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Qatar Medical Journal - Volume 2024, Issue 3
Volume 2024, Issue 3
- Research Paper
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Lipocalin-2 as a marker of inflammation, bone density, and triglyceride-glucose index for new-onset arthritis patients in Mosul, Iraq
Authors: Safa Rabea Saadon and Thikra Ali AllwshObjective: Lipocalin-2 is an acute phase-associated adipokine that can serve as an inflammatory and biomarker indicator of cartilage deterioration in osteoarthritis. However, its role in the musculoskeletal system remains not fully understood. Hence, this study aimed to evaluate lipocalin-2 and its relationship with markers of inflammation (Interferon-gamma, ESR, and CRP), bone density (vitamin D3 and calcium), and the triglyceride-glucose index in new-onset arthritis patients in Mosul, Iraq.
Methods: This study included 125 participants aged 20 to 65, divided into two groups. The Arthritis Patient Group comprised 70 participants (37 females and 33 males) attending the Bone Diseases Consultation Unit at the Ibn Sina Teaching Hospital in Mosul, Iraq. The Control Group comprised 31 females and 24 males. Ethical approval was obtained from the Iraqi Ministry of Health - Nineveh Health (No. 2022095).
Commercial ELISA kits were used to measure serum lipocalin-2, Interferon-gamma, ESR, and CRP as inflammation markers, vitamin D3, and calcium as bone density markers. Moreover, the Triglyceride Glucose (TYG) Index was evaluated.
Results: The findings revealed a significant increase in lipocalin-2 levels in males compared to females, with LCN-2 increasing with age. Arthritis patients showed a significant increase (72%) in lipocalin-2 levels. Inflammatory indicators (erythrocyte sedimentation rate, C-reactive protein, interferon-gamma) displayed significant increases (46%, 1200%, and 581%, respectively). Glucose (23%), triglycerides (71%), and TYG index (21%) also exhibited significant increases. Meanwhile, bone density indicators (vitamin D3 and calcium) found a significant decrease (53% and 20%, respectively) in arthritis patients.
Linear correlation coefficient (R) analysis revealed a significant positive relationship between lipocalin-2 and indicators of inflammation, glucose, TG, and TYG index.
Conclusion: This study’s findings suggest that LCN-2 serum levels were higher in patients with new-onset arthritis than in controls in Mosul, and LCN-2 serum increased in males compared with females and getting older serum LCN-2 increased for the patients and control groups. Furthermore, a significant correlation was found between the Triglyceride Glucose Index, which measures metabolic disorders, and serum LCN-2 levels and inflammatory indicators in new-onset arthritis patients in Mosul, Iraq.
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Using biothesiometer, Neuropathy Symptom Score, and Neuropathy Disability Score for the early detection of peripheral neuropathy: A cross-sectional study
Patients with peripheral neuropathy could have damaged peripheral nerves, which leads to sensory and motor dysfunction. Diabetes, infections, and trauma are the major causes of peripheral neuropathy. Vibratory perception threshold (VPT) tools are commonly used to detect peripheral neuropathy. This study aims to determine the assessment of peripheral neuropathy through the different diagnostic tools in the community in Malaysia. A total number of 1283 participants were recruited from the seven retail pharmacies located in Selangor, Malaysia. The peripheral neuropathy test was conducted based on VPT tools on both feet using the digital biothesiometer. Following that, Neurological Symptom Score (NSS) and Neurological Disability Score (NDS) were taken from the participants to assess the neurological symptoms. Participants had an average age of 40.6 ± 12.9 years and were mostly of Chinese ethnicity (54.1%). The findings show that increasing age was associated with more severe peripheral neuropathy across the various assessment tools, but gender differences were found with the biothesiometer test and ethnicity has severity in the biothesiometer and disability scores. The sensitivity and specificity of the biothesiometer test were 0.63 and 0.84, respectively. The combined tool NSS and NDS had high specificity and a high positive predictive value, suggesting that it could be a reliable indicator of peripheral neuropathy when both scores are elevated. The findings show that the biothesiometer test, NSS, and NDS are considered screening VPT tools for diagnosing peripheral neuropathy. However, further evaluation and diagnostic testing are necessary in cases of a positive test result.
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Severe acute respiratory infections: An epidemiological analysis of surveillance data in Bahrain, 2018–2022
Background: Severe acute respiratory tract infections (SARI) pose a health threat to children and adults worldwide. The SARI surveillance program was initiated in 2018 in Bahrain to monitor the activity of respiratory pathogens. Salmaniya Medical Complex (SMC) was chosen as the sentinel site for the SARI surveillance program. This study aimed to describe the epidemiology of SARI patients admitted to SMC from 2018 to 2022.
Methods: Patients meeting the World Health Organization definition of SARI and presenting with cough and fever within the last 10 days and admitted to SMC from January 2018 until December 2022 were included in the study. Epidemiological data on SARI cases were collected from SARI surveillance data and analyzed using SPSS version 25 and Excel.
Results: A total of 1362 SARI cases were enrolled from January 2018 to the end of December 2022; the majority were males (57.7%, n = 786). The highest SARI incidence rates were recorded among individuals over 65 years old (155.5 per 100,000) in 2021 and among those under 5 years old (887 per 100,000) in 2020. About half of the patients had at least one comorbidity (54.0%, n = 735), with diabetes (23.0%, n = 313) and hypertension (17.2%, n = 234) being the most common. The highest number of cases was observed in 2021 (27%, n = 373), followed by 2018 (20%, n = 267). A viral pathogen was detected in 30.7% (n = 418) of the SARI patients. The most prevalent pathogen was influenza A (11.5%, n = 156), followed by SARS-CoV-2 (9.7%, n = 132), respiratory syncytial virus (RSV) (5.1%, n = 69), and influenza B (3.9%, n = 53). The highest percentage of SARI cases was recorded in the winter months, mainly January (17%, n = 236). The percentages of influenza A and RSV cases were highest in December, at 22% (n = 39) and 14% (n = 25), respectively. Influenza B cases were recorded predominantly in March (9%, n = 11).
Conclusion: The incidence of SARI was highest among patients above 65 years old. The majority had comorbidities. Influenza and respiratory syncytial viruses were the most frequent causes of SARI, with influenza A being the most prevalent. December and January were the months with the highest SARI cases and viral detection rates. Promoting vaccination, timely testing, and prompt treatment, especially for the elderly and those with comorbidities, is key to reducing SARI-related morbidity and mortality, especially during peak seasons.
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Effect of SGLT2 inhibitors on kidney function of type 2 diabetes patients during Ramadan: A systematic review
Background: SGLT2 inhibitors are known for their osmotic diuretic effect, and their use by Muslim patients with type 2 diabetes during the fasting month of Ramadan may pose an increased risk of volume depletion, potentially impacting renal function.
Methods: We conducted a systematic review registered on PROSPERO (registration number CRD42020204582) of studies published between 2013 and January 2023, sourced from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. The study selection criteria included controlled studies that reported the use of SGLT2 inhibitors (SGLT2i) by fasting adult type 2 diabetes patients and provided data on creatinine or estimated glomerular filtration rate (eGFR) as outcomes.
Results: Two prospective observational studies, encompassing a total of 359 participants, of which 197 utilized SGLT2 inhibitors, were identified. Our findings indicated that the use of SGLT2 inhibitors during Ramadan did not result in a significant alteration in eGFR. In one study by Hassanein et al., the mean changes in eGFR for the SGLT2i group, as compared to the non-SGLT2i group, were -1.2 ± 19.4 and 3.1 ± 14.8, respectively (p = 0.06). In a study by Shao et al., the least squares mean changes for eGFR in the SGLT2i group, compared to the non-SGLT2i group, were -6.0 ± 1.5 (95% CI, -8.9 to -3.1) and -4.2 ± 1.6 (95% CI, -7.3 to -1.1), respectively (p = 0.39).
Conclusion: Despite the limited number of observational studies available, our analysis suggests that the use of SGLT2 inhibitors by type 2 diabetes patients during Ramadan does not appear to significantly impact kidney function.
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Description of clinical pharmacists reported interventions to prevent adverse drug events among patients with cardiovascular disease in Qatar
Background: Unidentified drug-related problems (DRPs) can cause negative health and economic consequences if not addressed appropriately. The literature revealed that interventions conducted by clinical pharmacists can positively impact patient safety and treatment outcomes. The role of clinical pharmacists has been continually growing while posing significant improvements in the provision of healthcare.
Objective: To describe clinical pharmacist interventions in hospitalized patients with cardiovascular disease (CVD) in Qatar.
Methods: This is a retrospective analysis of clinical pharmacist interventions documented in an electronic patient medical database. Data were retrieved from three date ranges and comprised demographic information, interventions, medical wards, drug therapy, and medical disorders. Clinical pharmacist interventions were categorized using a standardized intervention reporting sheet from the medical database in the hospital.
Results: A total of 845 interventions relating to 262 patients were included in this study. The study population consisted mainly of males (n = 158 [60%]) with an average age of 61 years (SD ± 13.05). The leading documented interventions were the addition of medication (n = 278 [32.9%]), medication discontinuation (n = 196 [23.2%]), and an increase in medication dosage (n = 155 [18.3%]). A similar trend was observed throughout all subcategories investigated in this study, that is, interventions according to age, ward, and gender. An exception to the common trend was demonstrated in the emergency department, where medication discontinuation was the most frequent intervention. The classes of medications with the highest frequency of reported interventions included cardiovascular medications, followed by endocrine and hormonal agents (n = 393 [46.51%] and n = 159 [18.7%], respectively).
Conclusion: Interventions conducted by clinical pharmacists have proven to have a positive impact on patient safety in addressing and resolving DRPs. Healthcare systems may benefit from future efforts directed toward studies of a prospective nature while developing a unique indicator of the validity and precision of documented interventions.
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Qatar’s assisted home hemodialysis program: A beacon of hope for the vulnerable patient
In a bold departure from conventional healthcare paradigms, Qatar’s Assisted Home Hemodialysis (AHHD) national program stands as a testament to Hamad Medical Corporation’s unwavering commitment to excellence. This innovative care model is tailored to address the distinct challenges of hemodialysis patients, particularly the elderly, who require ambulance transport. It provides them with the convenience of at-home dialysis with the full support of dedicated nursing care. AHHD included 76 patients from July 2021 to December 2022. It has significantly improved patients’ quality of life, achieving an exceptional 99% satisfaction rate with an extremely low complication rate. It has also delivered tangible improvements in health outcomes, marked by a reduction in hospitalizations, decreased transmission of COVID-19, cost-effectiveness, alleviating strain on ambulance services, and reducing demand for dialysis slots and manpower. In conclusion, the clinical and financial success of the AHHD program positions it as a superior alternative to traditional in-center dialysis, particularly in its capacity to cater to the needs of the most complex and challenging patient populations.
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A national study of psychiatry outpatient visits by lower-skilled male migrant workers in Qatar
Authors: Javed Latoo, Ovais Wadoo, Yousaf Iqbal, Faisal Khan, Khizara Amin, Sami Ouanes, Shuja Reagu and Majid AlabdullaBackground: Arab countries host 10% of all migrants globally. Migrant workers are known to have a high burden of physical and psychiatric morbidity. Most of the published literature on mental health among migrant workers is from non-Arab countries. The limited literature on migrant workers’ mental health in Arab countries is a critical research gap. It is pertinent to study well-defined migrant groups within well-defined host country conditions to yield pragmatic answers to inform service delivery.
Aims: The current study aims to complement existing data by characterizing psychiatric morbidity in a well-defined migrant group within a specifically defined context of migration.
Methods: Retrospective review of patient notes.
Results: All participants were men, and most of them were aged between 30 and 49 years. More than two-thirds presented with anxiety or depressive disorders. More than half had a past psychiatric history. Psychological distress was linked to stressors such as limited social support, living away from family, financial stressors, family-related stressors, and work-related stress. One-fourth of the participants reported stress related to the pandemic. Half of them reported physical health comorbidities. Two-thirds were not compliant with treatment plans, and one-fourth were lost to follow-up.
Conclusion: This is the first study to provide insight into the psychiatric morbidity of lower-skilled migrants presenting to outpatient psychiatry clinics in Qatar. The psychiatric morbidity of migrants is mainly centered around depressive and anxiety-related disorders. The most common challenges encountered in the management of patients include patient concordance with medication and loss to follow-up. Mitigation strategies are vital for ensuring the psychological well-being of migrant workers.
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Laparoscopic adrenalectomy performed by a general surgeon on functioning adrenal tumors: Treatment outcomes and risk prediction of persistent hypertension
More LessBackground: Functional adrenal tumors may contribute to poor hypertension control and electrolyte abnormalities, thus increasing the risk of cardiovascular mortality. Currently, laparoscopic adrenalectomy is an effective surgical option that contributes to improved treatment outcomes as compared to open surgery. The purpose of this study was to evaluate the outcomes of laparoscopic adrenalectomy performed by a general surgeon at a low-volume center and to identify clinicopathological risk factors for postoperative persistent hypertension.
Methods: A retrospective study of patients with functional adrenal tumors who underwent laparoscopic adrenalectomy at Srinakharinwirot University, Thailand, between 2014 and 2022. Clinicopathologic and postoperative data were examined.
Results: This study included twenty-five patients; the indications for laparoscopic adrenalectomy included primary aldosteronism in 19 (76%), pheochromocytoma in 4 (16%), and Cushing’s syndrome in 2 (8%). The average time of surgery was 103.5 ± 19.7 min, and intraoperative complications occurred in three patients (12%), with one patient requiring conversion to open surgery (4%). The postoperative systolic (125 ± 15 vs. 158 ± 18 mmHg; p < 0.001) and diastolic (78.5 ± 6.7 vs. 95.3 ± 10 mmHg; p = 0.013) blood pressure significantly decreased compared to prior surgery, but only 19 patients (76%) achieved a cure for hypertension. Multivariate analysis revealed that the patient’s physical status, as classified by the American Society of Anesthesiologists (odds ratio (OR) = 0.66, 95% confidence interval (CI) 0.43–1.32, p = 0.001), and the need for at least three antihypertensive medicines (OR = 0.7, 95% CI 0.36–1.2, p = 0.002), were independent predictive factors of persistent hypertension after surgery.
Conclusion: Laparoscopic adrenalectomy is a safe and effective surgical treatment for functional adrenal tumors, even when performed in a low-volume center. According to the American Society of Anesthesiologists’ physical categorization, the patient’s physical condition and the necessity for at least three antihypertensive medications are predictors of postoperative hypertension.
Trial registration: The study was registered with the Thai Clinical Registry Trials: TCTR20230707007.
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- Review
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Exploring program death-1 and cytotoxic T lymphocyte antigen-4 safety in gastric cancer clinical trials: A meta-analysis
Authors: Acquah Theophilus, Yahui Wang, Wenxin Da, Yang Xu, Qiu Li, Zhihong Chen, Jie Ma and Zakari ShaibuBackground: Gastric cancer is one of the leading causes of cancer-related deaths worldwide. Despite advances in treatment options, the overall prognosis for advanced gastric cancer remains poor. Immunotherapy has revolutionized the field of cancer treatment by harnessing the patient’s immune system to target and destroy cancer cells. Two important immune checkpoint inhibitors that have shown promise in various malignancies, including gastric cancer, are program death-1 and cytotoxic T lymphocyte-4 inhibitors.
Aims: To assess and analyze the occurrence of adverse events associated with program death-1 and cytotoxic T lymphocyte antigen-4 in patients diagnosed with advanced gastric cancer.
Methods: Relevant studies were searched in reputable databases such as PubMed, Embase, Google Scholar, and the Cochrane Library from October 6, 2017, to February 3, 2022. Studies were analyzed with Review Manager 5.4. PROSPERO: CRD42023479662.
Results: Of the 500 studies retrieved, nine randomized control trials involving 5,185 patients were included in the meta-analysis comparing TRAEs in advanced gastric cancer patients after immune checkpoint inhibitor monotherapy and combined immune checkpoint inhibitors treatment. There was a lower risk of any grade of treatment-related adverse events with program death -1 than in the control arm (76.5% vs. 79%, P = 0.02). Program death-1 observed a lesser risk of grade 3-4 treatment-related adverse events as compared to the control for nausea (0.3% vs. 3%, P = 0.007) and fatigue (1% vs. 2.7%, P = 0.006). Program death-1 monotherapy also saw a decrease in the incidence of common treatment-related adverse events such as diarrhea (9.6% vs. 16%, P < 0.00001), nausea (6.8% vs. 20.6%, P < 0.00001) and fatigue (11% vs. 15.9%, P = 0.001). However, pruritus occurrence increased (3.8% vs. 9%, P < 0.001) after program death-1 compared to control.
Conclusions: Patients with advanced gastric cancer endured program death-1 treatment effectively. Nonetheless, the combination of program death-1 and cytotoxic T lymphocyte-4 results in a greater occurrence of treatment-related adverse events.
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Comparison of clinical outcomes between culture-positive and culture-negative sepsis or septic shock pediatrics patients: A systematic review and meta-analysis
Authors: Rahil Khowaja and Fazila KarimiIntroduction: Comparatively, culture-negative septic shock or septic shock (CNSS) is frequently observed among pediatric patients, contrasting with the more distinct clinical profile and prognosis of post-surgical septic shock (CPSS). However, limited data are available on the outcomes of CNSS in comparison to CPSS in pediatric patients. This study seeks to conduct a systematic review and meta-analysis of existing literature to comprehensively compare outcomes between CNSS and CPSS in pediatric patients.
Methods: Electronic databases, such as PubMed, CINAHIL, and EMBASE, were systematically searched up to January 15, 2024, using predefined terms. We included all studies that compared outcomes between CPSS and CNSS in pediatric patients. The primary outcome evaluated in this study was all-cause mortality. Secondary outcomes included length of hospitalization, length of intensive care unit (ICU) stay, and duration of mechanical ventilation (all measured in days).
Results: Among the initially identified 1328 articles, six studies involving 2511 pediatric patients met the inclusion criteria and were part of this meta-analysis study. The pooled analysis revealed no significant differences in all-cause mortality (odds ratio: 1.26, 95% confidence interval (CI): 0.93 to 1.70, p = 0.14), length of ICU stay (mean difference (MD): 0.18, 95% CI: -0.33 to 0.68, p = 0.50), and duration of mechanical ventilation (MD: -0.74, 95% CI: -2.46 to 0.98, p-value = 0.40) between CPSS and CNSS. However, the length of hospital stay was longer in CPSS compared to CNSS (MD: 7.38, 95% CI: 5.50 to 9.27, p < 0.0001).
Conclusion: Approximately 26.56% of pediatric septic cases were culture-positive. There were no statistically significant differences in mortality, ICU stay, and duration of mechanical ventilation between CPSS and CNSS. However, hospital stay was prolonged by more than 7 days in culture-positive cases. Further multicenter studies are warranted to validate these findings and explore additional presentation characteristics.
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Human papillomavirus prevalence and genotypes in Gulf Cooperation Council countries: A scoping review 2017-2024
Authors: Nahlah AlMesbah, Jihene Maatoug, Nagah Selim and Iheb BougmizaBackground: Cervical cancer remains a global health challenge, claiming the lives of millions annually and having a significant impact on Gulf Cooperation Council (GCC) countries. Human papillomavirus (HPV), the primary causative agent, plays a central role, with regional variations in prevalence.1 The process from HPV infection to neoplastic changes takes 5–25 years to occur, hence, knowing its prevalence in our community is vital.2
Methods: PubMed and SCOPUS were searched to identify articles related to cervical and anogenital HPV prevalence and genotypes in Qatar, Kuwait, Bahrain, Oman, the United Arab Emirates (UAE), and the Kingdom of Saudi Arabia (KSA) published between 2017 and 2024.
Results: A total of 19 articles were included in this review. Eight studies were from KSA, four were from Kuwait, three were from the UAE, one was from Qatar, Oman, and Bahrain, and one presented data collectively from the KSA, UAE, Qatar, and Bahrain. The prevalence of HPV ranged between 4.7% and 77% in studies from the KSA, between 15% and 54.3% in studies from Kuwait, between 14.7% and 88% in studies from the UAE, was 8.1% and 31.3% in the two studies from Qatar, and was 17.8% and 20% in the studies from Oman and Bahrain, respectively. HPV 16 was the most prevalent high-risk genotype found in studies conducted in the KSA, UAE, Kuwait, and Qatar. In Oman, HPV 82 predominated. In Bahrain, the majority had other non-HPV 16/18/45 genotypes. In the UAE and Kuwait, HPV 11 was the predominant low-risk type, followed by HPV 6. In Qatar, HPV 81 was the most common low-risk type, followed by HPV 11. In Oman, HPV 54 was the most common low-risk type, followed by HPV 42.
Conclusion: There are no studies with data on HPV prevalence and genotypes among women who have been vaccinated against HPV in GCC countries.
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Significant association between asthma and a lower risk of mortality among COVID-19 patients in Spain: A meta-analysis
Authors: Liqin Shi, Xueya Han, Yadong Wang, Jie Xu and Haiyan YangBackground: Various prevalences of asthma in coronavirus disease 2019 (COVID-19) have been reported in different regions, and the association between asthma and COVID-19 subsequent mortality has been in debate. Thus, this study aimed to investigate whether there was a significant association between asthma and COVID-19 mortality in Spain through a meta-analysis.
Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were strictly complied with conducting this study. The pooled odds ratio (OR) with a corresponding 95% confidence interval (CI) was calculated by a random-effects model. The I2 statistics for heterogeneity, sensitivity analysis for robustness, Begg’s test, and Egger’s test for publication bias, along with subgroup analyses for confounding bias, were also performed to support the foundation of this study.
Results: The meta-analysis revealed that asthma was significantly associated with a lower risk of mortality among COVID-19 patients in Spain with a random-effects model (pooled OR = 0.78, 95% CI = 0.69–0.88, I2 = 35%). Further subgroup analyses by male proportion and sample size also indicated that a statistically significant negative correlation did exist between asthma and COVID-19 mortality. Robustness and no publication on-bias were evidenced by sensitivity analysis, Egger’s test, and Begg’s test, respectively.
Conclusion: In conclusion, patients with asthma were found to have a lower risk of mortality from COVID-19 in Spain, especially among elderly patients. In addition, asthmatic patients infected with COVID-19 may be at risk of death compared to non-asthmatic patients, which is not a cause for undue concern, thereby reducing the burden of medication.
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- Case Report
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Methicillin-resistant Staphylococcus aureus-associated empyema necessitans in a child: A case report and a literature review
Authors: Ghada Habachi, Sondes Sahli, Sabrine Ben Ammar, Bochra Aziza and Riadh JouiniIntroduction: Empyema is a known complication of severe pleuropneumonia. In rare cases, if poorly treated, it could result in dissemination and fistulization and transformation into empyema necessitans. The manifestation may appear as a superficial abscess. However, as management highly differs, the recognition of potentially severe phenomenon is required.
Case Presentation: We describe a case of empyema necessitans on a 4-year-old girl secondary to methicillin-resistant Staphylococcus aureus. It represents the sixth pediatric case reported in the literature. It was managed by open drainage and prolonged antibiotherapy. The outcome was favorable as guidelines were extracted from similar reported cases.
Conclusion: Empyema necessitans remains a rare complication with significant morbidity. Prompt diagnosis and adapted management have relied on limited literature. As such, further reports are necessary to establish proper guidelines.
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A case report on imaging findings of rare segmental necrotizing granulomatous neuritis of leprosy involving ulnar nerve
Authors: S. B. S. Netam, Nilesh Gupta and Nobal ChandrakarIntroduction: Segmental necrotizing granulomatous neuritis (SNGN) is a rare complication of leprosy involving peripheral nerves. It can appear alone in cases of pure neuritic leprosy or in combination with cutaneous lesions.
Case Presentation: A 15-year-old female diagnosed with borderline tuberculoid leprosy who received prior multidrug therapy presented 2 years later with occasional pain and tingling sensations along the inner aspect of her right arm and forearm. Imaging findings suggested SNGN, which was corroborated by cytopathological examination. She was considered relapsed from leprosy, and multi-drug therapy and steroids were started, following which she reported a decrease in the size of the swelling along with no further deterioration of the sensorineural deficit.
Discussion: SNGN, which is one of the rare complications of leprosy, can create diagnostic dilemmas as its differential diagnoses include reversal reactions, and peripheral nerve tumors (such as schwannoma and neurofibroma), which have been outlined in this article. SNGN is more likely when magnetic resonance imaging (MRI) shows a well-defined ovoid lesion with central necrosis and peripheral rim enhancement.
Conclusion: The incidence of SNGN is on the rise due to multi-drug therapy. In our case, the patient developed SNGN, which was considered a relapse from leprosy, and multi-drug therapy and steroids were started, following which the patient reported a significant reduction in the size of the swelling with no further deterioration of the sensorineural deficit. Hence, an appropriate diagnosis of SNGN through ultrasonography and MRI will lead to favorable outcomes, ultimately benefiting the patient.
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Reversible postoperative vision loss (POVL): A tale of four patients
Authors: Nissar Shaikh, Seema Nahid, Firdos Ummunnisa, Umm E Amara, Umme Nasrah, Azha Fatima, Fateen Shareef and Abul Rahman BalalBackground: Posterior reversible encephalopathy syndrome (PRES) is a clinic-imaging entity. PRES is rarely reported in the perioperative period to cause reversible postoperative vision loss (POVL). It is reported in the literature in the form of case reports for spinal and cardiac surgeries and eclampsia patients. The suggested diagnostic criteria for PRES are: (i) acute onset of neurological symptoms and signs; (ii) specific findings of vasogenic cerebral edema upon imaging studies; and (iii) reversibility of signs and symptoms as well as image study findings. We report a case series of four patients undergoing other than spinal, cardiac, or orthopedic surgeries who developed PRES and had reversible POVL.
Cases: The first case was a young female who had laparoscopic sleeve gastrectomy, had extreme hypertension at induction of anesthesia, had surgery and developed POVL after a few hours in the postoperative period, and had convulsions diagnosed to have PRES after computed tomography (CT) and magnetic resonance imaging (MRI). Managed with blood pressure and seizure control, vision returned gradually from 2nd postoperative day. The second case was also a young female who had appendicitis, requiring an appendectomy. Complicated by septic shock. Post-surgery, she was extubated after 1 day and immediately complained of total blindness. Local causes were ruled out, and an MRI diagnosed PRES. With supportive therapy, her vision started to return by Day 3 with improved normal vision. The third case was a female with recently diagnosed diabetes mellitus who presented with right upper limb embolic ischemia and had an embolectomy with a return of circulation. Her blood pressure was high and reached up to 200 mmHg after induction of anesthesia, which was controlled with deep anesthesia and a labetalol infusion in the perioperative period. After 8 h in the postoperative period, she was awake but searching for available objects. Relatives complained that she was unable to see. Local and fundus examinations were normal. She was awake but blind. Imaging studies confirmed PRES. Blood pressure was controlled using a labetalol infusion and continued supportive therapy. By Day 3, her vision became normal. The fourth case was an elderly patient who had hypertension, type 2 diabetes mellitus, and coronary artery disease. He underwent a right carotid endarterectomy under general anesthesia. He had severe hypertension in the perioperative area and blood pressure was controlled using a labetalol infusion. The surgery went smoothly. After 3 h, he had a loss of vision. Imaging studies confirmed PRES. His blood pressure was kept normal. After 2 days, his vision gradually returned to normal. Follow-up MRIs in the outpatient clinic for all four patients normalized in due time.
Conclusion: Extremes of hypertension and/or hypotension in the perioperative period can cause PRES, which may lead to reversible POVL.
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Penile Mondor’s disease after open hernia repair surgery: A case report
Background: Penile Mondor’s disease (PMD) is a rare syndrome characterized by sclerosis after superficial thrombophlebitis of the superficial penile veins. The most usual appearance of PMD is a tender, palpable, painful, and sometimes visible cord on the dorsal surface of the penis. Its pathogenesis is still unclear, and a standardized treatment has not been established.
Case report: A 54-year-old male patient presented with a left-sided indirect reducible inguinal hernia. The patient underwent Lichtenstein’s procedure for inguinal hernia repair. On the tenth postoperative day, he returned with PMD confirmed by Doppler ultrasonography examination. Treatment with 4000 UI low molecular weight heparin (LMWH) daily for three weeks resolved the symptoms, but mild venous ectasia just to the proximal part of the penis remained.
Discussion: The exact cause of PMD is not well understood, but various studies have identified certain factors associated with an increased risk of the condition. Out of various potential factors that could trigger PMD, the repair of an inguinal hernia has been reported only once. Treatment may involve pain management, anti-inflammatory medications, anticoagulants, and, in some cases, surgery.
Conclusion: PMD after open hernia repair surgery is a very rare benign condition. Correct diagnosis and prompt treatment allowed symptom resolution. Residual venous ectasia has no clinical significance other than a cosmetic appearance.
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The hyperemesis gravidarum and pulmonary embolism: A case report and review of literature
Authors: Nissar Shaikh, Umme Nashrah, Roaa Nasser Suleiman, Umm E Amara and Firdos UmmunnisaBackground: Nausea and vomiting occur in more than 70% of pregnant women,1 and only 2% of these females progress into hyperemesis gravidarum (HG).2 HG is the persistent and excessive vomiting before the 22nd week of gestation. HG patients can develop life-threatening electrolyte disturbances or thromboembolism. Pulmonary embolism (PE) is a thromboembolism that blocks and stops blood flow to an artery in the lung. Both HG and PE increase morbidity and mortality in pregnant patients. HG patients developing PE are reported only in two patients with fatal outcomes in the literature. We report a case of PE in a hospitalized HG patient with a better outcome.
Case Presentation: A 26-year-old previously healthy gravida 3 and para 2 patient was admitted to the Women Wellness and Research Center with HG at 10 weeks of gestation. She developed nausea and vomiting at 6 weeks of gestation and was treated in the emergency department, where she was started on intravenous (IV) fluids for hydration, an antiemetic, and deltaparin for prevention of deep venous thrombosis (DVT), as she was pregnant and dehydrated. She was on potassium replacement therapy for hypokalemia. The patient was improving; still had vomiting, but less frequent. On day 3, following admission, the patient suddenly developed hemoptysis, chest pain, and palpitation. She was tachycardic (120 bpm) and tachypneic (30 breaths per minute). She was feeling dizzy, and her oxygen saturation (Spo2) was around 95%. Her chest was clear on examination. Computerized tomographic pulmonary angiography showed bilateral PE. She was admitted to the highdependency unit. The patient was tachypneic and tachycardic and required non-invasive ventilation. A therapeutic dose of enoxaparin (1 mg/kg) was started and supplemented with fentanyl plus paracetamol for analgesia, continued IV fluids, and promethazine.
Her respiratory symptoms and tachycardia improved by day 6, she was transferred to the ward from there and discharged home by day 10, on enoxaparin therapeutic dose (1 mg/kg), and follow up in outpatient clinics showed no issues, and she is doing fine.
Discussion: HG is a severe clinical disease in pregnancy where patients have intractable nausea and vomiting with increased morbidity and even mortality. These patients frequently present with ketonuria, dehydration, electrolyte abnormalities, and a weight loss of 7%. Rarely, these patients’ present with severe vitamin deficiency, causing a neurological emergency called Wernicke’s encephalopathy. The occurrence of DVT is one of the main risk factors due to prothrombotic conditions in pregnancy in combination with dehydration in these patients. The occurrence of PE is reported in two cases of HG in the post-mortem. Our patient developed bilateral PE, a medical emergency due to immobility, dehydration, and prothrombotic predominance during pregnancy. PE was detected early and managed, leading to a better outcome.
Conclusion: HG should be diagnosed early, followed by admission of the patient to the hospital. Our patient with HG was complicated by a rare bilateral PE due to a combination of pregnancy, dehydration, and immobility, despite DVT prophylaxis with a favorable outcome. Clinicians should have an index of suspicion for DVT and PE in these dehydrated pregnant patients. A high index of suspicion, early diagnosis, and management by a multidisciplinary team are key for better outcomes of PE in our HG patient.
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Disseminated peritoneal leiomyomatosis: A benign condition with diagnostic and therapeutic challenges
Background: Disseminated peritoneal leiomyomatosis (DPL) is a variant of parasitic leiomyomas that is characterized by multiple peritoneal and subperitoneal nodules of proliferating smooth muscle cells that histologically resemble uterine leiomyoma. We report a case of recurrent DPL to highlight its diagnostic and therapeutic challenges at the Federal Medical Centre, Keffi, Nigeria.
Case Report: The patient is a 25-year-old woman with a previous history of myomectomy 3 years before presentation to the hematology unit on account of abdominal lymphoma. Based on the working diagnosis, she was referred to the general surgery unit for an open biopsy and cytoreductive surgery. She was explored, and intraoperative findings were in keeping with multiple well-circumscribed intra-abdominal masses of varying sizes. The multiple and widespread locations of the masses precluded the complete removal of the masses. Four months post-surgery, she presented with similar lesions and had a repeat laparotomy. At the surgery, she had a total abdominal hysterectomy with bilateral salpingophorectomy and excision of the abdominal masses. She was then placed on letrozole, which prevented further tumor growth and abated her symptoms.
Discussion: DPL is often rarely diagnosed preoperatively and thus poses a diagnostic challenge, with many cases asymptomatic and therapeutic challenges due to its tendency to recur. Its management currently lacks consensus and is often determined by many factors, such as the age of the patients, the number of nodules, and the desire to have more children, among others. Surgical excision combined with hormonal therapy is recommended for patients who wish to conceive. For postmenopausal women and those who no longer desire conception, total abdominal hysterectomy with bilateral salpingo-oophorectomy should be considered to prevent recurrence.
Conclusion: DPL is a rare form of multiple extrauterine leiomyomas. We report a case of DPL in a woman that was managed with surgical intervention and hormonal manipulation therapy following the failure of the initial surgical excision alone. We thus suggest a combination of surgical intervention and postoperative hormonal manipulation in its management, as such a multi-modality of therapy was employed in the index case without evidence of recurrence after a year post-surgery.
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- Research Paper
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Phenotype–genotype correlation in children with familial Mediterranean fever in Morocco
Authors: Manal Souali, Asmaa Sakhi, Ahmed Aziz Bousfiha and Kenza BouayedBackground: Familial Mediterranean fever (FMF) is an autosomal recessive disease caused by mutations in the MEFV gene and is characterized by recurrent febrile episodes of abdominal pain, chest pain, and joint involvement. We aim to study the clinical and genetic features of FMF in Moroccan children and to establish a phenotype–genotype correlation in this group of patients.
Methods: A total of 35 patients were included in this study. Genetic analysis of exon 10 of the MEFV gene was performed in 33 patients. To establish a phenotype–genotype correlation, we statistically compared clinical features between patients with and without the M694V mutation.
Results: Abdominal pain was observed in 82.9% of our patients, followed by fever (74.3%), arthralgia (85.7%), arthritis (42.8%), chest pain (34.3%), and IgA vasculitis (20%). Genetic analysis showed a predominance of the M694V mutation (62.5%), followed by A744S (11.4%) and K695R (5.7%). The presence of the M694V genotype was found to be significantly associated with a high frequency of arthralgia and arthritis. A significant association was found with an earlier age of onset in the absence of the M694V mutation.
Conclusion: Joint involvement is more common in the M694V genotype, and the genetic profile shows different results compared to neighboring countries.
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The epidemiology of spinal fractures: A nationwide data-based study in Iran
Background: Blunt trauma is a physical injury to a part of the body, mainly caused by road accidents, direct blows, attacks, sports injuries, and falls in elderly people. Spinal fractures are observed only in a small percentage of injured patients. Accordingly, the present study was conducted on collected data between 2018 and 2022 to determine the frequency of spinal fractures in blunt trauma in Iran while also considering the mechanism of injury as a secondary outcome of interest.
Methods: In this retrospective study, blunt trauma patients with spinal fractures, regardless of age were included by the census sampling method. Data were obtained from the National Trauma Registry of Iran. Means and standard deviations were used for continuous variables, and the chi-square test was used to assess the relationship between the variables.
Results: Among 25,986 cases of all-cause trauma patients, 1,167 cases (4.5%) of blunt trauma and spinal fracture were included in the study. Gender, the severity of injury, and the cause of trauma showed a significant difference among different age groups (p < 0.05). Significant differences were found in the injury mechanisms across various spine regions (p < 0.05). The majority of patients (68.2%) had lumbar spinal fractures. Road traffic collisions were the most common cause of spinal cord injuries, accounting for 58.3% of cases, followed by falls (36.1%). The injury severity score was higher in younger patients (under 18 years old), with a mean of 4.4 ± 3.5, and in patients with cervical injuries. The majority of injuries occurred in the lumbar area (68.2%), followed by the thoracic area. Furthermore, notable variations existed in Emergency Room (ER) stay duration, overall hospitalization, Intensive Care Unit (ICU) stay duration, and injury severity levels, all influenced by the spinal regions (p < 0.05). Distinctively, ICU stay durations and ER stay duration showed significant differences, particularly in relation to injuries in the lumbar and thoracic regions (p < 0.05).
Conclusion: According to the results of the present study, trauma is more severe, and cervical injuries are more common in young people, which is a critical finding that underscores the need for targeted interventions to mitigate the severity of trauma in this age group. Additionally, the majority of cervical injuries occurred in young people, which is a particularly concerning finding given the potential for long-term disability and impact on quality of life. Our findings suggest that strategies to reduce cervical injuries, such as speed control, seat belt use, and phone-free driving, are crucial interventions for mitigating the severity of trauma and promoting patient outcomes in young people.
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Predictors of thyroid cancer survival in Saudi Arabia: A retrospective 10-year analysis
Authors: Amen Bawazir, Sadeem Alhalafi, Omer Al-Aidaross, Abdulrahman Jazieh and Wasif Ali KhanBackground: Thyroid cancer (TC) is becoming more prevalent in Saudi Arabia, currently ranking among the top three cancers affecting women. Despite its rising prevalence, there has been limited assessment of the factors influencing the survival rate (SR) among the Saudi population over an extended period. Therefore, this study aims to address this critical gap in knowledge by identifying the factors affecting the SR of TC, comparing the SR with previous studies, and exploring potential areas for improving the SR of patients.
Methods: A retrospective study analyzed secondary data from patients diagnosed with TC, as recorded in the King Abdulaziz Medical City Cancer Registry in Riyadh, Saudi Arabia, over 10 years from 2009 to 2018.
Results: Of the total 665 TC cases, the mean age at diagnosis was 46.2 years (±SD 16), and most patients were women (78.5%), with the majority being under 50 years old. The most common type of cancer was papillary thyroid carcinoma, comprising 88.6% of all TCs. Over half of the cases were localized to one of the lobes of the thyroid gland, with almost equal frequency between the two lobes. The 5-year SR of localized papillary thyroid carcinoma reached 96.5%, in contrast to the extremely low SR of anaplastic thyroid carcinoma, where most patients died within a few months of the diagnosis. Factors such as morphology, tumor extension, male gender, and age at diagnosis significantly impacted patient survival, as analyzed by the Kaplan–Meier test (p < 0.001). Compared to other types of cancer, those with anaplastic thyroid carcinoma had a lower SR.
Conclusion: The SR of TC patients is predicted by factors such as their age, morphological type, and the presence of distant metastasis.
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Rehabilitation and functional outcomes of COVID-19 patients in a rehabilitation hospital in Qatar
Background: Patients recovering from severe COVID-19 infections have experienced prolonged cognitive, physical, and psychological sequelae, including cardiorespiratory and motor deconditioning, neurological deterioration, anxiety, and depression. The impact of rehabilitation post-acute COVID-19 infection was recognized in the literature, but studies assessing and quantifying specific functional outcomes were lacking. This study aims to describe the characteristics and quantify the changes in functional outcomes of patients admitted to Qatar Rehabilitation Institute (QRI) for inpatient rehabilitation (IPR) post-COVID-19 infection during a 10-month period in 2021.
Methods: This is a retrospective observational cohort study, which included individuals over 18 years of age with a documented COVID-19-positive diagnosis who were admitted to QRI for IPR due to COVID-19 complications. Data was collected by the investigators from January 1, 2021, until October 30, 2021. A total of 243 patients were included in this study. The changes in functional rehabilitation outcomes were assessed and quantified at both the patient’s baseline (on admission to QRI) and after completion of IPR (on discharge). The duration of the IPR program varied based on each patient’s baseline assessment. Patients were given a total of 8–12 weeks to achieve their rehabilitation goals and were discharged once those goals were met. Several validated tools were utilized in this study including Functional Independence Measure (FIM), Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Modified Medical Research Council (mMRC) Dyspnea Scale, Mini-Mental State Examination (MMSE), and Right- and left-Hand Grip Strength. In addition, patients’ diet, the need for respiratory support, and the presence of a tracheostomy tube before and after IPR were also recorded.
Results: In total, 84.4% of the included patients were males (n = 205); with a mean age of 52.44 ± 12.99 years. The most commonly reported comorbidities were type 2 diabetes (62.1%) and hypertension (49.8%) with 83.5% of patients experiencing critical illness neuromyopathy. The average patients’ length of stay in QRI was 33.92 ± 27.72 days. A statistically significant improvement in all functional outcome scales was noted following the completion of the IPR program (p = 0.001). The number of patients requiring modification to their diet or feeding via nasogastric tube (NGT) significantly decreased by 35% and 93%, respectively (p = 0.001). Patients requiring respiratory support decreased by 98% (p = 0.001) and the need for a tracheostomy tube among patients was reduced by 95% (p = 0.001).
Conclusion: IPR following COVID-19 infection was associated with significant functional, motor, and cardiorespiratory improvement. Dedicating clinics for post-COVID-19 rehabilitation would ensure improved patient outcomes and enhanced recovery.
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Liver ultrasound evaluation of acutely increased liver function tests of COVID-19 hospitalized patients
Authors: Salah Almughalles, Shazaly N. Khojaly, Abdulqadir J. Nashwan and Adham DarweeshBackground: The incidence of hepatic abnormalities has been notably higher following the coronavirus disease 2019 (COVID-19) infection, attributed to the virus’s entry into cells via angiotensin-converting enzyme 2 (ACE2) surface expression. The gastrointestinal tract’s significant ACE2 expression, alongside a lesser degree in the biliary epithelium, has been implicated in gastrointestinal symptoms and liver injury.
Purpose: The aim of this study was to determine whether specific ultrasonographic findings in the liver correlate with acute increases in liver function tests (LFTs) among hospitalized patients.
Methods: A retrospective analysis was conducted on hospitalized COVID-19 patients at Hazem Mebaireek General Hospital in Qatar, from March 1, 2020, to June 30, 2020. The study focused on patients who experienced acute increases in LFTs, excluding those with chronic liver disease. Ultrasound imaging and patient records were reviewed to gather data.
Results: Out of 223 ultrasound studies of COVID-19 patients, 158 met the inclusion criteria. The majority were male, with a mean age of 47.76 ± 13.76 years. Ultrasound results showed 43.7% normal liver parenchyma, while 56.3% exhibited nonspecific abnormalities such as diffuse liver hyperechogenicity (39.2%), enlargement with diffuse hyperechogenicity (12.7%), and other findings (4.4%). The biliary tree was predominantly normal (96.2%), with 3.8% showing abnormalities, including intrahepatic (2.5%) and extrahepatic (1.3%) dilatation. Gallbladder evaluations were normal in 60.1% of cases, with 39.9% showing abnormalities like stones (6.3%), stones with sludge (13.3%), polyps (6.3%), wall thickening (1.9%), and other conditions (12%). A significant correlation was found between abnormal liver parenchyma findings and elevated levels of bilirubin (total and direct) and alkaline phosphatase, with p-values < 0.05. Only aspartate aminotransferase levels showed a significant correlation with biliary tree abnormalities.
Conclusion: The most common ultrasonographic finding associated with acute increases in LFTs among hospitalized COVID-19 patients was diffuse liver hyperechogenicity, with or without enlargement. These findings suggest a nonspecific yet significant association with liver function anomalies in the context of COVID-19.
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- Case Report
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Pediatric puzzle: Large ovarian dermoid cyst and markedly elevated CA 19-9 in an 8-year-old
Authors: Muhamed Ahmed Abdelmoaty and Wael Soliman TahaBackground: Mature cystic teratomas, also known as dermoid cysts, are the most prevalent form of ovarian germ cell tumors. While they typically manifest in women of reproductive age, they can also occur in pediatric patients. These tumors are generally benign and comprise a diverse array of tissue types. However, large lesions, particularly those exceeding 10 cm in diameter, are infrequent and can present diagnostic and therapeutic challenges. Notably, elevated tumor markers, such as cancer antigen 19-9 (CA 19-9), are not commonly associated with mature cystic teratomas, rendering this case particularly unusual.
Case presentation: The clinical case involved an 8-year-old female patient who presented with an exceptionally large ovarian teratoma, measuring 13 × 12 cm. While the prepubertal presentation of such tumors is not uncommon, the remarkable size of the lesion was an extraordinary occurrence. Preoperative evaluation revealed markedly elevated levels of CA 19-9, a tumor marker, at 297 U/mL—an atypical finding for mature cystic teratomas. Imaging studies identified a complex cystic adnexal mass, indicative of a teratoma. Consequently, a laparotomy was performed, revealing an intact, benign lesion that was successfully resected via cystectomy, with preservation of the ovary. Histopathological examination confirmed the diagnosis of a mature cystic teratoma, without any evidence of malignant transformation. Notably, following the surgical intervention, the elevated CA 19-9 levels normalized, suggesting a potential association between the teratoma and the abnormal tumor marker levels.
Discussion: This report delineates the surgical management and clinical course of an exceptionally large ovarian teratoma in a pediatric patient with abnormal preoperative tumor markers. Despite atypical features, the excellent prognosis following fertility-sparing resection underscores the significance of conservative treatment in young females.
Conclusion: This case highlights the occurrence of a large mature cystic teratoma with elevated CA-19-9 in a pediatric patient with no complications such as torsion, rupture, or malignancy. The elevation in CA-19-9 likely relates directly to the teratoma itself. A conservative, fertility-sparing surgical approach proved effective, emphasizing the importance of careful preoperative evaluation and management in similar cases.
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- Review Article
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DAANISH: A mnemonic to aid in memorizing and recalling important strategies contributing to the prevention of perioperative stroke
More LessBackground: Perioperative stroke, defined as a stroke occurring within 30 days post-surgery, typically emerges within the first week. The incidence of perioperative stroke among adults undergoing non-cardiac and non-neurological surgeries ranges from 0.1% to 1% after a surgical intervention. Mortality rates following perioperative stroke surge, reaching up to eight times higher than controls, with approximately one in four cases resulting in death. Fortunately, various strategies are available to potentially prevent perioperative strokes. However, the vast amount of data poses challenges for physicians in memorization and recall for clinical use. This study aims to summarize essential perioperative stroke prevention strategies and determine an effective mnemonic for their memorization and recall.
Method: The initial search in PubMed focused solely on review articles published within the last 10 years. It utilized the keywords “perioperative stroke” and “prevention.”
Results: An initial search found 39 articles, with two suitable for review. Using data from selected review articles, further searches were conducted on Google Scholar and PubMed for articles from 2000 to 2024, identifying 30 additional suitable references. From these 32 articles, the author developed a mnemonic, “DAANISH,” to aid in remembering strategies for preventing perioperative stroke.
Conclusion: Implementing this mnemonic may help reduce the risk of perioperative stroke and improve patient outcomes. Future research is needed to confirm its effectiveness.
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- Research Paper
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Risk factors and associations with atopic diseases in the pediatric population in Qatar
Authors: Samer Hammoudeh, Prem Chandra and Ibrahim A. JanahiIntroduction: Asthma is a common noncommunicable disease with public health implications due to the rising number of cases among the pediatric population in Qatar.
Aim: The objective of the current study is to explore possible risk factors and associations in relation to pediatric asthma, allergic rhinitis, and eczema cases in Qatar.
Methods: Using the Global Asthma Network questionnaires, this study sampled 2646 children, of which 1210 were aged 6–7 years and 1436 were aged 13–14 years in addition to 3831 adult parents or guardians. The STROBE guidelines were used to ensure the reporting of this cross-sectional study. Univariate and multivariate logistic regression were used to produce the odds ratio for the various risk factors and associated factors, respectively. Multiple associations and risk factors for each of the three diseases were reported.
Results: Based on the outcome of a multivariate logistic regression, being born in Qatar was the only risk factor present across all three diseases. Being male, wheezing ever, wheezing after exercise, and having eczema were other risk factors reported for asthma. Being in the older age group, wheezing ever, and having hay fever were other risk factors reported for allergic rhinitis.
Conclusion: The study concluded that further evaluation into associated and risk factors for asthma, allergic rhinitis, and eczema is warranted in the future.
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