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The study aims to describe the clinical and histopathologic features of different types of dacryops and their clinical diagnostic challenges.This is a retrospective cohort study of all surgically excised cases of dacryops in 2 tertiary eye hospitals in Riyadh, Saudi Arabia.The study included 58 dacryops specimens from 55 patients with an average age of 41.2 years (range, 4-78 years). The most common location was the upper lid (60.3%), whereas the least expected location was the caruncle (6.9%). The most common site of dacryops occurrence was in the accessory lacrimal gland (55.2%), the main lacrimal gland (32.8%), and then ectopic dacryops (12%). All patients presented with lid swelling alone except for 3 patients who experienced secondary mechanical ptosis. On physical examination, conjunctival scarring existed in 4 patients (6.9%). Preoperative diagnosis of dacryops was accurate in 44.8% of the cases. Dacryops of the main lacrimal gland was accurately diagnosed clinically in all cases compared with other locations, which was statistically significant (p0.001). The causes of inaccurate clinical diagnoses were hidrocystoma (26.9%), inclusion cyst (11.5%), and dermoid cyst (7.7%), whereas the remaining cases were diagnosed as cysts without a specific subtype (53.9%). Recurrence of the lesion was observed in 2 cases (3.5%). No clinical or histopathologic factors were associated with a risk of recurrence.Dacryops can represent a diagnostic challenge to ophthalmologists. Familiarity with clinical presentations and findings is required to diagnose dacryops outside the main lacrimal gland.

Background Healthcare workers (HCWs) fighting against the COVID-19 pandemic are under incredible pressure, which puts them at risk of developing mental health problems. This study aimed to determine the prevalence of depression, anxiety, and stress among HCWs responding to COVID-19 and its associated factors. Methods A multi-country cross-sectional study was conducted during July–August 2020 among HCWs responding to COVID-19 in nine Eastern Mediterranean Region (EMR) countries. Data were collected using an online questionnaire administered using KoBo Toolbox. Mental problems were assessed using the Depression, Anxiety, and Stress Scale (DASS-21). Results A total of 1448 HCWs from nine EMR countries participated in this study. About 51.2% were male and 52.7% aged ≤ 30 years. Of all HCWs, 57.5% had depression, 42.0% had stress, and 59.1% had anxiety. Considering the severity, 19.2%, 16.1%, 26.6% of patients had severe to extremely severe depression, stress, and anxiety, respectively. Depression, stress, anxiety, and distress scores were significantly associated with participants’ residency, having children, preexisting psychiatric illness, and being isolated for COVID-19. Furthermore, females, those working in a teaching hospital, and specialists had significantly higher depression and stress scores. Married status, current smoking, diabetes mellitus, having a friend who died with COVID-19, and high COVID-19 worry scores were significantly associated with higher distress scores. Conclusions Mental problems were prevalent among HCWs responding to COVID-19 in EMR. Therefore, special interventions to promote mental well-being among HCWs responding to COVID-19 need to be immediately implemented.

Objective To assess concordance among criteria for inactive disease (ID) and low disease activity (LDA) in juvenile idiopathic arthritis (JIA) and to seek factors driving discordance. Methods The frequency of fulfillment of existing criteria was evaluated in information on 10,186 patients extracted from 3 cross-sectional data sets. Patients were divided up according to the functional phenotypes of oligoarthritis and polyarthritis. Concordance between criteria was examined using weighted Venn diagrams. The role of each individual component in explaining discordance between criteria was assessed by calculating the absolute number and percentage of instances in which the component was responsible for discrepancy between definitions. Results Criteria for ID were met by 28.6–41.1% of patients with oligoarthritis and by 24.0–33.4% of patients with polyarthritis. Criteria for LDA were met by 44.8–62.4% of patients with oligoarthritis and by 44.6–50.4% of patients with polyarthritis. There was a 57.9–62.3% overlap between criteria for ID and a 67.9–85% overlap between criteria for LDA. Parent and physician global assessments and acute-phase reactants were responsible for the majority of instances of discordance among criteria for ID (8.7–15.5%, 10.0–12.3%, and 10.8–17.3%, respectively). Conclusion We found fair concordance between criteria for ID and LDA in JIA, with the main drivers of discordance for ID being physician and parent global assessments and acute-phase reactants. This observation highlights the need for further studies aimed to evaluate the impact of subjective physician and parent perception of disease remission and of laboratory measures of inflammatory activity on the definition of ID.

Background The characteristics, outcomes, and risk factors for in-hospital death of critically ill intensive care unit (ICU) patients with coronavirus disease-2019 (COVID-19) have been described in patients from Europe, North America and China, but there are few data from COVID-19 patients in Middle Eastern countries. The aim of this study was to investigate the characteristics, outcomes, and risk factors for in-hospital death of critically ill patients with COVID-19 pneumonia admitted to the ICUs of a University Hospital in Egypt. Methods Retrospective analysis of patients with COVID-19 pneumonia admitted between April 28 and July 29, 2020 to two ICUs dedicated to the isolation and treatment of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in Cairo University Hospitals. Diagnosis was confirmed in all patients using real-time reverse transcription polymerase chain reaction on respiratory samples and radiologic evidence of pneumonia. Results Of the 177 patients admitted to the ICUs during the study period, 160 patients had COVID-19 pneumonia and were included in the analysis (mean age: 60 ± 14 years, 67.5% males); 23% of patients had no known comorbidities. The overall ICU and hospital mortality rates were both 24.4%. The ICU and hospital lengths of stay were 7 (25–75% interquartile range: 4–10) and 10 (25–75% interquartile range: 7–14) days, respectively. In a multivariable analysis with in-hospital death as the dependent variable, ischemic heart disease, history of smoking, and secondary bacterial pneumonia were independently associated with a higher risk of in-hospital death, whereas greater PaO2/FiO2 ratio on admission to the ICU was associated with a lower risk. Conclusion In this cohort of critically ill patients with COVID-19 pneumonia, ischemic heart disease, history of smoking, and secondary bacterial pneumonia were independently associated with a higher risk of in-hospital death.

Introduction Although minimally invasive surgery is becoming the standard technique in gastrointestinal surgery, implementation for small bowel neuroendocrine neoplasms (SB-NEN) is lagging behind. The aim of this international survey was to gain insights into attitudes towards minimally invasive surgery for resection of SB-NEN and current practices. Methods An anonymous survey was sent to surgeons between February and May 2021 via (neuro)endocrine and colorectal societies worldwide. The survey consisted of questions regarding experience of the surgeon with minimally invasive SB-NEN resection and training. Results A total of 58 responses from five societies across 20 countries were included. Forty-one (71%) respondents worked at academic centers. Thirty-seven (64%) practiced colorectal surgery, 24 (41%) endocrine surgery and 45 (78%) had experience in advanced minimally invasive surgery. An open, laparoscopic or robotic approach was preferred by 23 (42%), 24 (44%), and 8 (15%) respondents, respectively. Reasons to opt for a minimally invasive approach were mainly related to peri-operative benefits, while an open approach was preferred for optimal mesenteric lymphadenectomy and tactile feedback. Additional training in minimally invasive SB-NEN resection was welcomed by 29 (52%) respondents. Forty-three (74%) respondents were interested in collaborating in future studies, with a cumulative median (IQR) annual case load of 172 (86-258). Conclusions Among respondents, 69% applies minimally invasive surgery for resection of SB-NEN. Arguments for specific operative approaches differ, and insufficient training in advanced laparoscopic techniques seems to be a barrier. Future collaborative studies can provide better insight in selection criteria and optimal technique.

RATIONALE Lung ultrasound scores (LUS) might be useful in monitoring neonates with chronic pulmonary insufficiency of prematurity and in predicting bronchopulmonary dysplasia (BPD). Given their ease of use, accuracy and lack of invasiveness, LUS have been the subject of several recent studies. OBJECTIVE We sought to clarify whether LUS provide an accurate and early (within the first two weeks of life) prediction of BPD in preterm infants of gestational age 0.05). Repeating the analyses without outliers or with moderate-to-severe BPD as outcome yielded similar results. Meta-regressions showed that prenatal steroid prophylaxis and sex were not significant effect confounders. CONCLUSIONS LUS are accurate for early prediction of BPD and moderate-to-severe BPD, in an average population of preterm infants

Background: Necrotizing fasciitis is a serious infection of skin and soft tissues that rapidly progresses along the deep fascia. It’s a fatal infection with high mortality if treatment delayed. Early diagnosis, surgical debridement and broad-spectrum antibiotic therapy are the optimal treatments to reduce the mortality. Objective: The aims were to identify risk factors for Necrotizing fasciitis and to describe the outcome of management. Methods: A prospective descriptive study was conduted at AL-THAWRA HOSIPTAL located in Sana’a, Yemen. All medical records of patients with confirmed NF who admitted to surgical department between January 2020 and January 2021 were reviewed. Results: The study enrolled 54 patients diagnosed with Necrotizing fasciitis. Male patients were 43 patients (79.6%) and female patients were 11 patients (20.3%). The age rang was 9 – 75 years old and the peak age incidence was at 46–60 years (33.3%). The incidence of NF increases with aging, male gander (79.6%), in comorbid patients (64.9%) especially DM (37%). The etiologies of NF were trauma in (16.6%) and perianal abscess in (14.8%), but (27.7%) of NF patients hadn’t specific cause. The defected wound was treated by skin graft in (32.5%) and primary closure in (27.5%). The mortality rate was (27.7% n=15); (60%) of them died on first 5 days. Septic shock was the reason of death in (73.2%). The higher mortality rate was seen at male gander (66.6%), age group > 60 years (46.6%), in patients who presented in shocked state (73.3%) and in comorbid patients (73.3%). Conclusion: Necrotizing fasciitis represents a life threatening condition with challenges in diagnosis. Incidence and mortality of NF are common in male gander, an elderly patient, or in who suffers of comorbidities; especially DM.

Transient osteoporosis of the hip, also termed transient bone marrow edema, is a painful condition often occurring after trivial trauma. It can be diagnosed with MRI in patients whose radiographs are negative or inconclusive. In this case report we describe a 39-year-old female patient with this rare entity, who was successfully treated with oral Alendronate, active vitamin D and calcium supplementation combined with avoiding of weight bearing on the affected hip. She improved clinically within three months and on contrast enhanced MRI studies, as performed before and after treatment, complete regression of bone marrow edema was shown already after three months of treatment. The literature was reviewed regarding the pathophysiology of transient osteoporosis of the hip and the beneficial effects of Alendronate in this domain. The report is important because it will increase the awareness among clinicians and radiologists about this entity, as in neglected cases transient regional osteoporosis of the hip may progress to avascular necrosis with complete loss of hip function.

Introduction After high dose chemotherapy (HDC) and autologous stem cell transplantation (auto-SCT), in patients with relapsed/refractory diffuse large B cell lymphoma (DLBCL) and Hodgkin lymphoma (HL), involved field radiation therapy (RT) for consolidation and residual/progressive disease (PD) eradication is a common practice. Materials and methods Retrospective single-institution cohort analysis to evaluate the impact of early RT after HDC auto-SCT. Results Between 1996 and October 2019, 153 patients (43 DLBCL, 110 HL) underwent RT after HDC auto-SCT. Males 95 (62%), females 58 (38%), median age 24 years. Indications for RT was consolidation 65%: residual disease eradication 16%: and PD eradication 19%. For DLBCL, the median overall survival (OS) for the above indications was not reached (NR):NR:2 months and the KM 5-year OS was 72.6%:64.3%:12.5% respectively (P ≤ .000). Pair-wise analysis showed that consolidation versus residual disease eradication had no difference (P = .88) but both were superior to PD disease eradication (P ≤ 000 and P = .005 respectively). For HL, indication for RT was, 54%:23%:24% respectively. The median OS was NR:NR:28.8 months and KM 5-year OS was 82.3%:78%:30% respectively (P ≤ .000). Pair-wise analysis showed that consolidation versus residual disease eradication had no difference (P = .98) but both were superior to the PD eradication group (P ≤ 000). RT was well tolerated with no significant long-term toxicity. Conclusion Post HDC auto-SCT RT was well tolerated. DLBCL and HL patients with residual disease treated with the RT had similar long-term survival as those who received RT for consolidation. RT failed to improve the poor survival in patients with post-HDC auto-SCT PD.

Context Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol. Objective To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up. Evidence acquisition An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL. Evidence synthesis The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus. Conclusions Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL. Patient summary Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist’s experience, are critical to the safety and effectiveness of PCNL.

Key content Continuing financial constraints on the UK’s National Health Service means the need for clinicians to provide high-quality care in a cost-effective way has never been greater. While the medical education system equips doctors with skills to provide safe clinical care, it should also provide an understanding of healthcare costs and cost-effectiveness analysis. Value-based care is becoming a key paradigm in women’s health services, where clinicians must employ strategies for delivering value, rationalising costs and capitalising on the use of emerging technologies. The calculation of value of an intervention for providers and service users may differ; care must be taken to ensure this concept is adapted for, and not imposed on healthcare systems. Engaging trainees in systems transformation and embedding the concepts of ‘do no financial harm’ are essential to ensure sustainable healthcare services. Learning Objectives To understand the principles of value-based health care. To highlight the importance of adopting ‘cost-conscious’ care within daily clinical practice. To learn the differences between ‘cost’, ‘charge’, ‘price’ and ‘reimbursement. To encourage developing value-based competencies for future medical workforce through utilising out of programme placements and digital resources. Ethical Issues The ethical obligation of clinicians to consider cost may encompass justice and equity. However, the impact of practicing value-based health care is yet to be evaluated.

BackgroundThe rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU).MethodsThe SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations.ResultsThe SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations. ConclusionThe SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.

Background: Hughes-Stovin syndrome (HSS) is a systemic disease characterized by widespread vascular thrombosis and pulmonary vasculitis with serious morbidity and mortality. The HSS International Study Group is a multidisciplinary taskforce aiming to study HSS, in order to generate consensus recommendations regarding diagnosis and treatment. Methods: We included 57 published cases of HSS (43 males) and collected data regarding: clinical presentation, associated complications, hemoptysis severity, laboratory and computed tomography pulmonary angiography (CTPA) findings, treatment modalities and cause of death. Results: At initial presentation, DVT was observed in 29(33.3 %), thrombophlebitis in 3(5.3%), hemoptysis in 24(42.1%), and diplopia and seizures in 1 patient each. During the course of disease, DVT occurred in 48(84.2%) patients, and superficial thrombophlebitis was observed in 29(50.9%). Hemoptysis occurred in 53(93.0%) patients and was fatal in 12(21.1%). Pulmonary artery (PA) aneurysms (PAAs) were bilateral in 53(93%) patients. PAA were located within the main PA in 11(19.3%), lobar in 50(87.7%), interlobar in 13(22.8%) and segmental in 42(73.7%). Fatal outcomes were more common in patients with inferior vena cava thrombosis (p = 0.039) and ruptured PAAs (p < 0.001). Death was less common in patients treated with corticosteroids (p < 0.001), cyclophosphamide (p < 0.008), azathioprine (p < 0.008), combined immune modulators (p < 0.001). No patients had uveitis; 6(10.5%) had genital ulcers and 11(19.3%) had oral ulcers. Conclusions: HSS may lead to serious morbidity and mortality if left untreated. PAAs, adherent in-situ thrombosis and aneurysmal wall enhancement are characteristic CTPA signs of HSS pulmonary vasculitis. Combined immune modulators contribute to favorable outcomes.

Objectives To study the frequency of different autoantibodies to extractable nuclear antigens (ENAs) in rheumatoid arthritis (RA) patients and to correlate findings with clinical manifestations, disease activity and radiological damage. Methods A total of 230 RA patients were included and 75 healthy controls. In all patients rheumatological assessment was done and routine laboratory investigations and immune profile were performed in both patients and controls, including: RF, ACPA, ANA and anti-ENAs (Ro/SSA, La/SSB, U1-RNP, anti-Jo-1 and anti-Sm). Radiological damage was scored using Sharp/van der Heijde, and disease activity was evaluated by DAS28-ESR and DAS28-CRP. Results RF was positive in 101 (43.9%), ACPA in 220 (95.7%), ANA in 58 (25.2%), anti Ro in 31 (13.5%), anti-La in 10 (4.3%), anti-Jo1 in 5 (2.2%) and anti-RNP in 2 (0.9%). Anti-Ro/SSA positively correlated with sicca symptoms (p = .02), RF titer (p < .001), ANA (p < .001), DAS28-ESR (p = .026), and DAS28-CRP (p = .003). Anti-La antibodies correlated positively with SJC (p = .001), TJC (p = .001), ANA (p < .001), DAS-28 ESR (p = .007). Anti-Jo-1 correlated positively with interstitial lung disease (ILD) (p ≤ .001), RF titer (p = .037) and ANA (p ≤ .001). Anti-RNP antibodies correlated positively with disease duration (p ≤ .001), ACPA titer (p ≤ .001) and ANA (p = .014). In the controls ANA was positive in two (2.7%), anti-Ro in three (4%), and none of the controls tested positive for other autoantibodies. Conclusions In RA patients, positive ANA is frequent and positively associated with anti-Ro, anti-La and anti-Jo1 autoantibodies. Screening for autoantibodies against other anti-ENAs seems mandatory in RA patients especially when ANA is positive. RA cases with positive Anti-Jo-1 may develop anti synthetase syndrome and ILD.

Background: Myocardial infarction (MI) accompanies with different mechanical complications including ischemic mitral regurgitation (IMR) which is correlated with increased risk of mortality and heart failure. IMR existence and its severity had significant prognostic effect on patients’ mortality following acute myocardial infarction (AMI). Echocardiography is the choice imaging modality for the diagnosis and assessment of IMR and establishing its etiology. IMR usually results from papillary muscle displacement, ventricular dilation and remodeling with reduced closing forces. Objective: Assessment of the correlation between echocardiographic severity of ischemic mitral valve regurgitation following acute myocardial infarction and its electrocardiographic location. Patients and methods: This was a prospective study that included 100 patients admitted to CCU OF Beni-Suief General Hospital in the period from October 2019 to May 2020 . Those patients were divided on two equal groups: Group I: patients with STEMI and no, trivial or mild MR and Group II: patients with STEMI and moderate or severe MR. Results: Mean age of group I involved in the study was 55.44 ± 7.23 years and 70% of them were males. Mean age of group II was 58.38 ± 7.8 and 56% were males. 70 % of the group II had inferolateral STEMI compared to group I who had more anterior STEMI. Group II were more smokers with hyperlipidemia. Group II was with higher previous stable and unstable angina, with less streptokinase treatment, with higher abnormal chest radiogrgh and higher killip class. Group II had significantly lower EF and higher LVEDD, LVESD, LA diameter, RV diameter, MV A velocity, tricuspid valve excursion TAPSI and pulmonary artery pressure and more diastolic dysfunction. Mechanism of IMR in case group was mono leaflet tethering in 43 cases, both leaflet tethering in 7 cases and ring dilation in 30 cases. MR jet direction was medial commissure posterior in 31 (62%), lateral commissure anterior in 12 (24%), and both commissures central in 7 (14%) cases. Conclusion: Mitral regurgitation is common after acute myocardial infarction, especially in cases with inferior mitral regurgitation. The echocardiographic findings are indicative of left ventricular remodeling and abnormality of mitral valve apparatus.

Background: Despite advances in surgery and pharmacotherapy, there remains significant residual ischemic risk after coronary artery bypass grafting surgery. Methods: In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial), a multicenter, placebo-controlled, double-blind trial, statin-treated patients with controlled low-density lipoprotein cholesterol and mild to moderate hypertriglyceridemia were randomized to 4 g daily of icosapent ethyl or placebo. They experienced a 25% reduction in risk of a primary efficacy end point (composite of cardiovascular death, myocardial infarction, stroke, coronary revascularization, or hospitalization for unstable angina) and a 26% reduction in risk of a key secondary efficacy end point (composite of cardiovascular death, myocardial infarction, or stroke) when compared with placebo. The current analysis reports on the subgroup of patients from the trial with a history of coronary artery bypass grafting. Results: Of the 8179 patients randomized in REDUCE-IT, a total of 1837 (22.5%) had a history of coronary artery bypass grafting, with 897 patients randomized to icosapent ethyl and 940 to placebo. Baseline characteristics were similar between treatment groups. Randomization to icosapent ethyl was associated with a significant reduction in the primary end point (hazard ratio [HR], 0.76 [95% CI, 0.63–0.92]; P =0.004), in the key secondary end point (HR, 0.69 [95% CI, 0.56–0.87]; P =0.001), and in total (first plus subsequent or recurrent) ischemic events (rate ratio, 0.64 [95% CI, 0.50–0.81]; P =0.0002) compared with placebo. This yielded an absolute risk reduction of 6.2% (95% CI, 2.3%–10.2%) in first events, with a number needed to treat of 16 (95% CI, 10–44) during a median follow-up time of 4.8 years. Safety findings were similar to the overall study: beyond an increased rate of atrial fibrillation/flutter requiring hospitalization for at least 24 hours (5.0% vs 3.1%; P =0.03) and a nonsignificant increase in bleeding, occurrences of adverse events were comparable between groups. Conclusions: In REDUCE-IT patients with a history of coronary artery bypass grafting, treatment with icosapent ethyl was associated with significant reductions in first and recurrent ischemic events. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01492361.

Background and study aims: Gastrointestinal manifestations are common during coronavirus disease (COVID-19) infection. Indeed, they can occur before respiratory symptoms, resulting in a diagnostic delay and an increased risk of disease transmission. The current study reports that major gastrointestinal manifestations as initial symptoms of COVID-19 may suggest the diagnosis in patients who have been exposed, even in the absence of respiratory symptomatology. Patients and methods This prospective, descriptive, cross-sectional, and monocentric study of 713 cases was conducted in a field hospital in Morocco over a 5-week period from June 21 to July 25, 2020. Results The average age of our patients was 31.95 years. Clinically, on admission, anorexia was the main symptom, present in 32.3% of patients. Gastrointestinal manifestations were present in 14.9% of patients, including watery diarrhea in 8.6% of cases, nausea and/or vomiting in 4.6% of cases, and abdominal pain in 1.6% of cases. Six hundred thirty-two patients were treated in accordance with one of the two therapeutic protocols recommended by the National Ministry of Health. The treatment-related effects that occurred in 61.4% of patients were primarily digestive in 55.3% of cases. In multivariate analysis, following adjustment of the studied parameters, only the presence of gastrointestinal manifestations (odds ratio [OR]: 1.478 confidence interval [CI]: 1.286–1.698; p < 0.001) and treatment side effects (OR = 1.069, CI: 1.020–1.119, p = 0.005) altered the rate of negative polymerase chain reaction (PCR) tests on day 10. Conclusion Gastrointestinal manifestations are common during COVID-19 and appear to be linked to a longer duration of the disease. SARS-CoV-2 (the causative virus of COVID-19) can persist in the digestive tract, with the possibility of fecal–oral transmission. Therefore, hygiene is extremely important, especially handwashing and strict precautions when performing gastrointestinal endoscopy and handling stools from infected patients.

Objectives This study sought to determine whether the increased use of telehealth was associated with a difference in outcomes for outpatients with heart failure. Background The COVID-19 pandemic led to dramatic changes in the delivery of outpatient care. It is unclear whether increased use of telehealth affected outcomes for outpatients with heart failure. Methods In March 2020, a large Midwestern health care system, encompassing 16 cardiology clinics, 16 emergency departments, and 12 hospitals, initiated a telehealth-based model for outpatient care in the setting of the COVID-19 pandemic. A propensity-matched analysis was performed to compare outcomes between outpatients seen in-person in 2018 and 2019 and via telemedicine in 2020. Results Among 8,263 unique patients with heart failure with 15,421 clinic visits seen from March 15 to June 15, telehealth was employed in 88.5% of 2020 visits but in none in 2018 or 2019. Despite the pandemic, more outpatients were seen in 2020 (n = 5,224) versus 2018 and 2019 (n = 5,099 per year). Using propensity matching, 4,541 telehealth visits in 2020 were compared with 4,541 in-person visits in 2018 and 2019, and groups were well matched. Mortality was similar for telehealth and in-person visits at both 30 days (0.8% vs 0.7%) and 90 days (2.9% vs 2.4%). Likewise, there was no excess in hospital encounters or need for intensive care with telehealth visits. Conclusions A telehealth model for outpatients with heart failure allowed for distanced encounters without increases in subsequent acute care or mortality. As the pressures of the COVID-19 pandemic abate, these data suggest that telehealth outpatient visits in patients with heart failure can be safely incorporated into clinical practice., Central Illustration

OBJECTIVE To evaluate race and ethnicity differences in cesarean birth and maternal morbidity in low-risk nulliparous people at term. METHODS We conducted a secondary analysis of a randomized trial of expectant management compared with induction of labor in low-risk nulliparous people at term. The primary outcome was cesarean birth. Secondary outcome was maternal morbidity, defined as: transfusion of 4 or more units of red blood cells, any transfusion of other products, postpartum infection, intensive care unit admission, hysterectomy, venous thromboembolism, or maternal death. Multivariable modified Poisson regression was used to evaluate associations between race and ethnicity, cesarean birth, and maternal morbidity. Indication for cesarean birth was assessed using multivariable multinomial logistic regression. A mediation model was used to estimate the portion of maternal morbidity attributable to cesarean birth by race and ethnicity. RESULTS Of 5,759 included participants, 1,158 (20.1%) underwent cesarean birth; 1,404 (24.3%) identified as non-Hispanic Black, 1,670 (29.0%) as Hispanic, and 2,685 (46.6%) as non-Hispanic White. Adjusted models showed increased relative risk of cesarean birth among non-Hispanic Black (adjusted relative risk [aRR] 1.21, 95% CI 1.03-1.42) and Hispanic (aRR 1.26, 95% CI 1.08-1.46) people compared with non-Hispanic White people. Maternal morbidity affected 132 (2.3%) individuals, and was increased among non-Hispanic Black (aRR 2.05, 95% CI 1.21-3.47) and Hispanic (aRR 1.92, 95% CI 1.17-3.14) people compared with non-Hispanic White people. Cesarean birth accounted for an estimated 15.8% (95% CI 2.1-48.7%) and 16.5% (95% CI 4.0-44.0%) of excess maternal morbidity among non-Hispanic Black and Hispanic people, respectively. CONCLUSION Non-Hispanic Black and Hispanic nulliparous people who are low-risk at term undergo cesarean birth more frequently than low-risk non-Hispanic White nulliparous people. This difference accounts for a modest portion of excess maternal morbidity.

Introduction: The aim of the study was to examine the efficacy of JJ stenting in comparison with percutaneous nephrostomy (PCN) as a drainage method in patients with emphysematous pyelonephritis (EPN). Methods: We retrospectively identified patients with EPN between January 2000 and January 2021. Platelet-to-leukocytic ratio (PLR) at the time of hospital admission and discharge, time taken to clear air locules and to normalize leukocytic count, and air locule volume in mm3 were identified. Renal drainage by either PCN or JJ stent was required if symptoms persist for ≥3 days or in obstructed renal units. Failure of drainage method was defined as conversion to another method of drainage, need for intensive care unit admission, salvage nephrectomy, and mortality. Results: Twenty-nine patients were managed by JJ stent. Treatment success was identified in 20 patients and 19 patients who were managed by PCN and JJ stent, respectively. Higher air locule volume ≥16.7 mm3 and lower PLR ≤18.4 increased the risk of drainage failure (p = 0.009 and 0.001, respectively). Conclusion: Ureteral JJ stenting is an effective method for EPN drainage with a comparable overall success to the PCN use. Higher air locule volume and lower PLR increased the risk of drainage failure.

BACKGROUND Little is known about viral-associated hemophagocytic lymphohistiocytosis (HLH) in Oman. This study was done to assess the epidemiology, clinical features and outcome of viral-associated HLH in our setting. METHODS We retrospectively reviewed children (0-18 years) managed for viral-associated HLH at the Sultan Qaboos University Hospital, Oman, over a 15-year period (2006-2020). Patients' medical records were used to describe their demographic, clinical and laboratory features, management and outcome. RESULTS Fifty-six children were managed for HLH at Sultan Qaboos University Hospital over the last 15 years (2006-2020) of whom a third (19; 34%) had a viral trigger. The median age at the time of diagnosis of viral-associated HLH was 83 (13-96) months. Fever, cytopenia, hyperferritinemia and evidence of hemophagocytosis in bone marrow were the most consistent findings. Most of these children had either genetic predisposition to HLH (8/19; 42%) or underlying immunodeficiency secondary to malignant conditions or chemotherapy/hematopoietic stem cell transplantation (6/19; 32%). Epstein-Barr virus (9; 47%) followed by cytomegalovirus (6; 31%) was the most common viral trigger in our setting. Treatment included antivirals (8; 42%), HLH 2004 protocol (4; 21%), rituximab (4; 21%) and hematopoietic stem cell transplantation (3; 16%). Fourteen children (74%) had full recovery. CONCLUSIONS In our small cohort, viral-associated HLH was more frequently encountered in children with genetic predisposition to HLH or children with underlying immunodeficiency. In addition, we found that the outcome is overall good for children who have no genetic predisposition to HLH and children with genetic predisposition who underwent hematopoietic stem cell transplantation.

Summary A best evidence topic was constructed according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgery (VATS), compared to open lung resection, resulted in improved postoperative clinical outcomes, in patients with localized bronchiectasis indicated for surgery. A total of 1352 papers were found using the reported search, of which 5 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All of the identified studies were retrospective. The conversion rate from VATS to open procedure ranged from 0% to 15.3%. In comparison to thoracotomy, VATS resulted in a significant reduction of postoperative blood loss (1 study), length of hospital stay (2 studies), postoperative complication rate (2 studies), pain scales (2 studies) and chest tube duration (1 study). However, there was a significant increase in operative time (1 study) and whole cost (2 studies). There was no significant difference in the clinical recovery, which was defined by the disappearance or improvement of preoperative symptoms during the follow-up period (3 studies). We conclude that although there is limited high-level evidence, retrospective studies have suggested that VATS could significantly reduce complications rate, postoperative blood loss, pain scales, length of hospital stay and chest tube duration compared to open lung resection in selected patients with localized bronchiectasis.

BACKGROUND In mild psoriasis, topical agents remain the mainstay of treatment. However, the available treatments are not satisfactory for a significant proportion of patients in many terms such as efficacy and safety. Because of these deficits, augmentation of therapeutic effect seems desirable. THIS STUDY AIMS To evaluate the efficacy of topical cyclosporine cream, delivered by fractional CO2 laser vs the efficacy of topical clobetasol cream for the treatment of mild to moderate plaque psoriasis. PATIENTS AND METHODS Twenty-two patients with chronic plaque psoriasis involving

Lead has long been known as neurotoxic and immunotoxic heavy metal in human and animals including fish, whereas, 2, 3-dimethylsuccinic acid (DMSA) and fulvic acid (FA) are well-known biological chelators. The present investigation was carried out to assess the potential chelating and antioxidant effects of dietary supplementation with DMSA and FA against lead acetate (Pb)-induced oxidative stress in Nile tilapia, O. niloticus. One-hundred and eighty apparently healthy O. niloticus fish (30 ± 2.5 g) were allocated into six equal groups. The first group was fed on basal diet and served as control, while the second group was fed on DMSA-supplemented basal diets at levels of 30 mg/kg diet; the third group was fed on FA-supplemented basal diet at level of 0.3 mg/kg diet; the forth, fifths, and sixth groups were exposed to 14.4 mg Pb /L water (1/10 LC50) and feed on basal diet only, basal diet supplemented with DMSA (0.3 mg/kg diet), or basal diet supplemented with FA (0.3 mg/kg diet), respectively. Antioxidant and lipid peroxidative status, activity of glucose 6-phosphate dehydrogenase (G6PD), and lactate dehydrogenase (LDH) as well as the histopathologic findings were evaluated in brain tissues, while the Pb residues were evaluated in liver, muscles, and brain tissues. The results of the present study showed that DMSA and FA decreased malondialdehyde (MDA) and Pb residue in tissues of Pb-exposed fish and improved the histologic picture and brain contents of glutathione (GSH), glutathione-s-transferase (GST), glutathione peroxidase (GPx), superoxide dismutase (SOD), catalase (CAT), G6PD, LDH, and total antioxidant capacity (TAC). It could be concluded that DMSA and FA supplementation exhibited potential neuroprotective effect against Pb-induced oxidative brain damages in O. niloticus through improvement of antioxidant status of the brain tissue.

Physiologic-based management of hemodynamic instability is proven to guide the logical selection of cardiovascular support and shorten the time to clinical recovery compared to an empiric approach that ignores the heterogeneity of the hemodynamic instability related mechanisms. In this report, we classified neonatal hemodynamic instability, circulatory shock, and degree of compensation into five physiologic categories, based on different phenotypes of blood pressure (BP), other clinical parameters, echocardiography markers, and oxygen indices. This approach is focused on hemodynamic instability in infants with normal cardiac anatomy.Conclusion: The management of hemodynamic instability is challenging due to the complexity of the pathophysiology; integrating different monitoring techniques is essential to understand the underlying pathophysiologic mechanisms and formulate a physiologic-based medical recommendation and approach. What is Known: • Physiologic-based assessment of hemodynamics leads to targeted and pathophysiologic-based medical recommendations. What is New: • Hemodynamic instability in neonates can be categorized according to the underlying mechanism into five main categories, based on blood pressure phenotypes, systemic vascular resistance, and myocardial performance. • The new classification helps with the targeted management and logical selection of cardiovascular support.

Background To compare the outcomes between classic tubularized incised plate (C-TIP), known as Snodgrass urethroplasty, and grafted TIP (G-TIP) in the repair of primary distal penile hypospadias. Methods Parents of all children presented to our tertiary care institution with primary distal penile hypospadias were asked to participate in this study. Patients were equally randomized using closed envelope method into two groups; Group A underwent repair using G-TIP and Group B underwent repair using the C-TIP. Circumcised cases and/or cases with penile chordee > 30 degrees were excluded from this study. Urethral catheter was kept for 7 to 10 days after surgery. The success rate and cosmetic outcomes assessed by HOSE score were evaluated at 6-month postoperatively. Results A total of 55 patients were recruited in each group. One hundred and seven patients of the 110 patients (54 and 53 in groups A and B, respectively) were evaluated at 6-month postoperatively using HOSE score. All preoperative data were comparable in both groups. Success was documented in 49/54 patients (90.7%) in group A. The five failures were secondary to two cases of glans dehiscence and three cases of residual postoperative chordee. Whereas, success was documented in 48/53 patients (90.5%) in group B. Complications were: a case of meatal stenosis, three cases of fistula, and a case of combined meatal stenosis and fistula. The HOSE score was comparable between the two groups (15.4 ± 1.09 vs. 15.6 ± 0.55; p = 0.29). However, the operative time was statistically longer in the G-TIP compared with the C-TIP (91.4 ± 6.2 min vs. 85.2 ± 6.3 min; p Conclusion The G-TIP urethroplasty provided comparable results with C-TIP in terms of cosmoses, success rate, and complications. However, G-TIP was accompanied with significantly longer operative time.

Abdulaziz A Qurashi,1 Rashed K Alanazi,1 Yasser M Alhazmi,1 Ahmed S Almohammadi,1 Walaa M Alsharif,1 Khalid M Alshamrani2,3 1Diagnostic Radiology Technology Department, College of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia; 2College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; 3King Abdullah International Medical Research Center, Jeddah, Saudi ArabiaCorrespondence: Abdulaziz A QurashiDiagnostic Radiology Technology, Taibah University, Madinah, 42353, Saudi ArabiaTel +966 14 861 8888 Ext. 3603Email aaqurashi@taibahu.edu.saPurpose: Artificial intelligence (AI) in radiology has been a subject of heated debate. The external perception is that algorithms and machines cannot offer better diagnosis than radiologists. Reluctance to implement AI maybe due to the opacity in how AI applications work and the challenging and lengthy validation process. In this study, Saudi radiology personnel’s familiarity with AI applications and its usefulness in clinical practice were investigated.Methods: A cross-sectional study was conducted in Saudi Arabia among radiology personnel from March to April 2021. Radiology personnel nationwide were surveyed electronically using Google form. The questionnaire included 12-questions related to AI usefulness in clinical practice and participants’ knowledge about AI and their acceptance level to learn and implement this technology into clinical practice. Participants’ trust level was also measured; Kruskal–Wallis test was used to examine differences between groups.Results: A total of 224 respondents from various radiology-related occupations participated in the survey. The lowest trust level in AI applications was shown by radiologists (p = 0.033). Eighty-two percent of participants (n = 184) had never used AI in their departments. Most respondents (n = 160, 71.4%) reported lack of formal education regarding AI-based applications. Most participants (n = 214, 95.5%) showed strong interest in AI education and are willing to incorporate it into the clinical practice of radiology. Almost half of radiography students (22/46, 47.8%) believe that their job might be at risk due to AI application (p = 0.038).Conclusion: Radiology personnel’s knowledge of AI has a significant impact on their willingness to learn, use and adapt this technology in clinical practice. Participants demonstrated a positive attitude towards AI, showed a reasonable understanding and are highly motivated to learn and incorporate it into clinical practice. Some participants felt that their jobs were threatened by AI adaptation, but this belief might change with good training and education programmes.Keywords: artificial intelligence, AI-based applications, radiology, radiologists, imaging modalities

To assess the relationship between vitamin D deficiency and severity of coronary artery disease using multislice CT coronary angiography.100 patients diagnosed with coronary artery disease during multislice CT coronary angiography were subjected to full evaluation of coronary artery disease severity followed by measurement of serum vitamin D level.The mean value of serum vitamin D level was 13.35±7.49ng/ml. 76% of the patients had vitamin D deficiency (20ng/ml). 41% of the patients had single vessel disease, 28% had two vessel diseases, and 31% had multi-vessel disease. Patients with vitamin D deficiency had higher degree of coronary stenosis, higher coronary Ca score (p0.001) and higher number of affected vessels compared with normal vitamin D level subgroup (p0.001). Vitamin D level showed a significant negative correlations with age (r=-0.290, p=0.003), coronary Ca score (r=-0.630, p0.001) and severity of coronary lesions. Multivariate linear regression analysis showed that dyslipidemia and vitamin D level were independent predictors of percent severity of coronary stenosis.In addition to traditional cardiovascular risk factors, vitamin D deficiency looks to be independent predictor of coronary artery disease severity including percent stenosis, number of the affected vessels as well as degree of coronary calcification.

Background Video-assisted thoracoscopic sympathectomy (VATS) is a common procedure unusually practiced by neurosurgeons due to lack of training. Objective To evaluate the learning curve for VATS in a young neurosurgeon with no previous experience in open sympathectomy techniques or extracranial endoscopic procedures. Methods This is a retrospective review and analysis of prospectively collected data in 50 consecutive cases admitted to our facility with the diagnosis of essential palmar and axillary hyperhidrosis operated by a neurosurgical trainee under strict supervision of 2 experienced mentors. After an initial training phase, cumulative sum mation (CUSUM) analysis was used to evaluate the surgical performance of the trainee in terms of operating time, blood loss, hospital stay and failures. Results Improvement in operating time was noticed after the first 20 cases with significant affection by changes in OR team. The blood loss was significantly improved after the first 10 cases with less sensitivity to changes in OR team. Hospital stay and failures were steady and within expected values throughout the study. Conclusion An average of 20 cases may be enough for a neurosurgeon with basal knowledge to attain technical competence in VATS sympathectomy. Mentored surgical training on VATS sympathectomy is a safe and effective training method with failures within expected limits. The experience of the OR team plays an important role in the rapid improvement and consistency of performance.

Candida utilis and Stenotrophomonas maltophilia co-infections connected to meningitis are uncommon. We describe a patient who developed C. utilis and S. maltophilia after undergoing neurosurgery and received effective nosocomial meningitis treatment. Multiple neurosurgeries were required for a 16-year-old girl due to complications. For probable nosocomial meningitis, she was treated with cefepime with vancomycin. Meropenem and liposomal amphotericin B were prescribed after her seizure and positive CSF culture for Candida utilis. Consequently, S. maltophilia was discovered in the CSF, and ceftazidime and trimethoprim-sulfamethoxazole were prescribed. The patient has been hemodynamically stable for the past two months, and consecutive CSF cultures have been negative. To the best of our knowledge, this is the first case of C. utilis and S. maltophilia co-infection that has been successfully handled.

Background: Hand osteoarthritis (OA) can be a distressing disorder that impairs a patients' quality of life. There is a relation between OA and vascular damage, especially atherosclerosis, and OA are both common chronic conditions associated with aging and obesity. Aim of the study: The objective of this research was to examine nailfold microcirculation in individuals with hand OA Patients and Methods: a cross-sectional, observational study, about 56 patients with hand OA were enrolled. All subjects underwent a standard radiology X-Ray examination of the hands and a Nailfold vascular examination was performed. Results: of the 56 patients studied were females, and 12 were males. Regarding the Kellgren and Lawrence scoring, it was mild (grade II) in one patient (50%) and severe (grade IV) in one patient (50%) in the male patients without pain, while in those with hand pain, it was moderate (grade III) in eight patients (80%) and severe (grade IV) in two patients (20%).it was mild (grade II) in eight patients (22.2%), moderate (grade III) in 21 patients (58.3%) and severe (grade IV) in seven patients (19.4%). Nailfold examination for studied subjects showed that there were about 41 patients (73.2%) with low capillary density and 32 patients (57.1%) with morphological changes. Conclusion: Our findings provided a general description of the NFC findings most likely to be seen in OA patients; Vascular anomalies may play a role in the illness progression and may assist in elucidating because the condition is frequently found in the distal digit joints.

Metabolic (dysfunction)-associated fatty liver disease (MAFLD) affects a third of the population and is a leading cause of liver-related death. Since no effective treatments exist, novel approaches to drug development are required. Unfortunately, outdated terminology and definitions of the disease are hampering efforts to develop new drugs and treatments. An international consensus panel has put forth an influential proposal for the disease to be renamed from nonalcoholic fatty liver disease (NAFLD) to MAFLD, including a proposal for how the disease should be diagnosed. As allies with the many stakeholders in MAFLD care―including patients, patients’ advocates, clinicians, researchers, nurse and allied health groups, regional societies, and others―we are aware of the negative consequences of the NAFLD term and definition. We share the sense of urgency for change and will act in new ways to achieve our goals. Although there is much work to be done to overcome clinical inertia and reverse worrisome recent trends, the MAFLD initiative provides a firm foundation to build on. It provides a roadmap for moving forward toward more efficient care and affordable, sustainable drug and device innovation in MAFLD care. We hope it will bring promising new opportunities for a brighter future for MAFLD care and improve care and outcomes for patients of one of the globe’s largest and costliest public health burdens. From this viewpoint, we have revisited this initiative through the perspectives of drug development and regulatory science.

OBJECTIVE To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy. METHODS We retrospectively examined SMM using linked birth certificate and maternal hospital discharge records in California between 2007 and 2012. Epilepsy present at delivery admission was the exposure and was subtyped into generalized, focal and other less specified, or unspecified. The outcomes were SMM and nontransfusion SMM from delivery up to 42 days' postpartum, identified using Centers for Disease Control and Prevention indicators. Multivariable logistic regression models were used to adjust for confounders, which were selected a priori. We also estimated the association between epilepsy and SMM independent of comorbidities by using a validated obstetric comorbidity score. Severe maternal morbidity indicators were then compared using the same multivariable logistic regression models. RESULTS Of 2,668,442 births, 8,145 (0.3%) were to patients with epilepsy; 637 (7.8%) had generalized, 6,250 (76.7%) had focal or other less specified, and 1,258 (15.4%) had unspecified subtypes. Compared with patients without epilepsy, patients with epilepsy had greater odds of SMM (4.3% vs 1.4%, adjusted odds ratio [aOR] 2.91, 95% CI 2.61-3.24) and nontransfusion SMM (2.9% vs 0.7%, aOR 4.16, 95% CI 3.65-4.75). Epilepsy remained significantly associated with increased SMM and nontransfusion SMM after additional adjustment for the obstetric comorbidity score, though the effects were attenuated. When grouped by organ system, all SMM indicators were significantly more common among patients with epilepsy-most notably those related to hemorrhage and transfusion. CONCLUSION Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.

Background Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. Methods A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. Results The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. Conclusion Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Background Gaza has long been enduring a quasi-total siege that significantly undermines quality of life in the region. Gazan youth are particularly affected by the ongoing economic recession, a disrupted environment, and health and food insecurity. These critical circumstances are worsened by the ongoing conflict between Palestine and Israel, which is a cause of death and destruction. Aims This cross-sectional study investigated the effects of living under protracted siege conditions on mental distress, resilience, and social support among a sample of Palestinian university students living on the Gaza Strip. Methods Five hundred fifty Palestinian university students were recruited at four universities in Gaza. They completed a battery of instruments, including the Gaza Siege Checklist, Depression, Anxiety and Stress Scale (DASS), Resilience Scale (RS), and Berlin Social Support Scales (BSSS). We used structural equation modelling (SEM) to test a conceptual model of social support and resilience as protective factors against the impact on mental distress of living under siege. Results Our findings indicate that living under siege has direct adverse effects, leading to increased mental distress in the form of anxiety, depression, and acute stress. Enduring siege conditions compromises resilience and sources of social support, thereby increasing subjects' risk of developing psychological distress.

BACKGROUND This study evaluated the utility of self-reported quality of life (QOL) metrics in predicting mortality among all-comers with renal cell carcinoma (RCC) and externally tested the findings in a registry of patients with small renal masses. METHODS The Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) captured QOL metrics composed of mental component summary (MCS) and physical component summary (PCS) scores. Regression models assessed associations of MCS and PCS with all-cause, RCC-specific, and non-RCC-specific mortality. Harrell's concordance statistic (the C-index) and the Akaike information criterion (AIC) determined predictive accuracy and parsimony, respectively. Findings were tested in the prospective Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry. RESULTS In SEER-MHOS, 1494 patients had a median age of 73.4 years and a median follow-up time of 5.6 years. Each additional MCS and PCS point reduced the hazard of all-cause mortality by 1.3% (95% CI, 0.981-0.993; P < .001) and 2.3% (95% CI, 0.971-0.984; P < .001), respectively. Models with QOL metrics demonstrated higher predictive accuracy (C-index, 72.3% vs 70.1%) and parsimony (AIC, 9376.5 vs 9454.5) than models without QOL metrics. QOL metrics exerted a greater effect on non-RCC-specific mortality than RCC-specific mortality. External testing in the DISSRM registry confirmed these findings with similar results for all-cause mortality. CONCLUSIONS Models with self-reported QOL metrics predicted all-cause mortality in patients with RCC with higher accuracy and parsimony than those without QOL metrics. Physical health was a stronger predictor of mortality than mental health. The findings support the incorporation of QOL metrics into prognostic models and patient counseling for RCC.

Objective: We conducted this study to determine the associations of possible risk factors and prevalence of recurrent otitis media with effusion (OME) in a cohort of children in Upper Egypt. Methods: This was a cross-sectional study undertaken in two tertiary referral centers in Upper Egypt. Associations of possible risk factors with prevalence of recurrent OME were studied. Multi-factor logistic regression analysis was done to recognize the statistically significant risk factors associated with recurrent OME. Results: We collected the data of 2003 pediatric patients, of which 1016 were males (50.7%). A total number of 310 children have OME, including 159 males (51.3%). The prevalence rate of OME in our cohort was 15.5%. Multi-factor logistic regression analysis of the risk factors related to recurrent OME showed it was strongly associated with adenoid hypertrophy (P

Background: Any protrusion through the anterior abdominal wall with the exception of hernia through the inguino-femoral region is defined as ventral hernia. Incisional hernia and primary defects in the abdominal fascia, which can cause umbilical hernia, epigastric hernia, para-umbilical hernia and spigelian hernia are grouped under the definition of ventral hernia. Objective: To evaluate the recurrence rate of laparoscopic ventral hernia repair with closure and non-closure of the hernia defect in non-complicated ventral hernia cases. Patients and Methods: This prospective randomized study was conducted from March, 2015 till December, 2019 in General Surgery Department, Mansoura University Hospital. It involved 50 patients with ventral hernia, who were classified randomly into 2 groups by computer generated sampling technique after retrieval of the calculated sample size according to inclusion and exclusion criteria. Results: The mean age of the non-closure group and of the closure group was 39.96 ± 6.52 and 39.84 ± 7.48 years respectively. The males were 36.0% and females were 64.0% in non-closure group, while in the closure group males were 24.0%, and the females were 76.0%. The mean BMI in the non-closure group was 31.44 ± 3.76 kg/m2, while in the closure group was 30.88 ± 3.70 kg/m2. In the non-closure group, the most common hernia sites were epigastric (60.0%), followed by umbilical (40.0%) while in the closure group, the most common hernia sites were umbilical (96.0%). Conclusion: Laparoscopic ventral hernia repair is a safe and feasible technique. The great advance in abdominal laparoscopic surgery and advance in the equipments and instruments as well as individual skills make closure of the hernia defect represents a good alternative to conventional laparoscopic ventral hernia repair (LVHR) with mesh only.

Purpose Acne vulgaris is an inflammatory disorder of the skin and is the most common dermatological disease, affecting all ages and races. Acne is known to be associated with depression. This study aimed to assess the impact of depression on patient adherence to acne vulgaris treatment using The Expectation Confirmation Theory (ECT). Patients and Methods This cross-sectional study was conducted with 204 patients with acne using four scales (depression, satisfaction, intention to adhere to acne medication, and control for confirmation). ECT scales were used to assess patient satisfaction and intention to adhere to medication. Demographic data were also collected, and descriptive and analytical statistical analyses were performed. Results A total of 204 questionnaires were completed. The mean age of the respondents was 25 ± 7.2. The majority were female; 167 (83.50%). Multiple linear regression analysis indicated a negative association between depression (β= −0.121, p = 0.033; 95% CI, −0.232 to −0.009) and satisfaction, when holding other variables constant, and the expected medication effect (confirmation) had a positive association with satisfaction (β= 0.334, p< 0.001; 95% CI, 0.202 to 0.466), keeping all other factors constant. Male sex was negatively associated with satisfaction (β= −2.388, p= 0.015; 95% CI −4.303 to −0.473), while keeping all other covariate sconstant. Residence in central provinces was a significant predictor of satisfaction (β= 2.562, p= 0.004; 95% CI, 0.832 to 4.292), when holding other factors constant. After conducting a simple linear regression, a positive significant association was found between adherence and satisfaction (β = 0.1713; 95% CI, 0.068 to 0.274). Conclusion Adherence is the cornerstone for a successful treatment plan and prevention of relapse or treatment failure, and satisfaction is an essential indicator for improving health policies and implementing social service provisions.

Introduction Fibromyalgia syndrome (FMS) is a chronic condition characterized by generalized body pain, and mood disturbances of unknown etiology. Electromagnetic hypersensitivity (EHS), where patients report “hypersensitivity” to electro-magnetic fields (EMF). They wonder whether aches and pains, headaches, depression, sleeping disorders, could be associated with EMF exposure. Aim of the work Is to investigate if fibromyalgia symptoms and scores are affected by the exposure to EMF. Patients and methods This study included 80 FMS patients. The numerical pain rating scale (NPRS), Montgomery-Asberg Depression Rating Scale (MADRS) and the revised fibromyalgia impact questionnaire (FIQR) were used. A patient self-reporting questionnaire invented by the authors in Arabic for the frequency and intensity of EMF exposure was validated and used. Results The mean age of the patients was 38.7 ± 11 years and mean disease duration 4.5 ± 2.4 years. The male to female ratio was 1:2.8. A near-by cellular phone or electric tower did not significantly affect disease scores (p > 0.05), Microwave users appeared to have higher wide spread pain index (WPI) and system severity (SS) scores than non-users, but the difference was not statistically significant (p = 0.08 and 0.06) respectively. FMS scores significantly increased with higher TV watching duration, while MADRS score significantly decreased with higher cellular phone use indices. MADRS depression score was increased with shorter distance from electric tower, though not statistically significant (p = 0.76) Conclusion This study highlights a possible pathological link between fibromyalgia and exposure to electromagnetic radiation. Excess exposure to electromagnetic devices could be one of the underlying or at least augmenting factors of fibromyalgia symptoms.

Objectives Confirm existence of COVID-19 outbreak, conduct contact tracing, and recommend control measures. Methods Two COVID-19 cases in Sana’a Capital met the WHO case definition. Data were collected from cases and contacts who were followed for 14 days. Nasopharyngeal swabs were taken for confirmation by Polymerase Chain Reaction (PCR). Results Two confirmed Yemeni male patients aged 20 and 40 years who had no travel history were admitted to hospital on 24 April 2020. Regarding the first patient, symptoms started on April 18th, 2020 then the patient improved and was discharged on May 5th, while the second patient’s symptoms started on April 22nd but the patient died on April 29th, 2020. Both patients had 54 contacts, 17 (32%) were health workers (HWs). Four contacts (7%) were confirmed, two of them were HWs that needed hospitalization. The secondary attack rate (sAR) was 12% among HWs compared to 5% among other contacts. Conclusions First COVID-19 outbreak was confirmed among Yemeni citizens with a high sAR among HWs. Strict infection control among HWs should be ensured. Physical distancing and mask-wearing with appropriate disinfecting measures should be promoted especially among contacts. There is a need to strengthen national capacities to assess, detect, and respond to public health emergencies.

Background: Heart failure (HF) is a major and growing public health problem, as 21 million adults worldwide are living with heart failure and this number is expected to rise due to aging population, increasing prevalence of risk factors and improved post myocardial infarction (MI) survival. Objective: This study was discuss the effect of modern versus standard of care anti failure medications on LV function in heart failure patients with reduced ejection fraction using 2D speckle tracking echocardiography. Patients and methods: The study population includes 100 heart failure patients with reduced ejection fraction 50 on modern anti-failure medications including angiotensin receptor neprilysin inhibitor (ARNI) and 50 controls on standard anti-failure medications including angiotensin I-converting enzyme inhibitor (ACEI) or angiotensin II receptor blockers (ARBs). All patients attended the outpatient clinic of the Cardiology Department at Al-Azhar University Hospital (Cairo) from March 2020 to March 2021. Results: There was no significant statistical difference between groups also regard sex distribution there was no significant difference between groups and male were majority in both groups. There was no significant difference between the two studied groups regarding levels of serum creatinine and serum K. Results of comparison of end systolic, end diastolic diameters of left ventricle and diameter of left atrium showed no significant difference between both groups at pre medication assessment but there was a highly significant after medications in both groups (p= 0.00, 0.038 and 0.035 respectively) also in group A there was a significant decrease from pre to post assessment (p=0.003, 0.012 and 0.004 respectively). There was a statistically significant improve in mitral regurgitation after medication in group A than in group B (p=0.00) but was of no significant in pre medication assessment (p=0.48). Conclusion: In HFrEF patients, sacubitril/valsartan significantly improves the mitral regurgitation LV remodeling and with a significant effect on LV diastolic and systolic echo parameters. Accordingly, sacubitril/valsartan could be used at an earlier time in HFrEF patients in order to further limit LV remodeling.

Background: Systemic lupus erythematosus (SLE) is a systemic autoimmune disease where chronic inflammation and organ damage is observed due to various suspected causes e.g. inadequate levels of vitamin D (a steroid hormone with immunomodulatory effects). Objective: To assess vitamin D (VD) levels in serum of patients with lupus nephritis (LN) in comparison with patients with extra-renal lupus and healthy controls, and to assess the relation between VD levels and the various clinical and laboratory disease parameters. Patients and Methods: This was a case-control study that was held in Zagazig University Hospitals between June 2019 and July 2020. The study included 40 patients admitted with systemic lupus erythematosus (SLE) with and without lupus nephritis (LN), and 20 age-matched healthy subjects. Laboratory investigations such as complete blood count, electrolytes, PTH, acute phase reactant, complements, Ads DNA and 25(OH) D levels of the subjects were measured. Results: Patients with SLE with lupus nephritis were significantly lower regarding vitamin D with no significant difference between patients with SLE without LN and control group. Conclusions: Our study revealed a high frequency of Vit D deficiency and insufficiency among patients with SLE with LN compared to SLE without LN and healthy controls. Keywords

Background: A common type of strabismus known as concomitant exotropia (XT) occurs when mismatched eyes deviate outward and the angle of deviation is the same regardless of which eye is fixed. Among ophthalmologists, there is no agreement on non-surgical treatment options for XT. For those who suffer from strabismus, surgery is an option for correcting their visual axis and restoring their ability to see in both eyes simultaneously. Instead, then severing the muscle, muscle plication involves folding the muscle around itself and stitching it in place, essentially shortening and tightening the muscle. Muscle plication has been found to reduce the risk of anterior segment ischemia by protecting the anterior ciliary arteries. Objective: To hallmark the new guidelines options of concomitant exotropia management. Conclusion: Muscle-tightening techniques such as excision, plication, advancement, and transposition have been documented in the literature. Technical simplicity, the ability to reverse it, shorter operating times, reduced surgical trauma, and the preservation of anterior ciliary arteries are only a few of the many advantages of plication.

Background The use of Instrumented Gait Analysis (IGA) for the clinical management of individuals with cerebral palsy (CP) has increased in recent years. Previous systematic reviews have been completed to evaluate and summarize the evidence related to the efficacy of IGA in general. However, a focused summary of research studies on IGA for children with CP related gait disorders is needed. Research Question The purpose of the current work was to perform a scoping review to describe and categorize the range of existing literature about IGA as applied to the clinical management of children with CP related gait disorders. Method A health sciences librarian developed a search strategy to include four key inclusion criteria of original research study, population included children with CP, study employed IGA, available in English. The available literature was organized into six study categories: reliability and validity, documentation of subgroups or model development, IGA for clinical decision making, effectiveness of treatments that depend on IGA, cost effectiveness, IGA used to evaluate the outcome of surgical, medical or rehabilitation treatment. Results 909 studies met the inclusion criteria and were placed into the six study categories. 14 % of studies were in reliability and validity, 33 % in subgroups or modeling, 2% in IGA for clinical decision making, 2% in treatments that depend on IGA, 1% in cost effectiveness, and 49 % of studies had IGA used as an outcome measure for treatment. Significance This scoping review has documented the wide range, diversity and extent of original research studies investigating the use of IGA for the clinical management of children with CP related gait disorders. The large volume of studies provides a basis for future work to develop a CPG about the use of IGA for the clinical management of children with CP related gait disorders.

Background: Small-bowel ostomies and large-bowel ostomies are two subtypes of intestinal ostomies based on the portion of the intestine that is exposed above the skin. Protecting the anastomosis from infection and keeping the peritoneum clean are critical functions of ileostomy and colostomy. Objective: to evaluate short term outcome of ileostomy and colostomy closures to recognize which procedure is better for diversion based on the outcomes of the stoma reversal. Methods: Two groups of 32 patients having a colostomy or an ileostomy in Zagazig University Hospitals underwent a clinical comparison of the outcomes of stoma closure. 16 patients in Group 1 had an ileostomy for reversal. Those in Group 2 who had a temporary colostomy for reversal included 10 patients with Hartmann procedure and 6 patients with simple loop stoma. During the first month, patients were seen at the outpatient clinic once a week, then once a month for the next five months. Results: As regard intraoperative complications: Amount of blood loss was higher among Hartmann’s group (112 ±18 ml) due to severe adhesions during laparotomy compared to ileostomy group (89 ± 16 ml) and loop colostomy group (98 ± 16 ml). In terms of intraoperative blood loss, there was no statistically significant difference between ileostomy and loop colostomy, although there was a statistically significant difference between ileostomy and the Hartman procedure. In the ileostomy group, postoperative problems such as wound infection, anastomotic leakage, ileus, and intraabdominal collection were less common and more easily controlled. Conclusion: Ileostomy closure is superior to colostomy closure as simple closure with small circumferential incision was easier than colostomy which need exploration in most cases.