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We report the case of a patient who presented with septic shock and multiorgan failure. Methicillin-resistant Staphylococcus aureus and Talaromyces marneffei were cultured from his blood. He was treated with a course of vancomycin along with amphotericin. Further work-up revealed him to be HIV positive with an absolute CD4 count of 14 cells/μL. Despite aggressive medical support, he eventually succumbed to his illness with Klebsiella pneumonia sepsis. To the best of our knowledge, this is the first reported T. marneffei infection in the Middle East and the first observation of concomitant community-acquired methicillin-resistant S. aureus bacteraemia and talaromycosis from the Middle East region.

Introduction: This case report describes a conservative restorative approach in the management of severe generalized tooth wear. Case report: The male, aged 57 years, was mainly concerned with the poor appearance of his teeth with short and discolored upper incisors. History revealed that he suffered from gastric reflux for 25 years, for which he was prescribed Ranitidine and was advised to self-medicate with cider vinegar. Furthermore, he divulged that he ground his teeth at night and during the day and had a high intake of carbonated cola drinks. On examination, dentine was exposed in several areas, and to a significant extent, on the incisal aspects of the lower incisors, the palatal surfaces of the upper incisors, and the occlusal surfaces of the molars. Mandibular tori were present. The primary diagnosis was erosive tooth wear with elements of attrition and abrasion. The intervention included dietary advice and restoration with direct composite resin at an increased occlusal vertical dimension of 1.5mm on the retruded axis. The patient reported no functional problems and was pleased with the aesthetic result. Conclusion: Vinegar is promoted to have health benefits, especially with respect to glucose response, but the dental implications are overlooked. This paper reviews the literature on vinegar as a medicament and considers its role as a co-factor for erosion in this case. The clinical steps used to restore the eroded dentition by direct composite are described. The use of this approach is a safe, conservative and successful treatment option without recourse to complex and biologically costly conventional alternatives. The application of direct composite in tooth wear cases meets the European consensus requirements.

Objective: To compare the effects of gaze stability exercises with proprioception training to improve gait and functional independence in cerebellar ataxic patients. Methods: A Quasi experimental study was conducted in the physiotherapy department in Lahore General Hospital, Lahore, Pakistan from January 2018 to June 2018.All patients were diagnosed with cerebellar ataxia and referred by neurophysician to physiotherapy department. Forty-six (46) patients were divided into two equal groups by lottery method. (Group A =proprioception training), (Group B =gaze stability with proprioception training). Data was analyzed by using statistical package for social sciences (SPSS) 21. Results: In group A, males were 13(56.5%) and females 10(43.5%) while in Group B, males were 12(52.2%) and females 11(47.8%). Mean ages were (71.3±8.47) years in Group A and (70±7.67) years in Group B. Pre and Post Functional Independence Measure (FIM)score in groups A and B with mean and standard deviation were 13.08±1.86 and 15.43±1.74 respectively. Pre and Post Timed Up and Go (TUG) test score in groups A and B with mean and standard deviation were 0.79± 0.26 and 0.97 ±0.39 respectively. Both groups were statistically significant (P value ≤ 0.05) but on the basis of mean ± standard deviation Group B method was more effective than Group A. Conclusion: Gaze stability exercises added the effects of proprioception training in improving gait and functional independence in cerebellar ataxic patients. Keywords: Cerebellar ataxia, gaze, patients, proprioception

Background It is imperative to establish how students view and present themselves on social media and to assess level of awareness regarding the implications of their social media presence, e-professionalism, and accountability. The study objectives were to: 1) Determine the social media usage levels among medical and pharmacy students in the United Arab Emirates (UAE); 2) Characterize the students' views and perceptions, including their awareness of e-professionalism; and 3) Compare the responses in behavior between the two groups. Methodology A cross-sectional study was performed on 575 undergraduate students from two study disciplines, pharmacy (n = 325) and medicine (n = 250). Minor revisions were made to previously validated assessment tools and pilot tested. The study sample included students from five different universities across the country. Results In comparison to medical students, pharmacy students were observed to use social media more for learning purposes (χ2 = 6.8, P Conclusion The research findings converge to address the need for educators and administrators in the UAE to develop guidelines concerning its safe use and proactively integrate e-professionalism into their respective curriculum.

Background This study assessed retrospectively the clinical outcomes of single implant-supported crowns and implant-supported fixed dental prostheses (FDPs). Methods This case series compared biological and technical complications in single implant-supported crowns and implant-supported bridges in a time framed sample of all patients who received dental implants between 2009 and 2016 in Dubai Health Authority. Only 3-unit implant-supported prostheses (FDPs) with one intervening pontic and an implant each end were included for comparison to single crown supported implants. Cantilevered implants, implant-supported dentures and cases involving bone grafts or sinus lifts were excluded. The primary outcome measure was marginal bone loss, measured on digital radiographs taken after prosthesis placement at baseline and one year after implant loading, whilst peri-implantitis and technical complications were secondary outcomes. Mixed regression models adjusted for clustering of implants within patients was used for patient and implant factor associations. Results A total of 454 patients (152 males; 302 females) had 1673 implants. The mean age of males (53.7 years, SD 14.6) was significantly greater than females (49.3 years, SD 12.9, p Conclusions Mean marginal bone loss around the supporting implants of FDPs (3-unit fixed bridgework) was greater than on single implant-supported crowns at one year after implant loading. Position in the mouth was associated with bone loss. Biological and technical complications occurred rarely.

Background The term premenstrual syndrome (PMS) encompasses a variety of physical and psychological symptoms that are related to the menstrual cycle. The likelihood of developing this syndrome, along with its potential severity has been found to be linked to many environmental, nutritional, and genetic factors. Objective We aimed to evaluate the frequency of vitamin D receptor (VDR) - Fok1 Restriction fragment length polymorphism in young women complaining of PMS. Materials and methods The current study included evaluation of 340 female students by a validated questionnaire, anthropometric measurement, followed by collection of venous blood samples and DNA extraction. VDR-Fok1 polymorph was investigated by PCR then fragmentation by Fok1 restriction enzyme and finally detection of genotypes using agarose gel electrophoresis. Results and conclusion We observed a significant association between VDR FokI polymorphism and PMS. However, on subgroup analysis by ethnicity, the FF genotype was more predominant among Arab women. ff mutation was associated with a significantly higher risk for PMS [OR = 3.72, 95% CI = 1.65–8.35, p ≤0.05] among non-Arabs.

Summary Background In non-surgical settings, covert stroke is more common than overt stroke and is associated with cognitive decline. Although overt stroke occurs in less than 1% of adults after non-cardiac surgery and is associated with substantial morbidity, we know little about perioperative covert stroke. Therefore, our primary aim was to investigate the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery. Methods NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries, in which we assessed patients aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology experts, masked to clinical data, assessed each MRI for acute brain infarction. Using multivariable regression, we explored the association between covert stroke and the primary outcome of cognitive decline, defined as a decrease of 2 points or more on the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up. Patients, health-care providers, and outcome adjudicators were masked to MRI results. Findings Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study, 78 (7%; 95% CI 6–9) had a perioperative covert stroke. Among the patients who completed the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%) of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22–3·20, absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06–4·73, absolute risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year follow-up (HR 4·13, 1·14–14·99, absolute risk increase 3%; p=0·019). Interpretation Perioperative covert stroke is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery, and perioperative covert stroke occurred in one in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke. Funding Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region, China; and The Neurological Foundation of New Zealand.

Objective: One option to treat locoregional recurrence of thyroid carcinoma is with percutaneous ethanol injection (PEI). Although complications with this treatment are rare, we describe a patient who developed Horner syndrome after PEI. In addition, we reviewed the literature on complications after PEI for thyroid disease.Methods: A clinical case report was performed on a patient who underwent PEI and subsequently developed ptosis, miosis, and anhidrosis. Based on these classic findings, she was diagnosed with Horner syndrome. A Medline search was performed to identify all complications after PEI for thyroid disease.Results: A 31-year-old woman with stage 1 papillary thyroid carcinoma (PTC) metastatic to the cervical lymph nodes was treated by total thyroidectomy and central lymph node dissection followed by radioactive iodine. The disease recurred in a single lymph node in the right neck, and she opted for PEI treatment. Postprocedurally, the patient developed right-sided miosis, ptosis, and anhidrosis. Symptoms were consistent with Horner syndrome. She was treated with a steroid burst and taper. After 6 months, her symptoms improved but had not fully resolved.Conclusion: PTC can be treated in multiple ways. To avoid re-operation in patients with recurrent PTC that is limited to a few lymph nodes, PEI can be a useful treatment option. Ethanol injection into live tissue causes dehydrative effects and can damage nearby structures. However, the literature demonstrates that serious complications after PEI are rare. Nonetheless, these rare complications are important to acknowledge in order to better counsel patients prior to treatment.Abbreviations: PEI = percutaneous ethanol injection; PTC = papillary thyroid carcinoma

Potential surgical strategies for hypoplastic branch pulmonary arteries (BPAs) during tetralogy of Fallot repair include (1) extensive patch augmentation to the hilum (PATCH), (2) limited extension arterioplasty to the proximal pulmonary artery (EXTENSION), or (3) leaving the native vessels unaugmented (NATIVE). We explored the effect of these strategies on reintervention and BPA growth.From 2000 to 2012, 434 children underwent complete tetralogy of Fallot repair. Risk-adjusted parametric models were used to analyze the risk of BPA reintervention for (1) all children, (2) children with BPAs of 4 mm or smaller, and (3) children with BPAs of 3 mm or smaller. Repeated-measures analysis of more than 2,000 echocardiograms was used to characterize postoperative BPA growth and right ventricular pressure by using nonlinear mixed models.Overall survival (99% [3 deaths]) was excellent. The 10-year freedom from BPA reintervention was 84%. In risk-adjusted models (including baseline BPA z-score), PATCH had a decreased freedom from reintervention (73%; p0.01) vs EXTENSION (87%) or NATIVE (91%). For children with BPAs of 4 mm or smaller (28 PATCH, 60 EXTENSION, 75 NATIVE), baseline characteristics were similar. The risk-adjusted 5-year freedom from reintervention was 68% for PATCH, 76% for EXTENSION, and 85% for NATIVE. PATCH trended toward an increased risk of reintervention (p = 0.07). For children with BPAs of 4 mm or smaller left in their NATIVE state, only ∼15% required reintervention. After adjustment for baseline BPA z-score, the time-related BPA growth was decreased (p0.014) and right ventricular pressure was increased (p = 0.03) for the PATCH group.Aggressive PATCH augmentation of hypoplastic BPAs improves the short-term geometry but may lead to late stenosis and higher rates of reintervention. Hypoplastic BPAs in tetralogy of Fallot tend (∼85%) to grow well without instrumentation.

Background Cardiac surgery patients are at high risk for postoperative bleeding. Intravenous (IV) tranexamic acid (TxA) is a commonly used antifibrinolytic drug, but is associated with postoperative seizures. We conducted this pilot randomized controlled trial (RCT) to determine the feasibility of a larger trial that will be designed to investigate the impact of TxA administration route, intrapericardial (IP) vs IV, on postoperative bleeding and seizures. Methods In this single-center, double-blinded, pilot RCT we enrolled adult patients undergoing nonemergent on-pump cardiac operations through a median sternotomy. Participants were randomized to IP or IV TxA groups. The primary outcomes were cumulative chest tube drainage, transfusion requirements, and incidence of postoperative seizures. Results A total of 97 participants were randomized to the intervention and control groups. Baseline characteristics were similar in both groups. Most participants underwent a CABG and/or aortic valve replacement. There was no statistical difference. The IP TxA group was found to have a tendency for less chest tube drainage in comparison to the IV TxA group, 500.5 (370.0-700.0) and 540.0 (420.0-700.0) mL, respectively, which was not statistically significant (P = 0.2854). Fewer participants in the IP TxA group with cardiac tamponade and/or required a reoperation for bleeding and fewer packed red blood cell transfusions. None of the IP TxA group developed seizure vs one from the IV TxA group. Conclusion This is the first known pilot RCT to investigate the role of TxA route of administration in open cardiac surgery. Intrapericardial TxA shows promising results with decreased bleeding, transfusion requirements, reoperations, and postoperative seizures. A larger RCT is needed to confirm these results and lead to a change in practice.

BackgroundA wide variety of surgical strategies are used in tetralogy of Fallot repair. We sought to describe the international contemporary practice patterns for surgical management of tetralogy of Fallot.MethodsSurgeons from 18 international paediatric cardiac surgery centres (representing over 1800 tetralogy of Fallot cases/year) completed a Research Electronic Data Capture-based survey. Participating countries include: China (4), India (2), Nepal (1), Korea (1), Indonesia (1), Saudi Arabia (3), Japan (1), Turkey (1), Australia (1), United States of America (2), and Canada (1). Summary measures were reported as means and counts (percentages). Responses were weighted based on case volume/centre.ResultsPrimary repair is the prevalent strategy (83%) with variation in age at elective repair (range). Approximately 47% of sites use patient age as a factor in determining the strategy, with age 90% of all trans-annular repairs.ConclusionsIn this cohort representing 11 countries, there is variation in tetralogy of Fallot surgical management with no consensus on standard of practice. A large international prospective cohort study would allow analysis of impact of underlying anatomy and repair strategy on early and late outcomes.

A 5-month-old baby presented with a low-grade fever and tachypnoea and was found to have right upper lobe consolidation on chest radiograph. He was admitted with the diagnosis of bronchopneumonia and the treatment protocol for pneumonia was initiated. Blood culture samples were collected, and he was started on a course of intravenous amoxicillin–clavulanate. Blood culture results displayed pansensitive Gemella morbillorum bacteraemia and he was continued on intravenous antibiotic to which he responded in a short period and was discharged in good condition on the fourth day.

Learner centered education has been one of the major highlights that has revolutionized the teaching method in every department. While some effort has been made to better implement peer learning into the curriculum in some universities, it remains a vastly underused utility that can be employed both in and out of the classroom. Learning among, and teaching others who are at the same level of education does not only lead to enhanced memory and recall, it also develops critical real-world skills that can enhance the involved individual both professionally and academically. This article is a medical student’s perspective on encouraging peer assisted education in the healthcare environment, and a preliminary learning guide for the students who wish to implement this method of education.

Background We present the first reported case of robotic-assisted right atrial perforation repair and pacemaker lead extraction. Methods A 75-year-old female with symptomatic sinus node dysfunction underwent atrial single chamber permanent pacemaker insertion via a persistent left superior vena cava approach. At one week follow-up a chest radiograph and a computerized dynamic tomography demonstrated that the right atrial lead had perforated the right atrial free wall. The patient remained asymptomatic without signs of pericardial tamponade, however urgent repair was warranted. Results Utilizing the da Vinci robotic system (Intuitive Surgical Inc., Sunnyvale, California, USA), the pacer lead perforation was visualized, the lead retracted, and the right atrium repaired. The existing atrial lead was repositioned in the right atrial appendage. Conclusion The patient's postoperative convalescence was uneventful, and she was discharged home on the third post-operative day. This case demonstrates the increasing clinical utilization of robotic-assisted technology in minimally invasive cardiac surgery. Copyright © 2012 John Wiley & Sons, Ltd.

A 5-month-old baby presented with a low-grade fever and tachypnoea and was found to have right upper lobe consolidation on chest radiograph. He was admitted with the diagnosis of bronchopneumonia and the treatment protocol for pneumonia was initiated. Blood culture samples were collected, and he was started on a course of intravenous amoxicillin–clavulanate. Blood culture results displayed pansensitive Gemella morbillorum bacteraemia and he was continued on intravenous antibiotic to which he responded in a short period and was discharged in good condition on the fourth day.

Introduction: Right Ventricular End-Diastolic Volume indexed (RVEDVi) obtained by MRI is an accurate measure of RV size and a marker for secondary complications. Echo RV measurements are used early in life after TOF repair for practical reasons. We sought to examine the correlation between early echo Right Ventricular End-Diastolic Dimension z-score (RVEDDz) and MRI RVEDVi at 15 years post-repair. The relationship between these parameters and repair technique is investigated. Methods: 185 TOF patients were repaired at our institution from 1996-2002. Repair techniques were: annulus preservation (AP=124), trans-annular patch (TAP=56), and Pulmonary valve replacement (n=5, patients excluded). Data was reviewed for outcomes, echo studies, and MRI reports. A linear ordinary least square model demonstrated the relationship between early RVEDDz and late RVEDVi (n=57) . Longitudinal analysis with mixed effects model was performed on 783 serial echocardiograms (n=146) to demonstrate the effect of technique on RVEDDz progression. Results: RVEDDz at 1-5 years post-repair was a significant predicator for late RVEDVi (p=0.0016). A change in RVEDDz from 0-3 predicted an increase in RVEDVi of 28 mL. TAP repair was an independent predictor of a larger RVEDVi (p=0.0011). TAP was associated with more RV dilation throughout follow-up (0.37 RVEDDz higher every 5 years, p Conclusion: These results from a single institution support the use of RVEDDz by echo as an early maker for late MRI RV volumes in TOF. Early identification of high risk patients may influence decisions around follow-up and re-interventions. Larger population studies are needed to confirm these findings and the effects of technique on long-term RV health. Fig 1.

Introduction: We introduced the NASA “threat and error model” to our surgical unit; all admissions are considered “flights”, which should pass through stepwise de-escalations in risk. Hypothesis: Errors significantly influence risk de-escalation and contribute to poor outcomes. Methods: Patient flights (524) were tracked real-time for threats, errors and unintended states (figure). Expected risk de-escalation was: wean from mechanical support, sternal closure, extubation, ICU discharge and discharge home. Data were accrued via performance personnel, bedside data, reporting mechanisms and staff interviews. Infographics of flights were openly discussed weekly. Results: In 12% (64/524) of flights, the child failed to de-escalate sequentially through expected risk levels; unintended increments instead occurred. Failed de-escalations were highly associated with errors (426; 257 flights), however seemingly benign (P The most dangerous errors were “apical” errors typically (84%) occurring in the OR which led to cycles of propagating unintended states (n=110): these had 43% (47/110) rate of failed de-escalation (vs 4%, P Conclusions: Deaths and brain injury almost always occur from propagating error cycles that originate in the OR and are often amplified by additional ICU errors. Improvements in threat management, error detection/rescue and vigilance at times of failed de-escalation will translate into improved outcomes.

Syncope and atrial fibrillation are both common entities and frequently occur together in an acute clinical scenario. Treatment of each in this presentation requires acquiring a good history and understanding the presentation of the patient. In this manuscript, there are 5 case studies that demonstrate common misperceptions when attempting to treat syncope when it presents with the arrhythmia atrial fibrillation. Rarely, does atrial fibrillation cause syncope. However, when a patient presents in atrial fibrillation, it becomes the focus of therapy rather than trying to define the etiology of the syncopal episode. It may be that well thought out algorithms to treat atrial fibrillation in an acute setting are replacing deductive thinking particularly when it comes to diagnosing the cause of a syncopal spell.

Background: We present our experience with optimization and diagnostic use of quantitative real-time polymerase chain reaction (PCR) targeting the lytA gene of Streptococcus pneumoniae for the detection of S. pneumoniae in whole blood of children

We present the first reported case of robotic-assisted right atrial perforation repair and pacemaker lead extraction.A 75-year-old female with symptomatic sinus node dysfunction underwent atrial single chamber permanent pacemaker insertion via a persistent left superior vena cava approach. At one week follow-up a chest radiograph and a computerized dynamic tomography demonstrated that the right atrial lead had perforated the right atrial free wall. The patient remained asymptomatic without signs of pericardial tamponade, however urgent repair was warranted.Utilizing the da Vinci robotic system (Intuitive Surgical Inc., Sunnyvale, California, USA), the pacer lead perforation was visualized, the lead retracted, and the right atrium repaired. The existing atrial lead was repositioned in the right atrial appendage.The patient's postoperative convalescence was uneventful, and she was discharged home on the third post-operative day. This case demonstrates the increasing clinical utilization of robotic-assisted technology in minimally invasive cardiac surgery.

Social Networking is a very popular term which refers to online services or websites that focus on building social networks among people who like sharing common interests and activities. It allows people to socialise and network with others in an online environment. This research paper aims to study the positive and the negative impact of Social Networking on Emirati teenagers. By studying the impact, the work also aims to create awareness among teenagers, parents, schools and the community about the same.