with worse complications and higher mortality., (Copyright © 2019 Elsevier Inc. All rights reserved.)

It is unclear how age affects rates and causes of unplanned early readmissions after percutaneous coronary intervention (PCI). We analyzed patients in the Nationwide Readmission Database in the United States from 2010 to 2014 and examined the impact of age on readmissions after PCI. The primary outcomes were age-specific 30-day rates and causes of unplanned readmissions. A total of 2,294,345 procedures were analyzed with a 9.6% unplanned readmission rate within 30 days. Unplanned readmissions were 8.1%, 8.1%, 9.5%, and 12.6% for age groups <55, 55.0 to 64.9, 65.0-74.9, and ≥75 years, respectively. With increasing age, there was an increase in the rate of noncardiac causes for readmissions (for ages <55, 55.0 to 64.9, and ≥75 years, the rates were 54.1%, 54.8%, 56.6%, and 57.1%, respectively; p <0.001). Older age was associated with an increased prevalence of infections (13.9% ≥75 years vs 7.7% <55 years), gastrointestinal disease (11.5% ≥75 years vs 9.5% <55 years), and bleeding (7.4% ≥75 years vs 2.9% <55 years) as causes for noncardiac readmissions and a reduced prevalence of nonspecific chest pain (9.9% ≥75 years vs 31.4% <55 years). For cardiac causes, older age was associated with increased prevalence for readmissions due to heart failure (34.6% ≥75 years vs 11.9% <55 years) but a reduced prevalence of coronary artery disease, including angina (25.7% ≥75 years vs 51.3% <55 years). In conclusion, older patients have the highest rates of unplanned 30-day readmissions after PCI, with different causes for readmission compared with younger patients. Interventions designed to reduce readmissions after PCI should be age specific., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Fear of falling (FOF) and increased gait variability are both independent markers of gait instability. There is a complex interplay between both entities. The purposes of this study were (1) to perform a qualitative analysis of all published studies on FOF-related changes in gait variability through a systematic review, and (2) to quantitatively synthesize FOF-related changes in gait variability., Methods: A systematic Medline literature search was conducted in May 2014 using the Medical Subject Heading (MeSH) terms "Fear" OR "fear of falling" combined with "Accidental Falls" AND "Gait" OR "Gait Apraxia" OR "Gait Ataxia" OR "Gait disorders, Neurologic" OR "Gait assessment" OR "Functional gait assessment" AND "Self efficacy" OR "Self confidence" AND "Aged" OR "Aged, 80 and over." Systematic review and fixed-effects meta-analysis using an inverse-variance method were performed., Results: Of the 2184 selected studies, 10 observational studies (including 5 cross-sectional studies, 4 prospective cohort studies, and 1 case-control study) met the selection criteria. All were of good quality. The number of participants ranged from 52 to 1307 older community-dwellers (26.2%-85.0% women). The meta-analysis was performed on 10 studies with a total of 999 cases and 4502 controls. In one study, the higher limits of the effect size's confidence interval (CI) were lower than zero. In the remaining studies, the higher limits of the CI were positive. The summary random effect size of 0.29 (95% CI 0.13-0.45) was significant albeit of small magnitude, and indicated that gait variability was overall 0.29 SD higher in FOF cases compared with controls., Conclusions: Our findings show that FOF is associated with a statistically significant, albeit of small magnitude, increase in gait variability., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: To provide guidelines for medical professionals in Saudi Arabia regarding osteoporosis., Design and Settings: A panel of 14 local experts in osteoporosis assembled to provide consensus based on the strength of evidence and expert opinions on osteoporosis treatment., Patients and Methods: The Saudi Osteoporosis Society (SOS) formed a panel of experts who performed an extensive published studies search to formulate recommendations regarding prevention, diagnosis, and treatment of osteoporosis in Saudi Arabia. Both local and international published studies were utilized whenever available., Results: Dual x-ray absorptiometry (DXA) scanning is still the golden standard for assessing bone mineral density (BMD). In the absence of local, country-specific fracture risk assessment tool (FRAX), the SOS recommends using the USA (White) version of the FRAX tool. All women above 60 years of age should be evaluated for BMD. This is because the panel recognized that osteoporosis and osteoporotic fractures occur at a younger age in Saudi Arabia. Hormone replacement therapy (HRT) is not recommended for treating postmenopausal women with osteoporosis. BMD evaluation should be performed 1-2 years after initiating intervention, and the assessment of bone turnover biomarkers should be performed whenever available to determine the efficacy of intervention., Conclusion: All Saudi women above the age of 60 years must undergo a BMD assessment using DXA. Therapy decisions should be formulated with the use of the USA (White) version of the FRAX tool.

Antiserum from rabbits immunised with pure human fibrinogen was affinity purified on immobilised fibrin fragment E (FFE). This FFE antibody (Ab) induced significant growth inhibition of a human cancer xenograft in mice and suppression of tumour angiogenesis, leaving no formed vessels and only CD31-staining endothelial fragments in place. Tubule formation of HUVEC on MatrigelTM was also significantly inhibited by FFE Ab. Since MatrigelTM is fibrin-free, this effect implicated a different FFE Ab binding site than FFE. Flow cytometry of HUVEC showed that FFE Ab bound to HUVEC, but with a broad range of 55-98 %. Immunofluorescent staining of HUVEC explained this range, since FFE Ab was seen not to bind to human umbilical vein endothelial cells (HUVEC) directly but instead to a matrix protein variably adherent to HUVEC. This protein was identified as fibronectin (FN) by appearance, staining with FN Ab, and by a FN knockdown study. Neither HUVEC nor matrix reacted with fibrin D-dimer (DD) Ab. Immunofluorescent stains of HUVEC matrix with FFE and FN Ab's showed that these Ab's bound to the same epitopes on FN, as also seen on Western blots of purified FN. These findings indicate the presence of an antigenic determinant in fibrinogen/FFE that is homologous with an epitope(s) in FN recognised by FFE Ab, and critical for angiogenesis in this xenograft. The FN epitope(s) remains to be identified, but the present findings can be used for the selection of the appropriate clones from mice immunised with fibrinogen which can facilitate this identification, and which may also be of clinical use.

Objective: To compare gait variability among older community-dwellers with and without fear of falling and history of falls, and 2) to examine the association between gait variability and fear of falling while taking into account the effect of potential confounders., Methods: Based on a cross-sectional design, 1,023 French community-dwellers (mean age ± SD, 70.5 ± 5.0 years; 50.7% women) were included in this study. The primary endpoints were fear of falling, stride-to-stride variability of stride time and walking speed measured using GAITRite® system. Age, gender, history of falls, number of drugs daily taken per day, body mass index, lower-limb proprioception, visual acuity, use of psychoactive drugs and cognitive impairment were used as covariables in the statistical analysis. P-values less than 0.05 were considered as statistically significant., Results: A total of 60.5% (n=619) participants were non-fallers without fear of falling, 19% (n=194) fallers without fear of falling, 9.9% (n=101) non-fallers with fear of falling, and 10.7% (n=109) fallers with fear of falling. Stride-to-stride variability of stride time was significantly higher in fallers with fear of falling compared to non-fallers without fear of falling. Full adjusted linear regression models showed that only lower walking speed value was associated to an increase in stride-to-stride variability of stride time and not fear of falling, falls or their combination. While using a walking speed ≥ 1.14 m/s (i.e., level of walking speed that did not influence stride-to-stride variability of stride time), age and combination of fear of falling with history of previous falls were significantly associated with an increased stride-to-stride variability of stride time., Conclusions: The findings show that the combination of fear of falling with falls increased stride-to-stride variability of stride time. However, the effect of this combination depended on the level of walking speed, increase in stride-to-stride variability of stride time at lower walking speed being related to a biomechanical effect overriding fear of falling-related effects.

Objective: The vascular system is adapted to specific functions in different tissues and organs. Vascular endothelial cells are important elements of this adaptation, leading to the concept of 'specialized endothelial cells'. The phenotype of these cells is highly dependent on their specific microenvironment and when isolated and cultured, they lose their specific features after few passages, making models using such cells poorly predictive and irreproducible. We propose a new source of specialized endothelial cells based on cord blood circulating endothelial progenitors (EPCs). As prototype examples, we evaluated the capacity of EPCs to acquire properties characteristic of cerebral microvascular endothelial cells (blood-brain barrier (BBB)) or of arterial endothelial cells, in specific inducing culture conditions., Approach and Results: First, we demonstrated that EPC-derived endothelial cells (EPDCs) co-cultured with astrocytes acquired several BBB phenotypic characteristics, such as restricted paracellular diffusion of hydrophilic solutes and the expression of tight junction proteins. Second, we observed that culture of the same EPDCs in a high concentration of VEGF resulted, through activation of Notch signaling, in an increase of expression of most arterial endothelial markers., Conclusions: We have thus demonstrated that in vitro culture of early passage human cord blood EPDCs under specific conditions can induce phenotypic changes towards BBB or arterial phenotypes, indicating that these EPDCs maintain enough plasticity to acquire characteristics of a variety of specialized phenotypes. We propose that this property of EPDCs might be exploited for producing specialized endothelial cells in culture to be used for drug testing and predictive in vitro assays.