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Desensitization therapy for heart transplantation (HT) candidates can shorten transplant wait times and broaden the donor pool. Specific evidence-based recommendations on both protocols and indications are lacking. We retrospectively assessed left ventricular assist devices-bridged candidates who received pre-HT desensitization therapy. The therapeutic protocol consisted of intravenous immunoglobulin and rituximab followed by bortezomib and plasmapheresis if an insufficient response was achieved. Desensitization was attempted in 10 patients; only 7 tolerated therapy and underwent transplant. For those patients, median decrease in unacceptable calculated panel reactive antibody was 11%; there was no significant decrease for 3 patients. Post-desensitization adverse events were observed in all patients which included coagulopathy, bone marrow suppression, and infection. Median time to first infection was 16 days. One patient had clinically significant rejection and 3 patients had uptrending donor-specific antibodies. Decisions to proceed with desensitization should be individualized understanding potential risks and benefits.

BACKGROUND: Coenzyme Q10, or ubiquinone, is a non‐prescription nutritional supplement. It is a fat‐soluble molecule that acts as an electron carrier in mitochondria, and as a coenzyme for mitochondrial enzymes. Coenzyme Q10 deficiency may be associated with a multitude of diseases, including heart failure. The severity of heart failure correlates with the severity of coenzyme Q10 deficiency. Emerging data suggest that the harmful effects of reactive oxygen species are increased in people with heart failure, and coenzyme Q10 may help to reduce these toxic effects because of its antioxidant activity. Coenzyme Q10 may also have a role in stabilising myocardial calcium‐dependent ion channels, and in preventing the consumption of metabolites essential for adenosine‐5'‐triphosphate (ATP) synthesis. Coenzyme Q10, although not a primary recommended treatment, could be beneficial to people with heart failure. Several randomised controlled trials have compared coenzyme Q10 to other therapeutic modalities, but no systematic review of existing randomised trials was conducted prior to the original version of this Cochrane Review, in 2014. OBJECTIVES: To review the safety and efficacy of coenzyme Q10 in heart failure. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Web of Science, CINAHL Plus, and AMED on 16 October 2020; ClinicalTrials.gov on 16 July 2020, and the ISRCTN Registry on 11 November 2019. We applied no language restrictions. SELECTION CRITERIA: We included randomised controlled trials of either parallel or cross‐over design that assessed the beneficial and harmful effects of coenzyme Q10 in people with heart failure. When we identified cross‐over studies, we considered data only from the first phase. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods, assessed study risk of bias using the Cochrane 'Risk of bias' tool, and GRADE methods to assess the quality of the evidence. For dichotomous data, we calculated the risk ratio (RR); for continuous data, the mean difference (MD), both with 95% confidence intervals (CI). Where appropriate data were available, we conducted meta‐analysis. When meta‐analysis was not possible, we wrote a narrative synthesis. We provided a PRISMA flow chart to show the flow of study selection. MAIN RESULTS: We included eleven studies, with 1573 participants, comparing coenzyme Q10 to placebo or conventional therapy (control). In the majority of the studies, sample size was relatively small. There were important differences among studies in daily coenzyme Q10 dose, follow‐up period, and the measures of treatment effect. All studies had unclear, or high risk of bias, or both, in one or more bias domains. We were only able to conduct meta‐analysis for some of the outcomes. None of the included trials considered quality of life, measured on a validated scale, exercise variables (exercise haemodynamics), or cost‐effectiveness. Coenzyme Q10 probably reduces the risk of all‐cause mortality more than control (RR 0.58, 95% CI 0.35 to 0.95; 1 study, 420 participants; number needed to treat for an additional beneficial outcome (NNTB) 13.3; moderate‐quality evidence). There was low‐quality evidence of inconclusive results between the coenzyme Q10 and control groups for the risk of myocardial infarction (RR 1.62, 95% CI 0.27 to 9.59; 1 study, 420 participants), and stroke (RR 0.18, 95% CI 0.02 to 1.48; 1 study, 420 participants). Coenzyme Q10 probably reduces hospitalisation related to heart failure (RR 0.62, 95% CI 0.49 to 0.78; 2 studies, 1061 participants; NNTB 9.7; moderate‐quality evidence). Very low‐quality evidence suggests that coenzyme Q10 may improve the left ventricular ejection fraction (MD 1.77, 95% CI 0.09 to 3.44; 7 studies, 650 participants), but the results are inconclusive for exercise capacity (MD 48.23, 95% CI ‐24.75 to 121.20; 3 studies, 91 participants); and the risk of developing adverse events (RR 0.70, 95% CI 0.45 to 1.10; 2 studies, 568 participants). We downgraded the quality of the evidence mainly due to high risk of bias and imprecision. AUTHORS' CONCLUSIONS: The included studies provide moderate‐quality evidence that coenzyme Q10 probably reduces all‐cause mortality and hospitalisation for heart failure. There is low‐quality evidence of inconclusive results as to whether coenzyme Q10 has an effect on the risk of myocardial infarction, or stroke. Because of very low‐quality evidence, it is very uncertain whether coenzyme Q10 has an effect on either left ventricular ejection fraction or exercise capacity. There is low‐quality evidence that coenzyme Q10 may increase the risk of adverse effects, or have little to no difference. There is currently no convincing evidence to support or refute the use of coenzyme Q10 for heart failure. Future trials are needed to confirm our findings.

Mechanical heart valves left in situ at the time of left ventricular assist device (LVAD) implantation are thought to potentially increase the risk of thromboembolism. Recommendations exist to replace dysfunctional mechanical mitral valves and any mechanical aortic valves at the time of LVAD implantation. Due to potential increases in cardiopulmonary bypass time and associated comorbidities with valve replacement, leaving a functional mechanical valve in place at LVAD implantation has been suggested to be a safe option. We retrospectively reviewed all patients with prior mechanical mitral or aortic valves undergoing LVAD implantation at our center between 2012 and 2017. Echocardiograms were read by a single cardiologist to assess for mechanical valve dysfunction. We identified 15 patients. Five patients had major bleeding requiring transfusion. On follow-up, 2 patients had hemorrhagic stroke and 2 had transient ischemic attach/ischemic stroke. In addition, 2 patients had LVAD thrombosis and 2 patients had LVAD driveline malfunction. Mild mechanical valve regurgitation was identified on follow-up echocardiograms of 2 patients. Rate of complications in patients with mechanical valves undergoing LVAD implantation was comparable to that reported for the general LVAD population. Leaving a functional mechanical valve in place at the time of LVAD implantation could be a reasonable alternative to valve replacement. More data are required to further guide patient care in these individuals.

Outside of heart and lung transplantation, only few cases have been reported describing venoarterial extracorporeal membrane oxygenation (VA-ECMO) use in solid organ transplantation. We present a case of a staged combined heart–kidney transplant in which VA-ECMO was utilized after a complicated orthotopic heart transplantation to successfully complete the subsequent renal transplantation.

Background: Given the public health significance of anemia, the long-term sequelae of iron deficiency anemia (IDA) on children, the expected effect of war on the trends of anemia in Syrian society, and the lack of assessment on the national burden of anemia and/or iron deficiency (ID) data, there is a vital need to investigate all-cause anemia, ID, and IDA in Syria during the crisis. Objective: To investigate the prevalence of ID and IDA in Syrian children, the effectiveness of oral iron supplements in the management of ID, and the diagnostic effectiveness of conventional iron markers. Methods: We conducted a retrospective study on hemoglobin (Hb) levels in 4-month-old to 14-year-old children and a prospective study on hematological (complete blood count, reticulocytes, and reticulocyte Hb content) and biochemical iron indices (serum ferritin, iron, and total iron-binding capacity) of infants visiting the primary care clinic at Children's Hospital in Damascus, Syria. Results: Of the 1128 children in the retrospective study, 648 children (57%) were found to be anemic, with 417 (37%) moderately-severely anemic. The prevalence of ID and IDA in the 135 children of the prospective study was 71.85% and 55.55%, respectively. Infants with ID who underwent a 4–8-week course of oral iron supplementation demonstrated good responsiveness. Except mean corpuscular hemoglobin (MCH), conventional iron markers (i.e., ferritin) routinely used to assess iron status proved unreliable. Conclusion: This study reveals a high prevalence of anemia, ID, and IDA among a group of apparently healthy Syrian children. Our findings necessitate a framework of urgent public health interventions that can address two major limitations; the poor follow-up by the parents and unreliability of the conventional iron diagnostic markers. MCH may represent a simple and cheap ID screening index in children.

Background Hydatid cyst is an endemic infectious disease. Various modalities have been provided to approach hydatosis. This article reports a 20-years-experience of a new minimally invasive technique for the management of solitary pulmonary hydatid cysts using video-assisted thoracoscopic surgery (VATS) with mini-thoracotomy. Methods We reviewed the medical records of patients who underwent unilateral or bilateral single pulmonary hydatid cyst excision using VATS with mini-thoracotomy. All patients were managed by the same surgeon over the period from January 1996 till January 2015. Results The study involved 120 patients aged between 11 and 74 years (median age = 30 years). The overall number of conducted surgeries was 130 (10 patients needed two surgeries). No deaths were reported during or after surgery. No recurrences were seen in the follow-up period that ranged between 10 and 30 months. Three patients (2.3% out of the 130 surgeries) developed post-operative complications: one patient had prolonged air leak and two patients developed empyema. Conclusion VATS with mini-thoracotomy is an effective and safe option for managing intact or ruptured solitary pulmonary hydatid cysts. Further studies in controlled prospective design are needed to compare this approach to other modalities of management.

Introduction: Research is crucial for health-care delivery. However, medical students may not participate in research during their training, which might negatively affect their understanding of the importance of research and their future ability to conduct research projects. This is more prominent in developing countries. We aim to assess the attitudes of a sample of Syrian medical students toward research and suggest plausible solutions to reduce their self-reported barriers. Methods: A cross-sectional study was conducted using a self-administered, pretested questionnaire. Results: Three hundred and twenty-three responses were included. Most students demonstrated positive attitudes toward research. However, most of the responses indicated that they did not receive any training in academic writing or research and therefore did not have the opportunity to participate in formal research projects or scholarly writing. Students reported various types of barriers that challenged their progress in the field of research. Students who reported being encouraged by their professors to participate in research and writing/publishing scientific papers or reported receiving training about these activities were more likely to participate in research projects or writing scientific articles. Conclusion: Students have positive attitudes toward research and publication while they reported poor education, limited participation, and presence of many barriers that impede their participation in such activities.

Uninvestigated dyspepsia (UD), irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD) are common disorders universally. Many studies have assessed their epidemiological characteristics around the world. However, such information is not known for Syria. We aim to estimate the epidemiologic characteristics and possible risk factors for UD, IBS, and GERD among students at Damascus University, Damascus, Syria. A cross-sectional study was conducted in July–September 2015 at a campus of Damascus University. A total of 320 students were randomly asked to complete the survey. We used ROME III criteria to define UD and IBS, and Montreal definition for GERD. In total, 302 valid participants were included in the analysis. Prevalence for UD, IBS, and GERD was 25%, 17%, and 16%, respectively. Symptom overlap was present in 46 students (15%), with UD + IBS in 28 (9.3%), UD + GERD in 26 (8.6%), and IBS + GERD in 14 (4.6%) students. Eleven (3.6%) students had symptoms of UD + IBS + GERD. Each of these overlaps occurred more frequently than expected by chance. Significant risk factors included cigarettes smoking, waterpipe consumption, and body mass index

Background: The National Medical Unified Examination (NMUE) is currently required for graduation, joining postgraduate medical training, and practicing medicine in Syria. Objective: To investigate self-reported study habits that correlate with high performance on the NMUE. Methods: First through 3rd year residents at the three main hospitals in Damascus, Syria, were asked to complete a retrospective cross-sectional survey investigating their study habits and previous scores. Results: Significantly higher score was associated with >15 study h/day and allocating 1–40% of study time for practicing questions. Mean NMUE score was not significantly different in relation to preparation months for examination or for those who reported spending all their time studying alone compared with spending any amount of time in a group setting. Scores of 231–240 on the Syrian scientific high school exam correlated with significantly higher NMUE performance compared with fewer scores, except scores of 221–230. For every 10 point increase in medical school cumulative grades, the NMUE score increased 3.6 (95% confidence interval 2.5–4.8). Conclusion: The NMUE score was significantly affected by hours spent studying per day, number of practice questions completed, percentage of study time allocated for doing questions, Syrian scientific high school exam scores, and the cumulative medical school class grades. It was not significantly affected by preparation months or studying in a group setting. More studies are needed to further describe and investigate the factors that might affect performance in the NMUE.

Mulibrey (MUscle-LIver-BRain-EYe) nanism is a rare autosomal recessive disease characterized by growth failure, dysmorphic features and a wide range of abnormalities affecting multiple organ systems. This report is the first to present two cases of Mulibrey nanism affecting two siblings from Syria. Mulibrey nanism can be suspected clinically due to the distinctive features of the patients. The aim of this report is to document the presence of Mulibrey nanism in Syria and to familiarize physicians in and out of Syria with this rare disease and encourage them to develop high clinical suspicion if faced with patients with similar presentations.

Introduction With the advent of newer heart failure (HF) medications and devices such as implantable cardioverter-defibrillator (ICD), the survival benefits of long-term intravenous (IV) inotropes might be underestimated. 1-year mortality from outpatient IV inotropes (continuous and intermittent) have been reported between 25% to 47.6%. However, a study solely based on outpatient continuous inotropes for palliation has not been done in the past. This study hypothesizes that the survival rate of patients with end stage HF on palliative intravenous inotrope is better than previously expected (6 months) and may be a viable option for certain patients. Methods and Results We performed a single-center, retrospective chart review of HF patients who were discharged with an inotrope (milrinone or dobutamine) for palliation. Inclusion criteria included age > 18, diagnosis of HF, and patients discharged on inotropes after January 1, 2010. Exclusion criteria included patients who had received mechanical circulatory support (MCS) or patients who had received a heart transplant. Data were collected on 119 patients from the existing database of the Advocate Christ Medical Center's heart failure clinic. Primary outcome was survival on inotropes. Secondary outcomes included number of hospitalizations, number of clinic visits, infection rates and incidence of arrhythmia on inotrope. SAS software was used for statistical analysis. 87.38% of patients were discharged on Milrinone whereas 13.51% were discharged on dobutamine. Demographics, comorbidities, medications and devices are shown in table 1. The mean follow-up time was 255.36±23.93 days. 27.03% were alive on inotrope, 15.32% were alive but weaned off of inotrope, 18.92% were on hospice, 17.12% had expired, and 21.62% were lost to follow-up. Using product-limiting survival estimates, the unconditional probability of surviving beyond 6.5 months was 84%. Mean number of hospitalizations after discharge on inotrope was 1.92±0.25. Mean number of clinic visits in 3, 6 and 12 months were 2.61±0.26, 4.48±0.49, 7.92±0.95 respectively. The rate of peripherally inserted central catheter infection and arrhythmia were 8.11% and 9.91% respectively. Conclusions Palliative inotrope after diagnosis of end-stage heart failure is a safe option with moderate survival benefit in patients who opt out of or who do not meet criteria for MCS or transplant.

The ongoing Syrian war has resulted in many changes in the social and economic life of Syrians. To date, no study has documented the relationship between smoking behaviour and the war.To determine the prevalence of cigarette smoking among university students during the crisis in Damascus, Syrian Arab Republic, and the impact of the war on smoking behaviour.We conducted an anonymous online cross-sectional survey of 1027 undergraduate students from all years and colleges at Damascus University.The overall prevalence of tobacco smoking was 24.73% for cigarettes and 30.4% for waterpipe. Prevalence of cigarette smoking was significantly higher in men, non-health profession students, and in students living away from their families. There was no significant difference in prevalence of smoking cigarettes when comparing students according to their origin (urban vs rural), year of study, and change of residence due to war. War was associated with a significant increase in mean number of cigarettes smoked daily, and 53.1% of smokers reported that the number of cigarettes consumed per day had increased since the beginning of the war.Increased smoking is an additional health concern in areas of conflict and may require special consideration and efforts by public health authorities.سلوك التدخين وأنماطه في صفوف الطلاب الجامعيين خلال الأزمة السورية.عمرو إدريس، طارق السعدي، طارق ترك، محمود الخطيب، محمد زكريا، بشر صواف، باسل إدريس.أسفرت الحرب الدائرة في سوريا عن كثير من التغييرات في الحياة الاجتماعية والاقتصادية للسوريين. ولم توثّق، حتى تاريخه، أي دراسة للعلاقة بين سلوك التدخين والحرب.تحديد مدى انتشار تدخين السجائر بين الطلاب الجامعيين خلال الأزمة في دمشق، الجمهورية العربية السورية ، وأثر الحرب على سلوك التدخين.أجرينا مسحاً مقطعياً مغْفل الأسماء على الإنترنت لما مجموعه 1027 طالباً في المرحلة الجامعية من جميع السنوات الدراسية والكليات في جامعة دمشق.بلغ المستوى العام لانتشار تدخين التبغ 24.73 % بالنسبة لتدخين السجائر، و 30.4 % بالنسبة لتدخين الشيشة (الأرجيلة). وتبيّ أن مستوى انتشار تدخين السجائر أعلى بكثير بين الرجال وطلاب غير المهن الطبية والطلاب المغتربين عن أسرهم. ولم تظهر أي اختلافات كبيرة في مستوى انتشار تدخين السجائر عند مقارنة الطلاب وفقاً لمكان نشأتهم (ريفيين مقابل حضريين)، وسنة الدراسة، وتغيير محل الإقامة بسبب الحرب. وتبيّ ارتباط الحرب بزيادة كبيرة في متوسط عدد السجائر المدخّنة يومياً، وأفاد 53.1 % من المدخنين بزيادة عدد السجائر التي يستهلكونها يومياً منذ اندلاع الحرب. وتمثل زيادة التدخين شاغلاً صحياً إضافياً في مناطق النزاع وقد تتطلب اهتماماً وجهوداً خاصة من جانب السلطات المعنية بالصحة العمومية.تمثل زيادة معدلات التدخين شاغلاً صحياً إضافياً في مناطق النزاع وقد تتطلب اهتماماً وجهوداً خاصةً من جانب السلطات المعنية بالصحة العامة.Comportements et schémas tabagiques parmi les étudiants à l’université durant la crise syrienne.La guerre qui sévit en République arabe syrienne a conduit à de nombreuses modifications dans la vie sociale et économique des Syriens. À ce jour, aucune étude ne documente la relation entre les comportements tabagiques et la guerre.Déterminer la prévalence de la consommation de cigarettes parmi les étudiants à l’université pendant la crise à Damas, en République arabe syrienne, et l’impact de la guerre sur les comportements tabagiques.Nous avons organisé une enquête en ligne transversale et anonyme sur 1027 étudiants de premier cycle de toutes les années et dans toutes les facultés de l’Université de Damas.La prévalence globale du tabagisme était de 24,73 % pour la cigarette, et de 30,4 % pour la pipe à eau. La prévalence de la consommation de cigarettes était significativement plus élevée chez les hommes, les étudiants d’autres filières que celle de la santé, et chez les étudiants ne vivant plus dans leurs familles. Aucune différence significative n’a été observée pour la prévalence de la consommation de cigarettes en fonction de l’origine des étudiants (urbaine ou rurale), de leur année d’étude, ou de leur changement de résidence du fait de la guerre. La guerre était associée à une augmentation significative du nombre moyen de cigarettes consommées quotidiennement, et 53,1 % des fumeurs rapportaient que le nombre de cigarettes qu’ils consommaient par jour avait augmenté depuis le début de la guerre.L’augmentation du tabagisme est une préoccupation sanitaire supplémentaire dans les zones de conflit, et requiert une attention spéciale ainsi que des actions de la part des autorités de santé publique.

Hepatitis A is a common viral illness worldwide. It usually results in an acute, self-limiting disease and only rarely leads to fulminant hepatic failure or any other complications. During the period of conflict in Syria, and due to the damages to water infrastructure and poor sanitation, a dramatic increase in hepatitis A virus infection has been documented. Here we report a rare case of a 14-year-old male whose hepatitis A was complicated with hepatorenal syndrome and subacute liver failure. The war condition in Syria impeded transportation of the patient to a nearby country for liver transplantation, contributing to his unfortunate death.