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Objective: The goal of this study was to look into the clinical profile, incidence, and potential reasons of liver function test abnormalities among pregnant women. Study Design: Prospective/Observational study Place and Duration: Department of Medicine, OMC Hospital, Jail Road Lahore from February, 2020 to June, 2021. Methods: There were one hundred and five pregnant women had liver dysfunction were included. Age of the patients was between 19-45 years. All patients provided written consent before having their demographic data collected, including their age, BMI, gender, and trimester of pregnancy. Association of symptoms among presented patients was also recorded. Females were underwent for liver test to diagnose abnormalities. Prevalence of liver disease abnormalities and maternal outcomes were assessed in this study. We used SPSS 22.0 version to analyze complete data. Results: Mean age of the pregnant females was 26.47±7.49 years and had mean BMI 24.11±3.34 kg/m2. Majority of the patients 60 (57.1%) had parity I. Mean gestational age of the patients was 33.13±5.33 weeks. We found that majority of the patients were in 65 (61.9%) third trimester. Oedema, headache and fever were the most common symptoms presented. Prevalence of abnormal liver function test was among 85 (80.9%) cases. Most common cause was hyperemesis gravidarum found in 57 (54.3%) cases followed by hepatitis in 48 (45.7%) cases. Most common syndrome was HELLP 35 (33.3%) and AFLP in 18 (17.1%) females. Frequency of pre-eclampsia was in 29 (27.6%) cases. C-section was carried out in 36 (34.3%) cases. No maternal mortality found in our study but rate of mortality in fetals were 24 (28.2%). Conclusion: During the third trimester of pregnancy, pregnancy-related illnesses are the most common reason for abnormal liver function tests. Usually, pre-eclampsia is the root of this problem. Keywords: Pregnancy, Liver Dysfunction, LFT, Outcomes

Objective: To determine the frequency of low birth weight in pregnant women with anemia. Methodology: This descriptive cross-sectional survey, was conducted at OMC Hospital, Jail Road, Lahore and Medicine Deptt. of Lahore General Hospital during March 2020 to November 2020. We included 320pregnant females with gestational ages between 30 to 36 weeks with hemoglobin level of

Context: Coronavirus Disease 2019 (COVID-19) put a spotlight on focused cardiac ultrasound (FoCUS) However, the spectra of cardiac disease, and the resources available for investigation vary internationally The applicability of FoCUS to internal medicine (IM) and critical care medicine (CCM) practice in Saudi Arabia and their current use of FoCUS are unknown Aims: To determine the applicability of FoCUS to IM and CCM practice in Saudi Arabia and quantify the residents’ current proficiency, accreditation and use of FoCUS Methods: A questionnaire was distributed to the residents in IM and CCM at our institution to determine their proficiency, use of FoCUS, and perceptions of its applicability Results: In total, 110 residents (IM 100/108;CCM 10/10) participated (Response rate 93 2%) and reported that FoCUS was very applicable to their practice, most specifically for pericardial effusion, right heart strain, and left ventricular function Two IM residents had received postgraduate training, ten used FoCUS regularly, none were accredited and overall selfreported proficiency was poor In contrast all CCM residents had received postgraduate training and reported regular use of FoCUS Two were accredited Conclusions: Whilst FoCUS is applicable to IM practice in Saudi Arabia, significant skills gaps exist The skills gap in CCM is lower but unaccredited practice is common Our residents’ responses were similar to those from Canada Thus, international standardization of FoCUS training could be considered © 2020 Saudi Heart Association

Background Coronavirus disease 2019 (COVID-19) causes an atypical acute respiratory distress syndrome associated with thromboembolism and high shunt fraction. Shunt may be intrapulmonary, or extrapulmonary. Handheld devices are increasingly being used for point-of-care ultrasound, but their use to characterize shunt has not been reported. Objectives Determine the feasibility of using handheld ultrasound to detect and characterize anatomical substrates of hypoxia and deep vein thrombosis (DVT) in patients with COVID-19 suspected to have severe shunt. Methods A handheld ultrasound device (iQ, Butterfly, USA) was used to perform lung ultrasound, vascular assessment for DVT, and limited transthoracic echocardiography (TTE) with color Doppler and saline microbubble contrast in patients with COVID-19 suspected to have severe shunt. Images were reassessed by an independent reviewer. Results After screening 40 patients, six patients who fulfilled the inclusion criteria were identified. Two were excluded because palliation had been initiated. So, four patients were studied. Interpretable images were obtained in all cases. Interobserver agreement was good. All patients had abnormal lung ultrasound (lung ultrasound score range 17–22). Identified lung pathology included interstitial syndrome with light beams and small peripheral consolidation (4), lobar consolidation (1), and pleural effusion (1). Abnormal echocardiographic findings included interatrial shunt (2), intrapulmonary shunt (1), and dilated right ventricle with tricuspid valve regurgitation (1). Significant DVT was not detected. Conclusion Use of handheld ultrasound to perform combined lung ultrasound, DVT ultrasound, and limited TTE with color Doppler and saline microbubble contrast is feasible, and may be able to characterize shunt in critically hypoxic patients. Serial studies could be used to monitor changes in shunt. Further studies are required to determine whether this can guide treatment to improve the outcomes of patients with refractory hypoxia.

In this paper, we have been study a hybrid nanofluid over an exponentially oscillating vertical flat plate. Therefore the fractional derivatives definition of Caputo–Fabrizio approach is applied to transform the classical model for this hybrid nanofluid to fractional model. Together with an oscillating boundary motion, therefore the heat transfer is cause as a result of the buoyancy force produce due temperature differences between the plate and the fluid. The dimensionless classical model is generalized by transforming it to the time fractional model using Caputo–Fabrizio time fractional derivative. Exact analytical solutions are obtained by using Laplace transform method to the set of dimensionless fractional governing equations, containing the momentum and energy equations subjected to the boundary and initial conditions. Numerical computations and graphical illustrations are used to checked the results of the Caputo–Fabrizio time-fractional parameter, the second-grade parameter, the magnetic parameter and the Grashof numbers on the velocity field. An assessment for time spin-off is shown graphically of integer order versus fractional-order for these non-Newtonian hybrid nanofluid through Mathcad software. The fluid velocity increases for increasing the value of the fractional parameter, second-grade parameter and Grashof number. Also for increasing the values of the MHD parameter the fluid velocity decreases.

Right-to-left (RTL) interatrial shunt (IAS) may complicate select cases of COVID-19 pneumonia. We describe the use of serial imaging to monitor shunt in critically ill patients. A 52-year-old man presented with COVID-19 pneumonia. Hypoxia worsened despite maximal medical therapy and non-invasive ventilation. On day 8, saline microbubble contrast-enhanced transthoracic echocardiography revealed a patent foramen ovale (PFO) with RTLIAS. Invasive ventilation was initiated the next day. The course was complicated by intermittent severe desaturation without worsening aeration or haemodynamic instability, so PFO closure was considered. However, on day 12, saline microbubble contrast-enhanced transoesophageal echocardiography excluded RTLIAS. The patient was extubated on day 27 and discharged home 12 days later. Thus, RTLIAS may be dynamic and changes can be detected and monitored by serial imaging. Bedside echocardiography with saline microbubble contrast, a simple, minimally invasive bedside test, may be useful in the management of patients with severe hypoxia.

Background Infection by the 2019 novel coronavirus (COVID-19) has been reportedly associated with a high risk of thrombotic complications. So far information is scarce and rapidly emerging. Methods We conducted a scoping review using a single engine search for studies assessing thrombosis and coagulopathy in COVID-19 patients. Additional studies were identified by secondary review and alert services. Results Studies reported the occurrence of venous thromboembolism and stroke in approximately 20% and 3% of patients, respectively. A higher frequency seems to be present in severely ill patients, in particular those admitted to intensive care units. The thrombotic risk is elevated despite the use of anticoagulant prophylaxis but optimal doses of anticoagulation are not yet defined. Although an increase of biomarkers such as D-dimer has been consistently reported in severely ill COVID-19, the optimal cut-off level and prognostic value are not known. Discussion A number of pressing issues were identified by this review, including defining the true incidence of VTE in COVID patients, developing algorithms to identify those susceptible to develop thrombotic complications and severe disease, determining the role of biomarkers and/or scoring systems to stratify patients' risk, designing adequate and feasible diagnostic protocols for PE, establishing the optimal thromboprophylaxis strategy, and developing uniform diagnostic and reporting criteria., Highlights • Thrombotic events, venous and arterial are frequent in COVID-19, more so in critically ill patients. • Valid biomarkers to define risk and prognosis are still lacking. • Anticoagulant prophylaxis is needed in all patients. • The role of higher doses of anticoagulants in all patients is unclear. • There is a need to develop standard clinical definitions, common data elements, and standard reporting criteria.

Background and objective The use of point-of-care ultrasound (POCUS) is generally on the rise worldwide. However, as the epidemiology of diseases and the approach to their management vary internationally, POCUS may not be universally applicable. The resources available for medical education are generally limited. Thus, when considering the development of a training program during the internship year, we sought to determine interns' perceptions of the applicability of POCUS to clinical practice, the current skill gaps, and barriers to training. Methods A validated questionnaire was distributed to the interns of the College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh to determine their proficiency in POCUS, and their opinions on its applicability on a 5-point Likert scale. Each skill gap was calculated by subtracting self-reported proficiency in POCUS from its perceived applicability. Results Of the 300 total interns (male: 200, female: 100), 229 participated [response rate: 76%; male: 136 (68%), female: 93 (93%)]. The use of POCUS to detect abdominal free fluid was perceived to be the most applicable use (mean: 3.9 ±1.1); scanning for consolidation was the least applicable (mean: 3.0 ±1.2). Knowledge and proficiency among the sample were generally poor. The skill gap was greatest for the assessment of inferior vena cava collapsibility (mean: 1.4 ±1.3) and least for the identification of pneumothorax (mean: 0.5 ±1.5). Although three-quarters of the participants (170) agreed that POCUS was an essential skill, 36 (16%) stated that they had no interest in it, and nearly half (101) believed that they did not have time to learn POCUS. Conclusions While POCUS is applicable to medical interns in Saudi Arabia, significant skill gaps exist. However, our sample's perception of the applicability of POCUS was less favorable than that of internal medicine (IM) residents in Canada. Thus, initiating POCUS training during the internship year may yield suboptimal results. Interns must prioritize medical licensing examinations and applications for residency training. Indeed, many interns believe that they do not have enough time to learn POCUS. Thus, prioritizing the training of residents in POCUS may be a more effective use of the finite resources available for medical education.

BackgroundTraining in procedural skills is often suboptimal. The aim of this study was to quantify the needs of residents in internal medicine (IM), critical care (CC), and emergency medicine (EM) for instruction in ultrasound-guided procedures.MethodsAll IM, EM and CC residents (n = 200) at King Abdulaziz Medical City, Riyadh, Saudi Arabia, were invited to participate in a questionnaire-based survey to identify skill and experience gaps. The contribution of procedural skills to patient care (i.e. applicability) and proficiency in the sterile technique required to perform ultrasound-guided procedures were rated on Likert scales. Data on training, accreditation, and experience with and without ultrasound were collected.ResultsThe overall response rate was 72% (IM 91%, CC 100%, EM 40%). Although the sample reported that procedural skills were very applicable, 19% (IMn = 25, EMn = 2) had not performed any procedures. However, five residents were accredited in point-of-care ultrasound, 61% of the sample had performed ultrasound-guided procedures and 65% had used landmark techniques. Whilst more internists had performed procedures using landmark techniques, CC and EM residents had performed more ultrasound-guided procedures. Whilst CC residents had not missed any opportunities to perform procedures because supervisors were less available, EM (6) and IM (89) residents had. Whilst skill gaps were only identified in the IM residency programme, experience gaps were present in all three residency programmes. The IM residency programme had larger experience gaps than the CC and EM programmes for all procedural skills.DiscussionResidents in IM, CC and EM perceive that ultrasound-guided procedures are relevant to their practice. However, the IM residents performed fewer procedures than CC residents and EM residents at least partly because internists also lack skills in ultrasound. Training in ultrasound-guided procedures may reduce the use of landmark techniques and improve patient safety. Residents in IM, CC and EM therefore require training in ultrasound-guided procedures.

Highlights • Chest CT patterns in COVID-19 may be divided into three main phenotypes: 1) multiple, focal, possibly overperfused ground-glass opacities, mainly in the subpleural region; 2) inhomogeneously distributed atelectasis and peribronchial opacities; and 3) a patchy, ARDS-like pattern. • Noninvasive positive ventilation and continuous positive airway pressure may result in high inspiratory efforts and high negative intrathoracic pressures and can be detrimental if prolonged. • Endotracheal intubation is considered a high-risk procedure for aerosol-based transmission and should be performed cautiously. • In COVID-19 patients with phenotype 1, respiratory mechanics are consistent with high pulmonary compliance and severe hypoxemia, probably related to regional overperfusion and high shunting (corresponding to the ground-glass opacities). These patients may benefit from use of low to moderate PEEP to redistribute flow from damaged to undamaged areas of the lung and are likely to respond well to inhaled nitric oxide. • In phenotype 2, moderate to high PEEP as well as lateral and/or prone positioning may help recruit collapsed areas. Phenotype 3 resembles typical ARDS and should be managed as such. Finally, peripheral macro- and microemboli are common, and attention should be paid to the risk of pulmonary embolism, regardless of phenotype., Coronavirus disease 2019 (COVID-19) can cause severe respiratory failure requiring mechanical ventilation. The abnormalities observed on chest computed tomography (CT) and the clinical presentation of COVID-19 patients are not always like those of typical acute respiratory distress syndrome (ARDS) and can change over time. This manuscript aimed to provide brief guidance for respiratory management of COVID-19 patients before, during, and after mechanical ventilation, based on the recent literature and on our direct experience with this population. We identify that chest CT patterns in COVID-19 may be divided into three main phenotypes: 1) multiple, focal, possibly overperfused ground-glass opacities; 2) inhomogeneously distributed atelectasis; and 3) a patchy, ARDS-like pattern. Each phenotype can benefit from different treatments and ventilator settings. Also, peripheral macro- and microemboli are common, and attention should be paid to the risk of pulmonary embolism. We suggest use of personalized mechanical ventilation strategies based on respiratory mechanics and chest CT patterns. Further research is warranted to confirm our hypothesis.

Muscular dystrophies are a heterogeneous group of disorders that commonly involve cardiac and skeletal muscle. Comprehensive guidelines for the management of cardiac failure and arrhythmias are available. However, the studies from which their recommendations are derived did not include any patients with muscular dystrophy. Some medications (eg, betablockers) may have significant side effects in this cohort. In some situations the use of agents with unique mechanisms of action such as ivabradine (a ‘funny’ channel inhibitor) may be more appropriate. Use of ivabradine has not previously been reported in limb girdle muscular dystrophy (LGMD). We describe the course of a patient with LGMD type 2I, cardiomyopathy and inappropriate sinus tachycardia treated with ivabradine. As advances in respiratory support have improved the outcomes of patients with muscular dystrophy; the prognostic significance of cardiac disease has increased. Ivabradine is tolerated and may reduce symptoms, morbidity and mortality in this cohort.

Background Cardiac myxomas are the most common benign primary cardiac tumours. The natural history of left cardiac myxomas is thought to be of slowly growing tumours. Cardiac myxomas are a heterogeneous group with a variable growth rate. They present usually with stroke, valve obstruction, or non-specific symptoms. Surgical resection is the effective treatment. Case summary This case report describes a 56-year-old hypertensive and dyslipidaemic female, when she was admitted in January 1990, complaining of loss of appetite, aches, pains, and palpitations. Her workup included a transthoracic echocardiography and transoesophageal echocardiography, which showed a left atrial mass attached to the inter-atrial septum, highly suggestive of left atrial myxoma. She was referred for surgical removal of the left atrial mass. However, she was reluctant to undergo surgery as she felt better. The patient was followed-up for almost 30 years with the left atrial mass confirmed as left atrial myxoma by cardiac magnetic resonance imaging. The left atrial mass became smaller in size and more calcified. Discussion Cardiac myxomas are a group of heterogeneous tumours, thought to be slowly growing. The growth rate of cardiac myxomas prior to diagnosis is not well known, as the vast majority is treated with surgical resection immediately after diagnosis. Our case showed the natural progression of an unoperated smooth-surfaced left atrial myxoma followed-up for almost 30 years, which slowly became smaller and more calcified.

This paper examines the women’s perception about climate change and coping strategies in response to climate-related shocks in Pakistan. It is among the ten countries that have been affected most by climate change. There is no denying the fact that climate change is bringing miseries for the vulnerable population particularly for the rural women. The study used the Treatment Effect Model to evaluate the determinants of women’s perception and adoption of coping strategies using data from Climate Change Impact Survey (PIDE 2013). Secondary data of 3298 rural households in Punjab, Sindh and KPK as provided by Pakistan Institute of Development Economics (2013) were utilized to conduct this research. The results of this study demonstrate that age, education, farming experience, land rights, women empowerment, livestock ownership and change in rainfall are crucial factors for women’s coping strategies to avoid the adverse effect of climate change. There is dire need to raise awareness about climate change in women and provide credit facilities for undertaking adaptation measures, encourage informal social networks and enhance women capacity to climate change.

Objectives: To estimate the prevalence of subclinical hypothyroidism (SCH) in Saudi Arabia and assess the need for an SCH screening program. Methods: This cross-sectional study was conducted at King Abdulaziz Medical City and the Khashmulaan Clinic at the National Guard Health Affairs, Riyadh, Saudi Arabia in August 2016. All women attending the antenatal clinics were invited to participate in the study. In addition, data were retrieved from the files of pregnant women who had been screened for hypothyroidism from January 2016 to August 2016. A total of 384 pregnant women were included in the study. Results: The prevalence of SCH in pregnant women in this study was 50/384 (13%) with 95% confidence intervals (CIs): 9.82%-16.80%. Pregnant women who were randomly screened using a survey (n=127) were 3 times more likely (OR: 3.1; 95% CI: 1.182 to 8.704, p =0.022) to have SCH compared to pregnant women who were screened based on their physician’s judgement (n=257). Results showed older age (≥40 years) was associated with an insignificant decrease in the risk of SCH. Conclusion: Random screening for SCH in pregnant women showed a higher prevalence in comparison to women who were screened as a result of physician referrals. The results highlight the urgent need for larger studies to investigate the prevalence of SCH as well as the need for an SCH screening program. Saudi Med J 2018; Vol. 39 (3):254-260 doi: 10.15537/smj.2018.3.21621 How to cite this article: Al Shanqeeti SA, Alkhudairy YN, Alabdulwahed AA, Ahmed AE, Al-Adham MS, Mahmood NM. Prevalence of subclinical hypothyroidism in pregnancy in Saudi Arabia. Saudi Med J . 2018 Mar;39(3):254-260. doi: 10.15537/smj.2018.3.21621.

The limiting of water resource and traditional farming practices are threatening the sustainability of important minor crops in Pakistan, including berseem, which is a key source of fodder for dairy farms. Each year, 2% reduction of cultivated area, low yield and grower’s non-preference (to rotate or replace wheat-cotton pattern) factors are adversely affecting the livestock sector. Consequently, animal rearing business is suffering badly due to lack of fresh forage in the country. Therefore, a three-replicated randomized complete block design (RCBD) field experiment was conducted during rabi season to evaluate berseem crop in term of yield and profit under existing farming practice (85:115:00 NPK kg ha−1 + 12 irrigations with 15 days intervals) and optimized treatments (70:100:30 NPK kg ha−1, 55:85:15 NPK kg ha−1 + 12, 08, 04 irrigations + 15, 18, 21 days intervals). The net plot size was 12 m2 with a pH range of 8.1 silty clay loam soil type. In addition, the climate was monitored as well, there was no rainfall observed during the entire crop period. The analysis of statistical data showed a significant (p < 0.05) vegetative, reproductive and economic performance of berseem in optimized farming practices compared to traditional practice. Thus, maximum plant height, leaves plant−1, branches plant−1, plant weight, fodder and seed yield, net profit, and profit on $−1 (81.8 cm, 100.8, 36.0, 19.3 (g), 72.0 t, 829.30 kg ha−1, $1910.8 ha−1, $2.03 respectably) were measured from treatment 70:100:30 NPK kg ha−1 + 12 irrigations at 15 days intervals, which is recommended to the farmers of synonymic agro-environmental conditions. Furthermore, the treatment 70:100:30 NPK kg ha−1 + 8 irrigations was also better with the aspect of satisfactory outcome and 33% less use of water.

CONTEXT: Coronavirus disease 2019 (COVID-19) has put a spotlight on point-of-care diagnostic lung ultrasound (POCDLUS). However, the spectra of respiratory disease and resources available for investigation vary internationally. The applicability of POCDLUS to internal medicine (IM) practice in Saudi Arabia and the current use by Saudi physicians are unknown. AIMS: The aim of the present study was to determine the applicability of POCDLUS to IM practice in Saudi Arabia and quantify the residents' current skills, accreditation, and use of POCDLUS. METHODS: A questionnaire was distributed to the IM residents at our institution to assess their knowledge, use of POCDLUS, and their perceptions of its applicability in IM. STATISTICAL ANALYSIS: Standard descriptive statistical techniques were used. Categorical data, presented as frequency, were compared using the Chi-squared test. The Likert scale responses, presented as mean ± standard deviation, were compared with a Student's t-test. RESULTS: In total, 100 residents participated (response rate 92.6%) and reported that POCDLUS was applicable to their practice. Identifying pleural effusions was most applicable. A small proportion (n = 7) had received training, nine used POCDLUS regularly, none were accredited and the overall self-reported level of knowledge was poor. CONCLUSIONS: Whilst POCDLUS is applicable to IM practice in Saudi Arabia, the significant skills gap preclude the provision of a POCDLUS service. As COVID-19 can cause an interstitial syndrome, our pandemic preparation response should include POCDLUS training. The current study is supported by a similar Canadian study and the international standardisation of POCDLUS training may be feasible. The findings of the current study may facilitate the development of POCDLUS training programs for internists throughout Saudi Arabia.

Objective: To establish the health benefits of Syzgium cumin to discover functional components present in the seeds, fruit pulps and fresh juice of this fruit grown in Bangladesh. Methods: Thin layer chromatography and ultra-violet spectroscopy were used to detect the presence of various types of compound in seeds and juice. Antioxidant effects were measured by DPPH scavenging assay and total reducing assay. Receptor binding activities was performed by hemagglutination inhibition assay. Anti-inflammatory assay and hydrogen peroxide induced hemolysis assay was also investigated. Disc diffusion assay was performed to show the antibacterial effect using Gram positive, Gram negative strains of bacteria and fungi. Results: Methanolic extract of the seeds showed stronger antioxidant, hydrogen peroxide induced hemolysis activities, hemagglutination inhibition activities and membrane stabilization activities than those of fresh juice. However, fresh juice showed stronger antibacterial and antifungal activities than those of methanolic seed extract. The seed contains higher amount of polyphenols and flavanoids than those of fruit juice. Conclusions: Therefore, fruit juice, fruit pulp and seed of Syzygium cumini contain medicinal active components in different ratios.

A single ventricle is a rare congenital heart disease that accounts for less than 1% of all congenital heart diseases. A woman was assessed in our obstetric clinic for the first time at the gestational age of 28 weeks and found to have placental bleeding. She also had complex congenital heart disease and atrial fibrillation requiring anticoagulation. Echocardiography revealed double-inlet single ventricle with right and left atrioventricular valves entering into this chamber and levo-transposition of the great arteries. After an extensive discussion with the patient regarding the risks and benefits of anticoagulation including risk of stroke, the agreed plan was to start her on intravenous heparin with close observation and to continue pregnancy for at least 32 weeks in order to reduce the postpartum risk for the fetus. The pregnancy progressed without any further complications and the patient had elective caesarean section at 33 weeks of gestation and delivered a healthy baby boy.