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Background Salmonellosis is a foodborne zoonosis leaving gastrointestinal illness and drug-resistant genes to the consumers. To prevent Salmonella contamination associated health issues in the chicken meat sold in Riyadh city in Saudi Arabia. The evaluation of the Salmonella isolates from the meat sample needs to be screened for the composition of Salmonella serotypes and antimicrobial resistance pattern at the molecular level. Methods and results Using specific growth media for Salmonella spp., swabs taken from the whole-body surfaces of 200 chilled broiler chickens from different vendors in the city of Riyadh, were screened for Salmonella contamination. Biochemical and molecular characterization of the isolates showed the presence of the serovars, Salmonella enterica, Salmonella Enteritidis, S. Typhimurium, S. Kentucky, and S. Tennessee. The isolated serovars exhibited multidrug resistance [MDR] resistance to antibiotics. Molecular characterization of the different serovars shows the presence of sixteen drug-resistant genes. The drug resistance mechanism at the molecular level varied with serotypes according to the nature of the antibiotics they encountered. A comparative study of the nature of the drug-resistant gene and the common antibiotics used in poultry farming in that province matches much, indicating adaptive variation in S. enterica serotypes to survive in the host's gut biome. The resistance genes from the chicken meat have every chance to get into the human system. The native microbes in consumers may acquire drug-resistant genes from S. entericus serovars. Such conditions may lead to treatment complications in the hosts. Conclusions The results indicated that Salmonella infections constituted a potential risk to consumers through chicken flocks and noted that the genotypic resistance pattern to antibiotics draws attention in terms of both human and animal health. Also, promote other options for poultry farming, avoiding antibiotics supplementation.

Radical prostatectomy is a life saving treatment for localised prostate cancer but may come with debilitating consequences, such as incontinence and erectile dysfunction. Penile Prosthesis Implants (PPI) are the gold standard of treatment for patients with refractory Erectile Dysfunction (ED) resistant to conservative management. Likewise, an Artificial Urinary Sphincter (AUS) is gold standard for those with refractory severe urinary incontinence. This systematic review with cumulative analysis assesses the efficacy and complications rates for synchronous placement of PPI and AUS as a single-stage procedure. Systematic literature review was performed using the US National Library of Medicine’s life science database (MEDLINE) (2000 to May 2021), EMBASE (2000 to May 2021), Cochrane Central Register of Controlled Trials-CENTRAL (in the Cochrane Library-2021), Google Scholar and Individual journals. 5 studies were included for analysis, with total of 112 patients. The overall revision/replacement rate was 12.5% (n = 14). The revision rate for PPI alone was 4.5% (n = 5), for AUS was 6.5% (n = 9). The overall removal rate was 5.4% (n = 6). Removal rate for PPI alone was 0.9% (n = 1), for AUS was 1.4% (n = 3). There were only 2 case of dual prosthesis removal (1.4%). Our cumulative analysis has revealed that revision and removal rates for synchronous dual implants may be lower than previously believed. However, our review has highlighted the low quality of available data and stresses that more robust studies are required to validate the high satisfaction and low complication rates reported by small studies.

Objectives To review the latest innovations and advances in testosterone treatments including their advantages and disadvantages and to address important issues in testosterone therapy (TTh). Methods This review was conducted according to the Preferred Reporting Items for Systemic Reviews and Meta-analyses guidelines. The PubMed, MEDLINE, Scopus and Cochrane databases were searched using specifically related key words. The identified studies were screened for inclusion criteria that included studies discussing one of the four objectives of the systematic review: 1) cut–off references, 2) prevention/remission of type II diabetes mellitus (T2DM), 3) duration of treatment, and 4) prostate, lower urinary tract symptoms, prostate health, or cancer. The search was limited to the past 15 years. Any studies were not written in English were excluded. Results The initial literature search retrieved 393 studies. After screening four studies were removed due to duplication, 360 studies were further excluded after reviewing the title, abstract or the whole manuscript due to different exclusion criteria or being not focussed on the objective. Finally, 29 studies were included in the review. One study discussed the cut–off value, four studies discussed the effect of testosterone replacement therapy (TRT) on the control of T2DM, four studies on duration of TRT, and 20 studies discussed the effects of TRT on the prostate Conclusions Numerous studies have demonstrated the benefits of TTh in overtly hypogonadal men. There are several possible administration routes for testosterone treatment. Each approach has advantages and disadvantages, and the choice of the method of TRT will often be determined by patient preference or co-medication (no intramuscular injections in patients under coumarin or similar anticoagulants). Although new developments are promising, it seems that among the available treatments, only transdermal gel delivery and long-acting injectable testosterone undecanoate provide pharmacokinetic behaviour that gives a steady state level within a physiological range.

Background and Objectives There are some studies on the association between attention deficit and hyperactivity disorder (ADHD) and the risk of eating disorders (ED). Only few have examined the risk of ED among children and adolescents with ADHD. Previous research which included subjects with ADHD with other comorbidities used inadequate controls and did not focus on the type of ADHD or the role of pharmacological treatment. Methods This matched cohort study was conducted in the Child/Adolescents Psychiatry Unit (CAPU), Bahrain. Using the CAPU diagnostic frameworks, 70 subjects with ADHD were recruited and matched with their corresponding age- and sex- healthy controls at 1:2 ratio (70 cases:140 controls). The participants were children or adolescents aged between 8 and 19 years old. A brief interview was used to collect socio-demographic information and anthropometrics. The risk of ED was estimated using the eating attitude test −26 (EAT-2). Data were analyzed using cohort analysis. Results A total of 31.43% of the subjects with ADHD were screened using EAT-26 and found to be ‘at risk’ for ED, compared to 12.14% of the controls (OR 3.31, 95% CI 1.62–6.78). The prevalence of ED among female cases with ADHD was slightly higher than males (33.33% and 30.77%, respectively). Body weight or body mass index was a statistically significant explanatory factor for the risk of ED. Conclusions The present study shows that children and adolescents with ADHD have a three-fold increased risk of ED compared to healthy controls. This research raised the recommendation that children and adolescents with ADHD should be screened for disordered eating patterns.

Background: Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that was first discovered in December 2019 and turned to be pandemic in early March 2020. We aimed to describe the dominant ABO group and outcomes of critically ill patients (respiratory failure requiring mechanical ventilation and mortality) in a Saudi Arabian setting. Methods: We conducted an observational, analytic cross-sectional, retrospective study in a tertiary care hospital. Around 90 candidates tested positive for COVID-19 were enrolled in this study during admission to critical care unit between May 2020 and September 2020. Blood group was detected in all patients included in the study during admission to critical care unit. Results: In this study, data of 90 patients with COVID-19 admitted to critical care unit were collected. Some prevalent medical conditions were collected, in which hypertension (64.2%) and diabetes mellitus (58.9%) were the most reported comorbidities among patients and there was no significant difference between groups. Most of the sample had blood group of O (45.6%), while the least group was AB (5.6%). Patients with blood group of A/AB showed the highest mortality vs. group O/B (32% vs. 18.5%) with significant P value of 0.001. Patients of groups A/AB had higher risk for intubation than O/B groups (52.0% and 49.2%, respectively; confidence interval of 0.44 - 2.8 with insignificant P value of 0.055). Length of stay in critical care unit was significantly higher in group A/AB with a mean course of 18.20 days in comparison to group O/B with a mean course of 12.63 days (P = 0.033). Conclusion: Our data indicate that critically ill patients with COVID-19 with blood group A/AB are at increased risk of mortality and length of stay in critical care unit, with insignificant requirement of mechanical ventilation when compared with patients with blood group O/B. Future larger studies are needed to validate and understand the underlying mechanisms. J Hematol. 2021;10(2):64-70 doi: https://doi.org/10.14740/jh821

Thyroid cancer is a common endocrine neoplasm. Despite its good prognosis, it can lead to significant morbidity and mortality due to metastasis and recurrence. However, the factors involved in metastasis are not well studied. Therefore, we selected matrix metalloproteinases 2 (MMP2) and determined whether it has any role in thyroid cancer. We sequenced the exons of MMP2 in 211 samples including 16 multi-nodular goiters and 195 differentiated thyroid cancers. We identified four non-synonymous single nucleotide polymorphisms (SNPs) of the MMP2 gene in 3.06% (6/195) thyroid cancers. Of the four tumors harboring MMP2 SNPs, three (75%) concomitantly had BRAFV600E. Hence, we speculated that the MMP2 SNPs may cooperate with BRAFV600E in promoting tumor aggressiveness. Overexpression of two MMP2 SNPs (P38L and T458I) exhibited markedly enhanced gelatinase activity with an intact dimerization and induced strong cortactin foci formation in HEK293T cells. Stable expression of the two MMP2 SNPs in BRAFV600E positive BCPAP cells dramatically enhanced cell proliferation, colony formation, and focus formation. Analysis of the morphology of MMP2 SNP bearing BCPAPV600E cells exhibited highly invasive phenotypes characterized by a high rate of wound healing and enhanced cell invasion compared with parental BCPAPV600E cells bearing vector. We also determined that BCPAPV600E cells stably transfected with MMP2 SNPs were highly sensitive to the treatment of BRAF inhibitor, PLX4720. Our study demonstrates that MMP2 SNPs could cooperate with BRAFV600E to promote oncogenicity, migration, and invasiveness of PTC cells. These results suggest that a subset of papillary thyroid cancer with this genetic makeup may benefit from BRAF-mediated therapeutic interventions.

Traditional medicine is becoming a primary source of health care in many countries in recent years The current study proposes a new dimension of understanding a traditional origin treatment, using herbo-mineral preparations in nanoform The herbo-mineral preparation, Linga chenduram [HMLC], was prepared according to the ancient palm script protocol dates back to 1000 years In search of alternative therapy for the coronavirus, an attempt was made to determine this ethnic medicine formulation's therapeutic potential for viral hepatitis infection The Hepatitis C virus [HCV] has several genomic similarities with SARS-CoV-2 viruses The herbo-mineral formulation (HMLC) were analyzed using UV–vis, EDAX, FTIR, XRD, SEM, and TEM studies SEM images confirmed the ' presence of nanoparticles with agglomerated conditions having an average grain size of 18 to 25 nm EDAX studies showed the presence of metallic components in oxide or sulfide form in HMLC The HCV inhibitory effects of HMLC indicated a good response The cytotoxicity of this preparation against the Huh-7 human hepatoma cell line was significant The HMLC showed a strong inhibitory effect on HCV replication in a dose-dependent manner The genomic component of HCV is similar to COVID −19 virus The Hepatitis C virus (HCV) NS3/4A protease has a striking three-dimensional structural similarity to the SARS-CoV2 Mpro protease, particularly in the arrangement of key active site residues So HMLC can be tried to treat coronavirus infection At higher concentrations, HMLC exhibited over 100-fold inhibition In the MTT assay, HMLC did not show any apparent cytotoxic effect on cell viability at the concentrations 1–100 µg Histological studies indicated that the liver and kidney did not experience any toxicity by 7 and 15 consecutive days of administration of HMLC on experimental Wistar rats Hence, the HMLC can be tried as a therapy for COVID −19 infections using the preparations strictly according to ethnopharmacological protocol and optimum doses © 2020 The Author(s)

Simple renal cysts are common benign lesions of the kidney with up to 4% of patients developing symptoms necessitating intervention including pain and haematuria. We conducted a systematic review of the literature to determine the efficacy and safety of aspiration–sclerotherapy of symptomatic simple renal cysts. A systematic review using Cochrane guidelines was conducted on published literature from 1990 to 2020. RCTs, cohort studies and case series meeting the inclusion criteria were reviewed and cumulative analysis of outcomes was performed. A total of 4071 patients from 57 studies underwent aspiration ± sclerotherapy for their simple renal cysts. 87.7% of patients who had aspiration with sclerotherapy demonstrated ‘treatment success’ with a >50% reduction in cyst size and complete resolution of symptoms. 453 minor, transient complications occurred (11.2%) whilst a major complication rate of less than 0.1% (4 patients) was reported. Pooled analysis of all available current literature demonstrates that aspiration–sclerotherapy is a safe and effective first-line therapy for symptomatic simple renal cysts. Although we are unable to compare those undergoing aspiration alone to aspiration–sclerotherapy, it is evident the use of a sclerosing agent is integral to treatment success; however, the optimum agent, volume, injection frequency, and dwelling time are yet to be defined. Cyst size should be considered when discussing treatment options; however, we conclude it reasonable for aspiration–sclerotherapy to be used in the first instance in all cases of symptomatic simple renal cysts. Furthermore, we propose definitions of treatment outcome measures in order to allow direct comparative analysis across future studies.

Background: COVID-19 is a pandemic disease that has no definite treatment or preventive medication until late 2020 when vaccines were developed. Vaccines are a very useful new tool against COVID-19 that stimulate the immune system after recognition of viruses or their parts. Complications post vaccination could happen and they depend on the types, vaccine mechanism of action as well as some other patients' factors. Case report: We are reporting a 39 years old lady who is known as allergic to a strawberry and kiwi, otherwise medically free. She presented to the outpatient unit with a ten-days history of palms of the hands and soles of the feet itchiness that is associated with occasional redness after receiving the first dose of COVID-19 vaccination. There were no skin rashes or pruritis at any other sites. The patient was treated conservatively by antihistamine and the symptoms gradually resolved within five days. Conclusion: Allergic reaction is one of the expected complications post any COVID-19 or non-COVID-19 vaccination. Although the type, distributions and severity of allergic reactions are variable from person to another, yet isolated itching to palms and soles could be a rare side effect post first dose of COVID-19 vaccination (Pfizer-BioNTech) which is worth reporting. This presentation could be a type of allergic reaction which may require holding further doses, debate is there for further case reporting, research or evaluation.Learning points: • Isolated itching to palms and soles could be one of the side effects of COVID-19 vaccination (Pfizer-BioNTech) which is worth reporting.

Robotic radical cystectomy (RRC) has become a commonly utilised alternative to open radical cystectomy (ORC). We performed a systematic review and meta-analysis of RRC vs ORC focusing on perioperative outcomes and safety. Medline, EMBASE and CENTRAL were searched from January 2000 to April 2020 following the Preferred Reporting Items for Systematic Review and Meta-analysis Statement for study selection. In total, 47 studies (5 randomised controlled trials, 42 non-randomised comparative studies) comprising 12,640 patients (6572 ORC, 6068 RRC) were included. There was no difference in baseline demographics between the groups apart from males were more likely to undergo ORC (OR 0.77, 95% CI 0.69–0.85). Those with muscle-invasive disease were more likely to undergo RRC (OR 1.21, 95% CI 1.09–1.34), and those with high-risk non-muscle-invasive bladder cancer were more likely to undergo ORC (OR 0.80, 95% CI 0.72–0.89). RRC had a significantly longer operating time, less blood loss and lower transfusion rate. There was no difference in lymph node yield, rate of positive surgical margins, or Clavien–Dindo Grade I–II complications between the two groups. However, the RRC group were less likely to experience Clavien–Dindo Grade III–IV (OR 1.56, 95% CI 1.30–1.89) and overall complications (OR 1.45, 95% CI 1.26–1.68) than the ORC group. The mortality rate was higher in ORC although this did not reach statistical significance (OR 1.52, 95% CI 0.99–2.35). RRC has significantly lower blood loss, transfusion rate and is associated with fewer high grade and overall complications compared to ORC.

The aim of this study is to investigate oxidative stress and leptinlevel in obese women. Fifty obese women with BMI value of ≥ 30.0 kg/m2 and thirty healthy women with BMI

Background:The coronavirus disease 2019 (COVID-19) pandemic has impacted people with substance use disorders (SUDs) worldwide, and healthcare systems have reorganized their services in response to the pandemic.Methods:One week after the announcement of the COVID-19 as a pandemic, in a global survey, 177 addiction medicine professionals described COVID-19-related health responses in their own 77 countries in terms of SUD treatment and harm reduction services. The health responses were categorized around (1) managerial measures and systems, (2) logistics, (3) service providers, and (4) vulnerable groups.Results:Respondents from over 88% of countries reported that core medical and psychiatric care for SUDs had continued; however, only 56% of countries reported having had any business continuity plan, and 37.5% of countries reported shortages of methadone or buprenorphine supplies. Participants of 41% of countries reported partial discontinuation of harm-reduction services such as needle and syringe programs and condom distribution. Fifty-seven percent of overdose prevention interventions and 81% of outreach services were also negatively impacted.Conclusions:Participants reported that SUD treatment and harm-reduction services had been significantly impacted globally early during the COVID-19 pandemic. Based on our findings, we highlight several issues and complications resulting from the pandemic concerning people with SUDs that should be tackled more efficiently during the future waves or similar pandemics. The issues and potential strategies comprise the following: (1) helping policymakers to generate business continuity plans, (2) maintaining the use of evidence-based interventions for people with SUDs, (3) being prepared for adequate medication supplies, (4) integrating harm reduction programs with other treatment modalities, and (5) having specific considerations for vulnerable groups such as immigrants and refugees.

Background: The goal of the program was to establish a comprehensive dedicated Paediatric service for adolescents with an eating disorder which was multidisciplinary in approach, targeted at the specific needs of this client group and in line with international best practice. It was also a response to the increasing population of children and in particular those within the 15-17 age bracket where the population in Qatar is set to grow by 22% between 2014 and 2030 (HMC Strategic Planning Dept.) Eating disorders are complex illnesses that affect adolescents with increasing …

Background Establishing paediatric early warning system in a paediatric emergency department is a complex process and more so with COVID-19 pandemic. PUMA {PEWS Utilisation & Morality Avoidance} is a qualitative system assessment survey tool which assess the strengths and weaknesses of the patient care safety processes and systems within a department. 1 This model draws together evidence from two theoretically informed systematic reviews.1 2 Objectives To establish a Paediatric early warning system in the Sidra Paediatric Emergency Department Methods The Sidra Medicine ED Quality group surveyed online 200 staff in the department (physicians/nursing team) focussing on processes of monitoring patients and documentation, communication amongst the team and parents, staff empowerment, situational awareness, escalation processes and response to deteriorating child in the three broad domains of Detect, Prepare, and Act with further seven smaller domains (monitor, record, interpret, review, prepare, escalate and evaluate) (figure 1). Survey analysis enabled us to review our current practice, identify areas that are working well, and areas for improvement. Results The online survey platform helped us to achieve 85% return rate and to identify seven areas for improvement in our system. The spider diagram (Figure 2) illustrates the areas of strength and weakness in the seven domains of Detect, Prepare, and Act. We collaborated with Cerner team, created automatic documentation of vital signs from triage and treatment areas to patient Electronic Medical Record by associating patient's cardiac monitors to reduce manual errors and for the timely vitals monitoring. 'Back to Basics Training', a one day refresher course for nursing team has been conducted. A Senior Nurse as a watcher in the triage and treatment area identified children at high risk of deterioration. A Pediatric ED Situational Awareness Tool (PEDSAT) was developed locally and is in trial in the department to help manage sick children effectively. Conclusions PUMA, a novel system assessment tool empowered our emergency department to tailor a quality program with an aim to deliver effective and efficient patient care.

Objectives: To report the association between testosterone treatment in hypogonadal men with hepatic steatosis, non-alcoholic fatty liver disease and cardiovascular disease (CVD). Methods: A prospective study was conducted to assess the physiological and functional performance of the long-term effects of testosterone undecanoate treatment on hepatic steatosis in 496 hypogonadal men. Two groups were studied, the treatment group (T-group) of 312 patients treated with TU 1000 mg every 12 weeks and followed for 8 years, and an untreated control group (C-group) of 184 patients. We evaluated liver functions and Fatty Liver Index (FLI) according to Mayo Clinic parameters and guidelines. Results: The T-group showed a decrease in the FLI (from a mean [SD] of 83.70 [12.15] to 67.12 [19.21]), bilirubin (from a mean [SD] of 1.69 [4.21] to 1.31 [1.91] mg/dL), triglycerides (from a mean [SD] of 254.87 [92.99] to 213.37 [66.91] mg/dL), and gamma-glutamyl-transferase (from a mean [SD] of 39.45 [11.51] to 29.11 [7.68] U/L) over the duration of the study. Other parameters were also reduced in the T-group such as body mass index (from a mean [SD] of 31.59 [4.51] to 29.50 [3.84] kg/m2) and waist circumference (from a mean [SD] of 107.51 [9.95] to 101.86 [9.28] cm). A total of 25 deaths (7.8%) were recorded in the T-group, among them, 11 (44%) were related to CVD. While in the C-group 28 deaths (15.2%) were recorded and all the reported deaths (100%) were related to CVD. Conclusions: The findings suggest that long-term testosterone therapy in hypogonadal men improves liver function. While, the physiological and functional improvements in the liver may be associated with a decrease in CVD-related mortality. Abbreviations ALT: alanine transaminase; AR: androgen receptor; AST: aspartate transaminase; BMI: body mass index; CVD: cardiovascular disease; FLI: Fatty Liver Index; γ-GT: gamma-glutamyl-transferase; MetS: metabolic syndrome; LDL: low-density lipoprotein; NAFLD: non-alcoholic fatty liver disease; RCT: randomised controlled trial; T2DM: type II diabetes mellitus; TT: total testosterone; TTh: testosterone therapy; TU: testosterone undecanoate; WC: waist circumference

Objectives: To review the current evidence of clinical effectiveness of low-intensity extracorporeal shockwave therapy (LI-ESWT) treatment for erectile dysfunction (ED). Methods A selective database search using Medical Subject Headings (MeSH) terms ‘low intensity extracorporeal shock wave therapy’ and ‘erectile dysfunction’ was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta Analyses (PRISMA) guidelines to review the effectiveness of LI-ESWT for ED. We performed a systematic search of publications using the PubMed and Web of Science databases (January 2010–December 2020) for prospective randomised clinical trials (RCTs). The success rate of LI-ESWT associated with ED were recorded and analysed. Results A total of 106 articles were reviewed after searching for the keywords. Overall, 11 RCTs were included in this systematic review. A total of 920 male patients were treated in 11 RCTs. The patients’ ages ranged from 18 to 80 years and they had ≥3 months of ED symptoms. Vasculogenic and neurogenic causes were addressed in 81% and 19% of patients, respectively. Of the 920 patients, 348 patients had a statistically significant improvement in their erectile function after LI-ESWT; however, 572 did not have a statistically significant improvement. Conclusions The present review found that LI-ESWT has a role in ED treatment in laboratory studies, but its role in human clinical trials is still controversial. Further good quality studies need to be conducted to properly assess its true potential in ED treatment.

Introduction Crohn's disease (CD) is an idiopathic inflammatory disorder of unknown etiology with genetic, immunologic, and environmental influences. Infliximab is a treatment modality for fistulated Crohn's disease. Infliximab induced hemolysis is rare and very few cases reported before in Ulcerative colitis (UC) but not in Crohn's disease. Case presentation We are reporting a 63 years old gentleman who was diagnosed as Crohn's disease and started on Tumor necrosis factor Inhibitor (TNF) -α i.e. (infliximab - Remsima) infusion. The course was complicated by Coomb's negative hemolytic anemia which is suggestive of non-immune drug induced hemolysis. Our patient was treated with steroid and conservative measures. Upon following up, his hemoglobin level as well as all hemolytic markers showed dramatic improvement. Adalimumab was used to treat this patient as an alternative choice without relapse of hemolysis. Clinical discussion Drug induced Hemolysis is not a well-known complication post receiving Tumor necrosis factor Inhibitor (TNF) -α infusion in patients with Crohn's disease. Coombs negative hemolysis keeps in favor of non-immune drug induced rather than other differentials in our case scenario. Conclusion Although cross-reactivity is expected between one biological agent to another, in our case the use of Adalimumab as alternative choice post Tumor necrosis factor Inhibitor (TNF) -α (Remsima infliximab) induced hemolysis did not cause hemolysis or any type of reaction., Highlights • Crohn's disease is one of the Inflammatory bowel diseases (IBD) that can affect any part of gastrointestinal tract as well as extraintestinal organs. • Tumor necrosis factor Inhibitor (TNF) -α i.e. (infliximab - Remsima) is a treatment modality for fistulated Crohn's disease. • Drug induced Hemolysis is one of the complications that is not well-known post receiving Tumor necrosis factor Inhibitor (TNF) -α (Remsima) infusion.

INTRODUCTION AND OBJECTIVE:Diabetes mellitus (DM) is associated with an increased risk of erectile dysfunction (ED). Penile prosthesis implantation (PPI) is an efficient complementary therapeutic o...

Osteoporosis is a common progressive metabolic bone disease resulting in decreased bone mineral density (BMD) and a subsequent increase in fracture risk. The known bone markers are not sensitive and specific enough to reflect the balance in the bone metabolism. Finding a metabolomics-based biomarker specific for bone desorption or lack of bone formation is crucial for predicting bone health earlier. This study aimed to investigate patients’ metabolomic profiles with low BMD (LBMD), including those with osteopenia (ON) and osteoporosis (OP), compared to healthy controls. An untargeted mass spectrometry (MS)-based metabolomics approach was used to analyze serum samples. Results showed a clear separation between patients with LBMD and control (Q2 = 0.986, R2 = 0.994), reflecting a significant difference in the dynamic of metabolic processes between the study groups. A total of 116 putatively identified metabolites were significantly associated with LBMD. Ninety-four metabolites were dysregulated, with 52 up- and 42 downregulated in patients with LBMD compared to controls. Histidine metabolism, aminoacyl-tRNA biosynthesis, glyoxylate, dicarboxylate metabolism, and biosynthesis of unsaturated fatty acids were the most common metabolic pathways dysregulated in LBMD. Furthermore, 35 metabolites were significantly dysregulated between ON and OP groups, with 11 up- and 24 downregulated in ON compared to OP. Among the upregulated metabolites were 3-carboxy-4-methyl-5-propyl-2-2furanopropionic acid (CMPF) and carnitine derivatives (i.e., 3-hydroxy-11-octadecenoylcarnitine, and l-acetylcarnitine), whereas phosphatidylcholine (PC), sphingomyelin (SM), and palmitic acid (PA) were among the downregulated metabolites in ON compared to OP. This study would add a layer to understanding the possible metabolic alterations associated with ON and OP. Additionally, this identified metabolic panel would help develop a prediction model for bone health and OP progression.

Mustafa Alwani,1,2 Aksam Yassin,2– 4 Raidh Talib,2 Ahmad Al-Qudimat,2 Omar Aboumarzouk,2 Raed M Al-Zoubi,2,5 Farid Saad,6 Karim S Haider,7 Abdulla Al Ansari2 1Jordan University of Science and Technology, School of Medicine, Irbid, Jordan; 2Hamad Medical Corporation, Department of Surgery, Division of Urology/Andrology and Section of Surgical Research, Doha, Qatar; 3Weill Cornell Medical College, New York, NY, USA; 4Weill Cornell Medical College, Doha, Qatar; 5Jordan University of Science and Technology, Department of Chemistry, Irbid, Jordan; 6Dresden International University, Center of Medicine and Health Sciences, Dresden, Germany; 7Klinikum Bremen-Mitte, Department of Urology, Bremen, GermanyCorrespondence: Aksam Yassin Rathausallee 94 A, Norderstedt-Hamburg, 22846, GermanyTel +49 40 526 21 57Fax +49 40 526 28 20Email yassin@t-online.dePurpose: Erectile dysfunction (ED) is associated with testosterone deficiency and is a symptom of functional hypogonadism. A correlation between ED and cardiovascular disease (CVD) has been recognized, and ED has been proposed as an early marker of CVD. However, the relationship between ED and CVD risk in hypogonadism requires clarification and whether testosterone therapy (TTh) can be a beneficial treatment strategy, but long-term data are limited. This study investigates long-term TTh in men with hypogonadism and ED with a history of CVD.Methods: Seventy-seven patients with a history of CVD and diagnosed with functional hypogonadism and erectile dysfunction (erectile function domain score < 21 on the International Index of Erectile Function questionnaire (IIEF questions 1– 5)) were enrolled and TTh effects on anthropometric and metabolic parameters investigated for a maximum duration of 12 years. All men received long-acting injections of testosterone undecanoate at 3-monthly intervals. Eight-year data were analysed. Data collection registry started in November 2004 till January 2015.Results: In hypogonadal men receiving TTh, IIEF increased by 5.4 (p< 0.001). Total weight loss was 23.6 ± 0.6 kg after 8 years. HbA1c had declined by an average of 2.0% (P< 0.0001). Total cholesterol levels significantly declined following TTh after only 1 year (P< 0.0001), and HDL increased from 1.6± 0.5 at baseline to 2± 0.5 mmol/L following 8 years of TTh (P< 0.0001). SBP decreased from 164± 14 at baseline to 133± 9 mmHg, signifying a reduction of 33± 1 mmHg (P< 0.0001).Conclusion: In hypogonadal men with a history of CVD, TTh improves and preserves erectile function over prolonged periods with concurrent sustained improvements in cardiometabolic risk factors. Measuring ED and testosterone status may serve as an important male health indicator predicting subsequent CVD-related events and mortality and TTh may be an effective add-on treatment in secondary prevention of cardiovascular events in hypogonadal men with a history of CVD.Keywords: functional hypogonadism, testosterone therapy, erectile function, cardiovascular disease

Background: Establishing a paediatric early warning system in a paediatric Emergency Department (ED) is a complex process and more so with the COVID-19 pandemic. PUMA (PEWS Utilisation & Morality Avoidance) is a qualitative system assessment survey tool which assesses the strengths and weaknesses of the patient care safety processes and systems within a department1. This model draws together evidence from two theoretically informed systematic reviews1,2. Methods: The Sidra Medicine ED Quality group surveyed online 200 staff from the department of physicians/nursing team focussing on processes of monitoring patients and documentation, communication amongst the team and with parents, staff empowerment, situational awareness, escalation processes and response to the deteriorating child in the three broad domains of Detect, Prepare, and Act, with a further seven smaller domains (monitor, record, interpret, review, prepare, escalate, and evaluate) (Figure 1). Survey analysis enabled to review current practice, identify areas that are working well and areas for improvement. Results and implications: The online survey helped achieve a 85% return rate and identify seven areas for improvement in the system. The spider diagram (Figure 2) illustrates the areas of strength and weakness in the seven domains with respect to Detect, Prepare, and Act. We collaborated with the Cerner team, created an automatic documentation of vital signs from triage and treatment areas to the patient’s Electronic Medical Record by associating patient’s cardiac monitors to reduce manual errors and for the timely monitoring of vital signs. A one-day “Back to Basics Training” refresher course for the nursing team was conducted. A senior nurse, as a watcher in the triage and treatment area, identified children at high risk of deterioration. A Pediatric ED Situational Awareness Tool (PEDSAT) was developed locally and is in trial to help manage sick children effectively. Conclusion: PUMA, a novel system assessment tool, empowered our ED to tailor a quality program with an aim to deliver effective and efficient patient care.

BACKGROUND: Oral and systemic problems are common among pregnant women. Routine dental visits are important for the maintenance of optimal oral health which is linked with systemic health. AIM: To evaluate dental care utilization and related factors among pregnant women in the Eastern province of Saudi Arabia. METHODS: This cross-sectional study was conducted in hospitals and healthcare centers in the cities of Khobar, Dammam, and Qatif in the Eastern province of Saudi Arabia. A piloted tested self-administered questionnaire available in Arabic and English languages was distributed among a calculated sample of 341 pregnant women. Pearson's chi-square test and multiple logistic regression analyses were performed. RESULTS: In the study, 270 questionnaires were analyzed giving a response rate of 79.2%. Mean age of the participants was 29 ± 5.9 years. There were 43.7% pregnant women who received dental treatment when they have a dental problem and only 13.7% performed routine dental visit. Half the sample (52.6%) avoided dental visits during pregnancy and dental treatment being unsafe was the most common reason for avoiding dental visits. After adjustment, routine dental visits during pregnancy were 7.38 times higher among Saudis compared with non-Saudis women (p 0.05). The participants who had a negative perception about the safety of dental treatment had significantly lower odds (OR 0.31, p 0.036) of dental attendance for routine dental visits. CONCLUSION: Routine dental visits were low among pregnant women and many visited dentists when they had a dental problem. Negative perception about the safety of dental treatment was associated with reduced regular dental visits during pregnancy. Pregnant women should be educated about the importance of receiving dental care for the maintenance of optimal oral health.

Background Delirium is a medical emergency prevalent amongst hospitalised older patients and associated with prolonged hospital stay, functional and cognitive decline, institutionalisation and increased mortality. In Irish hospitals, multiple strategies, e-learning courses, delirium guidelines and prevention programs have aimed to improve delirium care with better diagnosis and prevention. With the increasing awareness campaigns, we aimed to review the prevalence, screening and management of delirium in our cohort of older patients. Methods A review of medical notes of all patients admitted under medical teams to an acute geriatric ward was carried out. Data was collected over a 3 week period in an Irish model 3 hospital. The following information was obtained from medical records: 1) Previous diagnosis of delirium/dementia 2) Documentation of a diagnosis of delirium 3) Features of delirium 4) Development of delirium as an inpatient 5) Formal screening for delirium 6) Cause and management of delirium 7) Length of stay. Results Of 79 consecutive admissions to an acute geriatric ward (mean age 81.4, 57% female, 30% previous history of delirium or dementia), 25% (n=20) had a diagnosis of delirium documented. 22% (n=18) of patients had confusion and features of delirium highlighted but no formal diagnosis of delirium made during their inpatient stay. A further 20% (n=16) developed delirium on admission. Only 2.5% (n=2) of admissions had formal screening for delirium with the 4AT. 27.5% (n=11) of patients with delirium had a cause and management plan recorded. 70% (n=28) of patients with delirium had a length of stay of over 15 days. Conclusion This review showed delirium recognition, screening, prevention and management were overlooked to an alarming extent in our cohort of older patients. The next step is introduction of the 4AT screening tool and regular education sessions to increase the awareness of delirium amongst medical teams looking after older patients and improve care and outcomes.

Introduction: There is a growing body of evidence suggesting that acute cardiovascular events including stroke are not distributed randomly over time but instead depend on months/season of the year. We report the impact of meteorological variables in extremely hot and arid climate on stroke. Methods: Acute stroke patients admitted from January 2014 to December 2017 were included. The data included demographics, clinical risk factors, temperature, solar radiation, relative humidity, dew point, wind speed, and atmospheric pressure. We calculated stroke rates/100,000/month. Results: There were 3654 cases of stroke (ischemic stroke [IS]: 2956 [80.9%]; and intracerebral hemorrhage [ICH]: 698 [19.1%]) with no difference in hematocrit, creatinine, and blood urea between hot and cold seasons (p > .05). We observed a positive significant correlation of IS with the mean temperature (AOR: 1.023; 95% CI: 1.009-1.036; P = .001) and mean solar radiation (AOR: 1.268; 95% CI: 1.021-1.575; P = .032) showing a 2.3% and 26.8% higher risk relative to ICH respectively, a negative correlation between IS with relative humidity (AOR: 0.99; 95% CI: 0.984-0.997; P = .002), and atmospheric pressure (AOR: 0.977; 95% CI: 0.966-0.989; P < .001) was observed, 1% increase in the relative humidity correlate with 2.4% and 1% lower risk of IS incidence relative to ICH respectively. Conclusion: We demonstrated a distinct seasonal pattern in the incidence of stroke with an increase in IS rates relative to ICH during the summer months with higher solar radiations that cannot be explained by physiological measures suggestive of dehydration or hem-concentration. - 2019 Elsevier Inc. Scopus

Background/aims Cerium oxide nanoparticles (CeO₂ NPs) are released from diesel engines that use cerium compounds as a catalytic agent to decrease the diesel exhaust particles, leading to human exposure by inhalation to CeO₂ NPs. We have recently demonstrated that pulmonary exposure to CeO₂ NPs induces lung inflammation, thrombosis, and oxidative stress in various organs including kidneys. It is well known that particulate air pollution effects are greater in patients with renal diseases. The aim of this study is to investigate the effects of pulmonary exposure to CeO₂ NPs in a rat model of acute kidney injury (AKI). Methods AKI was induced in rats by a single intraperitoneal injection of cisplatin (CP, 6 mg/kg). Six days later, the rats were intratracheally (i.t.) instilled with either CeO₂ NPs (1 mg/kg) or saline (control), and various renal and pulmonary endpoints were assessed 24 h afterward using histological, colorimetric assay, enzyme-linked immunosorbent assay and Comet assay techniques. Results CP alone decreased body weight, and increased water intake, urine volume and relative kidney weight. CP also increased the plasma concentrations urea and creatinine, and decreased creatinine clearance. In the kidneys, CP significantly increased renal injury molecule-1, interleukin-6 (IL-6), tumor necrosis factor α (TNFα) and glutathione concentrations, and caused renal tubular necrosis, and DNA injury assessed by Comet assay. All these actions were significantly aggravated in rats given both CP and CeO₂ NPs. Histopathological changes in lungs of CeO₂ NPs-treated rats included marked interstitial cell infiltration and congestion. These were aggravated by the combination of CP + CeO₂ NPs. Moreover, this combination exacerbated the increase in the concentrations of TNFα and IL-6, and the decrease in the activity of pulmonary catalase and total nitric oxide concentration, and lung DNA damage. Conclusion We conclude that the presence of CeO₂ NPs in the lung exacerbated the renal and lung effects of CP-induced AKI.

Postural orthostatic tachycardia syndrome (POTS) is a form of chronic dysautonomia, most commonly seen in women of child-bearing age and often associated with reduced quality of life. Current diagnostic criteria require an increase in heart rate of 30 beats per minute (bpm), or over 120 bpm in the first 10 min of standing, in the absence of orthostatic hypotension, and associated with orthostatic intolerance. Other symptoms suggestive of autoimmune failure include sudomotor dysfunction and gastrointestinal dysmotility. However, the heterogeneity of clinical presentation and uncertainty of pathogenesis, often prompts a search for alternative causes before a diagnosis of POTS, a made.

Essential thrombocythemia is one of the famous diseases under the category of myeloproliferative disorder. It is an end result of a genetic mutation of one or more of the most frequent oncogenes such as Janos kinase 2 (JAK2), MPL proto-oncogene, thrombopoietin receptor (MPL), and calreticulin (CALR). However, negative genetic markers, so-called (triple negative disease), can happen in the presence of other uncommon types of mutation. TET2 (ten-eleven translocation 2) positive as isolated genetic marker in triple negative essential thrombocythemia is uncommon genetic presentation. For that, we are reporting a 22-year-old lady who presented with a feature of dyspepsia and accidentally found to have persistently high platelet count, even after treating her mild iron deficiency anemia with no other secondary causes. Further investigations and bone marrow biopsy supported the diagnosis of isolated TET2 positive in triple negative essential thrombocythemia. We treated her conservatively with good hydration and low dose of aspirin. In conclusion, isolated TET2 positive in triple negative essential thrombocythemia at presentation is uncommon with no clear management or risk stratification guideline. However, it is hypothesized that TET2 mutation precedes JAK2; therefore, the detection of isolated TET2 in a triple negative essential thrombocythemia case should be closely followed for clonal evolution in long term. Further study and guidelines required in this area.

Background:Little is known about the etiology of meningitis in the MENA region, including Qatar. Viral agents are considered the major cause for meningitis worldwide. Here, we present primary data about the etiology and clinical and demographic characteristics of viral meningitis (VM) in Qatar between 2015 and 2018.Methods:We retrospectively collected data from Hamad Medical Corporation (HMC), which provides about 80% of healthcare services in Qatar. Data were collected for the period between 2015 and 2018. During this time period, 6,705 specimens were collected from patients with suspected meningitis attending HMC and primary healthcare centers. These specimens were tested for a panel of viruses using the “FTD Viral meningitis” multiplex real-time PCR kit that detects Adenovirus (ADV), Human herpesvirus 1&2 (HSV1 and HSV2), Epstein–Barr virus (EBV), Enteroviruses (EV), Cytomegalovirus (CMV), Varicella zoster virus (VZV), and Parechovirus (PV).Results:Only 10.9% (732/6,705) of all suspected meningitis cases were caused by viral agents. 60.9% of the reported cases were males, compared to 39.1% in females. Most of the infections (73.9%) were reported in children younger than 10 years of age. EV were identified as the main causative agent (68.7%), followed by EBV (7.5%) and ADV (6.8%). Other viral agents including VZV, PV, HSV-1, and HSV-2 were also detected with a lower frequency. Confirmed VM were more prevalent among Qatari subjects compared to other nationalities. We observed no specific seasonality of viral agents, but a slight rise was recorded during the spring seasons (March to June). Fever (59.4%, 435/732) and acute central nervous system (CNS) infection (15.6%, 114/732) were initial symptoms of most cases.Conclusion:This is the first report about the molecular epidemiology of VM in Qatar. In line with the international records, our data showed that EV is responsible for 68.7% of Qatar's VM cases. Further studies are needed to genotype and serotype the identified viruses.

Background To assess the prevalence of symptoms of depression, anxiety, and stress among mothers of children with autism spectrum disorders (ASD), type 1 diabetes (DM), and typical development (TD), in a geographical area where such data are lacking Method A descriptive study with the three groups of parents of children with and without a condition was conducted (ASD n=126, group 1; DM n=43, group 2; and TD n= 116, comparative group). Measures of depression, anxiety, and stress were collected to examine the prevalence of factors, difference between groups, and their association with demographic characteristics. Results On the DASS-21, both groups 1 and 2 had higher mean scores for depression (37.86), anxiety (4.58), and stress (29.81) than the control group (P=0.015). On the PSS-14, the mean score was higher in group 2 (28.63) than in group 1 (27.61) and the comparison group (25.87) (P=0.004). On the DASS 21, group 1 scored higher in the depression domain (P=0.046), whereas group 2 scored higher in the anxiety domain (P=0.034) and stress domain (P=0.009) than the TD group. Conclusion Mothers of children with ASD should be assessed for the presence of depression following diagnosis. Mothers of children with type 1 diabetes require careful monitoring for the effects of anxiety and stress on their mental health and therefore their ability to cope with diabetes management plans. Trial registration Not applicable.

In recent years increased attention is focussed on microorganisms inhabiting the digestive system that provides prophylactic and therapeutic benefits to the host. After Metchnikoff exposed the secret behind Bulgarian peasants' extended longevity, a graze to incorporate the responsible microbes in functional food emerged. Then interest towards microbe-rich food went to the vegetative phase for some time, but now a renaissance to engage these wonder microbes in the healthcare sector is increasing. With a new definition, probiotics, these good microbes have been widely applied in different types of products, either as pharmaceuticals, nutritional supplements, or foods. Probiotics, a significant source in functional dairy products, claims diverse roles such as improving intestinal tract health, enhancing the immune system, synthesizing and enhancing the bioavailability of nutrients, reducing symptoms of lactose intolerance, decreasing the prevalence of allergy in susceptible individuals, and reducing the risk of certain cancers. In the recent COVID-19 issue, searches are going fast to use probiotics as vaccine carriers, dysbiosis balancer, and immunity booster. The high expectation from probiotics expanded the development of bioengineered probiotics as new-generation probiotics. From the animal model and in vitro studies, the probiotic intervention is extrapolated to innate and adaptive immunity inducer against SARS viral infections. The possibility of using it as prophylactic and therapeutic agents in COVID-19 is explored. However, its significant activity against corona virus-induced respiratory syndromes is questioned by a few researchers also. The emerging citations on the research approach and meta-analysis of probiotic intervention against the re-emerging pandemic viral attack on the respiratory and gastrointestinal domains need to be analyzed in this context. As it is essential to understand the reality of recent experimental outcomes in the probiotic approach towards SARS-CoV-2 prevention, management, and control, the recent publications were focused on this review.

Introduction Coronavirus disease (COVID-19) pandemic has started to affect Saudi Arabia in the beginning of March 2020 and is expected to cause significant morbidity to many patients, especially to elderly, who might require intensive care unit (ICU) support to survive as its lethality increases with the increasing age. Recent publications suggested the benefit of utilizing convalescent plasma from recovered donors as a therapeutic approach in treating COVID-19 patients. Convalescent plasma could provide our first-line defense for people with COVID-19, especially those who are older and at a much higher risk for complications., therefore, we developed a national protocol to investigate the safety, benefit and applicability at larger scale and at different health care facilities in Saudi Arabia (KSA). Objectives Primary endpoints are 1. ICU (or designated area for critical patients) length of stay 2. Safety of convalescent plasma> Secondary endpoints included: 1. 30 days mortality 2. Number of days on mechanical ventilation 3. Days to clinical recovery Method Eligible convalescent plasma donors will be invited to participate in trial. The arrangement for plasmapheresis will start after obtaining donor informed consent. The collected plasma will be treated with pathogen reduction system. The convalescent plasma units will be labelled, stored and shipped as per the standard transfusion medicine protocols. It will be used only for eligible patients' "recipients" as per the following eligibility criteria: 1. Inclusion criteria: - Confirmed case of SARS-CoV-2 infection with POSITIVE rRT PCR test -18 or older -Must have been requiring ICU care or severe or immediately life-threatening care (any one of the following): 1. Patient requiring ICU care/admission. 2. Severe disease is defined as: a. Dyspnea b. Respiratory frequency ≥ 30/min c. Blood oxygen saturation ≤ 93% d. Partial pressure of arterial oxygen to fraction of inspired oxygen ratio < 300, and/or Lung infiltrates > 50% within 24 to 48 hours 3. Life-threatening disease is defined as: a. Respiratory failure b. Septic shock, and/or c.Multiple organ dysfunction or failure Exclusion criteria: 1. Negative or non-conclusive test COVID-19 rRT PCR test 2. Mild symptoms 3. Hospitalization not requiring ICU care/admission Eligible Patients will be infused with the convalescent plasma (200-400 ml / treatment dose)at least once & if possible, daily, for up to 5 sessions. Other supportive and therapeutic measures should continue according to the locally approved protocols with due diligence. Sample size was calculated with 80% power and 5% level of significance based on the recently published data to detect statistical difference in the study outcome. Therefore, we plan to recruit total of 575 patients. Convalescent plasma Recipient Group: 115 patients (recipients) who have COVID 19 as per the inclusion criteria. Comparative control Group: 460 Patients who are eitherCOVID 19 historical control or only consent for sharing their clinical and laboratory data Matching for age, gender, Hypertension, Diabetes and intubation status were done based on the propensity score. Continuous variables will be presented as the median and interquartile range (IQR). Statistical software SPSS 24.0 will be used. Demographic, Clinical, imaging and laboratory information of all enrolled patients will be retrieved from the hospital electronic/paper records system to be used for the outcomes analysis. Results 22 sites across KSA that participated in the study. Tertiary, secondary, academic and non-academic centers participated (real world data). There were no unusual safety issues related to convalescent plasma infusion since all mortalities in the plasma group were not related to plasma infusion which represent similar finding from other the published international reports. Keeping in-mind that our data is still maturing, 30 survival probability in the plasma group was 69% compared to 56% in the comparative group (p value = 0.066) (figure-1). This benefit to seem to be more noticeable in the COVID-19 cases who did not meet the criteria for life-threatening disease (figure-2). Conclusion Our study supports the safety of convalescent plasma in treating COVID-19 patients. Patients who are in the category of life-threating/end organs failure do not seem to benefit. There might be a benefit in the other subgroups. Disclosures No relevant conflicts of interest to declare.

Background: To assess the prevalence of symptoms of depression, anxiety, and stress among mothers of children with autism spectrum disorders (ASD), type 1 diabetes, and typical development (TD), in a geographical area where such data are lacking.Method: The study sample comprised a group of mothers of children with ASD (group 1; n=126), a group of mothers of children with diabetes mellitus (group 2; n=43), and a control group of mothers of children with TD (n=116).Results: On the DASS-21, both groups 1 and 2 had higher mean scores for depression (37.86), anxiety (4.58), and stress (29.81) than the control group (P=0.015). On the PSS-14, the mean score was higher in group 2 (28.63) than in group 1 (27.61) and the control group (25.87) (p=0.004). On the DASS 21, group 1 scored higher in the depression domain (p=0.046), whereas group 2 scored higher in the anxiety domain (p=0.034) and stress domain (p=0.009) than the TD group.Conclusion: Mothers of children with ASD should be assessed for the presence of depression following diagnosis. Mothers of children with type 1 diabetes require careful monitoring for the effects of anxiety and stress on their mental health and therefore their ability to cope with diabetes management plans.

What is known and objectives Acetaminophen has been increasingly used in treating patent ductus arteriosus (PDA) in preterm neonates. Variations were observed in the dosing regimen of acetaminophen across the studies. There is hardly any data available for a relatively higher dose of intravenous acetaminophen (15 mg/kg/dose every 6 hours) in the preterm population. We present here the results of a prospective study with this dose of intravenous acetaminophen for treating PDA in critically ill preterm neonates. Methods Preterm neonates (≤37 weeks of gestational age) with haemodynamically significant PDA were enrolled. Intravenous acetaminophen at 15 mg/kg/dose every 6 hours was administered. Echocardiographic monitoring, liver and renal function tests were carried out. Standard definitions were adhered for defining acute kidney injury (AKI) and hepatotoxicity. Results Fifty-five neonates were recruited. Following the first dose, less than half had their serum acetaminophen concentrations in the therapeutic range. Extreme preterm neonates were less likely to have a sustained therapeutic acetaminophen concentration after the first dose. Following multiple doses and at steady state, 97.2% and 98.8% respectively were in the therapeutic range. Forty-three (78.2%) neonates had successful closure of the ductus arteriosus of which 22 were extreme preterm, 17 were very preterm and 4 were late preterm neonates; and considering their birthweights, 21 were extremely low, 16 were very low and 6 were low birthweight categories. Ten neonates had elevated alanine aminotransferase levels with three in the low-to-moderate risk of hepatotoxicity category. Eight neonates had altered renal function tests indicating AKI. What is new and conclusion Intravenous acetaminophen at 15 mg/kg/dose every 6 hours was efficacious in 78.2% of the preterm neonates with PDA. We observed a lower incidence of hepatotoxicity, and AKI in the study population. No association was observed between the serum acetaminophen concentrations and PDA closure.

Liver detoxifies majority of chemicals and plays an important role in the maintenance of homeostasis of the body. In the recent years due to overwhelming use of drugs and alcohol there is an increased incidence of liver toxicities. The tubers of Actinoscirpus grossus are used in liver disease as a liver tonic in folklore medicine; However, there is no experimental basis for its therapeutic use. Hence the present study was conducted to evaluate the hepatoprotective potentials of ethanolic extract of Actinoscirpus grossus tubers in ethanol induced hepatotoxicity in albino rats. Daily administration of 20% ethanol v/v p.o. at a dose of 5 g/kg for 30 consecutive days caused significant liver toxicity and there after maintained for 15 consecutive days with normal rat pellet and water ad libitum. The treatment groups were administered with group specific drugs for 15 consecutive days after 30 days of ethanol administration and control group rats were maintained for 15 consecutive days with normal rat pellet and water ad libitum. Liver toxicity was assessed on 45th day by estimating biochemical, histological and antioxidant level. Daily administration of 20% ethanol significantly increased liver enzymes and caused oxidative stress by increase in the lipid peroxidation and reduction in the catalase and glutathione peroxidase activity in liver homogenate. The histopathological examination revealed micro vesicular and macro vesicular fatty changes predominantly with mild periportal inflammation, cell infiltrate and areas of mild dilatation of sinusoids with ballooning degeneration of hepatocytes. Treatment with ethanolic extract of A. grossus tuber significantly restored the liver enzymes especially SGOT and attenuated elevated lipid peroxidation and restored catalase and glutathione peroxidase activity. The histopathological changes revealed significant reduction in the hepatocyte ballooning portal fibrosis. Thus, tubers of A. grossus plant may serve as reservoir of natural products having diverse functions and could be utilised as a potent hepatoprotective agent.

Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is caused by proliferation of smooth muscle cells in the wall of small mesenteric veins and venules with accumulation of a proteoglycan matrix leading to a non-thrombotic, non-inflammatory venous occlusion resulting in venous ischemia. IMHMV is a rare and poorly understood disease, with

Allergic rhinitis is a common disease with a reported prevalence ranging between 10 and 30%. It has a significant impact on the patients’ health, quality of life, and work performance. In this chapter, the pathophysiology and the classification of patients with this disease will be discussed. Further, the diagnostic tools and different treatment options will be outlined.

Cancer of the nasal cavity and paranasal sinuses is rare comprising less than 1% of all human malignancies. The maxillary antrum is the most frequently involved site. Tumor histology is very diverse with varying biological aggressiveness. Epithelial tumors constitute more than two-thirds of those tumors where squamous carcinoma is the most common. Early tumors present with nonspecific signs and symptoms. A high index of suspicion with the liberal use of CT scans may identify such early cases. There is an estimated average delay of 6–8 months between the first symptom and diagnosis which renders 70–80% of patients presenting at an advanced stage disease. Preoperative biopsy and a definitive histopathological diagnosis are mandatory before deciding on any treatment. The treatment of sinonasal malignancies is multimodal in most instances where surgical resection plays a very important role in management for most histopathological types. Open surgical approaches remain the golden standard of management, however recently there was an increasing role of endoscopic resection of such tumors as studies have demonstrated comparable results with open approaches in selected cases.

This chapter is mainly discussing the common systemic and inflammatory conditions that could present with ENT symptoms as nasal bleeding, neck swelling, or difficulty breathing. We will go roughly through the definition of each disease, pathophysiology, clinical manifestations, focusing on ENT manifestation and management.

Background Thrombotic thrombocytopenic purpura (TTP) is an uncommon haematological disease which can occur at any age and may present with COVID-19. This case describes a COVID-19 complication associated with a presentation resembling TTP. Case description A 51-year-old man who had received a kidney transplant and was on immunosuppressant medication, was admitted to a critical care unit with severe COVID-19 pneumonia/acute respiratory distress syndrome (ARDS) which required intubation, mechanical ventilation and inotropic support. The course was complicated by the classic pentad of thrombocytopenia, intravascular haemolysis, acute kidney injury, neurological symptoms and fever, which prompted the diagnosis of probable TTP. After five sessions of therapeutic plasma exchange, the patient's general status improved, he was weaned off mechanical ventilation and his renal panel and haemolytic markers normalized. Conclusion TTP is a life-threatening condition which requires urgent management with therapeutic plasma exchange. This case highlights some possible complications of COVID-19 generally and in immunocompromised patients specifically. The potential role of plasma exchange in COVID-19 patients without a positive diagnosis of TTP (the so-called 'TTP resembling presentation') is an area of further research. Learning points COVID-19 can manifest as a picture of thrombotic thrombocytopenic purpura (TTP) which requires therapeutic plasma exchange as in other cases of TTP.Further research is required on the use of therapeutic plasma exchange in severe COVID-19 with cytokine storm.

Introduction Endometrial cancer (ECa) usually presents as early stage disease when primary surgery is the recommended management. Patients with advanced disease pose a more challenging problem if disease is locally advanced, when primary surgery may be difficult and potentially morbid. Limited data exists regarding neoadjuvant chemotherapy (NACT) and surgery in this setting. We present our initial experiences with NACT and surgery in patients with endometrial cancer >stage 2. Methodology Data were collected retrospectively from patients with ECa treated between January 2015-June 2020. Outcome measures include response; survival; and treatment-related morbidity. Results We identified 12 patients aged 39–70 yrs. Data is complete for 11 as one patient had surgery overseas. Histological type was: endometrioid (75%), serous (25%). 50% were stage IV; 42%stage III; 8% stage II. All patients received combination Carboplatin/Paclitaxel chemotherapy. One patient received radiotherapy in addition prior to surgery. 67% had 3 cycles of chemotherapy; 17% had 4 cycles. One patient is recently diagnosed and still receiving treatment. 90% had optimal debulking surgery, 10% sub-optimal debulking and one patient has unknown operative findings. Data regarding survival is available for 11 patients. Two have died. Nine are alive without recurrence with survival ranging 2–40 mth. Overall median survival is 18 mth. 70% had no complications post-treatment; 20% had wound infection; 10% had neuropathy. Conclusions NACT and surgery can deliver high rates of optimal debulking in patients presenting with advanced stage ECa. There were acceptable levels of treatment-related morbidity. It is too early to assess the survival of patients with this strategy although our initial experience shows promising results.

Background. Periodontal disease is a public health problem and is strongly associated with systemic diseases; however, its worldwide distribution is not fully understood.Objective. To evaluate global data of periodontal disease: (1) among adolescents, adults, and older population and (2) in low-, middle-, and high-income countries.Methods. This ecological study included data of periodontal disease from the World Health Organization’s data bank which are based on the Community Periodontal Index of Treatment Needs (CPITN code: 0 = no disease; 1 = bleeding on probing; 2 = calculus; 3 = periodontal pocket (PD) 4-5 mm; 4 = PD (6+ mm). Age- and income-related periodontal disease inequalities were evaluated across the globe.Results. Compared with 9.3% of adults and 9.7% of older persons, 21.2% of adolescents had no periodontal disease (P=0.005). Nearly 18.8% of adolescents compared with 8.9% of adults and 5% of older persons had bleeding on probing (P≤0.001). Similarly, 50.3% of adolescents, 44.6% of adults, and 31.9% older persons demonstrated the occurrence of calculus (P=0.01). On the other hand, older persons had the highest prevalence of PD 4-5 mm and PD 6+ mm than adults and adolescents (P≤0.001). The distribution of periodontitis (CPITN code 3 + 4) in adults differed significantly in low- (28.7%), lower-middle- (10%), upper-middle- (42.5%), and high-income countries (43.7%) (P=0.04). However, no significant differences in periodontitis (CPITN code 3 + 4) were observed in adolescents and older persons in low- to high-income countries.Conclusions. Within the limitations of data, this study found that the distribution of periodontal disease increases with age. Periodontitis was the most common in older persons and in population from high-income countries.

With prostate cancer not observed in eunuchs and total androgen suppression by castration an effective first-line treatment for advanced prostate cancer, the dramatic regression seen in tumour symptoms after castration, lead to the theory that high levels of circulating androgens were a risk factor for prostate cancer. This theory however, ignored the effects testosterone variations within a physiologic range could have on early tumour events and since the early 2000s, clinical evidence discounting testosterone as a linear mechanistic cause of prostate cancer growth mounted, with alternative mechanistic hypotheses such as the saturation model being proposed. Together with a growing understanding of the negative health effects and decreased quality of life in men with testosterone deficiency or hypogonadism, a paradigm shift away from testosterone as a prostate cancer inducer occurred allowing clinicians to use testosterone therapy as potential treatment for men with difficult and symptomatic hypogonadism that had been previously treated for prostate cancer. In this review we contextualise the idea of testosterone as a risk factor for prostate cancer inducement and compile the most current literature with regards to the influence of testosterone and testosterone therapy in prostate cancer.

Urosepsis contributes significantly to the epidemiology of sepsis. Urosepsis can be classified as community acquired or hospital acquired, depending upon the origin of infection acquisition: either from the community or from a healthcare facility. A great deal of literature is available about nosocomial urosepsis, but the literature regarding community-acquired urosepsis (CAUs) is limited, and studies are underpowered. The aim of our study was to determine the epidemiology, bacteriology, severity, and outcome of CAUs. Methods and Patients: All patients admitted from the emergency department to the surgical intensive care unit (SICU) with urosepsis over a period of 10 years were identified and included retrospectively from the SICU registry. The study was retrospective. Data were entered into the SPSS program version 23, and groups were compared by using chi-square and t-tests. Results were considered statistically significant at p ≤ 0.05. Results: During the study period, 302 patients with CAUs were admitted to the SICU. The common etiology was obstructive uropathy (60%). The Local Arab population outnumbered the non-Arab population (164/54.3%), and there were equal numbers of patients of both genders. Diabetes mellitus and hypertension together were the common comorbidities. Seventy-five percent of patients had acute kidney injury (AKI). Thirty-eight percent of patients had percutaneous nephrostomy, and 24.8% of patients underwent endoscopic stent insertion to relieve the obstruction. Ninety-three percent of patients were admitted with septic shock, and 71.5% had bacteremia. The common bacteria (36.1%) was extended-spectrum beta-lactamase-(ESBL)-producing bacteria, with a predominance of Escherichia coli (31.5%). Fifty-four percent of patients required a change of antibiotics to carbapenem. Eighty-two percent of patients had acute respiratory distress syndrome (ARDS). Patients with bacteremia had a statistically significant AKI, ARDS, and septic shock (p p Conclusion: In our patients, obstruction of urine flow was the most common cause of CAUs. Our urosepsis patients had a higher bacteremia rate, which led to higher incidences of organ dysfunction and septic shock. ESBL bacteria were a frequent cause of urosepsis, requiring a change of the initial antibiotic to carbapenem. Male patients had a significantly higher rate of organ dysfunction. Mortality in our urosepsis patients was lower than mentioned in the literature.

Objectives To assess the construct validity and reliability of the motivation section of the Motivated Strategies for Learning Questionnaire in Saudi Arabia. Methods A cross-sectional study using the Motivated Strategies for Learning Questionnaire (MSLQ) was conducted. The MSQL has essentially two sections: a motivation section and a learning strategies section. The motivation section, which consists of 31 items, was used. A total of 146 medical students who were all male completed the questionnaire. Confirmatory factor analysis was used to test the hypothesised factor structure, and to identify the validity and reliability of the motivation section of the MSQL. Results A selected group of fit statistics showed that the hypothesised model did not fit the sample data fairly well. The Intrinsic Goal Orientation subscale consisted of 4 items (α = 0.75), the Extrinsic Goal Orientation subscale consisted of 4 items (α = 0.78), the Task Value subscale consisted of 6 items (α =0.86), the Control of Learning Beliefs consisted of 4 items (α =0.78), the Self-Efficacy for Learning and Performance consisted of 8 items (α =0.89), and the Test Anxiety consisted of 5 items (α =0.77). Conclusions It is concluded that the hypothesised model did not fit the data well. This may suggest that the motivation section of the MSQL may not work for Saudi Arabian students. However, this could be due to the fact that the sample data available on this study did not represent female students. Further work is required to establish this. Limitations of the study are discussed.