A Plasmodium falciparum ubiquitin-specific protease (PfUSP) is essential for parasite survival and its disruption enhances artemisinin efficacy.

Proteins associated with ubiquitin-proteasome system (UPS) are potential drug targets in the malaria parasite. The ubiquitination and deubiquitination are key regulatory processes for the functioning of UPS. In this study, we have characterized the biochemical and functional role of a novel ubiquitin-specific protease (USP) domain-containing protein of the human malaria parasite Plasmodium falciparum (PfUSP). We have shown that the PfUSP is an active deubiquitinase associated with parasite endoplasmic reticulum (ER). Selection linked integration (SLI) method for C-terminal tagging and GlmS-ribozyme mediated inducible knock-down (iKD) of PfUSP was utilized to assess its functional role. Inducible knockdown of PfUSP resulted in a remarkable reduction in parasite growth and multiplication; specifically, PfUSP-iKD disrupted ER morphology and development, blocked the development of healthy schizonts, and hindered proper merozoite development. PfUSP-iKD caused increased ubiquitylation of specific proteins, disrupted organelle homeostasis and reduced parasite survival. Since the mode of action of artemisinin and the artemisinin-resistance are shown to be associated with the proteasome machinery, we analyzed the effect of dihydroartemisinin (DHA) on PfUSP-iKD parasites. Importantly, the PfUSP-knocked-down parasite showed increased sensitivity to dihydroartemisinin (DHA), whereas no change in chloroquine sensitivity was observed, suggesting a role of PfUSP in combating artemisinin-induced cellular stress. Together, the results show that Plasmodium PfUSP is an essential protease for parasite survival, and its inhibition increases the efficacy of artemisinin-based drugs. Therefore, PfUSP can be targeted to develop novel scaffolds for developing new antimalarials to combat artemisinin resistance.

Anticoagulation Prescribing Patterns in Intensive Care Unit Patients Admitted with Prehospital Direct Oral Anticoagulant Therapy: A Single Academic Center Experience.

OBJECTIVE: To describe the current prescribing practices of direct oral anticoagulants (DOACs) in intensive care unit (ICU) patients and the associated clinical outcomes, including the incidence of major bleeding episodes and the need for intervention (endoscopic, surgical, or interventional radiology guided). DESIGN: Observational, retrospective chart review. SETTING AND PARTICIPANTS: Single large academic center study. Participants included patients with critical illness who were admitted to the intensive care units (ICU) at Mayo Clinic from January 1st, 2012, until May 4th, 2018. Adult ICU patients with a DOAC (apixaban, rivaroxaban, dabigatran, or edoxaban) listed as one of the active medications at the time of hospital admission were included. RESULTS: 37 249 patients in medical and surgical intensive care units were screened for the study period. After excluding patients who did not qualify, 558 unique encounters were included. The median age was 69 (IQR 59-78) years; most patients were male, white Caucasians, and had a median SOFA score of 4. After excluding the patients who had major bleeding episodes in the first 24 hours, 188 (39%) were continued on the same DOAC therapy, 204 (42%) were discontinued without transitioning to another agent, and 95 (20%) were transitioned to another agent. Finally, 410 (84%) were dismissed on DOAC therapy at the end of hospitalization. The difference in the continuation rate of the same DOAC agent beyond 24 hours, discontinuation without transition to an alternate agent, or discontinuation of DOAC with a transition to an alternate anticoagulation agent was not statistically significant (P = .60). A total of 52 major bleeding events were identified. Gastrointestinal bleeding was the most common bleeding complication [n (%): 34 (65)], followed by intra-abdominal and peri-procedural bleeding [7 (13.5) and 7 (13.5)]. Thirty-three (65%) patients had a major bleeding complication requiring intervention. CONCLUSIONS: Our single-center retrospective study describes the current prescribing practices and preliminary outcomes in ICU patients with prehospital use of DOACs. Up to 20% of the patients were transitioned to a different agent within 24 hours of ICU admission, whereas a significant proportion of patients (42%) had anticoagulation discontinued altogether. Most patients who suffered a major bleeding episode required either endoscopic or surgical intervention to control bleeding.

BEHAVIOURAL SCIENCES AT UNIVERSITY OF HEALTH SCIENCES: THE WAY FORWARD.

BACKGROUND: The association of medical ethics with teaching and training and health profession has been informal, largely dependent on role modelling and the social contract of the physicians with the community that they abide by. This study was conducted to examine the effect, if any, of introducing the subject of Behavioural Sciences on students' performance in the clinical years' 'viva voce' and 'patient interactions' components of the examinations. METHODS: A prospective study on four cohorts of students at UHS from 2007 to 2012 (8,155 candidates). Reliability was calculated through Cronbach's Alpha. Linear Regression Analysis was applied to determine the relationship between the scores of Basic Medical Sciences, Behavioural Sciences and Forensic medicine with the viva voce and Structured Stations marks of the Clinical Sciences in OSCE. Gender and demographics analysis was also done. RESULTS: Cronbach's Alpha was 0.47, 0.63, 0.67 and 0.53 for the Papers of Behavioural Sciences from 2007 to 2010 respectively. Poor predictive value of Behavioural Sciences for performance in tlhe clinical years' viva voce and OSCE was identified. Basic Medical Sciences and Forensic Medicine were statistically significant predictors for the performance of female candidates in all four cohorts of the study (p < 0.05). In Central Punjab, Behavioural Sciences statistically significantly predicted for better performance in all four cohorts of the study (p < 0.05). CONCLUSION: It is premature to understand the results of Behavioural Sciences teaching at University of Health Sciences (UHS). We can still safely conclude that it can only have a positive sustained effect or the healthcare delivery systems and patient care in Pakistan if it is integrated within each subject and taught and learned not as a theoretical construct but rather an evaluation of one's values within the code of conduct of medical professionalism in the larger context of the societal and cultural norms.

SOCIO-DEMOGRAPHIC STUDY OF HEPATITIS C PATIENTS VISITING TERTIARY CARE HOSPITAL.

BACKGROUND: Hepatitis C is a very common blood-borne disease of liver caused by Hepatitis C Virus and about two third of these patients will ultimately end up having liver cirrhosis or hepatocellular carcinoma. This study was carried out to determine the sociodemographic status of the hepatitis C infected patients visiting tertiary care hospitals in Lahore, Pakistan. METHODS: This study was conducted during the months of October and November 2009. In this cross sectional study, 154 volunteer patients of HCV were included. They were investigated for sociodemographic variables and were statistically analysed by SPSS-15. RESULTS: Of these 154 patients, a high percentage of patients were females (70.1%). Majority of the patients belonged to the families of labour occupation (39.4%) of which 71.4 % were illiterate. Gender was found significantly associated with categories of sleep disturbance (p<0.05) and tension (p<0.05) among HCV patients. Married patients were significantly associated with tension (p<0.05) and a significant emotional and behavioural change in their attitude was also found (p<0.05). Patients with shorter interval after first diagnosis of the disease felt more emotional and had greater behavioural changes in their attitude (p<0.05). CONCLUSION: Incidence of Hepatitis C was higher in females and married females with shorter interval after first diagnosis of the disease were more depressed.

Predictive validity of medical and dental colleges' entrance test in Punjab: the way forward.

OBJECTIVE: To identify the strengths and weaknesses of the current selection process for admissions to public medical colleges being followed in the province of Punjab and to suggest changes. METHODS: The prospective study comprised candidates sitting the Medical and Dental Colleges Entrance Tests administered by the University of Health Sciences, Lahore, from 2008 to 2011. The marks of pre- and post-admission examinations were entered in SPSS 17 and performance of candidates in different examinations up to 2012 was compared using parametric statistical tests. P ≤ 0.05 was considered statistically significant. Reliability of the entrance test question paper was calculated through Cronbach's Alpha. RESULTS: Overall 1,01,273 candidates sat in the entrance test during the study period, and of them 14, 995 (14.8%) students were admitted to public and private medical colleges in Punjab affiliated with the University of Health Sciences, Lahore. Cronbach's Alpha showed excellent internal consistency reliability of the question paper of 220 items for all these four years. Overall, students scored significantly lower marks (p < 0.05) in all their MBBS Professional Examinations than their pre-admission tests. A similar pattern of difference was seen in entrance test marks in different geographical localities as in the case with MBBS Professional Examination. Students from Islamabad and Rawalpindi regions scored significantly higher marks in all MBBS examinations as well as in the entrance test and aptitude test, but lower in the Higher Secondary School Certificate examination. Internal consistency reliability of the aptitude test was found to be 0.83. Linear regression analysis showed that Estimated Regression Coefficient of the Higher Secondary School Certificate marks was negative, but positive for entrance test and indicated that the latter results were a good positive predictor for the post-selection performance. In the sub-components, only the Biology and Chemistry regression coefficient section was found to be positive. CONCLUSIONS: Entrance and aptitude tests in Punjab were found to be valid and reliable with incremental predictive validity at least for performance in the pre-clinical years. It is suggested that Higher Secondary School Certificate-marks should have little, if any, weightage in the selection process.

Comparison of pre-medical academic achievement, entrance test and aptitude test scores in admission selection process.

OBJECTIVE: To compare the awards of various pre-medical academic achievements with aptitude test scores obtained by candidates taking the Entrance Test 2011, and to identify demographic differences in the trend, if any. METHODS: The cross-sectional study involved a 22-item aptitude test administered to all the students taking the Medical College Admission Test conducted by the University of Health Sciences, Lahore, on September 13, 2011. The Matriculation, Intermediate, EntranceTest and AptitudeTest scores of all the students along with their demographic variables were entered into SPSS 16 and statistically analysed by using parametric tests. A p value of < 0.05 was considered statistically significant. RESULTS: Out of the 32,746 students, 22,935 (70%) were females. Students who scored more than 75% marks (n = 4,723; 14%) also scored higher marks in the Aptitude Test (p < 0.05). Female candidates in general scored higher marks in the Entrance Test (p < 0.05) and in the Aptitude Test (p < 0.05). Overall, students from the economically and academically underdeveloped districts of Punjab scored less marks in the Entrance Test (p < 0.05) and the Aptitude Test (p < 0.05).The difference in Entrance Test and Aptitude Test marks of students from underdeveloped districts was greater than that of students for the developed districts (p < 0.05). However, in Matriculation and Intermediate examinations, students from the underdeveloped districts scored higher marks than the developed districts (p < 0.05). Students scoring higher marks in Matric and Intermediate, scored low marks in the Aptitude Test (p < 0.05). CONCLUSION: The Entrance Test and Aptitude Test scores correlated poorly with Intermediate and Matriculation scores. There is a need to strengthen the underdeveloped areas academically. Besides, the predictive value of the Aptitude Test scores related to future performance of candidates selected needs to be ascertained with further studies.

Medical colleges admission test in Punjab, Pakistan.

BACKGROUND: Nearly 18,000 candidates securing 60% and above marks in Higher Secondary School Certificate (HSSC) examination contest for admission in Medical Colleges, in Punjab, Pakistan by sitting in the Medical College Admission Test (MCAT) each summer. This cross-sectional study was conducted to identify patterns related to demographic, economic and educational backgrounds, over a two-year-period, in this population, and how HSSC and MCAT marks predict future performance of the selected candidates. METHODS: Marks obtained by candidates in HSSC, MCAT, and 1st Professional MBBS (Part-I) Examinations over two years 2008-2009, were analysed using parametric tests in SPSS. RESULTS: Total 18,090 candidates in 2008 and 18,486 in 2009 sat in the MCAT. National IHSSC candidates scored higher marks in HSSC and MCAT but lower marks than their foreign qualified HSSC counterparts (e.g., Advanced-levels from Cambridge University, UK) in Part-I overall and in all its subcomponents individually (p < 0.05). Female students scored higher marks than males in HSSC (p > 0.05). MCAT (p > 0.05) and Part-I theory, practical, viva voce, continuous assessment and Objective-Structured Performance Evaluation (OSPE) components (p < 0.05). In both years, students from the Dera Ghazi Khan District scored the highest marks in the HSSC Examinations (p < 0.05) but least marks in MCAT in 2008 (p < 0.05) and in Part-I in 2008 and 2009 (p < 0.05). Students from 'tougher' Boards like Rawalpindi in 2008 and the Federal Board in 2009 who scored least marks in HSSC scored highest marks in MCAT. and in Part-I Examinations (p < 0.05). Linear regression on Part-I by taking HSSC and MCAT marks as independent variables showed that the MCAT marks exerted the greatest positive influence consistently at 0.104 (2008) and 0.106 (2009). In 2009 HSSC marks were shown to exert a negative influence (-0.08) on Part-I. CONCLUSION: There is need to standardise HSSC education and examination across all Intermediate Boards. MCAT is a better predictor of Medical Students' future performance.

Clinical and Echocardiographic Predictors of Recovery of Moderate-to-severe Sepsis-associated Acute Kidney Injury in Critically Ill Patients.

Background: Acute kidney injury (AKI) is associated with significant short- and long-term morbidity and mortality. In critically ill patients with sepsis, AKI tends to be more severe, more likely to require kidney replacement therapy (KRT), with less chance of recovery. Consequently, critically ill patients with sepsis-associated AKI (SA-AKI) have extended intensive care unit (ICU) stays and higher mortality rates. This study evaluated the predictive value of clinical and transthoracic echocardiographic (TTE) parameters for recovery from moderate-to-severe SA-AKI in critically ill patients. Methods: This single-center historical cohort study was conducted at a tertiary academic medical center. We analyzed the data of all adults (age ≥18 years) admitted to the ICU at Mayo Clinic, Rochester, MN, from June 1, 2018, to December 31, 2020. We included all patients who developed sepsis within the initial 24 h of their ICU stay. Results: We identified 2919 eligible septic patients with available TTE, among which 1431 patients (49%) had moderate-to-severe SA-AKI. The mean age of the patients was 68 ± 15 years, and the male-to-female ratio was 1.3:1. The most common comorbidities were diabetes mellitus and chronic lung and kidney diseases. Clinical predictors associated with SA-AKI non-recovery were the presence of stage III AKI (HR 1.5, 95% CI 1.0-2.1, p = 0.03) and utilization of kidney replacement therapy (KRT) (HR 6.8, 95% CI 3.6-12.4, p = 0.01). On the other hand, higher TAPSE was the only TTE variable associated with SA-AKI recovery (HR 1.1; 95% CI 1.08-1.15; p = 0.01). Conclusion: Our data from a single-center provide new information on the clinical (AKI stage, utilization of KRT, BMI, and peak serum creatinine) and echocardiographic features (TAPSE) associated with improved recovery in SA-AKI. There is a definite knowledge gap in the current literature regarding optimizing recovery in moderate-to-severe SA-AKI. Larger, multi-center studies are required to confirm these findings.

Impact of COVID-19 on cancer management in military hospitals of Saudi Arabia.

OBJECTIVES: To evaluate the impact of COVID-19 on cancer management in Saudi Arabia's military hospitals. METHODS: This multi-centric, retrospective study compared cancer patients diagnosed from February-July 2019 and 2020, focusing on the time duration for acceptance and time for oncologic treatment initiation. Eligibility and referral status were recorded. Clinical data of COVID-19-positive cancer patients were collected and evaluated their outcomes and survival. RESULTS: Data of 1574 cancer patients (mean age, 57.1 years) were collected. Mean time for acceptance was 7.3 days in 2019 and 8 days in 2020, with no statistically significant difference. Mean time for oncology treatment initiation was 38.4 days in 2019 and 44.3 days in 2020, with no statistically significant difference. The number of new cancer patients decreased in 2020 but increased in peripheral hospitals. It decreased in Riyadh and Jeddah hospitals. Concerning referral status, a statistically significant modification was recorded only in Riyadh and Tabuk hospitals. No significant changes observed in time duration for acceptance of new patients and oncology treatment initiation from 2019-2020. A total of 76 COVID-19-positive cancer patients recorded; 72% were symptomatic, 73.6% recovered, 22.3% died due to COVID-19 complications, and 8% died due to cancer; cancer progressed in 7 patients. CONCLUSION: COVID-19 did not affect oncology service in Saudi Arabia's military hospitals. New cancer cases reduced during the pandemic. Cancer patients are at increased risk for COVID-19 complications, including death.

Impact of COVID19 on resident physicians of a community hospital in New York city.

Introduction: Novel Corona Virus Disease 19 has created unforeseen burden on health care. New York city is one of the epicenters of pandemic and here we explore physical, mental and social impact of COVID 19 on Resident Physicians (RP) working within the center of this epicenter. Methods: This is a single-center cross-sectional web-based survey involving RP of a community hospital in Brooklyn, New York. Questionnaire was formulated in online platform. We used a convenient sampling method. Univariate analysis was conducted and presented the distribution of qualitative responses as frequency and percentages. Result: COVID19 related symptoms were reported by 39.8% RP. COVID19 IgG and IgM antibodies, both negative were reported by 34.9%, while only 6% RPs were IgG antibody positive. Symptomatic RP tested for COVID19-PCR was positive in 42.42%. Self-isolation from family during the pandemic was reported by only 14.5%. Financial constraints, lack of accommodation, and emotional reasons were main reasons of not being able to self isolate. Being bothered by 'Anxiety' and 'Nervousness' were reported by 8.5% on 'Almost every day' while 46.3% reported on 'several days in the two weeks duration'. 'Uncontrollable worrying', 'Feeling down', 'Depressed,' or 'Hopeless' was reported as 'Not at all' by 78.8% and 3.7% reported it to 'occur nearly every day for the last two weeks'. Conclusion: Aftermath of fight against pandemic has left RP with significant physical, mental, and social impact. Appropriate stress management and safety interventions are urgently needed. Further studies are needed to explore the detailed impact of COIV19 on RP.

Developing the outcomes of a baccalaureate of dental surgery programme.

BACKGROUND: Curriculum broadly falls into two categories, prescriptive and outcome-based. In the prescriptive curricula emphasis is placed on teaching with generally little integration between subjects and across disciplines. Currently, universities in Pakistan are undergoing a cultural change in the curricular design in order to apply an outcome-based learning instead of prescriptive teaching. Regionally, the need for change was recognised on account of the vast body of evidence available internationally. In order to bring about a shift towards an outcome based curriculum in the 4-year BDS programme, we first need to specify the outcomes/traits that the dental health professionals should be able to demonstrate upon leaving the programme. This paper describes the process and outcome of arriving at the desired consensus through a series of workshops involving all stakeholders including students, community members, teaching faculty, programme directors and representatives of the dental health industry. METHODS: A series of workshops were conducted between September 2009 to February 2010 in all of the 18 disciplines of basic and dental sciences individually and then collectively. A questionnaire sought responses from the participants regarding their perception about the status of the current BDS curriculum and their understanding of an outcome-based integrated curriculum, as well as whether such an integrated curriculum should be adopted or not? In the second half of the workshop through brainstorming and Delphi technique, the outcomes in terms of measurable traits that should be possessed by a graduate dental health professional entering community service were enlisted. The pre- and post-workshop questionnaire scores were entered into SPSS-16 and paired sample t-test as well as chi-square test were applied. Cron back alpha value of < 0.05 was taken as statistically significant. Secondly, the outcomes developed in each workshop were entered into Ethnograph and common outcomes of the 4-year BDS programme were extracted. RESULTS: In total, 234 participants attended the workshop over a period of five months in 18 discipline-wise workshops and four integrated workshops involving faculty members of all disciplines. Results indicate clearly that the workshop resulted in an attitude shift of the participants and their perception of the current curriculum and the need and rationale for a move towards an outcome-based curriculum. The 30 outcomes identified were grouped under two categories namely 'clinical skills' and 'professional behaviours'. CONCLUSION: Defining the final programme outcomes is only the initial step in developing an outcome-based, objective, integrated curriculum which will require considerable work in the future.

Relationship of awards in multiple choice questions and structured answer questions in the undergraduate years and their effectiveness in evaluation.

BACKGROUND: A number of evaluation tools for assessing the cognitive and affective domains in accordance with Bloom's taxonomy are available for summative assessment. At the University of Health Sciences, Lahore, Multiple Choice Questions (MCQs) and Structured Answer Questions (SAQs) are used for the evaluation of the cognitive domain at all six hierarch levels of taxonomy using the tables of specifications to ensure content validity. The rationale of having two evaluation tools seemingly similar in their evaluative competency yet differing in feasibility of construction, administration and marking is being challenged in this study. METHODS: The MCQ and SAQ awards of the ten percent sample population amounting to 985 students in fifteen Medical and Dental Colleges across Punjab were entered into SPSS-15 and correlated according to the cognitive and affective level of assessment in relation to the Bloom's taxonomy and their grouping in the Tables of Specifications, using parametric tests. 3494 anonymously administered questionnaires were analyzed using ethnograph. RESULTS: No statistically significant difference was found in the mean marks obtained by the students when MCQs and SAQs were compared according to their groupings in the Tables of Specifications at all levels of cognitive hierarchical testing. End-of-yearcognitive level testing targets set were not met and more questions were set at the lower cognitive testing levels. Expenses incurred in setting MCQs and SAQs were comparable but conduct and assessment costs for MCQs and SAQs were 6% and 94% of the total respectively. In both MCQs and SAQs students performed better at higher cognitive testing levels whereas the SAQs and MCQs were able to marginally test the lower levels of affective domain only. Student's feedback showed that attempting MCQs required critical thinking, experience and practice. CONCLUSION: MCQs are more cost effective means at levels of cognitive domain assessment.

Outcomes of multidisciplinary team interventions in the management of sickle cell disease patients with opioid use disorders. A retrospective cohort study.

OBJECTIVES: To identify the magnitude of opioid use disorder (OUD) among sickle cell disease (SCD) patients; emphasize on multidisciplinary team (MDT) role; estimate cost-effectiveness following the proper use of therapeutic guidelines; and facilitate the reduction of emergency room (ER) visits and the length of stay (LOS). METHODS: This retrospective cohort study included SCD patients aged 14 years and above, who have OUD. Data was collected between January 2016 and December 2018. Data included ER visits, hospital LOS, opioid consumption, and narcotic prescription tracking. The target group was followed with a set of interventions for pain management and healthcare resource utilization. Results: Twenty one SCD patients were identified with OUD. Following the interventions, there was a statistically significant decrease in ER visits of these OUD patients (from 8709 visits in 2016 to only 94 in 2018). Morphine consumption decreased by 82% and meperidine by 60%, over the 3-year period. Moreover, there was a huge reduction in both ER and LOS costs for this cohort of patients. CONCLUSION: Establishing an MDT and a series of interventions for SCD patients with OUD, including educational activities for caregivers and patients; establishing a palliative/pain clinic and a SCD addiction clinic; and implementing an adequate opioid prescription tracking system resulted in a significant reduction in both the cost and number of ER visits and hospital LOS and dramatically decreased opioid consumption.

Pulmonary Kaposi Sarcoma: an uncommon presentation in HIV heterosexual female on antiretroviral therpay.

Kaposi sarcoma (KS) is caused by Human Herpesvirus 8 (HHV-8), and it affects 15 times more common in men than women. It has varied clinical presentation from classic, endemic, organ transplant-related, and acquired immunodeficiency syndrome (AIDS)-related. Clinical features of pulmonary KS might be challenging to distinguish from pneumonia in immunocompromised patients and could lead to diagnostic challenges. Hence Pulmonary KS should also be considered in the differential when HIV-infected patients develop rapidly progressive respiratory symptoms after the initiation of glucocorticoid therapy and immunocompromised not responding to antibiotic treatment for pneumonia, especially when CD4 < 100 and viral load >10,000. Early diagnosis and treatment are essential for a better outcome and prevent morbidity and mortality. Highly active antiretroviral therapy (HAART) is the only proven therapy to prevent Kaposi sarcoma. We report the case of a young woman who presented with symptoms of pneumonia and was later found to have pulmonary KS (PKS).

The Impact of Hospital Teaching Status on Colonoscopy Perforation Risk: A National Inpatient Sample Study.

BACKGROUND: Colonoscopy has been widely used as a diagnostic tool for many conditions, including inflammatory bowel disease and colorectal cancer. Colonoscopy complications include perforation, hemorrhage, abdominal pain, as well as anesthesia risk. Although rare, perforation is the most dangerous complication that occurs in the immediate post-colonoscopy period with an estimated risk of less than 0.1%. Studies on colonoscopy perforation risk between teaching hospitals and non-teaching hospitals are scarce. METHODS: The National Inpatient Sample database was queried for patients who underwent inpatient colonoscopy between January 2010 and December 2014 in teaching versus non-teaching facilities in order to study their perforation rates. Our study population included 257,006 patients. Univariate regression was performed, and the positive results were analyzed using a multivariate regression module. RESULTS: Teaching hospitals had a higher risk of perforation (odds ratio 1.23, confidence interval 1.07 - 1.42, P = 0.004). Perforation rates were higher in females, patients with inflammatory bowel disease and dilatation of strictures. Polypectomy did not yield any statistical difference between the study groups. Other factors such as African-American ethnicity appeared to have a lower risk. CONCLUSION: Perforation rates are higher in teaching hospitals. More studies are needed to examine the difference and how to mitigate the risks.

In-hospital outcomes of angiography versus intravascular ultrasound-guided percutaneous coronary intervention in ST-elevation myocardial infarction patients.

BACKGROUND: We compared the in-hospital complications, outcomes, cost, and length of stay (LOS) between angiography-guided percutaneous coronary intervention (PCI) and intravascular ultrasound (IVUS)-guided PCI in patients with ST-elevation myocardial infarction (STEMI) in the USA. METHODS: A nationwide inpatient database was queried to identify patients >18 years with STEMI who underwent angiography-guided and IVUS-guided PCI from January 2016 to December 2016. We compared the in-hospital mortality, complications, cost, and LOS between the two groups. RESULTS: We identified 100,485 patients who underwent angiography-guided PCI and 5,460 patients who underwent IVUS-guided PCI. In-hospital mortality was not statistically different (odds ratio [OR] 0.76, 95% CI 0.46 - 1.22, P = 0.24). Patients who underwent PCI with IVUS were more likely to have coronary artery dissection (OR 4.26, 95% CI 2.34 - 7.7, p = <0.01), and both groups had a similar incidence of acute kidney injury requiring hemodialysis. The mean LOS was similar, but the mean total cost was higher in the group that underwent PCI under IVUS guidance. CONCLUSIONS: The in-hospital mortality, hemodialysis, and the use of support devices did not reach a statistical difference between the two groups. However, we observed higher rates of coronary dissection with the use of IVUS in STEMI management.

Incidence, Predictors, Causes, and Cost of 30-Day Hospital Readmission in Chronic Obstructive Pulmonary Disease Patients Undergoing Bronchoscopy.

Introduction Chronic obstructive pulmonary disease (COPD) has a significant disease burden and is among the leading causes of hospital readmissions, adding a significant burden on healthcare resources. The association between 30-day readmission in a COPD patient undergoing bronchoscopy and a wide range of modifiable potential risk factors, after adjusting for sociodemographic and clinical factors, has been assessed, and comparison has been made with COPD patients not undergoing bronchoscopy. Methods We conducted a comprehensive analysis of the 2016 Nationwide Readmission Database (NRD) of 30-day all-cause readmission among COPD patients undergoing bronchoscopy. A Cox's proportional hazards model was used to obtain independent relative risks of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy. Our primary outcome was the 30-day all-cause readmission rate in both groups. Other secondary outcomes of interest were the 10 most common reasons for readmission, resource utilization, independent predictors of readmission, and relative proportion of comorbidities between the index admission (IA) and the readmission in both groups. Results The overall rate of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy was 17.32% and 15.87%, respectively. The final multivariate model in the bronchoscopy group showed that the variables found to be an independent predictor of readmission were: pulmonary hypertension (hazard ratio [HR] 2.35; 95% confidence interval [CI] 1.26-4.25; P < .01), adrenal insufficiency (HR 4.47; 95% CI 1.44-13.85; P = .01) and discharge to rehab status. Independent predictor variables of admission in Group B were gender (women < men; HR 0.91; 95% CI 0.88-0.93; P < .01), and type of insurance (Medicaid > Medicare > private insurance). For all patients undergoing bronchoscopy, the mean length of stay (LOS) for IA was 11.91 ± 20.21 days, and LOS for readmission was 5.87 ± 5.48 days. The mean total cost of IA for patients undergoing bronchoscopy was much higher than that of readmission ($26,916 vs. $12,374, respectively). The entire LOS for readmission was 1,265 days, with a total cost of $2.66 million. For patients not undergoing bronchoscopy during the IA, mean LOS for IA was 4.26 ± 4.27 days, and mean LOS for readmission was 5.39 ± 5.51 days, which was longer than the IA in Group B but still shorter than LOS for readmission in Group A (patients undergoing bronchoscopy). The mean total cost of readmission was higher than the IA ($8,137 for IA vs. $10,893 for readmission). The total LOS in this group of patients was 313,287 days, with the total cost of readmission at $628 million. Conclusions Patients undergoing bronchoscopy have a slightly higher rate of 30-day readmissions as compared to patients not undergoing bronchoscopy, and the LOS is also slightly higher in this group during subsequent readmissions as compared to readmission in patients not undergoing bronchoscopy in IA. The readmission rate in COPD patients is impacted by a variety of social, personal, and medical factors. Patients with multiple medical comorbidities have a higher risk of readmission. In our understanding, bronchoscopy in a patient with acute exacerbation of COPD should be reserved for selected patients, and the rationale should be clarified, as it affects the overall LOS and healthcare expenditure.

Dronedarone-induced Phototoxicity in a Patient with Atrial Fibrillation.

Dronedarone is a class III antiarrhythmic agent and a potent blocker of multiple intracardiac ion channels with many electrophysical properties common with amiodarone. Oral dronedarone, 400 mg twice daily, is approved for the maintenance of normal sinus rhythm in patients with a history of atrial fibrillation (AF) or atrial flutter. It is primarily used for the maintenance of sinus rhythm in patients with paroxysmal or persistent AF or atrial flutter. Dronedarone is a relatively new therapeutic agent which is a non-iodinated congener of amiodarone and hypothesized to have far lesser side effects. Photosensitivity is an uncommon side effect of dronedarone and not much has been described in the literature. Here we describe a patient with such complication.

Systematic psychiatric assessment of patients with sickle cell disease.

OBJECTIVES: To determine the level of the psychological problems such as depression and anxiety in sickle cell disease (SCD) patients in Tabuk region, northwestern Saudi Arabia. Methods: In this cross-sectional study, 89 patients with SCD was assessed in the outpatient clinics of King Salman Armed Forces Hospital,   Tabuk, Saudi Arabia between March 2017 and August 2017. Two validated Arabic translated questionnaires, the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7), were used to assess the type and degree of psychopathology (anxiety or depression) each patient suffered.  Chi-square test was used to assess the differences between anxiety and depression levels according to the different sociodemographic characteristics of the participants. Results: The values were computed by analyzing the Cronbach's alphas for the GAD-7 (0.83) and PHQ-9 (0.81) questionnaires. The rate of depression was 36% and anxiety was 29%. Female patients with SCD reported a higher incidence of depression and anxiety than males (p greater than 0.05). Patients with a higher level of education were significantly more anxious about their illness than those with a lower level education (p=0.02). CONCLUSION: A statistically insignificant association was reported between depression and anxiety with regard to gender; however, female patients reported a higher incidence of depression and anxiety than male patients. A significant association with anxiety was reported among patients with higher levels of education.

A Case of Hydroxocobalamin-Induced False Blood Leak Alarm on Dialysis Machine.

Hemodialysis machines are equipped with a blood leak detector/alarm to prevent loss of blood following rupture of semipermeable membrane; the blood leak alarms could also be triggered by sensor malfunction or presence of air bubbles in the system. Hydroxocobalamin is a Food and Drug Administration-approved rapid-acting antidote to cyanide poisoning that converts cyanide to nontoxic cyanocobalamin. Side effects are reddish discoloration of skin and body fluids, urticarial rash, and rarely anaphylaxis. In this article, a case of false blood leak alarm following treatment of cyanide poisoning with hydroxocobalamin is reported, wherein the blood leak detector in dialysis machines prevented the patient from undergoing hemodialysis by repeatedly activating blood leak alarms. Continuous renal replacement therapy was used to overcome this problem. As the use of hydroxocobalamin increases, health care professionals should be educated about its potential to interfere with hemodialysis.