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Background: Current medical simulators for extracorporeal membrane oxygenation (ECMO) are expensive and rely on low-fidelity methodologies. This creates a challenge that demands a new approach to eliminate high costs and integrate with critical care environments, especially in light of the scarce resources and supplies available after the COVID-19 pandemic., Methods: To address this challenge, we examined the current state-of-the-art medical simulators and collaborated closely with Hamad Medical Corporation (HMC), the primary healthcare provider in Qatar, to establish criteria for advancing the cutting-edge ECMO simulation. This article presents a comprehensive ambulatory high-realism and cost-effective ECMO simulator., Results: Over the past 3 years, we have surveyed relevant literature, gathered data, and continuously developed a prototype of the system modules and the accompanying tablet application. By doing so, we have successfully addressed the issue of cost and fidelity in ECMO simulation, providing an effective tool for medical professionals to improve their understanding and treatment of patients requiring ECMO support., Conclusions: This paper will focus on presenting an overall ambulatory ECMO simulator, detailing the various sub-systems and emphasizing the modular casing of the physical components and the simulated patient monitor., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Intravenous (IV) therapy using short peripheral IV catheters (PIVC) is commonplace with neonatal patients. However, this therapy is associated with high complication rates including the leakage of infused fluids from the vasculature into the surrounding tissues; a condition referred to as, peripheral IV infiltration/extravasation (PIVIE)., Objective: The quality improvement project aimed to identify the prevalence of known risk factors for PIVIE in the neonatal intensive care unit (NICU) and explore the feasibility of using novel optical sensor technology to aid in earlier detection of PIVIE events., Methods: The plan, do, study, act (PDSA) model of quality improvement (QI) was used to provide a systematic framework to identify PIVIE risks and evaluate the potential utility of continuous PIVC monitoring using the ivWatch model 400 ® system. The site was provided with eight monitoring systems and consumables. Hospital staff were supported with theoretical education and bedside training about the system operations and best use practices., Results: In total 113 PIVIE's (graded II-IV) were recorded from 3476 PIVCs, representing an incidence of 3.25%. Lower birth weight and gestational age were statistically significant factors for increased risk of PIVIE ( p  = 0.004); all other known risk factors did not reach statistical significance. Piloting the ivWatch with 21 PIVCs using high-risk vesicant solutions over a total of 523.9 h (21.83 days) detected 11 PIVIEs (graded I-II). System sensitivity reached 100%; 11 out of 11 PIVIEs were detected by the ivWatch before clinician confirmation., Conclusions: Prevailing risk factors for PIVIE in the unit were comparable to those published. Continuous infusion site monitoring using the ivWatch suggests this technology offers the potential to detect PIVIE events earlier than relying on intermittent observation alone (i.e. the current standard of care). However, large-scale study with neonatal populations is required to ensure the technology is optimally configured to meet their needs., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: There has been significant improvement in treating metastatic non-small-cell lung cancer (mNSCLC) over the past 2 decades. The aim of this study is to describe the use of tyrosine kinase inhibitors (TKIs) in Qatar. This study focuses on the objective response rate (ORR) and reported adverse drug events (ADEs) of TKIs used for the management of patients with mNSCLC., Methods: This is a descriptive retrospective cohort study. All non-small-cell lung cancers (NSCLCs) with epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) mutations who received TKIs between 2015 and 2019 in Qatar were included. The TKIs used during this period include EGFR inhibitors such as afatinib, erlotinib, gefitinib, and osimertinib and ALK inhibitors such as alectinib and crizotinib. The response on each TKI was identified by reporting the ORR (as the sum of the complete response [CR] and the partial response [PR]), in addition stable disease (SD) and disease progression (DP) were reported. While ADEs were reported using the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE)., Results: A total of 63 patients were included, of which 36 cases (57.1%) expressed EGFR mutation, and 27 patients (42.9%) expressed ALK rearrangement. The ORR in EGFR inhibitors was as follows: osimertinib 40%, gefitinib 33%, afatinib 22%, and erlotinib 18%. However, the response to the ALK-targeted therapy was 43% with alectinib and 40% with crizotinib. A total of 112 ADEs were reported. They were distributed as 63.4% (71 of 112) with the anti-EGFR and 36.6% (41 of 112) ADEs with the ALK inhibitors. In the anti-EGFR group, the most common types of ADEs were dermatological toxicity 30%, whereas, in the anti-ALK group, gastrointestinal toxicity was the most common (29%)., Conclusions: The EGFR-targeted and ALK-targeted therapies appear to have acceptable clinical response rate and safety profile in our population. Close and frequent monitoring of adverse events is advised to ensure a good quality of life and prevent serious complications., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Polypharmacy and potentially inappropriate medications are significant challenges in older adults' medication management. The Consolidated Framework for Implementation Research (CFIR) is a comprehensive approach used to explore barriers and enablers to the healthcare system in guiding the effective implementation of evidence-based practices., Objectives: This study examines the barriers and enablers to promote safe medication management among older adults in Qatar from healthcare professionals' perspectives. This includes identifying critical factors within the healthcare system influencing medication management and suggesting practical solutions to improve it., Design: The study employs a qualitative design. Focus Groups (FGs) were conducted with healthcare professionals from the geriatric, mental health and medicine departments of Hamad Medical Corporation (HMC), the leading governmental sector in Qatar serving the older adult population., Methods: Utilising the CFIR, this study analysed feedback from healthcare professionals through FGs at HMC. A combined inductive and deductive thematic analysis was applied to transcripts from five FGs, focusing on identifying barriers and enablers to safe medication management among older adults. Two researchers transcribed the audio-recorded FG discussions verbatim, and two researchers analysed the data using a mixed inductive and deductive thematic analysis approach utilising CFIR constructs., Results: We engaged 53 healthcare professionals (31 physicians, 10 nurses and 12 clinical pharmacists) in FGs. The analysis identified current barriers and enabler themes under different CFIR constructs, including inner settings, outer settings, individual characteristics and intervention characteristics. We identified 44 themes, with 25 classifieds as barriers and 19 as enablers. The findings revealed that barriers and enablers within the inner settings were primarily related to structural characteristics, resources, policies, communication and culture. On the other hand, barriers and enablers from the outer settings included patients and caregivers, care coordination, policies and laws, and resources., Conclusion: This study identified several barriers and enablers to promote medication management for older adults using the CFIR constructs from the perspective of healthcare professionals. The multifaceted findings emphasise involving stakeholders like clinical leaders, policymakers and decision-makers to address medication safety factors. A robust action plan, continuously monitored under Qatar's national strategy, is vital. Further research is needed to implement recommended interventions., (© The Author(s), 2024.)

Background: Antiplatelet therapy plays an important role in reducing the risk of stroke recurrence in patients with mild ischemic stroke or high-risk transient ischemic attack (TIA). However, data regarding the effectiveness and safety of using aspirin plus clopidogrel in dual antiplatelet therapy (DAPT) compared to aspirin alone in mild ischemic stroke is limited. Methods: PubMed/MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) that compared DAPT to aspirin alone started within 72 hours in mild ischemic stroke or high-risk TIA. We used a random effects model to pool risk ratios (RRs) along with 95% CIs for clinical outcomes. Results: Four RCTs with 16,547 patients were included in this study. DAPT significantly reduced the risk of recurrent stroke by 26% (RR: 0.74; 95% CI: 0.67-0.83; p < 0.00001), ischemic stroke by 28% (RR: 0.72; 95% CI: 0.65-0.80; p < 0.00001), and major adverse cardiovascular events (MACE) by 24% (RR: 0.76; 95% CI: 0.68-0.84; p < 0.00001) compared to aspirin monotherapy. However, DAPT was associated with a significantly increased risk of moderate or severe bleeding (RR: 1.88; 95% CI: 1.10-3.23; p = 0.02) compared to aspirin alone. No significant differences were observed for hemorrhagic stroke (RR: 1.77; 95% CI: 0.96-3.29; p = 0.07), all-cause mortality (RR: 1.25; 95% CI: 0.87-1.80; p = 0.23), cardiovascular mortality (RR: 1.38; 95% CI: 0.81-2.33; p = 0.23), and myocardial infarction (RR: 1.63; 95% CI: 0.77-3.46; p = 0.20). Conclusion: DAPT involving aspirin plus clopidogrel reduces stroke recurrence and MACE but can lead to an increased risk of moderate or severe bleeding compared to aspirin monotherapy. (PROSPERO ID: CRD42024499310) ., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Food and nutritional supplements can interact with medication and cause drug interaction. Registered nurses play an essential role in patients' safety related to drug interaction., Objective: Explore nurses' knowledge, attitudes, and awareness regarding food-drug interactions (FDIs)., Method: A cross-sectional survey was conducted among nurses working in the general medical wards at Hamad General Hospital (HGH) in Qatar. The survey questionnaire comprised 50 multiple-choice questions, encompassing three key sections: (a) demographic details, (b) assessment of FDIs knowledge, and (c) exploration of beliefs, attitudes, and practices concerning FDIs., Results: A total of 227 surveys were collected. Nurses' average score for FDI knowledge across all responses was 20 out of 34 (IQR 16-25). Notably, there were no statistically significant differences in average scores based on respondents' demographic subgroups. While nurses displayed a high level of knowledge (over 90%) regarding the timing of food and drug intake for proton pump inhibitors, nonsteroidal anti-inflammatory drugs, and thyroid hormones, they exhibited limited awareness of the possible FDIs related to carvedilol and furosemide. Approximately half of the participating nurses (56.4%) rated their FDI knowledge as satisfactory. However, only 42.3% claimed to be always educating patients about FDIs in their daily practice. Two-thirds (67.4%) of respondents believed educating patients about FDIs should primarily fall under the responsibility of pharmacists., Conclusion: This study highlights the nurses' knowledge, attitudes, and beliefs of FDIs. Prompt intervention is required to enhance the nurse's awareness and knowledge in this domain which may impact patient care and drug safety., Competing Interests: All listed authors meet the authorship criteria. All authors approved the final version and are in agreement with the content of the manuscript for submission. Exact author's contributions were as following: R.E. Conceptualization, Investigation, Formal Analysis, methodology, Project Administration, Validation, Original Draft, Writing-review & Editing.R.A. Conceptualization, Investigation, Methodology, Validation, Original Draft, Writing-review & Editing.V.K. Methodology, Investigation, Writing-review & Editing.K.A. Methodology, Investigation, Writing-review & Editing.E.S. Investigation, Methodology, Validation Original Draft, Writing-review & Editing.The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Epicutaneo-caval catheters (ECC) are vital in neonatal intensive care units (NICU) in enabling prolonged venous access. Despite their benefits, central line-associated bloodstream infections (CLABSI) pose a potential risk. The ECC removal procedure may contribute to an increased risk of post removal sepsis through biofilm release. Antimicrobial-impregnated ECCs have been proposed as a potential solution to prevent this complication, but research on their effectiveness in neonates is limited., Objective: To compare post-ECC or neonatal peripherally inserted central catheter (n-PICCs) removal sepsis rates when using conventional or antimicrobial-impregnated catheters in neonates., Methods: A retrospective, single center cohort analysis using 2019 data from 421 neonates after successful ECC insertion at the Women's Wellness and Research Center, a large tertiary level NICU in Qatar. The study systematically collected data on demographics, insertion, and removal as well as microbiology, and infection data. Statistical analyses compared conventional and antimicrobial ECCs, with a focus on the incidence of sepsis within 72 hr post-removal., Results: After excluding non-eligible, 349 cases were included in the analysis (138 conventional, 211 antimicrobial-impregnated). There were no significant demographic differences between the two groups. The CLABSI incidence was higher amongst the antimicrobial ECC group (4% vs 0.6%, p  = 0.031). Among the included neonates, the confirmed post-removal sepsis incidence was 4.3% (6 cases) for the conventional and 10% (21 cases) for the antimicrobial ECC groups, which was not statistically significant ( p  = 0.055)., Conclusion: The study noted a higher, but statistically insignificant, incidence of post removal sepsis when using antimicrobial-impregnated ECCs. This finding raises questions about the effectiveness of antimicrobial ECCs in preventing post-removal sepsis in this patient population. Further randomized trials are needed to assess the role of antimicrobial ECCs amongst neonates and to refine neonatal ECC care strategies., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Following transient ischemic attack (TIA) and minor stroke, the risk of recurrent stroke can be significantly reduced with short-duration dual antiplatelet therapy (DAPT). We wish to investigate whether 10 days of DAPT is as effective as 21 days' treatment., Study Design: This is an open-label, randomized, parallel-group study comparing whether 10 days of DAPT treatment (ASA + clopidogrel) is non-inferior to 21 days of DAPT in patients with acute ischemic stroke (AIS) or high-risk TIA. In both groups, DAPT is started within 24 hours of symptom onset. This study is being conducted in approximately 15 study sites in the Kingdom of Saudi Arabia. The planned sample size is 1932., Outcomes: Non-inferiority of 10 days compared to 21 days of DAPT in the prevention of the composite endpoint of stroke and death at 90 days in AIS/TIA patients. The primary safety outcome is major intra-cranial and systemic hemorrhage., Study Period: Enrolment started in the second quarter of 2023, and the completion of the study is expected in the fourth quarter of 2025., Discussion: The trial is expected to show that 10 days of DAPT is non-inferior for the prevention of early recurrence of vascular events in patients with high-risk TIAs and minor strokes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The perioperative arena is a unique and challenging environment that requires coordination of the complex processes and involvement of the entire care team. Pharmacists' scope of practice has been evolving to be patient-centered and to expand to variety of settings including perioperative settings., Objectives: To critically appraise, synthesize, and present the available evidence of the characteristics and impact of pharmacist-led interventions on clinically important outcomes in the perioperative settings., Design: A systematic review and meta-analysis., Methods: We searched PubMed, Embase, and CINAHL from index inception to September 2023. Included studies compared the effectiveness of pharmacist-led interventions on clinically important outcomes (e.g. length of stay, readmission) compared to usual care in perioperative settings. Two independent reviewers extracted the data using the DEPICT-2 (Descriptive Elements of Pharmacist Intervention Characterization Tool) and undertook quality assessment using the Crowe Critical Appraisal (CCAT). A random-effect model was used to estimate the overall effect [odds ratio (OR) for dichotomous and standard mean difference (SMD) for continuous data] with 95% confidence intervals (CIs)., Results: Twenty-five studies were eligible, 20 (80%) had uncontrolled study design. Most interventions were multicomponent and continuous over the perioperative period. The intervention components included clinical pharmacy services (e.g. medication management/optimization, medication reconciliation, discharge counseling) and education of healthcare professionals. While some studies provided a minor description in regards to the intervention development and processes, only one study reported a theoretical underpinning to intervention development. Pooled analyses showed a significant impact of pharmacist care compared to usual care on length of stay (11 studies; SMD -0.09; 95% CI -0.49 to -0.15) and all-cause readmissions (8 studies; OR 0.60; 95% CI 0.39-0.91). The majority of included studies ( n  = 21; 84%) were of moderate quality., Conclusion: Pharmacist-led interventions are effective at improving clinically important outcomes in the perioperative setting; however, most studies were of moderate quality. Studies lacked the utilization of theory to develop interventions; therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. Future research should prioritize the development and evaluation of multifaceted theory-informed pharmacist interventions that target the whole surgical care pathway., (© The Author(s), 2024.)

Background: Evidence-based insertion and maintenance strategies for neonatal vascular access devices (VAD) exist to reduce the causes of VAD failure and complications in neonates. Peripheral intravenous catheter failure and complications including, infiltration, extravasation, phlebitis, dislodgement with/without removal, and infection are majorly influenced by catheter securement methods., Methods: A retrospective, observational study using routinely collected data on intravenous device use in a large neonatal intensive care unit in Qatar. A 6-month historical cohort was compared with a 6-month cohort after the introduction of an octyl-butyl-cyanoacrylate glue (CG). In the historical cohort, the catheter was secured using a semi-permeable transparent membrane dressing while in the CG cohort, CG was applied at the insertion site on initial insertion and after any dressing change. This was the only variable intervention between both groups., Results: A total of 8330 peripheral catheters were inserted. All catheters were inserted and monitored by members of the NeoVAT team. 4457 (53.5%) were secured with just a semi-permeable transparent dressing and 3873 (46.5%) secured a semi-permeable transparent dressing with the addition of CG. The odds ratio for premature failure after securement with CG was 0.59 (0.54-0.65) when compared to the catheters secured with a semi-permeable transparent dressing, which was statistically significant ( p  < 0.001). The correlation between the occurrence of a complication and the use of CG for device securement was significant ( p  < 0.001)., Conclusions: The risk of developing device-related phlebitis and premature device removal, increased significantly if CG was not used for adjunct catheter securement. In parallel with the currently published literature, this study's findings support the use of CG for vascular device securement. When device securement and stabilization concerns are most pertinent CG is a safe and effective adjunct to reducing therapy failures in the neonatal patient population., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Drug-related problems (DRPs) affect the health outcomes of patients during hospitalization. We sought to analyze the clinical pharmacist-documented interventions among hospitalized patients in the cancer hospital in Qatar., Methods: A retrospective analysis of electronically reported clinical pharmacist interventions of patients admitted to cancer units at Hamad Medical Corporation, Qatar was conducted. Extracted data was based on an overall 3-month follow-up period; March 1-31, 2018, July 15-August 15, 2018 and January 1-31, 2019. Categorical variables were expressed as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation (SD)., Results: A total of 281 cancer patients with 1354 interventions were included. The average age of the study participants was 47 years (SD ± 17.36). The majority of the study population was females ( n  = 154, 54.80%). The prevailing pharmacist intervention was the addition of a drug therapy ( n  = 305, 22.53%), followed by medication discontinuation ( n  = 288, 21.27%) and the addition of a prophylactic agent ( n  = 174, 12.85%). This pattern was similar across all subgroups (i.e., gender, age, ward), except for the urgent care unit, where an increase in medication dose was the third highest frequently identified intervention ( n  = 3, 0.22%). The two medication groups associated with the majority of interventions were the anti-infective and fluid/electrolyte agents. Most of the interventions documented were in the oncology ward (73.19%), while the urgent care unit had the least documented interventions (1.62%)., Conclusions: Our analysis showed that clinical pharmacists can effectively identify and prevent DRPs among hospitalized cancer patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Objectives: Clinical research professionals must be equipped with adequate training in sound scientific methods and appropriate ethics. In this study, we aimed to assess the current clinical research self-efficacy of researchers at Hamad Medical Corporation (HMC). We also evaluated the effects of training courses on researchers' self-efficacy., Methods: Utilizing a cross-sectional design, we used the shortened Clinical Research Appraisal Inventory (CRAI-12) through an online survey to assess the current clinical research self-efficacy of 600 researchers at HMC, Doha, Qatar. After conducting descriptive analyses, unpaired t test and ANOVA were used to determine significant mean percentages between variables. Pearson correlation coefficients were also calculated to measure the association among the interval variables. All tests were 2-sided, and significance was defined as P  < .05., Results: For all questions, except those related to "funding," most participants scored on the upper half of the scale (>5), reflecting higher self-efficacy for the topics covered in CRAI. Gender differences were significant across all factors, with males reporting higher levels of self-assessed efficacy and in clinical research. Other factors such as higher education degrees and previous (external) clinical research training were also associated with higher self-reported clinical research efficacy., Conclusions: The findings of this study indicate that researchers at HMC possess high clinical research self-efficacy overall, but lower self-efficacy in securing funding. Gender and education level positively influence self-efficacy across CRAI factors. Notably, clinical research training boosts self-efficacy, especially when obtained outside HMC. In conclusion, healthcare providers are strongly encouraged to engage in effective clinical research training courses, both within and outside of their healthcare institutions, to improve their clinical research efficacy and enhance clinical practice., Competing Interests: The authors declare that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest., (© The Author(s) 2024.)

Objectives: Treatment options for preventing vaso-occlusive crises among sickle cell disease patients are on the rise, especially if hydroxyurea treatment has failed. This economic analysis is conducted to assess the comparative clinical effectiveness, safety, and acquisition cost of l-glutamine and crizanlizumab for older adolescents and adults (⩾16 years old) with sickle cell disease in Qatar, with an emphasis on treatment costs and acute pain crises., Methods: We conduct a decision-tree model, where we compare the clinical and economic outcomes of two novel Food and drug administration (FDA)-approved medications which are available in Qatar; l-glutamine and crizanlizumab over a time horizon of 1 year in a hypothetical cohort of adult sickle cell disease patients from a Qatar healthcare perspective. The main outcome is incremental cost per sickle cell disease-related acute pain crises averted. Model clinical parameters were derived from individual drug randomized trials, published literature, whereas cost parameters from Qatar healthcare payer system (2020-2021). A sensitivity analysis was carried out, and the study results were robust around model inputs. Costs were converted to 2020 US dollars., Results: Study results showed that both treatment modalities' costs were the main driver of this analysis, with an average annual cost of the treatments per patient being $189,014 for crizanlizumab (5 mg/kg), $143,798 for crizanlizumab (2.5 mg/kg), and $74,323 for l-glutamine. The probability of no first-time sickle cell disease-related vaso-occlusive crises averted was 0.001/year for glutamine, 0.26/year for crizanlizumab (5 mg/kg), and 0.34/year for crizanlizumab (2.5 mg/kg). Lower dose crizanlizumab (2.5 mg/kg) dominated the higher one (5 mg/kg). The incremental cost-effectiveness ratio of crizanlizumab (2.5 mg/kg), when compared to l-glutamine was $81,265 per sickle cell disease-related vaso-occlusive crises averted. When comparing crizanlizumab (5 mg/kg) and l-glutamine, crizanlizumab (5 mg/kg) showed higher efficacy, yet the crizanlizumab incremental cost-effectiveness ratio was at $459,620 than l-glutamine., Conclusions: Crizanlizumab (2.5 mg/kg) may be a cost-effective intervention, yet it is not the approved dose for preventing vaso-occlusive crises in adolescents and adults with sickle cell disease. Crizanlizumab (5 mg/kg) was more cost-effective than the approved l-glutamine per sickle cell disease vaso-occlusive crisis prevented. Of note, we primarily focused on modeling acute vaso-occlusive pain, which limited our ability to consider other key outcomes in sickle cell disease., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Introduction: Off-pump coronary artery bypass grafting (OPCABG) was introduced many years ago aiming to reduce the known complications of conventional on-pump coronary surgeries. Heparin is required during the procedures, but the available protocols have diverse dosage regimens. The primary objective of this systematic review is to examine the effect of different heparin doses on the outcomes of OPCABG., Evidence Acquisition: MEDLINE and EMBASE were searched. Four reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias using Cochrane tool. The primary outcome was the activated clotting time (ACT) at three minutes. The secondary outcomes were proportion of patients requiring blood products and the length of hospital stay. An aggregate data approach was used., Evidence Synthesis: Three single-center randomized studies recruiting 256 patients were included. The studies compared low-dose (1.5-2 mg/kg) and high-dose (3 mg/kg) heparin boluses. The overall mean difference for ACT after three minutes between low- and high-dose heparin is - 126.16 (95% CI: - 142.19, - 110.14). The proportion of patients requiring blood products after surgery [odd ratio 1.27 (95% CI: 0.69, 2.32)] or the overall length of stay [mean difference -0.15 (95% CI: -0.84, 0.53)] did not differ between the heparin doses., Conclusions: In OPCABG, high-dose compared with low-dose heparin did not affect the utilization of more blood products or increased the overall length of stay. Unsurprisingly, ACT values were higher in the high-dose heparin group. Larger and adequately powered randomized clinical trials are indicated to resolve the uncertainty., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This letter highlights the impact of environmental drivers on antimicrobial resistance (AMR) in low and middle-income countries (LMICs) and highlights the need for a comprehensive approach to address this global health threat. Key factors, such as agricultural practices, wastewater treatment, and pollution, contribute to the development and spread of resistant pathogens. Utilizing the One Health approach, the paper emphasizes the importance of promoting responsible antimicrobial use, strengthening public health systems, investing in innovative research, and raising public awareness. By understanding and addressing these environmental drivers, we can work toward safeguarding global health and ensuring a sustainable future., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

The ulnar nerve is the second most commonly entrapped nerve after the median nerve. Although clinical evaluation and electrodiagnostic studies remain widely used for the evaluation of ulnar neuropathy, advancements in imaging have led to increased utilization of these newer / better imaging techniques in the overall management of ulnar neuropathy. Specifically, high-resolution ultrasonography of peripheral nerves as well as MRI has become quite useful in evaluating the ulnar nerve in order to better guide treatment. The caliber and fascicular pattern identified in the normal ulnar nerves are important distinguishing features from ulnar nerve pathology. The cubital tunnel within the elbow and Guyon's canal within the wrist are important sites to evaluate with respect to ulnar nerve compression. Both acute and chronic conditions resulting in deformity, trauma as well as inflammatory conditions may predispose certain patients to ulnar neuropathy. Granulomatous diseases as well as both neurogenic and non-neurogenic tumors can also potentially result in ulnar neuropathy. Tumors around the ulnar nerve can also lead to mass effect on the nerve, particularly in tight spaces like the aforementioned canals. Although high-resolution ultrasonography is a useful modality initially, particularly as it can be helpful for dynamic evaluation, MRI remains most reliable due to its higher resolution. Newer imaging techniques like sonoelastography and microneurography, as well as nerve-specific contrast agents, are currently being investigated for their usefulness and are not routinely being used currently., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Health professionals/clinicians interview people regularly as part of their role. However, a qualitative research interview differs considerably to a clinical interview. If clinicians approach qualitative research interviewing based on their expertise in clinical interviewing, it could cause insufficiencies in qualitative data generation. In this reflection article, we, a team of four experienced clinical occupational therapists with no previous experience in qualitative research interviewing, share our experiences while learning to become qualitative research interviewers before undertaking our first qualitative research project. We engaged in self-directed reading, formal training on qualitative interviewing, and practice interviews and used peer feedback and reflection to prepare ourselves to conduct qualitative interviews. We drew upon the work-role transitions theory to work through our adjustment to the new role. Although we set out to "switch hats" as the research topic itself was not clinical, interviewing people on health-related topics will mean bringing our clinical instincts into our research role, while still recognizing the difference between a clinical and research interview. This article can inform experienced clinicians/novice qualitative researchers as they develop this new skillset., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose : Minimally invasive and surgical spine procedures are commonplace with various risks and complications. Cranial nerve palsies, however, are infrequently encountered, particularly after procedures such as lumbar punctures, epidural anesthesia, or intrathecal injections, and are understandably worrisome for clinicians and patients as they may be interpreted as secondary to a sinister etiology. However, a less commonly considered source is a pneumocephalus which may, in rare cases, abut cranial nerves and cause a palsy as a benign and often self-resolving complication. Here, we present the case of a patient who underwent an intrathecal methotrexate infusion for newly diagnosed non-Hodgkin's T -cell lymphoma and subsequently developed an abducens nerve palsy due to pneumocephalus. We highlight the utility of various imaging modalities, treatment options, and review current literature on spinal procedures resulting in cranial nerve palsies attributable to pneumocephalus presenting as malignant etiologies., Competing Interests: Declaration of conflicting interestsThe authors have no conflicts of interest to declare that are relevant to the content of this article.

Background: Diabetes mellitus and central obesity are more common among South Asian populations than among White British people. This study explores the differences in diabetes and obesity in South Asians with stroke living in the United Kingdom, India, and Qatar compared with White British stroke patients., Methods: The study included the UK, Indian, and Qatari arms of the ongoing large Bio-Repository of DNA in Stroke (BRAINS) international prospective hospital-based study for South Asian stroke. BRAINS includes 4580 South Asian and White British recruits from UK, Indian, and Qatar sites with first-ever ischemic stroke., Results: The study population comprises 1751 White British (WB) UK residents, 1165 British South Asians (BSA), 1096 South Asians in India (ISA), and 568 South Asians in Qatar (QSA). ISA, BSA, and QSA South Asians suffered from higher prevalence of diabetes compared with WB by 14.5% (ISA: 95% confidence interval (CI) = 18.6-33.0, p  < 0.001), 31.7% (BSA: 95% CI = 35.1-50.2, p  < 0.001), and 32.7% (QSA: 95% CI = 28.1-37.3, p  < 0.001), respectively. Although WB had the highest prevalence of body mass index (BMI) above 27 kg/m 2 compared with South Asian patients (37% vs 21%, p  < 0.001), South Asian patients had a higher waist circumference than WB (94.8 cm vs 90.8 cm, p  < 0.001). Adjusting for traditional stroke risk factors, ISA, BSA, and QSA continued to display an increased risk of diabetes compared with WB by 3.28 (95% CI: 2.53-4.25, p  < 0.001), 3.61 (95% CI: 2.90-4.51, p  < 0.001), and 5.24 (95% CI: 3.93-7.00, p  < 0.001), respectively., Conclusion: South Asian ischemic stroke patients living in Britain and Qatar have a near 3.5-fold risk of diabetes compared with White British stroke patients. Their body composition may partly help explain that increased risk. These findings have important implications for public health policymakers in nations with large South Asian populations., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The use of beta-blockers (BB) in reduced left ventricular ejection fraction (LVEF) post-myocardial infarction (MI) is associated with reduced 1-year mortality, while their role in patients with mid-range and preserved LVEF post-MI remains controversial. We studied 31,620 patients who presented with acute coronary syndrome (ACS) enrolled in seven Arabian Gulf registries between 2005 and 2017. Patients with LVEF ≤40% were excluded. The remaining cohort was divided into two groups: BB group ( n = 15,541) and non-BB group ( n = 2,798), based on discharge medications. Patients in the non-BB group were relatively younger (55.3 vs. 57.4, P = .004) but higher risk at presentation; with higher Global Registry of Acute Coronary Events (GRACE) score (119.2 vs 109.2, P < .001), higher percentage of cardiogenic shock (3.5 vs 1.4%, P < .001), despite lower prevalence of comorbidities, such as hypertension and hyperlipidemia. BB use was associated with lower 1-year mortality in a multivariate logistic regression analysis, adjusting for major confounders [adjusted odds ratio (OR): 0.71 (95% CI 0.51-0.99)]. This remained the case in a sensitivity analysis using propensity score matching [adjusted OR: 0.34 (95% CI 0.16-0.73)]. In this study, using Arabian Gulf countries registries, the use of BB after ACS with LVEF >40% was independently associated with lower 1-year mortality., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Atrioventricular block (AVB) is a rare cardiac manifestation of hyperthyroidism (HTH). The scientific literature contains multiple reports of AVB in patients with HTH, ranging from subclinical to overt HTH and even thyroid storm. However, much remains unknown about the true prevalence, clinical course, optimal management, and outcomes of AVB in patients with HTH. Such patients are possibly overtreated with pacemakers because of a lack of understanding that AVB might be secondary to the hyperthyroid state and thus reversible. This narrative review discusses the pathophysiology of AVB in patients with HTH in the context of the available evidence., Competing Interests: Declaration of conflicting interestsThe author declares that there is no conflict of interest. The author is an editorial board member for the Journal of International Medical Research.

Background: Infants in neonatal units are susceptible to numerous potential iatrogenic risks. One key concern is central line-associated blood stream infection (CLABSI). To ensure patient safety and reduce the incidence of CLABSI toward zero, numerous evidence-based clinical interventions and product innovations have been implemented. Nevertheless, sustaining zero CLABSI for sustained periods remains challenging., Aim: The purpose of this study was to evaluate the impact on CLABSI rates of introducing a preassembled closed intravenous (IV) administration set in a neonatal intensive care unit (NICU)., Methods: This was a retrospective observational analysis of routinely collected anonymized IV therapy infection data in a NICU. The study period was from January 2019 through June 2020., Results: Nine-hundred eighty five patients with a Epicutaneo-Caval Catheter (ECC) were included (456 legacy IV set, 529 closed IV set). Patient demographics were comparable between the two groups. ECC dwell time was the only IV characteristic associated ( p  = 0.04) with CLABSI. Mann-Whitney U-test demonstrated significant differences between the two sets for CLABSI complication events ( p  = 0.031). Prior to using the closed IV administration sets (January 2019-September 2019) the mean monthly CLABSI rate was 2.87 (/1000 device days). This figure declined to 0.22 (/1000 device days) afterwards (October 2019-June 2020). Zero CLABSIs were observed during January to June 2020., Conclusions: Utilization of a pre-assembled closed IV administration set was associated with a reduction in CLABSI rates. The study results suggest that using a pre-assembled closed IV set concurrently with evidence-based central line infection control interventions can help attain extended periods of zero CLABSI., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In neonatal settings vascular access devices are essential for treatment. However, their use is not without risks. The design and materials of peripheral vascular access devices have been evaluated amongst adult populations, but contemporary studies in neonatal settings are scant., Purpose/outcome Measures: This research describes the prevalence of peripheral intravenous catheter failure related to three different catheter types with the intent to identify modifiable risks that might be used to evaluate device efficacy, innovate neonatal practice, and support future policy developments., Method and Setting: This was a retrospective observational analysis of routinely collected anonymized intravenous therapy related data. The study was carried out at the tertiary neonatal intensive care unit (112 beds) of the Women's Wellness and Research Center of Hamad Medical Corporation, Doha, Qatar., Participants: Neonates who were admitted to the unit requiring intravenous treatment wherefore peripheral intravenous cannulation was indicated, were included in this study., Results: The use of different type of catheters resulted in significantly less therapy failures as phlebitis and increased dwell time, compared with the control groups. This remains significant after adjusting for age at insertion, gestational age, birth weight, and catheter type., Conclusions: The study's findings are in accord with international literature concerning adult and pediatric patients concerning the superiority of PUR over PTFE catheters with respect to the risk of phlebitis and longer dwell times. However, the risk of failure of therapy did not differ between catheters. This finding is reassuring and supports practitioner judgment when selecting peripheral catheter devices., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: There is a paucity of studies about the readiness of community pharmacists to manage the safe and effective use of oral anticancer medicines (OAMs) in developing settings., Objectives: Using the readiness component (knowledge and willingness) of the situational theory of leadership, the study assessed community pharmacists' readiness to manage the safe and effective use of OAMs in Qatar, and also identified its significant predictors., Methods: A cross-sectional assessment of 252 community pharmacists was conducted with a pre-tested 48-item questionnaire. Readiness was assessed with a 5-point Likert-type scale and the maximum obtainable score was 70. The mean was used as the cut-off point to categorize willingness and knowledge as either high (≥ mean) or low (< mean). Independent t -test, one-way analysis of variance and multiple linear regression was used for data analyses., Results: The mean SD score for the readiness of community pharmacists was 39.3 ± 11.2 (min = 11, max = 70). Only a minority of the respondents expressed an excellent understanding of the chemotherapy cycles (19.6%; 45/230), and familiarity with targeted anticancer therapy (14.3%; 33/230), side effects (22.2%; 51/230), and dosing of OAMs (14.4%; 33/230). Employment status, number of OAMs prescriptions dispensed per month and adequacy of the contents related to OAMs in undergraduate training were the significant predictors of readiness ( R 2  = 0.558, (F (11, 209) = 3.559, p  = 0.0001)., Conclusions: Community pharmacists' readiness appear inadequate especially regarding its dosing, side effects, handling, and disposal of OAMs. These inadequacies probably underline community pharmacists' low familiarity and comfortability with dispensing and educating patients on the effective and safe use of OAMs., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ulnar-sided wrist pain can be attributed to various bony and ligamentous structures. The purpose of this review is to compare outcomes following surgical interventions for isolated lunotriquetral (LT) interosseous ligament injuries in adults. We assessed 202 procedures from 9 retrospective case series studies of low to moderate quality based on the Structured Effectiveness Quality Evaluation Scale. The comparative outcomes (ie, range of motion, pain, strength, quality of life, complications, return to work, and patient satisfaction) were aggregated and categorized under arthrodesis, capsulodesis, ligament repairs and reconstruction, and ulna shortening osteotomy procedures. Although the comparison of outcomes was largely inconclusive due to the heterogeneity and the omission of preoperative characteristic data, we did observe higher complications and reoperation rates post LT arthrodesis. It is recommended that all outcomes be standardized and presented uniformly with best practices developed to better characterize the injury's severity and integrity in future studies.

Intracranial aneurysms are focal pathological dilatation of the arteries with a prevalence of 3.2%. Fusiform aneurysms are rare and mainly due to dissection or atherosclerosis. They may manifestas as stroke, cranial nerve palsies, brainstem compression and Sub-arachnoid hemorrhage. A diameter greater than 10 mm is a risk factor for rupture and warrants early intervention.

Objectives: Distal forearm fractures are the most common pediatric fractures. This study aimed to investigate the effectiveness of below-elbow cast treatment for displaced distal forearm fractures in children compared to above-elbow cast through meta-analysis of randomized controlled trials., Methods: Several databases from January 1, 2000 until October 1, 2021 were searched for randomized controlled trials that assessed below versus above-elbow cast treatment of displaced distal forearm fractures in pediatric patients. The main meta-analysis comparison was based on the relative risk of loss of fracture reduction between children undergoing below versus above-elbow cast treatment. Other outcome measures including re-manipulation and cast-related complications were also investigated., Results: Nine studies were eligible of the 156 articles identified, with a total of 1049 children. Analysis was undertaken for all included studies with a sensitivity analysis conducted for studies with high quality. In the sensitivity analysis, the relative risks of loss of fracture reduction (relative risk = 0.6, 95% confidence interval = 0.38, 0.96) and re-manipulation (relative risk = 0.3, 95% confidence interval = 0.19, 0.48) between the below and above-elbow cast groups were in favor of below-elbow cast and statistically significant. Cast-related complications were in favor of below-elbow cast but did not attain statistical significance (relative risk = 0.45, 95% confidence interval = 0.05, 3.99). Loss of fracture reduction was noted in 28.9% of patients treated with above-elbow cast and 21.5% in below-elbow cast. Re-manipulation was attempted in 48.1% versus 53.8% of children who lost fracture reduction in the below-elbow cast and above-elbow cast groups, respectively., Conclusion: Below-elbow cast treatment was favored, with statistical significance, in terms of loss of fracture reduction and re-manipulation, and was not associated with a higher risk of cast-related complications. The accumulative evidence currently does not support above-elbow cast treatment and below-elbow cast treatment should be the mainstay for displaced distal forearm fractures in children., Level of Evidence: Level I, meta-analysis of therapeutic level I studies., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Introduction : Simulation training offers an authentic team-based learning opportunity without risk to real patients. The Educational Corner at the annual congress of the European Branch of Extracorporeal Life Support Organisation (EuroELSO) provided an opportunity for multiple simulation training sessions facilitated by experts from all over the world. Aim : We aimed to review the educational impact of EuroELSO Educational Corner and whether it provides a quality ECLS training to a wide spectrum of multidisciplinary international attendees utilising high and low fidelity simulation, workshops and hands on sessions. Methods : During the congress, 43 sessions were conducted dedicated to ECLS education with identified educational objectives. The sessions focused on management of adults and children on V-V or V-A ECMO. Adult sessions covered emergencies on mechanical circulatory support with management of LVAD and Impella, managing refractory hypoxemia on V-V ECMO, emergencies on ECMO, renal replacement therapy on ECMO, V-V ECMO, ECPR cannulation and performing perfect simulation. Paediatric sessions covered ECPR neck and central cannulation, renal replacement on ECMO, troubleshooting, cannulation workshop, V-V recirculation, ECMO for single ventricle, PIMS-TS and CDH, ECMO transport and neurological injury. Results : The Educational Corner was attended by more than 400 participants over the two congress days. Majority of responders (88%) reported that training sessions met the set educational goals and objectives and that this would change their current practice. Almost all (94%) reported that they received useful information and 95% would recommend the session to their colleagues. Conclusion : The Educational Corner, as an integral component of the annual EuroELSO congress, achieved the set educational goals and provided quality education based on the recipient survey. Structured multidisciplinary ECLS education with standardised curriculum and feedback is an important key step in delivering quality training to an international audience. Standardisation of European ECLS education remains an important focus of the EuroELSO.

Reducing thrombus burden would improve patient's outcomes. Low-dose intracoronary thrombolytic agent administration has been considered to improve myocardial microcirculation, cardiac function, and major adverse cardiovascular events in patients presenting with ST-segment elevation myocardial infarction and high thrombus burden. This paper discusses published meta-analyses on intracoronary thrombolysis in primary percutaneous intervention.

Background: Tranexamic acid (TXA) has been widely used in various orthopaedic subspecialities to decrease blood loss, transfusions, and wound complications. However, the role of TXA in foot and ankle surgery is not clearly delineated. This meta-analysis aims to report the efficacy and safety of TXA in relation to foot and ankle surgical procedures., Methods: Database searches were conducted for eligible studies from data inception through January 2022. Clinical studies on the use of TXA in foot and ankle procedures reporting the desired outcomes were included. Outcomes were estimated blood loss, change in hemoglobin, and overall complications. Risk of bias was assessed using the Newcastle-Ottawa quality assessment scale and the Joanna Briggs Institute (JBI) critical appraisal tool., Results: Nine studies met the inclusion criteria. A total of 752 foot and ankle procedures were included, in which 511 (67.95%) procedures received TXA whereas 241 (32.05%) served as controls and did not receive TXA. The pooled data of change in hemoglobin and overall complications showed no difference between the TXA and control group. Estimated blood loss was significantly lower in the patients who received TXA., Conclusion: In conclusion, TXA use was associated with lower estimated blood loss in foot and ankle surgeries without increased risk of thromboembolic events, wound complications, or changes in hemoglobin., Level of Evidence: Level IV, meta-analysis.

Background: Cardiovascular disease (CVD) is one of the most common chronic illnesses in the Eastern Mediterranean. There have been few studies on medication adherence in Arab patients with CVD., Aim: To investigate the rates and the reasons for medication adherence in Arab patients with CVD., Methodology: The Joanna Briggs Institute methodology for prevalence systematic reviews was used. MEDLINE, EMCARE, CINAHL, Scopus, Science Direct, PsychINFO, and the Cochrane Central Register of Controlled Trials were searched., Results: Thirteen quantitative studies on medication adherence in Arab adult CVD patients were included.Pooled data from nine studies demonstrated that 53.2% (95% confidence interval = [51.2%, 55.1%]) of patients were adherent to their medications. Reasons for nonadherence to medication include personal factors, understanding, and complexity of treatment regimes, medication knowledge and structural barriers., Conclusion: Medication adherence appears to have a social gradient, and families should be actively involved in future strategies to increase medication adherence.

Background: There has been a rising prevalence of polypharmacy among people living with HIV (PLWH). Uncertainty however remains regarding the exact estimates of polypharmacy among these cohorts of patients., Methods: We conducted a systematic search of PubMed; EMBASE, CROI, Cochrane Database of Systematic Reviews; Science Citation Index and Database of Abstracts of Reviews of Effects for studies between 1 January 2000 and 30 June 2021 that reported on the prevalence of polypharmacy (ingestion of > 5 non-ART medications) among PLWH on antiretroviral therapy regimen (ART). Prevalence of polypharmacy among HIV-positive patients on ART with Clopper-Pearson 95% confidence intervals were presented. The heterogeneity between studies was evaluated using I 2 and τ 2 statistics., Results: One hundred ninety-seven studies were initially identified, 23 met the inclusion criteria enrolling 55,988 PLWH, of which 76.7% [95% confidence interval (CI): 76.4-77.1] were male. The overall pooled prevalence of polypharmacy among PLWH was 33% (95% CI: 25-42%) ( I 2  = 100%, τ 2  = 0.9170, p  < 0.0001). Prevalence of polypharmacy is higher in the Americas (44%, 95% CI: 27-63%) ( I 2  = 100%, τ 2  = 1.0886, p  < 0.01) than Europe (29%, 95% CI: 20-40%) ( I 2  = 100%, τ 2  = 0.7944, p  < 0.01)., Conclusion: The pooled prevalence estimates from this synthesis established that polypharmacy is a significant and rising problem among PLWH. The exact interventions that are likely to significantly mitigate its effect remain uncertain and will need exploration by future prospective and systematic studies., Registration: PROSPERO: CRD42020170071 ., Plain Language Summary: Background: In people living with HIV (PLWH), what is the prevalence of polypharmacy and is this influenced by sociodemographic factors? Methods and Results: In this systematic review and meta-analysis of 23 studies comprising 55,988 participants, we have for the first time found an estimated polypharmacy pooled prevalence of 33% among PLWH. There was a relatively higher pooled prevalence of polypharmacy among the America's compared with European cohorts of PLWH. Conclusion: Polypharmacy among PLWH is a rising morbidity that needs urgent intervention both at policy and patient levels of care., Competing Interests: Competing interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2022.)

Background: Central line-associated bloods tream infections (CLABSIs) are among the most common healthcare-associated infections (HAIs)., Aims: To assess the rates of CLABSIs and to investigate predictors of knowledge and compliance of registered nurses to central venous catheters (CVCs) maintenance care bundle in intensive care units (ICUs)., Methods: A cross-sectional correlational design was used. A convenient sample of 114 registered nurses was selected from three hospitals in Jordan. Nurses' knowledge and compliance were measured by previously established measures and an observational checklist developed according to the Center for Disease Control and Prevention (CDC)., Findings: The rate of CLABSI was the lowest in the hospital that applies the CVC bundle of care. Nurses' knowledge about CLABSI prevention practices was significantly correlated with their compliance to CVCs maintenance care bundle. Nurses' knowledge differed bytheirage, income, experience in ICU, and nurse-to-patient ratio, and in multiple regressions, age was the single predictor of knowledge of CLABSI prevention. Significant differences were also found in nurses' compliance to the CVC care bundle according to the hospital and nurse-to-patient ratio. The nurse-to-patient ratio was the single significant predictor, and it attenuated the effect of age and income on nurse's compliance to the CVC care bundle., Conclusion: This study indicated the need to expand the application of the CVC maintenance care bundle in hospitals. Programs that target promoting nurses' knowledge about CLABSI prevention and compliance to CVC care need to consider some factors, such as nurses' age and the circumstances of their work (nurse-to-patient ratio)., Competing Interests: The authors have no conflicts of interest to disclose., (© The Author(s) 2022.)

Introduction: Mitral regurgitation (MR) is defined as an abnormal reversal of blood flow from the left ventricle to the left atrium (LA). It is caused by disruption in any part of the mitral valve apparatus. Surgical intervention remains the mainstay of management for severe cases., Case Summary: We are reporting a case of pneumonia with severe sepsis, that had a complicated hospital course. The patient developed multi-organ failure. Echocardiography on admission showed severe mitral regurgitation. He required early mechanical ventilation and then Veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) over 29 days. He might be the first case of Coronavirus Disease 2019 (COVID-19) in our hospital. Mitral valve replacement was done after stabilization of the patient and weaning from the ECMO., Discussion: Our report demonstrates that the use of a long term VV-ECMO as a bridge for stabilization, facilitates management of the critically ill respiratory failure patient with severe MR and patient outcomes. Still the long-term results and the optimal timing of intervention need more research to define., Conclusion: Our report demonstrates that the use of a long term VV ECMO facilitates management of patients with respiratory failure associated with severe MR. Future studies focusing on stabilizing such patients, might help to define the optimal timing for intervention in these patients and the long-term outcome.

Pneumonia is one of the illnesses for which pulmonary embolism (PE) is most often mistaken because of the considerable overlap in their clinical picture. Moreover, pneumonia may occasionally mask PE, particularly in patients with predominant systemic symptoms such as fever, and with no evidence of deep vein thrombosis (DVT) or trauma. In this report, we presented a 35-year-old male patient with pneumonia and PE in whom pneumonia initially masked the diagnosis of PE. The patient presented with fever, productive cough associated with streaks of blood and pleuritic chest pain for 3 days duration, and was admitted as a case of lobar pneumonia based on his clinical presentation as well as on chest X-ray and non-enhanced computed tomography chest. He had an initial improvement in response to antibiotics; however, during his follow-up at the clinic, he appeared sick, complaining of right-sided persistent pleuritic chest pain and persistent cough, occasionally associated with streaks of blood and breathlessness on exertion. The patient was readmitted and PE was confirmed by computed tomography pulmonary angiography. Anticoagulation initiated with noticeable clinical improvement. This case highlights the importance of considering PE in patients with pneumonia when there was an initial therapeutic response followed by worsening of the condition during the treatment of pneumonia.

Background: Syndesmotic ankle sprains are common and challenging injuries for athletes. The management of such injuries is controversial, with a paucity of evidence on treatment protocols with unpredictability regarding the time lost to participate in sports following injury. The present study seeks to review and report the return to play (RTP) time and examine the outcomes and complications of ankle syndesmotic sprains in the athletic population., Methods: PubMed, Cochrane Library, and Google Scholar were queried in August 2021 for case series, cohorts, and randomized controlled trials that evaluated return to play time after ankle syndesmotic sprains. The primary outcomes were the rate and time to return to play after syndesmotic ankle sprains for both surgical and nonsurgical treatment. Secondary outcomes included short-term complications and recurrence., Results: Eighteen articles were eligible for meta-analysis with a total of 1133 syndesmotic sprains. The overall RTP was 99% (95% CI 0.96, 1.00), the overall mean RTP was 52.32 days (95% CI 39.01, 65.63). Pooled RTP for surgically treated patients was 70.94 days (95% CI 47.04, 94.85), whereas it was 39.33 days (95% CI 28.78, 49.88) for nonsurgically treated cases. A low incidence of recurrence and complications were reported., Conclusion: This article reports a high rate of RTP after syndesmotic sprains. Grade of injury and surgical vs conservative management can affect the time to RTP in high-level athletes. Level of Evidence : Level IV, systematic review and meta-analysis., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Study Design: Meta-analysis., Objective: To compare outcomes between minimally invasive scoliosis surgery (MISS) and traditional posterior instrumentation and fusion in the correction of adolescent idiopathic scoliosis (AIS)., Methods: A literature search was performed using MEDLINE, PubMed, EMBASE, Google scholar and Cochrane databases, including studies reporting outcomes for both MISS and open correction of AIS. Study details, demographics, and outcomes, including curve correction, estimated blood loss (EBL), operative time, postoperative pain, length of stay (LOS), and complications, were collected and analyzed., Results: A total of 4 studies met the selection criteria and were included in the analysis, totaling 107 patients (42 MIS and 65 open) with a mean age of 16 years. Overall there was no difference in curve correction between MISS (73.2%) and open (76.7%) cohorts. EBL was significantly lower in the MISS (271 ml) compared to the open (527 ml) group, but operative time was significantly longer (380 min for MISS versus 302 min for open). There were no significant differences between the approaches in pain, LOS, complications, or reoperations., Conclusion: MISS was associated with less blood loss but longer operative times compared to traditional open fusion for AIS. There was no difference in curve correction, postoperative pain, LOS, or complications/reoperations. While MISS has emerged as a feasible option for the surgical management of AIS, further research is warranted to compare these 2 approaches.

Background: Previous research has established an association between pandemic fears and the development of obsessive-compulsive symptoms mainly in the general population., Aim: To explore whether COVID-19 pandemic fears are associated with obsessive-compulsive symptoms and vice versa in adolescents with preexisting mental and behavioural disorders., Methods: A questionnaire-based cross-sectional study among adolescents with pre-existing mental disorders. The extent of worrying related to the COVID-19 pandemic was measured using the COVID-19 inventory whereas obsessive-compulsive symptoms were assessed using the obsessive-compulsive inventory-revised (OCI-R). Pearson correlation coefficient ( r ) was used to explore the relationship between COVID-19 pandemic fears and the development of obsessive-compulsive symptoms., Results: A total of 57 patients out of 63 participants (90.4%) had a COVID-19 inventory score of 12 or higher suggesting that a vast majority of young people with mental disorders had significant pandemic-related worries. Out of these 57 patients, over half (31) had an OCI-R modified score of 17 or higher indicating significant obsessive-compulsive symptoms. A positive correlation was found between the means of the two scores. This relationship was statistically significant - { r  = 0.405, Sig. (two-tailed) = 0.001}., Conclusion: Adolescents with mental disorders can exhibit significant pandemic fears and this is likely to be associated with obsessive-compulsive symptoms.

Anxiety related to the COVID-19 pandemic is prevalent among the nursing workforce and has the potential to affect well-being and performance in the workplace. This paper reports on a joint education/nursing and midwifery workforce quality improvement initiative in the State of Qatar to address an urgent need for COVID-19 preparedness during the second wave of infection. A Simulation-Based Education (SBE) program was developed and delivered over a period of 2 months (February to April 2021) to prepare nurses for deployment to COVID-19 facilities. Perceived anxiety scores related to COVID-19 deployment were collected from 121 nurses before and after SBE attendance. The data demonstrates that SBE is an effective method to reduce deployment-related anxiety among registered nurses., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: Proximal fifth metatarsal fractures are among the most common forefoot injuries in athletes. The management of this injury can be challenging because of delayed union and refractures. Intramedullary (IM) screw fixation rather than nonoperative management has been recommended in the athletic population., Purpose: To provide an updated summary of the return-to-play (RTP) rate and time to RTP after Jones fractures in athletes with regard to their management, whether operative or nonoperative, and to explore the union rate and time to union as well as the rate of complications such as refractures., Study Design: Meta-analysis., Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases including PubMed, MEDLINE, Embase, Google Scholar, Web of Science, Cochrane Library, and ClinicalTrials.gov through November 2019 to identify studies reporting on Jones fractures of the fifth metatarsal exclusively in athletes. The primary outcomes were the RTP rate and time to RTP, whereas the secondary outcomes were the number of games missed, time to union, and union rate as well as the rates of nonunion, delayed union, and refractures., Results: Of 168 studies identified, 22 studies were eligible for meta-analysis with a total of 646 Jones fractures. The overall RTP rate was 98.4% (95% CI, 97.3%-99.4%) in 626 of 646 Jones fractures. The RTP rate with IM screw fixation only was 98.8% (95% CI, 97.8%-99.7%), with other surgical fixation methods (plate, Minifix) was 98.4% (95% CI, 95.8%-100.0%), and with nonoperative management was 71.6% (95% CI, 45.6%-97.6%). There were 3 studies directly comparing RTP rates with surgical versus nonoperative management, which showed significant superiority in favor of surgery (odds ratio, 0.033 [95% CI, 0.005-0.215]; P < .001). The RTP rate according to type of sport was 99.0% (95% CI, 97.5%-100.0%) in football, 91.1% (95% CI, 82.2%-99.4%) in basketball, and 96.6% (95% CI, 92.6%-100.0%) in soccer. The overall time to RTP was 9.6 weeks (95% CI, 8.5-10.7 weeks). The time to RTP in the surgical group (IM screw fixation) was 9.6 weeks (95% CI, 8.3-10.9 weeks), which was significantly less than that in the nonoperative group of 13.1 weeks (95% CI, 8.2-18.0 weeks). The pooled union rate in the operative group (excluding refractures) was 97.3% (95% CI, 95.1%-99.4%), whereas the pooled union rate in the nonoperative group was 71.4% (95% CI, 49.1%-93.7%). The overall time to union was 9.1 weeks (95% CI, 7.7-10.4 weeks). The time to union with IM screw fixation (8.2 weeks [95% CI, 7.5-9.0 weeks]) was shorter than that with nonoperative treatment (13.7 weeks [95% CI, 12.7-14.6 weeks]). The rate of delayed union was 2.5% (95% CI, 1.2%-3.7%), and the overall refracture rate was 10.2% (95% CI, 5.9%-14.5%)., Conclusion: The RTP rate and time to RTP after the surgical management of Jones fractures in athletes were excellent, regardless of the implant used and type of sport. IM screw fixation was superior to nonoperative management, as it led to a higher rate of RTP, shorter time to RTP, higher rate of union, shorter time to union, and improved functional outcomes. We recommend surgical fixation for all Jones fractures in athletes.

Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To assess the frequency, appropriateness, and radiation doses associated with multiphase computed tomography (CT) protocols for routine chest and abdomen-pelvis examinations in 18 countries., Materials and Methods: In collaboration with the International Atomic Energy Agency, multi-institutional data on clinical indications, number of scan phases, scan parameters, and radiation dose descriptors (CT dose-index volume; dose-length product [DLP]) were collected for routine chest (n = 1706 patients) and abdomen-pelvis (n = 426 patients) CT from 18 institutions in Asia, Africa, and Europe. Two radiologists scored the need for each phase based on clinical indications (1 = not indicated, 2 = probably indicated, 3 = indicated). We surveyed 11 institutions for their practice regarding single-phase and multiphase CT examinations. Data were analyzed with the Student t test., Results: Most institutions use multiphase protocols for routine chest (10/18 institutions) and routine abdomen-pelvis (10/11 institutions that supplied data for abdomen-pelvis) CT examinations. Most institutions (10/11) do not modify scan parameters between different scan phases. Respective total DLP for 1-, 2-, and 3-phase routine chest CT was 272, 518, and 820 mGy·cm, respectively. Corresponding values for 1- to 5-phase routine abdomen-pelvis CT were 400, 726, 1218, 1214, and 1458 mGy cm, respectively. For multiphase CT protocols, there were no differences in scan parameters and radiation doses between different phases for either chest or abdomen-pelvis CT ( P = 0.40-0.99). Multiphase CT examinations were unnecessary in 100% of routine chest CT and in 63% of routine abdomen-pelvis CT examinations., Conclusions: Multiphase scan protocols for the routine chest and abdomen-pelvis CT examinations are unnecessary, and their use increases radiation dose.

The severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) pandemic, became rapidly recognised by variable phonotypic expressions that involve most major body organs. Neurological complications of severe acute respiratory syndrome coronavirus disease are increasingly encountered in patients with COVID-19 infection, more frequently in patients with severe infection, and develop as a consequence of the neurotropic potential of this virus, secondary cytokine storm and acquired syndrome of COVID-19 coagulopathy. Spinal cord involvement after COVID-19 more commonly includes infectious transverse myelitis, para and post infection myelopathy and, rarely, spinal cord ischaemia related to increased coagulopathy with thromboembolic consequences. We herein report a COVID-19-positive patient with increased coagulopathy and vertebral artery thrombosis leading to posterior circulation and subsequent spinal cord infarction.

Introduction: Many risk factors have been reported to increase mortality among burn patients. Previously, a higher mortality incidence was reported in acute burn patients infected with multidrug-resistant organisms (MDROs) when compared to patients infected with non-MDROs. However, considering this as an independent risk factor for mortality in acute burn patients is not yet confirmed., Methods: We conducted an observational retrospective study in Qatar. We included adult patients admitted to the surgical intensive care unit (ICU) between January 2015 and December 2017 with burn injuries involving either at least 15% of the total body surface area (TBSA) or less than 15% with facial involvement. All patients developed infection with a positive culture of either MDRO or non-MDRO. The primary outcome was in-hospital mortality. Other outcomes included days of mechanical ventilation, ICU, length of stay in hospital, and requirement of vasoactive agents., Results: Fifty-eight patients were included in the final analysis: 33 patients in the MDRO group and 25 patients in the non-MDRO group. Six patients (18.2%) died in the MDRO group versus four patients (16%) in the non-MDRO group ( P = 1). No significant difference was observed between the two groups with regard to the ICU length of stay. However, there was a trend towards increased median length of stay in hospital in the MDRO group: 62 days versus 45 days in the non-MDRO group ( P = 0.057). No significant differences were observed in the other outcomes., Conclusion: In severely burned patients, infection with MDRO was not associated with increased mortality. There was a trend towards increased hospitalisation in MDRO-infected patients. Further studies with a larger sample size are needed to confirm these results., Lay Summary: Many factors affect mortality in burn patients admitted to the intensive care unit, such as age, total body surface area involved in the injury, and others. In this retrospective study, we evaluated whether wound infection with a bacterial organism resistant to multiple classes of antibiotics (multidrug-resistant) is considered an independent risk factor for mortality in critically ill burn patients. We included 58 patients requiring intensive care admission with burn injuries involving 15% or more of the total body surface area or less than 15% but with facial involvement. A total of 33 patients were infected with multidrug-resistant organisms (MDROs) and 25 patients with non-MDROs. Six patients (18.2%) from the MDRO group died versus four (16%) in the non-MDRO group. The MDRO group required a longer stay in hospital and an average of one more day on a mechanical ventilator. We concluded that wound infection with MDROs might not increase mortality when compared to wound infection with non-MDROs, although other studies with a larger number of patients involved need to be conducted to validate these results., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Dental trauma is common in the UK, with more than one in ten children having experienced some form of dental trauma. In addition, one in ten patients have been reported to have experienced dental trauma before orthodontic treatment. A recent survey of orthodontists' knowledge and experience of orthodontic management of traumatised teeth has highlighted large inconsistencies in management of traumatised teeth among UK orthodontists, highlighting the need for further information or training on orthodontic management of traumatised teeth.Therefore, the following guidelines have been developed in order to provide an evidence-based approach to treat this cohort of patients. The following guidance is based on the available literature, expert opinion and UK orthodontists' consensus drawn from a recent survey.