Milrinone Versus Sildenafil in Treatment of Neonatal Persistent Pulmonary Hypertension: A Randomized Control Trial.

ABSTRACT: Persistent pulmonary hypertension of the newborn (PPHN) is a condition caused by failure of pulmonary vascular adaptation at birth, resulting in severe hypoxia. Several therapeutic modalities are being tried in developing countries where established therapies (inhaled nitric oxide and extracorporeal membrane oxygenation) are widely unavailable. This study aimed to assess the efficacy of milrinone versus sildenafil as available alternative therapeutics in treating PPHN. Forty neonates (>34 weeks) admitted to neonatal intensive care units with evidence of PPHN were randomly allocated to receive either oral sildenafil (0.5-2 mg/kg/6 hours) or intravenous milrinone (0.25-0.75 mic/kg/min). Primary outcomes included improvements in systolic pulmonary artery pressure and oxygen saturation index (OSI) at 24 and 48 hours after treatment. Secondary outcomes included the duration of hospitalization and mechanical ventilation. The ClinicalTrials identifier is NCT04391478. Both groups showed significant improvement in the post-treatment hemodynamic variables compared with pretreatment levels ( P < 0.05 for all parameters). Systolic pulmonary artery pressure and OSI values significantly improved in both study groups compared with baseline ( P < 0.001). The 24-hour and 48-hour post-treatment OSI values were much lower in the milrinone group than those in the sildenafil group ( P < 0.05). The length of hospital stay was significantly shorter in the milrinone group than that in the sildenafil group ( P < 0.05). There were no significant differences in the duration of mechanical ventilation, incidence of intracranial hemorrhage and pulmonary hemorrhage, or mortality between the 2 groups ( P > 0.05). In conclusion, milrinone and sildenafil are effective and well-tolerated in neonates with PPHN, particularly when inhaled nitric oxide and extracorporeal membrane oxygenation are not available. Milrinone is superior to sildenafil in improving oxygenation without lowering blood pressure parameters.

A multicriteria decision analysis (MCDA) tool to purchase implantable medical devices in Egypt.

BACKGROUND: With the availability of several similar medical devices performing the same function, choosing one for reimbursement is not easy, especially if purchased for a large number of patients. The objective of this project was to create a multicriteria decision analysis (MCDA) tool, that captures and compares all implantable medical devices' attributes, to provide an objective method for choosing among the available options in Egypt. METHOD: We conducted a systematic review and expert interviews, to identify the relevant criteria for inclusion in the tool. Subsequently, a workshop was conducted, that involved experts in procuring and tendering medical devices. Experts chose the criteria, ranked them, assigned weights and scoring functions for each criterion, and then created the draft tool. A pilot phase followed; then, another workshop was conducted to fine-tune the tool. We readjusted the tool based on experts' experience with the draft tool. RESULTS: The final tool included eight criteria, arranged according to their weightage: technical characteristics (29.4%), country of origin (19.5%), use in reference countries (14.9%), supply reliability (11.7%), previous use in tenders (9.0%), instant replacement within product variety (6.9%), pharmacovigilance (4.6%), and refund or replacement (4.0%). Each medical device was assessed on these eight criteria to achieve a final score, that was compared to the alternative devices' scores. Price is not included in the MCDA tool, but it will be added in the financial evaluation phase. CONCLUSION: Decisionmakers could use the MCDA tool, to make evidence-based and objective decisions for purchasing implantable devices, in the Egyptian public sector. Post price evaluation, the product with the best value will be chosen for reimbursement. HIGHLIGHTS: We created an MCDA tool to help decision makers choose between alternative implantable medical devices in Egypt. The MCDA tool includes eight criteria, where price is evaluated as a separate step. "Technical characteristics" and "country of origin" criteria carried the highest weights, thus representing approximately 50% of the decision.

Oral piercings and orthodontic treatment: A questionnaire-based national survey.

OBJECTIVE: To obtain opinions from orthodontic colleagues nationally on how they currently manage orthodontic patients with oral piercings. The secondary objectives were to assimilate the national opinions from the survey and attempt to generate educational material as an advice sheet and a patient information leaflet for the professionals and the patients respectively for the British Orthodontic Society (BOS). DESIGN: Cross-sectional survey. SETTING: Primary and secondary care orthodontic providers. PARTICIPANTS: Members of the BOS. METHODS: An electronic questionnaire was developed and circulated to members of the BOS to obtain their opinions on the effects of oral piercings on their patients' orthodontic treatment 'journey'. In addition, the need for the development of informative material around the management of orthodontic treatment and appliances in patients with oral piercings was explored. RESULTS: A total of 110 responses were received. However, only 88 respondents out of 110 attempted all the questions within the survey. There were 22 respondents who attempted it partially. We did include these partial responses well while analysing the results, since many of these offered personalised comments in the free-text boxes within the survey. CONCLUSION: The most common general complications associated with oral piercings were inflammation of the surrounding tissue and enamel/dentine wear. Moreover, orthodontic complications, reported commonly, were inadequate oral hygiene maintenance, entanglement with the orthodontic appliance causing damage and interference with retainers. Most respondents expressed the need for the development of a web-based patient information leaflet and an advice sheet as educational tool, both of which have been proposed to and agreed by the BOS before submission of this publication.

An IoT-Based Gamified Approach for Reducing Occupants' Energy Wastage in Public Buildings.

Conserving energy amenable to the activities of occupants in public buildings is a particularly challenging objective that includes associating energy consumption to particular individuals and providing them with incentives to alter their behavior. This paper describes a gamification framework that aims to facilitate achieving greater energy conservation in public buildings. The framework leverages IoT-enabled low-cost devices, to improve energy disaggregation mechanisms that provide energy use and-consequently-wastage information at the device, area and end-user level. The identified wastages are concurrently targeted by a gamified application that motivates respective behavioral changes combining team competition, virtual rewards and life simulation. Our solution is being developed iteratively with the end-users' engagement during the analysis, design, development and validation phases in public buildings located in three different countries: Luxembourg (Musée National d'Histoire et d'Art), Spain (EcoUrbanBuilding, Institut Català d'Energia headquarters, Barcelona) and Greece (General Secretariat of the Municipality of Athens).

Management of patients with CHB outside the guidelines: Insights from Egyptian cohort with long-term follow-up.

It is alarming that globally, only 2.2% (6.6 million) of patients with chronic hepatitis B (CHB) received treatment in 2019. One contributing factor to this low treatment rate is the complexity and restrictive nature of clinical practice guidelines. Since 1998, we have adopted a "treat-all" approach to patients with CHB. A retrospective study was conducted involving patients with CHB who received treatment from 1998 to 2020 at 2 institutions in Egypt. These patients underwent evaluation through various clinical and laboratory methods, which included testing for liver enzymes and HBV DNA. The study analyzed 1825 patients with HBV, finding that 27.4% had viremia levels under 2000 IU/mL. Most (88%) were HBeAg-negative, with 12% positive. A large portion (77.6%) had normal alanine aminotransferase levels, though 5.6% exceeded twice the upper limit of normal. About 14.2% were diagnosed with liver cirrhosis, and 9.6% with F3 stage fibrosis at enrollment. Notably, 2% (25 cases) lost HBsAg over a median of 52 months. Patients with HBV DNA <2000 IU/mL had a higher HBsAg loss rate (4.2%) compared to those with levels >2000 IU/mL (1.3%). During follow-up, 9.5% (117 patients) experienced decompensation, with a higher incidence in those with HBV DNA <2000 IU/mL (16.8%) than those >2000 IU/mL (7.1%). HCC developed in 5.2% of patients with lower HBV DNA and 2.6% with higher levels, showing significant differences. Liver-related deaths occurred in 2.8% of the cohort, with a slightly higher rate in those with lower initial HBV DNA levels (3.5% vs. 2.5%). The findings suggest a paradigm shift in CHB management toward early and broader eligibility for antiviral therapy. This could improve patient outcomes and address the global treatment gap in CHB management, especially in regions with high CHB prevalence.

Feedback in an Epidemic?

Undergraduates and postgraduates frequently receive feedback on their clinical and non-clinical performance and progression throughout their studies and career. Good quality feedback has been shown to improve trainees' confidence and performance. This article discusses the benefits of feedback and reviews the communication, technical, financial, and networking barriers to feedback introduced by coronavirus disease 2019 (COVID-19) and its impact on the quality of medical and dental education in the UK, followed by a critical reflection. In addition, it reviews the pros and cons of self-assessment of clinical learning, and it provides an overview of the most widely accepted feedback models: Pendleton's rules, SET-GO method, agenda-led, outcome-based analysis (ALOBA) model and Prepare to Ask-Discuss-Ask-Plan Together (Prepare to ADAPT) on the quality of feedback received. The aim is to identify the most suitable feedback method to help trainees with their clinical and professional development during the COVID-19 pandemic and any possible pandemics in the future.