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Background ST-segment elevation myocardial infarction (STEMI) patients are treated with dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor. Clopidogrel is widely used in these patients in several areas worldwide, such as Middle East, but is associated to sub-optimal platelet inhibition in up to 1/3 of treated patients. We investigated a CYP2C19 genotype-guided strategy to select the optimal P2Y12 inhibitor. Methods This prospective randomized clinical trial included STEMI patients. The standard-treatment group received clopidogrel, while the genotype-guided group were genotyped for CYP2C19 loss-of-function alleles and carriers were prescribed ticagrelor and noncarriers were prescribed clopidogrel. Primary outcome was a combined ischemic and bleeding outcome, comprising myocardial infarction, non-fatal stroke, cardiovascular death, or Platelet Inhibition and Patient Outcomes major bleeding one year after STEMI. Results STEMI patients (755) were randomized into a genotype-guided- (383) and standard-treatment group (372). In the genotype-guided group, 31 patients carrying a loss-of-function allele were treated with ticagrelor, while all other patients in both groups were treated with clopidogrel. Patients in the genotype-guided group had a significantly lower risk of primary outcome (odds ratio (OR) 0.34, 95% confidence interval (CI) 0.20–0.59,), recurrent myocardial infarction (OR 0.25, 95%CI 0.11–0.53), cardiovascular death (OR 0.16, 95%CI0.06–0.42) and major bleeding (OR 0.49, 95%CI 0.32–0.74). There was no significant difference in the rate of stent thrombosis (OR 0.85, 95%CI 0.43–1.71). Conclusion A genotype-guided escalation of P2Y12 inhibitor strategy is feasible in STEMI patients treated with clopidogrel and undergoing PCI and is associated with a reduction of primary outcomes compared to conventional antiplatelet therapy.

Background Diabetes distress (DD) has broad-ranging effects on type 2 diabetes (T2DM) management and outcomes. DD research is scarce among ethnic minority groups, particularly Arabic-speaking immigrant communities. To improve outcomes for these vulnerable groups, healthcare providers, including pharmacists, need to understand modifiable predictors of DD. Aim To assess and compare DD and its association with medication-taking behaviours, glycaemic control, self-management, and psychosocial factors among first-generation Arabic-speaking immigrants and English-speaking patients of Anglo-Celtic background with diabetes, and determine DD predictors. Setting Various healthcare settings in Australia. Method A multicentre cross-sectional study was conducted. Adults with T2DM completed a survey comprised of validated tools. Glycated haemoglobin, blood pressure, and lipid profile were gathered from medical records. Multiple linear regression models were computed to assess the DD predictors. Main outcome measure Diabetes distress level. Results Data was analysed for 696 participants: 56.3% Arabic-speaking immigrants and 43.7% English-speaking patients. Compared with English-speaking patients, Arabic-speaking immigrants had higher DD, lower medication adherence, worse self-management and glycaemic control, and poorer health and clinical profile. The regression analysis demonstrated that higher DD in Arabic-speaking immigrants was associated with cost-related medication underuse and lower adherence to exercise, younger age, lower education level, unemployment, lower self-efficacy, and inadequate glycaemic control. Whereas among English-speaking patients, higher DD was associated with both cost- and non-cost-related underuse of medication and lower dietary adherence. Conclusion Results provided new insights to guide healthcare providers on reducing the apparent excess burden of DD among Arabic-speaking immigrants and potentially improve medication adherence, glycaemic control, and self-management.

Worldwide, thyroid cancer accounts for some 10% of total cancer incidence, most markedly for females. Thyroid cancer radiotherapy, typically using 131I (T1/2 8.02 days; β− max energy 606 keV, branching ratio 89.9%), is widely adopted as an adjunct to surgery or to treat inoperable cancer and hyperthyroidism. With staff potentially receiving significant doses during source preparation and administration, radiation protection and safety assessment are required in ensuring practice complies with international guidelines. The present study, concerning a total of 206 patient radioiodine therapies carried out at King Faisal Specialist Hospital and Research Center over a 6-month period, seeks to evaluate patient and occupational exposures during hospitalization, measuring ambient doses and estimating radiation risk. Using calibrated survey meters, patient exposure dose-rate estimates were obtained at a distance of 30-, 100- and 300 cm from the neck region of each patient. Occupational and ambient doses were measured using calibrated thermoluminescent dosimeters. The mean and range of administered activity (AA, in MBq) for the thyroid cancer and hyperthyroidism treatment groups were 4244 ± 2021 (1669–8066), 1507.9 ± 324.1 (977.9–1836.9), respectively. The mean annual occupational doses were 1.2 mSv, that for ambient doses outside of the isolation room corridors were found to be 0.2 mSv, while ambient doses at the nursing station were below the lower limit of detection. Exposures to staff from patients being treated for thyroid cancer were less compared to hyperthyroidism patients. With a well-defined protocol, also complying with international safety requirements, occupational exposures were found to be relatively high, greater than most reported in previous studies.

Objectives Brain neoplasms or intracranial tumors, which are more common in older adults, can affect individuals of any age including pediatric and children. Exposure to carcinogenic agents including ionizing radiation and family history is one of the main causes of the disease. Early diagnosis is crucial to avoid prolonged. patients' suffering. The aim of the study was to efficiently recognize the brain tumors from the other brain tissues which include grey and white matter as well as cerebrospinal fluid (CSF). Materials and methods This study was performed using axial, sagittal and coronal views for fifty brain tumor patients randomly selected from a set of 200 patients, with a “control” set consisting of images showing no sign of disease; and the “test” brain MRI images for patients diagnosed with brain tumor. The study includes both genders with age ranging from 18 years to 83 years old, (56.5 ± 17.2). The brain images were acquired using a standard head coil Philips Intera 1.5 Tesla machine (USA). The thickness of each section in the entire sequence was 8 mm. Acquisition of T2-weighted and T1-weighted were performed. Interactive Data Language software was used to analyze the data. Results The results of this study showed that: the overall accuracy of classification process was 94.8%, and for the tumor; the sensitivity was 97.3%. White matter and grey matter showed a classification accuracy of 95.7% and 89.7% and for CSF the accuracy was 94.3%. Conclusion The results showed that brain tumor can be classified successfully and delineated using texture analysis with minimum efforts and with high accuracy for brain tumors.

Introduction: Bladder cancer (BC) is one of the most frequent malignancy of the urinary tract. Recent studies demonstrated the role of aquaporins urothelial tumor cells (AQPs) as potential prognostic factor for tumor progression and invasion. In this study we investigated the AQP3 expression levels inside primary superficial (pTa) low grade bladder cancer, correlating with pathological parameters and clinical outcomes. Materials and methods: We retrospectively analyzed tumor samples of 66 patients with diagnosis of superficial urothelial (pTa) bladder cancer between 1997 and 2007. All patients underwent transurethral bladder resection (TURB ) and immediate single instillation of mitomycin C. All tumors samples were blindly reviewed by two expert anatomopathologists and only pTa low grade urothelial bladder cancer were included. Cancer recurrence was defined as the detection of bladder lesions during follow-up cystoscopy. AQP3-immunoreactive areas detected at immunohistochemical analysis were classified as AQP3 positive. Results: Of these 60.6% of patients was detected as negative for AQP3 expression. Forty-two patients develop cancer recurrence during follow-up with a mean progression free survival of 16.44 months. The absence of reaction for AQP3 was observed 56% (9/16) tumor grading G1 and 62% (31/50) tumor grading G2. No correlation was observed with sexual gender, grading of tumor differentiation, and recurrence of cancer disease. Kaplan-Meier curves of disease-free survival (DFS) showed a significant separation ( p = 0.028) between patients AQP3-positive and AQP3-negative. It was observed a mean DFS of 23.83 and 14.43 months respectively in absence and presence of AQP3 expression. Conclusion: AQP3 expression is related to disease-free interval (DFI) and the absence of AQP3 expression correlates with a late relapse. The expression of AQP3 does not provide a reproducible quantitative aspect. AQP3 are not suitable to forecast tumor cell behavior but they perform a role as regulator for tumor cell homeostasis and for additional therapeutic developments.

Background Pudendal neuropathy is a chronic, disabling form of perineal pain that involves the pudendal nerve, a mixed somatic and autonomic nerve that originates from sacral nerve roots. Peripheral nerve stimulation of the pudendal nerve can be useful to decrease symptom burden in patients who have failed initial conservative treatment modalities. Methods In this manuscript, we describe an approach to the placement of a peripheral nerve stimulator for the treatment of pudendal neuralgia. We present a case of complex pelvic neuropathy and review the factors that lead to successful placement. Technical aspects of stimulator placement and ultrasound landmarks are reviewed. Results A lateral to medial approach with ultrasound guidance at the level of the ischial spine is likely to facilitate proper lead placement along the course of the pudendal nerve. Aftercare and adherence to postimplant activity restrictions–particularly avoiding use of the extremes of hip flexion and extension for four weeks—lead to the absence of lead migration. Conclusions Pudendal nerve stimulation is an emerging technique for neuromodulation of refractory pudendal neuralgia. Ultrasound-guided pudendal nerve stimulation is a viable technique for neuromodulation of pudendal neuralgia. Optimization of patient selection, ultrasound guidance, and proper adherence to postimplant activity restrictions may be helpful for long-term therapeutic success.

BackgroundChronic headaches are the second most prevalent disease and second most common cause for years lived with disability worldwide. Occipital neuralgia can cause headaches or be present in addition to other more prevalent causes of headache. If these headaches fail to respond to conservative and pharmacological therapy, physicians proceed to more invasive treatments, starting with infiltration of the greater occipital nerve with local anesthetic with or without corticosteroids, followed by nerve ablation or stimulation. Occipital nerve stimulation gained more popularity as the technology improved and more pain physicians received training on interventional procedures.MethodsIn this manuscript, we are presenting our experience with ultrasound-guided implant of occipital nerve stimulators using peripheral nerve stimulator systems. After confirming appropriateness of treatment by a successful occipital nerve block (i.e., resulting in >50% relief in patients’ pain intensity), we implanted five stimulator systems in three patients (two bilateral).ResultsWe followed these patients for an average of eight months, and the average pain reduction was ∼50%. We did not observe any adverse events during or immediately after surgery. One patient developed an adverse reaction to the adhesive of the battery transmitter, but it was not severe enough to stop her from using the stimulator.ConclusionsConsidering the ease of implant and minimal side effects, implant of peripheral nerve stimulators to stimulate the occipital nerve is a promising treatment modality for patients with chronic headache who present with features of occipital neuralgia. However, wider use of this treatment modality is subject to further studies.

Background Patient portals provide patients and their caregivers online access to limited health results. Health care employees with electronic health record (EHR) access may be able to view their health information not available in the patient portal by looking in the EHR. Objective In this study, we examine how employees use the patient portal when they also have access to the tethered EHR. Methods We obtained patient portal and EHR usage logs corresponding to all employees who viewed their health data at our institution between January 1, 2013 and November 1, 2017. We formed three cohorts based on the systems that employees used to view their health data: employees who used the patient portal only, employees who viewed health data in the EHR only, and employees who used both systems. We compared system accesses and usage patterns for each employee cohort. Results During the study period, 35,172 employees accessed the EHR as part of patients' treatment and 28,631 employees accessed their health data: 25,193 of them used the patient portal and 13,318 accessed their clinical data in EHR. All employees who accessed their records in the EHR viewed their clinical notes at least once. Among EHR accesses, clinical note accesses comprised more than 42% of all EHR accesses. Provider messaging and appointment scheduling were the most commonly used functions in the patient portal. Employees who had access to their health data in both systems were more likely to engage with providers through portal messages. Conclusion Employees at a large medical center accessed clinical notes in the EHR to obtain information about their health. Employees also viewed other health data not readily available in the patient portal.

This study was designed to characterize portal hypertension (PH) by assessing cirrhosis, estimating portal vein (PV) width and spleen size, identifying ascites and deciding abnormal collateral rout...

Highlights • Rarity of this presentation. • Controversies on treatment. • Controversies about diagnosis., Introduction Painful tip penile ischemic lesion that varies from ulceration to dry gangrene which is calcified in a patient with ESRD on chronic dialysis is a seriously complicated disease due to microvascular disease of subcutaneous and adipose tissue. Case presentation 72 gentleman who is on chronic dialysis for the last 8 years because of ESRD, In which he developed many vascular disease and amputation done for him presented with spreading black painful areas at the tip of the glans for which conservative treatment took place for about month. Discussion The diagnosis and management of this rare disease still unclear. Diagnosis mostly clinical, treatment conservative versus surgical. Conclusion Controversies of for penile Calciphylaxis diagnosis and treatment for its rarity, high mortality rate, and as its part of systematic disease treatment till know individualized according to patient status and extent of the necrotic area.

Background Neonatal sepsis is a global concern with increasing morbidity and mortality. The burden of neonatal sepsis is highest in developing countries, especially in those lacking proper surveillance systems. The causative pathogens and their drug-resistance levels vary between countries with emergence of multidrug resistance organisms. Thus, accurate records on the recent trends of organisms causing neonatal sepsis will provide vital information for appropriate intervention. We aimed to investigate neonatal sepsis, identify its associated factors and causative pathogens and to assess the antibiotic susceptibility patterns in Sana’a city, Yemen. Methods A cross-sectional study was conducted on neonates admitted to intensive care units of six hospitals in Sana’a city, Yemen, in the period from January 15, to March 30, 2020. Natal and prenatal medical data were collected using well-structured questionnaire. Neonates were subjected to sepsis work-up including blood culture, complete blood count and C-reactive protein. Organisms were identified by Gram staining and analyzed by the VITEK II system for bacterial bio-typing and antibiotic susceptibility testing. Findings Of the 199-neonates with suspected neonatal sepsis, 154 (77.38%) had culture-proven sepsis. Early-onset neonatal sepsis (EOS) was higher (50.25%; 100/199) than late-onset neonatal sepsis (LOS) (27.13%; 54/199). Multivariable analysis identified vaginal delivery as an independent risk factor for neonatal sepsis p = 0.005. Majority of isolated bacteria (74.39%) were gram-negative with Burkholderia cepacia (39%) and Klebsiella oxytoca (13%) being the most common pathogens of EOS and LOS. The most common gram-positive pathogens were Staphylococcus haemolyticus (9.1%) and Staphylococcus epidermidis (7.1%). B. cepacia showed multidrug resistance except for cefepime. All Klebsiella species isolates (100%) and most Pantoea species (93%) were ESBL and carbapenemase positive. All Escherichia coli and Acinetobacter baumannii isolates were ESBL positive. A significant number of gram-positive bacteria showed resistance to vancomycin. Conclusion The study findings show a high proportion of neonatal sepsis among neonates admitted to hospitals in Sana’a city with antibiotic-resistant B. cepacia being the single most common pathogen causing EOS and LOS. Findings also emphasize the emerging threat of multidrug-resistant bacteria in neonatal units and will help develop evidence-based management of neonatal sepsis in Yemen.

Introduction In early 2019 increased referrals to the Breast 2WW Service, limited radiologist capacity and the pension crisis combined to cause the 2 week wait target to fail. A multidisciplinary solution was sought. Using the Nottingham Breast Institute triage criteria and decoupling clinical and radiological assessments, patients were referred along 2 pathways; red and blue flag. Methods Patients were clinically assessed by a trained breast surgeon within 2 weeks. Red flag patients underwent standard triple assessment. The aim for blue flag patients was to undergo any necessary imaging within 10 days. In both cohorts selected patients were given a patient satisfaction questionnaire. Data from red flag clinics were obtained from cancer services. Notes were reviewed for blue flag patients. Results Data on 858 blue flag patients seen were analysed. There was no difference between satisfaction scores. Conclusions The 2WW target was regained within a month of implementing change. As long as the standard operating procedure is maintained, the triage criteria adopted were successful and reduced pressure on radiology services. Patient safety and satisfaction were maintained.

Background Among the different cancers found in women, breast cancer is the most common. Breast cancer-related lymphedema is a serious health complication affecting the quality of life and sleep quality. This study evaluates the quality of life and sleep quality among Saudi women with different stages of lymphedema following the treatment of breast cancer. Methods This cross-sectional correlational study included 163 Saudi women with breast cancer-related lymphedema (Stages I-III), aged 28 to 56 years. From the patients identified for this study, women who suffered from mental and psychological dysfunctions or other malignant disorders were excluded. Copies of structured questionnaires were given to each participant during their visits to outpatient physiotherapy clinics. Quality of life was assessed using a valid questionnaire (EORTC QLQ-C30), while sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). The differences between the different lymphedema stages have been assessed. Results Of the total number of participants 27 women had been diagnosed with stage I lymphedema, 84 women had been diagnosed with stage II lymphedema, and 52 women had been diagnosed with stage III lymphedema. All participants have shown low scores on both EORTC QLQ-C30 and PSQI. While analyzing the differences between the 3 stages of lymphedema with the Kruskal–Wallis test, noteworthy statistical differences between the 3 stages of lymphedema ( P Conclusion and Recommendations Both quality of life and quality of sleep have significantly decreased in Saudi women with different stages of breast cancer-related lymphedema. Quality of life and quality of sleep are the worst in stage III lymphedema patients. Future research should consider repeat and enlarge these results as well as assess the risk factors that affect the quality of life and quality of sleep among Saudi women suffering from breast cancer-related lymphedema.

Background: As of 26 June 2020, the global number of infections caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), had reached 11 million, with more than 500 thousand associated deaths1. Limited clinical information about COVID-19 on solid organ transplant (SOT) are available so far. We herein report our preliminary experience with COVID-19 in SOT recipients in the first few weeks of the outbreak in Qatar. Method: All SOT recipients with laboratory-confirmed COVID-19 up to 23 May 2020 were included. Baseline characteristics, antivirals and immunosuppressive management, complications, and outcomes were retrospectively extracted from the electronic health system. Categorical data are summarized as frequency and percentages, while continuous variables are presented as medians and ranges. Results: Twenty-four SOT patients with COVID-19 were included in this report (kidney: 16, liver: 6, heart: 1, and combined liver and kidney: 1). The median age was 57 years (range 24–72). Thanks to proactive screening, five (21%) asymptomatic cases were diagnosed (Table S1). Among the other 19 symptomatic patients, fever (15/19) and cough (13/19) were the most frequent presenting symptoms (Table S1). All patients were hospitalized; 5 (21%) required invasive mechanical ventilation in the intensive care unit (ICU) (Table S2 ). Eleven (46%) patients developed acute kidney injury as a complication, including 3 in association with drug-drug interactions involving investigational COVID-19 therapies (Table S2). Maintenance of immunosuppressive therapy was changed in 18 (75%) patients, but systemic corticosteroids were not withdrawn in any. After a median follow up of 43 days (26–89), 18 (75%) patients had been discharged home, 3 (12.3%) were still hospitalized, 2 (8.3%) were still in ICU, and 1 (4.2%) had died (Table S2). Conclusion: Although higher mortality rates were observed in other reports,2,3 our results suggest that asymptomatic COVID-19 is possible in SOT recipients and that overall outcomes are not consistently worse than other immunocompetent patients. The results require validation in larger cohorts.

Background: Clinical data on Coronavirus Disease 2019 (COVID-19) in solid organ transplant (SOT) recipients are limited. We herein report the initial clinical experience with COVID-19 in SOT recipients in Qatar. Methods: All SOT recipients with laboratory-confirmed COVID-19 up to May 23, 2020 were included. Demographic and clinical data were extracted retrospectively from the hospital’s electronic health records. Categorical data are presented as frequency and percentages, while continuous variables are summarized as medians and ranges. Results: Twenty-four SOT recipients with COVID-19 were identified (kidney 16, liver 6, heart 1, and liver and kidney 1). Organ transplantation preceded COVID-19 by a median of 60 months (range 1.7–184). The median age was 57 years (range 24–72), and 9 (37.5%) transplant recipients were females. Five (21%) asymptomatic patients were diagnosed through proactive screening. For the rest, fever (15/19) and cough (13/19) were the most frequent presenting symptoms. Five (20.8%) patients required invasive mechanical ventilation in the intensive care unit (ICU). Eleven (46%) patients developed acute kidney injury, including three in association with drug-drug interactions involving investigational COVID-19 therapies. Maintenance immunosuppressive therapy was modified in 18 (75%) patients, but systemic corticosteroids were not discontinued in any. After a median follow-up of 226 days (26–272), 20 (83.3%) patients had been discharged home, 2 (8.3%) were still hospitalized, 1 (4.2%) was still in the ICU, and 1 (4.2%) had died. Conclusions: Our results suggest that asymptomatic COVID-19 is possible in SOT recipients and that overall outcomes are not uniformly worse than those in the general population. The results require confirmation in large, international cohorts.

Bladder myxoma is a very rare tumor that happens in a benign manner. The mesenchymal origin is typically the supply of these tumors. This tumor is usually diagnosed by the excisional biopsy due to the difficulty of diagnosis preoperatively as different bladder tumors’ types. During this paper, we tend to represent a case report of this terribly rare mesenchymal growth within the urinary bladder which is an unusual location for myxoma tumors to occur. A 48-year-old feminine was hospitalized because of obscure abdominal pain. The patient underwent partial cystectomy, and the histopathology reported the presence of myxoma of urinary bladder.

Objective A growing research literature has highlighted the work of managing and triaging clinical messages as a major contributor to professional exhaustion and burnout. The goal of this study was to discover and quantify the distribution of message content sent among care team members treating patients with breast cancer. Materials and Methods We analyzed nearly two years of communication data from the electronic health record (EHR) between care team members at Vanderbilt University Medical Center. We applied natural language processing to perform sentence-level annotation into one of five information types: clinical, medical logistics, nonmedical logistics, social, and other. We combined sentence-level annotations for each respective message. We evaluated message content by team member role and clinic activity. Results Our dataset included 81 857 messages containing 613 877 sentences. Across all roles, 63.4% and 21.8% of messages contained logistical information and clinical information, respectively. Individuals in administrative or clinical staff roles sent 81% of all messages containing logistical information. There were 33.2% of messages sent by physicians containing clinical information—the most of any role. Discussion and Conclusion Our results demonstrate that EHR-based asynchronous communication is integral to coordinate care for patients with breast cancer. By understanding the content of messages sent by care team members, we can devise informatics initiatives to improve physicians’ clerical burden and reduce unnecessary interruptions.

The aims of the present work were to quantify radiation doses arises from patients' exposure in mammographic X-ray imaging procedures and to estimate the radiation induced cancer risk. Sixty patients were evaluated using a calibrated digital mammography unit at King Khaled Hospital and Prince Sultan Center, Alkharj, Saudi Arabia. The average patient age (years) was 44.4 ± 10 (26–69). The average and range of exposure parameters were 29.1 ± 1.9 (24.0–33.0) and 78.4 ± 17.5 (28.0–173.0) for X-ray tube potential (kVp) and current multiplied by the exposure time (s) (mAs), respectively. The MGD (mGy) per single projection for craniocaudal (CC), Medio lateral oblique (MLO) and lateromedial (LM) was 1.02 ± 0.2 (0.4–1.8), 1.1 ± 0.3 (0.5–1.8), 1.1 ± 0.3 (0.5–1.9) per procedure, in that order. The average cancer risk per projection is 177 per million procedures. The cancer risk is significant during multiple image acquisition. The study revealed that 80% of the procedures with normal findings. However, precise justification is required especially for young patients. Keywords: Mammography, Mean glandular dose, Cancer risk, Medical exposure, Radiation dosimetry

Background The pure large cell type is a rare variant of primary neuroendocrine carcinoma of the gallbladder. Few reports have mentioned extended survival. Although a multimodal treatment has been described in the treatment of such rare disease, redo liver resection has not yet been mentioned. Case report A 67-year-old lady was found to have poorly differentiated, high grade, pure large cell neuroendocrine tumor of the gallbladder after cholecystectomy for gallstones. After the diagnosis, staging workup showed a lesion in segment IVB/V of the liver, and chromogranin was elevated (982 mcg/L). The patient underwent central inferior hepatectomy and wedge excision of a lesion in segment III (discovered intra-operatively), with hilar lymphadenectomy. Three months after the first liver resection, she developed a new liver lesion II/III and underwent left lateral liver resection. The patient remained disease-free for 4 months following the second liver resection but then developed recurrent liver disease and was started on chemotherapy. Further progression led to multi-organ failure and death at 26 months from initial diagnosis. Conclusion This is the first reported repeat liver resection in such a rare disease that has led to extended overall survival. We suggest that a group of selected patients with this rare malignancy, and liver-limited disease, may benefit from repeated liver resection.

Objectives: Since the uprising in 2011, there have been limited health-care data from inside Syria regarding women’s health. This study aimed to provide an updated account of women’s health, including pregnancy, perinatal care, childbirth, and other conditions to identify obstacles and challenges to health-care delivery in Northwestern Syria. Methods: This is a prospective data registry study, using a medical electronic records system that builds on the International Classification of Diseases, Tenth Revision (ICD-10) codes. We collected data from one medical center in Northwestern Syria during 2017. We conducted a survey to understand patients’ knowledge of and barriers limiting antenatal care (ANC). Results: We studied 7213 patients’ health status and surveyed 134 regarding ANC. Prenatal care, delivery, and miscarriage treatment represented the most common (70%) reasons for women’s health-care visits, followed by menstrual disorders (17%). From 2057 delivery records, 70% delivered vaginally and 30% required cesarean delivery. Our findings showed that 1169 (24%) of the pregnant women (4936) in 2017 were adolescents, of them 22 (0.44%) were 14 years old. Regarding ANC visits, 85% of respondents did not have a single ANC visit in the first trimester, 82% had no visits in the second trimester, and 44% had no visits in the third trimester. Thirty-one percent had no ANC visit throughout the entire pregnancy. Only 13% had postnatal care (PNC) visits. Women who live in the refugee camp are 2.7 times less likely to meet the World Health Organization (WHO) criteria for focused ANC (FANC = 4 visits) compared to those who reside in town (P < 0.001), with only 14% having met the FANC. The major barrier to ANC is related to transportation (34%), followed by factors related to the study center (29%) and knowledge and education (19%). We estimated the number of obstetrics-gynecology doctors per 1000 populations to be 0.02. Conclusions: We found a huge deficiency in ANC and PNC visits, a high adolescent birth rate, and a higher cesarean-to-vaginal delivery ratio than what is recommended by the WHO. We also found a severe shortage in the number of obstetrician-gynecologists serving this population.

Highlights • The volume of the liver that can be resected is limited by the need to leave behind liver tissue of sufficient volume to carry our normal liver functions and allow regeneration. • Two staged hepatectomy and portal vein embolization/ligation allow hypertrophy of the future liver remnant, but the long period required may allow tumor progression. • ALPPS combines portal vein ligation with transection of the liver tissue, inducing rapid hypertrophy of the future remnant liver. • Despite high morbidity and mortality initially, the procedure is now safe due to better technique and the selection criteria. • Future efforts are directed towards better evaluation of liver function, refinements in the technique, and more accurate patient selection., Introduction Associating Liver Partition and Portal Vein Ligation for Staged -hepatectomy (ALPPS) is an evolving procedure that allows rapid hypertrophy of the future liver remnant (FLR). We describe the first two cases performed in Qatar. Case presentations Case 1: A 53 -year old male with sarcoma metastases to the liver 8 years after resection of an abdominal wall tumor, requiring an extended right hepatectomy but with in an inadequate FLR. ALPPS was done and he achieved 147% increase in the volume of the FLR within 6 days (from 15.9%–34.2%). The second stage was completed successfully on day 7. Case 2: A 59-year old male patient had colorectal liver metastases that required an extended right liver resection and had inadequate FLR of 19.8%. Seven days after the first stage, the FLR hypertrophied to 37.7% (90.2% increase in volume) and the second stage was completed successfully on day 8. Both patients had uneventful recovery and no recurrence or complications on follow up. Discussion ALPPS allows large liver resections while circumventing the long delay in the conventional two staged hepatectomy and portal vein ligation/embolization. The reported morbidity and mortality in earlier series was high, but recent selection criteria and technique refinements reduce this morbidity. Many variations are still being reported. Conclusion ALPPS is an evolving technique that adds to the armamentarium of the liver surgeon to allow larger liver resections in a timely manner. It is feasible and safe to be performed with careful selection.

Eye lenses lie within the radiation field during computed tomography (CT) procedures of the brain. Therefore, patients are at risk of forming eye lens opacity when exposures exceed the threshold for such onset. The purpose of this study was to estimate the eye lens equivalent and radiation effective doses during CT procedures of the brain, facial bones, and paranasal sinuses. A total of 85 patients were examined using a 16-detector CT machine. The organ and surface dose received by specific radiosensitive organs was carried out using software from the National Radiological Protection Board (NRPB). The overall mean patient doses were as follows: CTDIvol, 45.7 ± 15.6 mGy for brain; and 7.6 mSv for the eye lens. The mean eye lens equivalent dose per CT procedure was 11.5 mSv, 4.5 mSv, and 6.7 mSv for the brain, paranasal sinuses, and facial bones, respectively. The radiation risk per procedure equates to 1 cancer case per 11 × 10−3 procedures. The study shows there to be great need for improving the imaging protocol and for continuous training of staff. Dose reduction techniques in brain CT are required, eye lens irradiations potentially generating lens opacities.

Laboratory experiments were conducted to evaluate the efficacy of the three types of garlic oils; Sudanese, Chinese and Egyptian on the eggs of cowpea beetle Callosobruchus maculatus. Volatile oils from Sudanese and Chinese garlic were obtained by steam distillation and Soxhlet extraction using ethanol correspondingly, whereas Egyptian garlic oil was bought as a ready-made product. The oils were tested at concentrations of 0.01%, 0.1%, 1%, 5% and 10%, at exposure periods ranging from 24-72 hrs. Respective average number of eggs laid after exposure to the lowest concentration of Sudanese, Chinese and Egyptian oils were; 5.4, 4.0, 4.1 after 24 hrs; 0.7, 0.1, 0.1 after 48 hrs 0.2, 0.5, 0.5 after 72 hrs. The oils from the three garlic cultivars significantly reduced number of eggs laid with the highest dose (10%) caused complete inhibition of egg laying. Average number of eggs hatched when exposed to the lowest concentration (0.01%) were; 0.25 after one day and 1.00 after 7 days of exposure to Sudanese oil vapours, 0.00 after one day and 0.75 after 7 days of exposure to Chinese oil vapour and 0.00 after one day and 0.75 after 7 days of exposure to Egyptian oil vapour.

Background Diabetes distress (DD) has broad-ranging effects on type 2 diabetes (T2DM) management and outcomes. DD research is scarce among ethnic minority groups, particularly Arabic-speaking immigrant communities. To improve outcomes for these vulnerable groups, healthcare providers, including pharmacists, need to understand modifiable predictors of DD. Objective To assess and compare DD and its association with medication-taking behaviours, glycaemic control, self-management, and psychosocial factors among first-generation Arabic-speaking immigrants and English-speaking patients of Anglo-Celtic background with diabetes, and determine DD predictors. Setting: Various healthcare settings in Australia. Method: A multicentre cross-sectional study was conducted. Adults with T2DM completed a survey comprised of validated tools. Glycated haemoglobin, blood pressure, and lipid profile were gathered from medical records. Multiple linear regression models were computed to assess the DD predictors. Main outcome measure: Diabetes distress level. Results Data was analysed for 696 participants: 56.3% Arabic-speaking immigrants and 43.7% English-speaking patients. Compared with English-speaking patients, Arabic-speaking immigrants had higher DD, lower medication adherence, worse self-management and glycaemic control, and poorer health and clinical profile. The regression analysis demonstrated that higher DD in Arabic-speaking immigrants was associated with cost-related medication underuse and lower adherence to exercise, younger age, lower education level, unemployment, lower self-efficacy, and inadequate glycaemic control. Whereas among English-speaking patients, higher DD was associated with both cost- and non-cost-related underuse of medication and lower dietary adherence. Conclusion Results provided new insights to guide healthcare providers on reducing the apparent excess burden of DD among Arabic-speaking immigrants and potentially improve medication adherence, glycaemic control, and self-management.

Differences in obesity and body fat distribution across gender and race/ethnicity have been extensively described. We sought to replicate these differences and evaluate newly emerging data from the All of Us Research Program (AoU). We compared body mass index (BMI), waist circumference, and waist-to-hip ratio from the baseline physical examination, and alanine aminotransferase (ALT) from the electronic health record in up to 88,195 Non-Hispanic White (NHW), 40,770 Non-Hispanic Black (NHB), 35,640 Hispanic, and 5,648 Asian participants. We compared AoU sociodemographic variable distribution to National Health and Nutrition Examination Survey (NHANES) data and applied the pseudo-weighting method for adjusting selection biases of AoU recruitment. Our findings replicate previous observations with respect to gender differences in BMI. In particular, we replicate the large gender disparity in obesity rates among NHB participants, in which obesity and mean BMI are much higher in NHB women than NHB men (33.34 kg/m2 versus 28.40 kg/m2 respectively; p-308). The overall age-adjusted obesity prevalence in AoU participants is similar overall but lower than the prevalence found in NHANES for NHW participants. ALT was higher in men than women, and lower among NHB participants compared to other racial/ethnic groups, consistent with previous findings. Our data suggest consistency of AoU with national averages related to obesity and suggest this resource is likely to be a major source of scientific inquiry and discovery in diverse populations.

Introduction: The Neuropathic Pain Questionnaire-Short Form (NPQ-SF) is the shortest diagnostic tool for the assessment of neuropathic pain, designed with the goal to differentiate between neuropathic and nonneuropathic pain. The aim of this study was to translate, culturally adapt, and validate the NPQ-SF questionnaire in Arabic. Methods: A systematic translation process was used to translate the original English NPQ-SF into Arabic. After the pilot study, the Arabic version was validated among patients with chronic pain in two tertiary care centers. Reliability of the translated version was examined using internal consistency, test-retest reliability, and intraclass correlation coefficient (ICC). We examined the validity of the Arabic NPQ-SF via construct validity, concurrent validity (associations with the numeric pain scale, Brief Pain Inventory, and Self-completed Leeds Assessment of Neuropathic Symptoms and Signs [S-LANSS]), face validity, and diagnostic validity. To investigate the responsiveness, the translated NPQ-SF questionnaire was administered twice among the same group of patients. Results: A total of 142 subjects (68 men, 74 women) were included in the study. Cronbach's α were 0.45 (95% CI: 0.29, 0.61) and 0.48 (95% CI: 0.33, 0.63), and the ICC was 0.78 (95% CI: 0.72, 0.85). The NPQ-SF was moderately to strongly associated with the S-LANSS questionnaire. Results showed our Arabic NPQ-SF to have good diagnostic accuracy, with area under the curve of 0.76 (95% CI: 0.67, 0.84). Results from the receiver operating characteristic analysis identified a cut-off score of ≥0.52 as the best score to distinguish between patients with or without neuropathic pain, which was higher than the recommended cut-off score (≥0) in the original study. With both sensitivity and specificity of 71%. Most patients found the NPQ-SF questionnaire to be clear and easy to understand. Conclusion: Our translated version of NPQ-SF is reliable and valid for use, thus providing physicians a new tool with which to evaluate and diagnose neuropathic pain among Arabic-speaking patients.

Introduction: The douleur neuropathique 4 (DN4) questionnaire is a widely used tool for diagnosis of neuropathic pain (NP). The aim was to translate, culturally adapt, and validate the DN4 questionnaire in Arabic. Methods: A systematic translation process was used to translate the original English DN4 into Arabic. After the pilot study, the Arabic version was validated among patients with chronic pain in two tertiary care centers. The reliability of the translated version was examined using internal consistency, test-retest reliability, and intraclass correlation coefficients. We examined the validity of the Arabic DN4 via construct validity, concurrent validity (associations with the numeric rating scale, brief pain inventory, and Self-Completed Leeds Assessment of Neuropathic Symptoms and Signs [S-LANSS]), face validity, and diagnostic validity. To investigate the responsiveness, the translated DN4 was administered twice among the same group of patients. Results: A total of 142 subjects (68 men, 74 women) were included in the study. Cronbach's α was 0.67 (95% confidence interval [CI]: 0.59–0.75), and interclass correlation coefficients was 0.81 (95% CI: 0.76–0.87). The DN4 was moderately associated with the S-LANSS questionnaire. Results showed our Arabic DN4 to have good diagnostic accuracy, with area under the curve of 0.88 (95% CI: 0.82–0.94). As with the original version, a score of ≥4 was found to be the best cut-off for the diagnosis of NP, with a sensitivity of 88.31%, specificity of 74.47%, a positive predictive value of 85%, and a negative predictive value of 80%. Most patients found the DN4 questionnaire to be clear and easy to understand, and thought the questionnaire items covered all their problem areas regarding their pain. Conclusion: Our Arabic version of the DN4 is a reliable and valid screening tool that can be easily administered among patients to differentiate between NP and non-NP.

AIM To assess the value of the ratio of signal intensities at high and low b-values (b800/b0 ratio) during diffusion-weighted imaging (DWI) for gallbladder cancer diagnosis. MATERIALS AND METHODS All patients presenting with suspicious gallbladder lesions between January 2011 and December 2016 who underwent DWI and histopathological diagnoses of the lesions were assessed. RESULTS Thirty-two patients (24 men, eight women) were identified. Eighteen patients had benign gallbladder lesions while 14 had malignant lesions. The mean apparent diffusion coefficient (ADC) value was 1.62 (±0.57)×10−3 mm2/s for benign cases and 1.27 (±0.39)×10−3 mm2/s for malignant cases; this difference was not significant (p=0.0773). The mean b800/b0 ratio was 0.31 (±0.19) for benign cases and 0.48 (±0.13) for malignant cases; this difference was significant (p=0.007). The ROC curve for b800/b0 had an AUC of 0.782 (95% confidence interval [CI]: 0.616–0.947) with a sensitivity and specificity of 85.7% and 72.2%, respectively, at a cut-off point of 0.33. CONCLUSION The b800/b0 ratio can help differentiate benign and malignant gallbladder lesions and may be more reliable than ADC values in quantitative DWI assessments.

Background Arab-Americans constitute ~ 5% of Michigan’s population. Estimates of obesity in Arab-Americans are not up-to-date. We aim to describe the distribution of and factors associated with obesity in an Arab-American population in Southeastern Michigan (SE MI). Methods Retrospective medical record review identified n = 2363 Arab-American patients seeking care at an Arab-American serving clinic in SE MI, located in a city which is home to a large proportion of Arab-Americans in the United States (US). Body mass index (BMI) was the primary outcome of interest. Distribution of BMI was described using percentages, and logistic regression models were constructed to examine the association between obesity, other comorbid conditions and health behaviors. This cohort was compared to Michigan’s Behavioral Risk Factor Surveillance System (BRFSS) data from 2018 (n = 9589) and to a cohort seeking care between 2013 and 2019 from a free clinic (FC) located in another city in SE MI (n = 1033). Results Of the 2363 Arab-American patients, those who were older or with HTN, DM or HLD had a higher prevalence of obesity than patients who were younger or without these comorbidities (all p-value p p p Conclusion Overall obesity rates in Arab-Americans were comparable to the population-based BRFSS rates, and lower than the patients seen at the FC. Further studies are required to understand the impact of obesity and the association of comorbidities in Arab-Americans.

COVID-19 pandemic evolved rapidly and necessitated rapid, dynamic service reorganisation. Utilisation and distribution of our individual team members’ skillsets demonstrates our adaptive leadership across all aspects of the service. We adhered to the Association of Breast Surgeons guidelines for breast cancer care to downsize activity and resources. Objective of strategy was to maintain a consistent high standard of care, without compromising on NHS targets or cancer outcomes. Face-to-face appointments (FA) were minimised to reduce the risk of COVID-19 infection. A novel Vetting System stratified patients’ symptom into High Risk of cancer (FA) or Low Risk (Telephone Consultation, TC). Detailed patient spreadsheets were created, accessible on a shared drive as a real time dashboard - monitoring patient flow, recording triage decisions & outcomes. We redesigned patient spaces with an ‘in car’ waiting room, single direction flow and patient-only admittance for clinic safety. We suspended non-essential services: to preserve hospital resources; reducing non-essential attendances and allowing re-deployment of staff to acute areas. Data comparison over same period the previous year was used to gain an idea of the impact of activity changes and to anticipate additional workload post-lockdown. March 23 to May 1st, 2020: 45 cancer surgery 296 new breast clinics 531 follow-ups (104 elected to postpone) 427 (331 TC, 96 FA) 26 breast screening March 25 to May 3rd, 2019: 53 cancer surgery 507 new breast clinics 674 follow-ups 32 breast screening Shortfall in new patients was related to reduced GP activity/patient reluctance to seek medical help. Shortfall in follow ups due to postponements. Subsequently clinical evaluation with patient experience questionnaires confirmed no cancer missed, no delays to treatment and no harm caused. Adaptive leadership was essential in a time of unprecedented challenges.

The high transmissibility rate of Covid, obliged us to adapt and transform our symptomatic clinic to be able to continue diagnosing and treat breast cancer and at the same time protect patients and staff. Prior analysis of clinical activity suggests at least 80 per cent of patient attending breast clinics are either healthy or found to have benign conditions, identification of this group of patients ahead of time would allow assess and treat them safely with a telephone clinic consultation instead On this tenet we worked, in compliance to new and emerging guidance about breast cancer care during the pandemic from the Association of Breast Surgeons and the National Institute for Clinical Excellence, to devise a novel vetting system for stratifying and prioritizing all new referral to out-patient clinics. All changes were discussed at MDTS. Adjustments and refinements were made as necessary due to the dynamic and evolving situation; changing guidance and staff availability due to illness, need for self-isolation and those shielding at home. Patients were stratified according to their history and symptoms and their likely cancer risk,. Patients with high risk of cancer were offered face-to-face consultation, those at low risk were offered telephone consultation. From 23rd March to 1st May 2020, we moved all possible patients to phone consultations. 299 new patients were vetted: 149 allocated phone appointment, 150 attended face-to-face clinics, of these 62 were diagnosed with breast cancer. Initial phone contact appears safe with low risk patients. This will maximize available resources and reduce the pressures imposed by two week waiting list clinics on the breast services. Covid-19 gave us the opportunity of demonstrating the strong, shared leadership existing in our group. The entire team proved able to adapt to different ways of working and embrace change, whilst continuing to innovate and thrive.

Objectives: This study aims to first measure patient doses during computed tomography (CT) chest, abdomen, and extremities procedures for evaluation lymphedema, and second to estimate the radiation dose-related risks during the procedures. Material and Methods: Radiation effective doses from CT lymphography procedures quantified using CT machines from different vendors. After the calibration of CT systems, the data collected for a total of 28 CT lymphography procedures. Effective and organ doses extrapolated using national radiological protection software based on Monte Carlo simulation. Results: The mean patient doses for chest and abdomen procedures in term of CTDIvol (mGy) and DLP (mGy.cm) are 10.0 ± 3 and 425 ± 222 and 24 ± 12 and 1118 ± 812 for CT 128 and CT 16 slice, respectively. The mean DLP (mGy.cm) for extremities was 320 ± 140 and 424 ± 212 for CT 128 and CT 16 slice, in that order. Conclusion: Patients’ dose showed significant differences due to variation in the scan length and clinical indication. Organs lay in the primary beam received high radiation doses especially in the chest region which increases the probability of radiation-induced cancer. The current patient’s doses are higher compared to the previous studies.

BackgroundThere are limited data on Coronavirus Disease 2019 (COVID-19) outcomes at a national level, and none after 60 days of follow up. The aim of this study was to describe national, 60-day all-cause mortality associated with COVID-19, and to identify risk factors associated with admission to an intensive care unit (ICU).MethodsThis was a retrospective cohort study including the first consecutive 5000 patients with COVID-19 in Qatar who completed 60 days of follow up by June 17, 2020. Outcomes included all-cause mortality at 60 days after COVID-19 diagnosis, and risk factors for admission to ICU.ResultsIncluded patients were diagnosed with COVID-19 between February 28 and April 17, 2020. The majority (4436, 88.7%) were males and the median age was 35 years [interquartile range (IQR) 28– 43]. By 60 days after COVID-19 diagnosis, 14 patients (0.28%) had died, 10 (0.2%) were still in hospital, and two (0.04%) were still in ICU. Fatal COVID-19 cases had a median age of 59.5 years (IQR 55.8–68), and were mostly males (13, 92.9%). All included pregnant women (26, 0.5%), children (131, 2.6%), and healthcare workers (135, 2.7%) were alive and not hospitalized at the end of follow up.A total of 1424 patients (28.5%) required hospitalization, out of which 108 (7.6%) were admitted to ICU. Most frequent co-morbidities in hospitalized adults were diabetes (23.2%), and hypertension (20.7%). Multivariable logistic regression showed that older age [adjusted odds ratio (aOR) 1.041, 95% confidence interval (CI) 1.022–1.061 per year increase; P ConclusionsIn a relatively younger national cohort with a low co-morbidity burden, COVID-19 was associated with low all-cause mortality. Independent risk factors for ICU admission included older age, male sex, higher BMI, and co-existing diabetes or chronic kidney disease.

Maturity onset diabetes of the young (MODY) is a rare cause of diabetes. Most clinical information required to diagnose MODY is difficult to extract from Electronic Health Records (EHR) due to the lack of specific billing code and diagnoses found only in clinical notes. Natural language processing (NLP) can be used to extract information from clinical text and assign labels. In this study, we designed NLP algorithms to scan clinical notes, characterize structured information, and confirmed classification with chart review to develop a reusable process to identify MODY patients in EHR.A de-identified version of the EHR from a large academic medical center was used. We built NLP algorithms to identify notes that mention MODY or MODY 14 genes. We further characterized the relevant mention with context labels), then reviewed charts to confirm MODY cases. We implemented published electronic phenotype algorithms for type 1 diabetes (T1D) and type 2 diabetes (T2D) to identify alternative diagnoses and characterize overlap. Finally, we extracted structured clinical features related to diabetes including frequency of billing codes, outpatient diabetes prescriptions, and laboratory values (A1C, c-peptide, antibody).The total number of notes identified with NLP was 6240 belonging to 959 unique subjects. The notes including negation, affirmation, possible, and family FH were 799, 3407, 1408, and 372 and subjects were 122, 354, and 181, respectively. The MODY count confirmed with review was 354.In MODY cohort, 66% of MODY subjects had T1D codes, 59% had T2D codes, 45% had both T1D and T2D codes, and 20% had no diabetes codes. The number of subjects identified using published algorithms that overlapped the MODY cohort was 26 subjects for T2D and 6 subjects for T1D. On average, MODY subjects had more T1D codes compared to T2D diabetes (59.8 vs. 35.3). The mean A1C of MODY subjects was 7.7 which was lower than for algorithm defined T1D, 8.2. They received lower insulin treatment compared to non-insulin treatment, on average. Disclosure L. Sulieman: None. A. Ramirez: None.

Background Arab-Americans constitute ~ 5% of Michigan’s population. Estimates of obesity in Arab-Americans are not up-to-date. Here we describe the distribution of, and factors associated with obesity in an Arab-American population.Methods Arab-American patients, ages 18–98 years, from Arab Community Center for Economic and Social Services (ACCESS) clinic located in Dearborn, Michigan were identified from medical records. Retrospective chart review abstracted age, sex, marital status, employment, body mass index (BMI), hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLD), employment status, tobacco use and alcohol consumption. This cohort was compared to Michigan’s Behavioral Risk Factor Surveillance System (BRFSS) data from 2018 and to a cohort seeking care between 2013–2019 from a free clinic in Ferndale, Michigan.Results Of the 2,363 Arab-American patients from the ACCESS clinic, 67% (n = 1591) were female and 33% (n = 772) were male. Among Arab-Americans, patients who were older or with HTN, DM or HLD had a higher prevalence of obesity than patients who were younger or without these comorbidities (all p-value Conclusion Obesity rates in Arab-Americans were comparable to their BRFSS counterparts, and lower than their FCFC counterparts. Further studies are required to understand the impact of obesity and the association of comorbidities in Arab-Americans residing in the US.

Electronic Health Records (EHR) contain rich data to identify and study diabetes. Many phenotype algorithms have been developed to identify research subjects with type 2 diabetes (T2D), but very few accurately identify type 1 diabetes (T1D) cases or more rare forms of monogenic and atypical metabolic presentations. Polygenetic risk scores (PRS) quantify risk of a disease using common genomic variants well for both T1D and T2D. In this study, we apply validated phenotyping algorithms to EHRs linked to a genomic biobank to understand the independent contribution of PRS to classification of diabetes etiology and generate additional novel markers to distinguish subtypes of diabetes in EHR data. Using a de-identified mirror of medical center’s electronic health record, we applied published algorithms for T1D and T2D to identify cases, and used natural language processing and chart review strategies to identify cases of maturity onset diabetes of the young (MODY) and other more rare presentations. This novel approach included additional data types such as medication sequencing, ratio and temporality of insulin and non-insulin agents, clinical genetic testing, and ratios of diagnostic codes. Chart review was performed to validate etiology. To calculate PRS, we used genome wide genotyping from our BioBank, the de-identified biobank linking EHR to genomic data using coefficients of 65 published T1D SNPS and 76,996 T2D SNPS using PLINK in Caucasian subjects. In the dataset, we identified 82,238 cases of T2D but only 130 cases of T1D using the most cited published algorithms. Adding novel structured elements and natural language processing identified an additional 138 cases of T1D and distinguished 354 cases as MODY. Among over 90,000 subjects with genotyping data available, we included 72,624 Caucasian subjects since PRS coefficients were generated in Caucasian cohorts. Among those subjects, 248, 6,488, and 21 subjects were identified as T1D, T2D, and MODY subjects respectively in our final PRS cohort. The T1D PRS did significantly discriminate well between cases and controls (Mann-Whitney p-value is 3.4 e-17). The PRS for T2D did not significantly discriminate between cases and controls using published algorithms. The atypical case count was too low to calculate PRS discrimination. Calculation of the PRS score was limited by quality inclusion of variants available, and discrimination may improve in larger data sets. Additionally, blinded physician case review is ongoing to validate the novel classification scheme and provide a gold standard for machine learning approaches that can be applied in validation sets.

Artículo con numerosos autores, sólo se mencionan el primero, los de la UAM y grupo colectivo, A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1–70.8) million) to 6.4% (58.3 (47.6–70.7) million), but is predicted to remain above the World Health Organization’s Global Nutrition Target of, This work was primarily supported by grant OPP1132415 from the Bill & Melinda Gates Foundation awarded to S.I.H.

The main research conducted to know the importance of duplex Ultrasonography in the control, follow-up & the diagnosis of the different types of liver post-transplantation problems. Three hundred normal liver Doppler scan done to be as a reference (liver span and echotexure by the naked eye; not by image processing programme - IPP; in young expected normal patients in relation to normal liver transplanted patients- not a diseased liver, cirrhosis or hepatitis) to the Sudanese normal livers before starting the research, and about 65 Sudanese patients found with liver transplantations from them only 45 were available for liver Doppler scan. The data had been collected from the 300 normal objects population are the students of faculty of medicine in Al Rabat University (ages between 16-22 yrs., 48 % M; 52% F); the study done during the period from 1st April 2016 to 30th July 2017. The liver span is in the range (9.5-13.9 cm), the majority is of homogenous echo - level grading. The Statistical Package for Social Science – SPSS version 20.0 is used; no significant difference found between young males and females, however, that the upper limit of the liver span is a little bit more than the international values.

Highlights • Pancreatic masses pose a diagnostic challenge, and cancer has to be always considered. • IgG4-related disease is a rare cause of pancreatic masses. • Biopsy from the pancreas is not always required if histopathology from a more accessible peripheral site lesion confirms the diagnosis. • Multiorgan involvement and aortitis should raise suspicion of IgG4-related disease., Introduction Most patients with pancreatic masses pose a diagnostic challenge when a benign lesion is suspected, and often, resection is needed before a benign diagnosis is confirmed. Presentation of case A 57 years old male patient presented with a pancreatic head mass, obstructive jaundice and submandibular lymph node enlargement. He also had a history of recurrent eye pain and redness, skin lesions, and benign prostatic hypertrophy. MRI showed a pancreatic head mass with double duct sign, aortic thickening, bilateral renal lesions, diffuse lymph node enlargement, and prostatic enlargement. FDG-PET/CT demonstrated abnormal uptake corresponding to the MRI lesions, and there were elevated IgG4 levels on blood investigations. Biopsy of an inguinal lymph node revealed infiltrates with IgG4 plasma cells, consistent with the diagnosis of IgG4 disease. The patient was treated with IV steroids and showed significant improvement. Discussion IgG4 related disease is a rare entity that is characterized by lesions that show heavy infiltration with IgG4 positive plasma cells, storiform fibrosis, and obliterative phlebitis. The pancreas is the most commonly involved organ, but several other organ systems are involved, and this helps in clinical suspicion of the diagnosis. A biopsy from any easily accessible site that shows the characteristic histological features is sufficient for diagnosis. Patients respond quickly to steroids, but recurrence is frequent. Conclusion IgG4 related disease is a rare cause of pancreatic tumorous lesions that need a high index of suspicion for diagnosis and should be differentiated from pancreatic neoplastic lesions.

Although chronic intestinal pseudo-obstruction (CIPO) is a rare disorder, it presents a wide spectrum of severity that ranges from abdominal bloating to severe gastrointestinal dysfunction. In the worst cases, patients may become dependent upon artificial nutrition via parenteral nutrition or choose to have an intestinal transplant. However, whatever the severity, a patient's quality of life can be seriously compromised. This article defines the disorder and discusses the spectrum of disease and challenges to providing adequate nutrition to help improve a patient's quality of life.

While cerebral arteriovenous malformations (AVM) are common, a presentation of this vascular lesion involving the internal auditory canal (IAC) is rare. We describe a case of an un-ruptured AVM within the right IAC of a 55-year-old male who presented following a whiplash injury and left-ear (contralateral to the lesion) unilateral non-pulsatile tinnitus. On magnetic resonance imaging (MRI), an incidental atypical linear enhancement suspicious for a vascular lesion within the right IAC was identified and investigated further using magnetic resonance angiography and venography (MRA/MRV), which illustrated serpentine flow voids that confirmed the presence of an AVM. Given the patient's intact hearing and rare location of the AVM, treatment options including watchful waiting, stereotactic radiosurgery, embolization, and microsurgery were discussed, of which observation was chosen.

Background. Traumatic dental injury (TDI) is a challenging public health problem. Its incidence and prevalence vary within countries, states, and different social groups.Aim. The purpose of this study was to determine the prevalence of traumatic dental injuries in primary incisors among 3–5-year-old Sudanese preschool children and associated factors such as age, sex, and size of overjet and anterior open bite.Materials and Methods. Descriptive cross-sectional study was carried out among 600 preschool children (3–5 years old) selected by multistage cluster technique from preschools located in Khartoum city, Sudan. The data regarding age, sex, causes, and treatment of TDI were collected from the mothers through structured interview questionnaire. Children were examined in an upright position, using mouth mirror and torch. A single examiner assessed the type of trauma, the tooth involved, and overbite/overjet. The data were analyzed statistically through descriptive analysis, and the chi-square test was used to compare between different variables withP<0.05.Results. The prevalence of traumatic dental injuries (TDIs) was 18.5%. Enamel fractures were the most common type (74.8%), followed by enamel and dentin (11.7%). The maxillary central incisors were the most commonly affected teeth, and the home was most common place for TDI. The prevalence rate was 45% in boys and 55% in girls with a statistically significant difference (P=0.02).Conclusions. The prevalence of traumatic dental injuries to the primary anterior teeth among the Sudanese preschool children was relatively high (18.5%). Factors such as overjet size, overbite size, and lip competency were not significantly correlated with dental trauma among the studied population.

Introduction Hemophagocytic lymphohistiocytosis (HLH) is a clinical syndrome of hyperinflammation leading to an uncontrolled and ineffective immune response, associated with high mortality. Case report A 26-year-old woman with acute lymphoblastic leukemia, 8 months in remission, was found to have HLH. Without any improvement, stem cell transplantation was considered. Then, Mycobacterium avium complex (MAC) infection was identified as cause of her HLH. With appropriate therapy for infection, HLH improved and transplantation was averted. Conclusion MAC should be included in the list of potential causes of HLH.

Patient: Male, 50 Final Diagnosis: Spinal cord compression associated with spinal abscess Symptoms: Diarrhea • fever • low back pain Medication: — Clinical Procedure: Laminectomy Specialty: Hematology Objective: Rare co-existance of disease or Background: In Primary Myelofibrosis (PMF; a clonal disorder arising from the neoplastic transformation of early hematopoietic stem cells) patients, spinal cord compression (SCC) is a common complication or even a presentation symptom due to extramedullary hematopoiesis (EMH). However, a case of SCC caused by a spinal abscess is unusual. To the best of our knowledge, this is the first case report of this rare condition. Case Report: We are reporting the case of a 50-year-old male with primary myelofibrosis and long-standing splenomegaly with back pain as a presenting symptom who was found to have spinal cord compression. An MRI was performed, as EMH was suspected. The blood cultures revealed an infection with Salmonella, so the patient was placed on ceftriaxone, with no response. The patient demonstrated substantial clinical improvement after 2 weeks of neurosurgical intervention and pain management. Conclusions: In PMF patients, back pain with fever or mild neurological symptoms needs to be investigated urgently because of the high risk of irreversible spinal cord damage leading to partial or complete loss of functional independence and shortened survival. The compression could be related to EMH or infections due to an immunodeficiency.

Objectives: To determine the prevalence of uncorrected refractive errors (URE) among children 3-10 years and to affirm the necessity of a national school-based visual screening program for school-aged children. Methods : This retrospective cross-sectional study was conducted in Medina, Saudi Arabia in 2015. Children were selected through a multistage stratified random sampling from 8 kindergarten and 8 primary schools. Those included were screened to diagnose UREs using a visual acuity chart and an auto refractometer according to American guidelines. The prevalence and types of UREs were estimated. Results : Of the 2121 children enumerated, 1893 were examined, yielding a response rate of 89.3%. The prevalence of UREs was 34.9% (95% CI = 32.8%-37.1%), with significant differences in different age groups. The prevalence of astigmatism (25.3%) was higher compared to that of anisometropia (7.4%), hypermetropia (1.5%), and myopia (0.7%). Risk of uncorrected refractive error was positively associated with age, and this was noted in astigmatism, myopia, and anisometropia. In addition, the risk of hypermetropia was associated with boys and that of myopia was associated with girls. Conclusions : The prevalence of UREs, particularly astigmatism, was high among children aged 3-10 years in Medina, with significant age differences. Vision screening programs targeting kindergarten and primary schoolchildren are crucial to lessen the risk of preventable visual impairment due to UREs. Saudi Med J 2017; Vol. 38 (8): 804-810 doi: 10.15537/smj.2017.8.20412 How to cite this article: Alrahili NHR, Jadidy ES, Alahmadi BSH, Abdula'al MF, Jadidy AS, Alhusaini AA, et al. Prevalence of uncorrected refractive errors among children aged 3-10 years in western Saudi Arabia. Saudi Med J . 2017 Aug;38(8):804-810. doi: 10.15537/smj.2017.8.20412.

Schistosomiasis is the most prevalent parasitic disease after malaria in terms of socioeconomic and public health importance in the developing world. In Sudan, since the year 1919, the disease has been discovered in the northern part of the country, and later it was reported from different parts including Eastern and Western Sudan, Lake Nasser area, and many agricultural schemes such as Gezira Scheme, Rahad Scheme and Gunaid Sugar Cane Scheme.

Background The most cost-effective reconstruction after resection of bone sarcoma is unknown. The goal of this study was to compare the cost effectiveness of osteoarticular allograft to endoprosthetic reconstruction of the proximal tibia or distal femur. Methods A Markov model was used. Revision and complication rates were taken from existing studies. Costs were based on Medicare reimbursement rates and implant prices. Health-state utilities were derived from the Health Utilities Index 3 survey with additional assumptions. Incremental cost-effectiveness ratios (ICER) were used with less than $100 000 per quality-adjusted life year (QALY) considered cost-effective. Sensitivity analyses were performed for comparison over a range of costs, utilities, complication rates, and revisions rates. Results Osteoarticular allografts, and a 30% price-discounted endoprosthesis were cost-effective with ICERs of $92.59 and $6 114.77. One-way sensitivity analysis revealed discounted endoprostheses were favored if allografts cost over $21 900 or endoprostheses cost less than $51 900. Allograft reconstruction was favored over discounted endoprosthetic reconstruction if the allograft complication rate was less than 1.3%. Allografts were more cost-effective than full-price endoprostheses. Conclusions Osteoarticular allografts and price-discounted endoprosthetic reconstructions are cost-effective. Sensitivity analysis, using plausible complication and revision rates, favored the use of discounted endoprostheses over allografts. Allografts are more cost-effective than full-price endoprostheses.

Background: Basal cell carcinoma (BCC) is a frequently diagnosed skin cancer with variable histopathological types. BCC was not widely studied in Sudan as it is in the Caucasian population. Objectives: To appraise the clinical and histopathological aspects of BCC of the skin in Sudan. Materials and methods: A retrospective descriptive analysis of 84 histologically diagnosed BCC specimens seen at three hospitals in four-year duration were reviewed and classified into histological variants according to the WHO classification 2006. Data were analyzed using Statistical Package for the Social Sciences, version 23.0. Results: The mean age (±SD) of the study participants was 56 (±1.75) years, ranging from 20 to 92 years and 63.1% were females (Female to male ratio 1.7:1). The most common incidence was among the age group 51 - 60 years. The face was the primary tumor site in 89.3% with a predilection for the nasal area (31% of those in the face), followed by the trunk (6%). Out of the total, 54.8% were histologically categorized as nodular/solid, while infiltrative accounts for 11.9% followed by the superficial type (8.3%). Surgical margins were involved in 34.5% of cases and peri-neural invasion was seen in 3.6% of cases, mostly were of the infiltrative variant. Conclusion: BCC in Sudan is commonly present in the head as solid nodular histopathological variant which is correlated with worldwide distribution but has slightly younger age and female predominance; thus further studies are needed to assess risk factors in Sudanese patients and improve approaches for earlier diagnosis and better management.

Introduction: The Hospital Anxiety and Depression Scale (HADS) is widely used to predict and diagnose hospital anxiety and depression. It has been translated and validated in many languages, but the existing Arabic version was not validated in hospitalized patients. The aim was to translate, culturally adapt, and validate the HADS Questionnaire into Arabic language for in-patient use, especially for surgical wards. Methods: A systematic translation process was used to translate the original English HADS into Arabic. After the pilot study, we validated our version in surgical patients at two tertiary care centers. We tested the reliability of our version using internal consistency. We examined the validity by assessing construct validity, concurrent validity (by testing the associations between HADS, Generalized Anxiety Disorder 7-item scale [GAD-7], and Major Depression Inventory [MDI]), and face validity. The questionnaire was administered before and after surgery to examine responsiveness. Results: A total of 110 patients (22 men, 88 women) were included in the study. Cronbach's αs for the HADS anxiety subscale were 0.83 (95% confidence interval: 0.79– 0.88) and for the HADS depression subscale were 0.77 (0.7–0.83). Nearly 36% of the patients reported symptoms indicative of borderline or case anxiety before surgery, which decreased to 25% 1 week after surgery. HADS anxiety score was strongly correlated with GAD-7, and HADS depression score was strongly associated with MDI. Patients with higher American Society of Anesthesiologists Physical Status and those who remained hospitalized for more than 5 days were more likely to report depression symptoms. Most patients found the HADS questions to be clear and easy to understand, and thought the questionnaire items covered all their problem areas regarding their hospital anxiety and depression. Conclusions: Our Arabic version of HADS is a reliable and valid tool to assess the mood states in hospitalized patients.