Effect of Low-dose Ketamine Infusion on Opioid Consumption in Children Undergoing Open Cardiac Surgery: A Randomized Controlled Double-Blind Study.

OBJECTIVE: This study was designed to evaluate the effect of low-dose ketamine infusion on the perioperative consumption of opioids in pediatric open cardiac surgery. DESIGN: A randomized, controlled, double-blinded single-center study was conducted. SETTING: The study took place in a tertiary care children's hospital. PARTICIPANTS: Patients of both sexes aged 2-12 years who underwent cardiac surgery were included. INTERVENTIONS: Patients in the ketamine group received a bolus of 0.3 mg/kg of ketamine before skin incision followed by continuous intraoperative infusion of 0.25 mg/kg/h and postoperative infusion of 0.1 mg/kg/h for 24 h. Patients in the control groups received volumes of normal saline either bolus or continuous infusion like that of the ketamine group. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the total dose of fentanyl consumed over the first 24 hours postoperatively. Secondary outcomes were intraoperative fentanyl consumption, time to extubation, modified objective pain score, and incidence of vomiting, pruritus, diplopia, or hallucinations. A total of 80 patients were recruited but the final analysis was done on 35 patients in the ketamine group and 34 in the control group. Fentanyl consumption during surgery and in the first 24 hours postoperatively was significantly lower in the ketamine than the control group. Patients in both the ketamine and control groups had similar times to extubation. Modified objective pain scores were significantly lower in the ketamine group than the control group. None of the patients in either group had diplopia or hallucinations. CONCLUSIONS: Low-dose ketamine infusion in children undergoing open cardiac surgery reduced intra- and postoperative opioid consumption and postoperative pain scores. Moreover, ketamine did not cause diplopia or hallucinations.

A Model Selection Approach for Time Series Forecasting: Incorporating Google Trends Data in Australian Macro Indicators.

This study examined whether the behaviour of Internet search users obtained from Google Trends contributes to the forecasting of two Australian macroeconomic indicators: monthly unemployment rate and monthly number of short-term visitors. We assessed the performance of traditional time series linear regression (SARIMA) against a widely used machine learning technique (support vector regression) and a deep learning technique (convolutional neural network) in forecasting both indicators across different data settings. Our study focused on the out-of-sample forecasting performance of the SARIMA, SVR, and CNN models and forecasting the two Australian indicators. We adopted a multi-step approach to compare the performance of the models built over different forecasting horizons and assessed the impact of incorporating Google Trends data in the modelling process. Our approach supports a data-driven framework, which reduces the number of features prior to selecting the best-performing model. The experiments showed that incorporating Internet search data in the forecasting models improved the forecasting accuracy and that the results were dependent on the forecasting horizon, as well as the technique. To the best of our knowledge, this study is the first to assess the usefulness of Google search data in the context of these two economic variables. An extensive comparison of the performance of traditional and machine learning techniques on different data settings was conducted to enable the selection of an efficient model, including the forecasting technique, horizon, and modelling features.

Combined Colloid Preload and Crystalloid Coload Versus Crystalloid Coload During Spinal Anesthesia for Cesarean Delivery: A Randomized Controlled Trial.

BACKGROUND: The optimal strategy of fluid administration during spinal anesthesia for cesarean delivery is still unclear. Ultrasonography of the inferior vena cava (IVC) has been recently used to assess the volume status and predict fluid responsiveness. In this double-blind, randomized controlled study, we compared maternal hemodynamics using a combination of 500-mL colloid preload and 500-mL crystalloid coload versus 1000-mL crystalloid coload. We assessed the IVC at baseline and at subsequent time points after spinal anesthesia. METHODS: Two hundred American Society of Anesthesiologists physical status II parturients with full-term singleton pregnancies scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive either 500-mL colloid preload followed by 500-mL crystalloid coload (combination group) or 1000-mL crystalloid coload (crystalloid coload group) administered using a pressurizer. Ephedrine 3, 5, and 10 mg boluses were administered when the systolic blood pressure decreased below 90%, 80% (hypotension), and 70% (severe hypotension) of the baseline value, respectively. The IVC was assessed using the subcostal long-axis view at baseline, at 1 and 5 minutes after intrathecal injection, and immediately after delivery; the maximum and minimum IVC diameters were measured, and the IVC collapsibility index (CI) was calculated using the formula: IVC-CI = (maximum IVC diameter - minimum IVC diameter)/maximum IVC diameter. The primary outcome was the total ephedrine dose. RESULTS: Data from 198 patients (99 patients in each group) were analyzed. The median (range) of the total ephedrine dose was 11 (0-60) mg in the combination group and 13 (0-61) mg in the crystalloid coload group; the median of the difference (95% nonparametric confidence interval) was -2 (-5 to 0.00005) mg, P = .22. There were no significant differences between the 2 groups in the number of patients requiring ephedrine, the incidence of hypotension and severe hypotension, the time to the first ephedrine dose, and neonatal Apgar scores at 1 and 5 minutes. The maximum and minimum IVC diameters in each group increased after spinal anesthesia and after delivery, and they were larger in the combination group. The IVC-CI after delivery was higher in the crystalloid coload group. CONCLUSIONS: The combination of 500-mL colloid preload and 500-mL crystalloid coload did not reduce the total ephedrine dose or improve other maternal outcomes compared with 1000-mL crystalloid coload. The IVC was reliably viewed before and during cesarean delivery, and its diameters significantly changed over time and differed between the 2 groups.

Effects of family conversation on health care practices in Ethiopia: a propensity score matched analysis.

BACKGROUND: Maternal and newborn mortality rates in Ethiopia are among the highest in sub-Saharan Africa. The majority of deaths take place during childbirth or within the following 48 h. Therefore, ensuring facility deliveries with emergency obstetric and newborn care services available and immediate postnatal follow-up are key strategies to increase survival. In early 2014, the Family Conversation was implemented in 115 rural districts in Ethiopia, covering about 17 million people. It aimed to reduce maternal and newborn mortality by promoting institutional delivery, early postnatal care and immediate newborn care practices. More than 6000 Health Extension Workers were trained to initiate home-based Family Conversations with pregnant women and key household decision-makers. These conversations included discussions on birth preparedness, postpartum and newborn care needs to engage key household stakeholders in supporting women during their pregnancy, labor and postpartum periods. This paper examines the effects of the Family Conversation strategy on maternal and neonatal care practices. METHODS: We used cross-sectional data from a representative sample of 4684 women with children aged 0-11 months from 115 districts collected between December 2014 and January 2015. We compared intrapartum and newborn care practices related to the most recent childbirth, between those who reported having participated in a Family Conversation during pregnancy, and those who had not. Propensity score matched analysis was used to estimate average treatment effects of the Family Conversation strategy on intrapartum and newborn care practices, including institutional delivery, early postnatal and immediate breastfeeding. RESULTS: About 17% of the respondents reported having had a Family Conversation during their last pregnancy. Average treatment effects of 7, 12, 9 and 16 percentage-points respectively were found for institutional deliveries, early postnatal care, clean cord care and thermal care of the newborn (p < 0.05). CONCLUSION: We found evidence that Family Conversation, and specifically the involvement of household members who were major decision-makers, was associated with better intrapartum and newborn care practices. This study adds to the evidence base that involving husbands and mothers-in-law, as well as pregnant women, in behavior change communication interventions could be critical for improving maternal and newborn care and therewith lowering mortality rates.

Effects of a participatory community quality improvement strategy on improving household and provider health care behaviors and practices: a propensity score analysis.

BACKGROUND: Maternal and newborn health care intervention coverage has increased in many low-income countries over the last decade, yet poor quality of care remains a challenge, limiting health gains. The World Health Organization envisions community engagement as a critical component of health care delivery systems to ensure quality services, responsive to community needs. Aligned with this, a Participatory Community Quality Improvement (PCQI) strategy was introduced in Ethiopia, in 14 of 91 rural woredas (districts) where the Last Ten Kilometers Project (L10 K) Platform activities were supporting national Basic Emergency Obstetric and Newborn Care (BEmONC) strengthening strategies. This paper examines the effects of the PCQI strategy in improving maternal and newborn care behaviors, and providers' and households' practices. METHODS: PCQI engages communities in identifying barriers to access and quality of services, and developing, implementing and monitoring solutions. Thirty-four intervention kebeles (communities), which included the L10 K Platform, BEmONC, and PCQI, and 82 comparison kebeles, which included the L10 K Platform and BEmONC, were visited in December 2010-January 2011 and again 48 months later. Twelve women with children aged 0 to 11 months were interviewed in each kebele. Propensity score matching was used to estimate the program's average treatment effects (ATEs) on women's care seeking behavior, providers' service provision behavior and households' newborn care practices. RESULTS: The ATEs of PCQI were statistically significant (p < 0.05) for two care seeking behaviors - four or more antenatal care (ANC) visits and institutional deliveries at 14% (95% CI: 6, 21) and 11% (95% CI: 4, 17), respectively - and one service provision behavior - complete ANC at 17% (95% CI: 11, 24). We found no evidence of an effect on remaining outcomes relating to household newborn care practices, and postnatal care performed by the provider. CONCLUSIONS: National BEmONC strengthening and government initiatives to improve access and quality of maternal and newborn health services, together with L10 K Platform activities, appeared to work better for some care practices where communities were engaged in the PCQI strategy. Additional research with more robust measure of impact and cost-effectiveness analysis would be useful to establish effectiveness for a wider set of outcomes.

Correlates of the Women's Development Army strategy implementation strength with household reproductive, maternal, newborn and child healthcare practices: a cross-sectional study in four regions of Ethiopia.

BACKGROUND: To address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women's Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices. METHODS: Using cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents' individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest. RESULTS: Average numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category). CONCLUSION: Higher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery.

Effects of a community-based data for decision-making intervention on maternal and newborn health care practices in Ethiopia: a dose-response study.

BACKGROUND: Community participation and community health volunteer programs are an essential part of the health system so that health services are responsive and accountable to community needs. Information systems are necessary for community health volunteer programs to be effective, yet effectiveness evaluations of such information systems implemented at scale are rare. In October 2010, a network of female volunteers with little or no literacy, the Women's Development Army (WDA), was added to extend Ethiopia's Health Extension Program services to every household in the community. Between July 2013 and January 2015, a health management information system for the WDA's Community-Based Data for Decision-Making (CBDDM) strategy was implemented in 115 rural districts to improve the demand for and utilization of maternal and newborn health services. Using the CBDDM strategy, Health Extension Workers (HEWs) fostered the WDA and community leaders to inform, lead, own, plan, and monitor the maternal and newborn health interventions in their kebeles (communities). This paper examines the effectiveness of the CBDDM strategy. METHODS: Using data from cross-sectional surveys in 2010-11 and 2014-15 from 177 kebeles, we estimated self-reported maternal and newborn care practices from women with children aged 0 to 11 months (2124 at baseline and 2113 at follow-up), and a CBDDM implementation strength score in each kebele. Using kebele-level random-effects models, we assessed dose-response relationships between changes over time in implementation strength score and changes in maternal and newborn care practices between the two surveys. RESULTS: Kebeles with relatively high increases in CBDDM implementation strength score had larger improvements in the coverage of neonatal tetanus-protected childbirths, institutional deliveries, clean cord care for newborns, thermal care for newborns, and immediate initiation of breastfeeding. However, there was no evidence of any effect of the intervention on postnatal care within 2 days of childbirth. CONCLUSIONS: This study shows the extent to which an information system for community health volunteers with low literacy was implemented at scale, and evidence of effectiveness at scale in improving maternal and newborn health care behaviors and practices.

The effect of implementation strength of basic emergency obstetric and newborn care (BEmONC) on facility deliveries and the met need for BEmONC at the primary health care level in Ethiopia.

BACKGROUND: Basic emergency obstetric and newborn care (BEmONC) is a primary health care level initiative promoted in low- and middle-income countries to reduce maternal and newborn mortality. Tailored support, including BEmONC training to providers, mentoring and monitoring through supportive supervision, provision of equipment and supplies, strengthening referral linkages, and improving infection-prevention practice, was provided in a package of interventions to 134 health centers, covering 91 rural districts of Ethiopia to ensure timely BEmONC care. In recent years, there has been a growing interest in measuring program implementation strength to evaluate public health gains. To assess the effectiveness of the BEmONC initiative, this study measures its implementation strength and examines the effect of its variability across intervention health centers on the rate of facility deliveries and the met need for BEmONC. METHODS: Before and after data from 134 intervention health centers were collected in April 2013 and July 2015. A BEmONC implementation strength index was constructed from seven input and five process indicators measured through observation, record review, and provider interview; while facility delivery rate and the met need for expected obstetric complications were measured from service statistics and patient records. We estimated the dose-response relationships between outcome and explanatory variables of interest using regression methods. RESULTS: The BEmONC implementation strength index score, which ranged between zero and 10, increased statistically significantly from 4.3 at baseline to 6.7 at follow-up (p < .05). Correspondingly, the health center delivery rate significantly increased from 24% to 56% (p < .05). There was a dose-response relationship between the explanatory and outcome variables. For every unit increase in BEmONC implementation strength score there was a corresponding average of 4.5 percentage points (95% confidence interval: 2.1-6.9) increase in facility-based deliveries; while a higher score for BEmONC implementation strength of a health facility at follow-up was associated with a higher met need. CONCLUSION: The BEmONC initiative was effective in improving institutional deliveries and may have also improved the met need for BEmONC services. The BEmONC implementation strength index can be potentially used to monitor the implementation of BEmONC interventions.

Changes in equity of maternal, newborn, and child health care practices in 115 districts of rural Ethiopia: implications for the health extension program.

BACKGROUND: Reducing within-country inequities in the coverage of maternal, newborn, and child health (MNCH) interventions is essential to improving a country's maternal and child health and survival rates. The community-based health extension program (HEP) of Ethiopia, launched in 2003, aims to provide equitable primary health care services. Since 2008 the Last Ten Kilometers Project (L10K) has been supporting the HEP in promoting equitable MNCH interventions in 115 districts covering about 14 million people. We report the inequities in MNCH programmatic indicators in 2008 and in 2010 in the L10K areas, along with changes in equity between the two survey periods, and the implications of these results for the national program. METHODS: The study used cross-sectional surveys of 3932 and 3867 women from 129 representative kebeles (communities) conducted in December 2008 and December 2010, respectively. Nineteen HEP outreach activity coverage and MNCH care practice indicators were calculated for each survey period, stratified by the inequity factors considered (i.e. age, education, wealth and distance from the nearest health facility). We calculated relative inequities using concentration indices for each of the indicators and inequity factors. Ninety-five percent confidence intervals and survey design adjusted Wald's statistics were used to assess differentials in equity. RESULTS: Education and age related inequities in the MNCH indicators were the most prominent (observed for 13 of the 19 outcomes analyzed), followed in order by wealth inequity (observed for eight indicators), and inequity due to distance from the nearest health facility (observed for seven indicators). Age inequities in six of the indicators increased between 2008 and 2010; nevertheless, there was no consistent pattern of changes in inequities during that period. Some related issues such as inequities due to wealth in household visits by the health extension workers and prevalence of modern family household; and inequities due to education in household visits by community health promoters showed improvement. CONCLUSIONS: Addressing these inequities in MNCH interventions by age, education and wealth will contribute significantly toward achieving Ethiopia's maternal health targets for the Millennium Development Goals and beyond. HEP will require more innovative strategies to achieve equitable MNCH services and outcomes and to routinely monitor the effectiveness of those strategies.

Effectiveness of scaling up the 'three pillars' approach to accelerating MDG 4 progress in Ethiopia.

This paper describes the integrated approach taken by the Government of Ethiopia with support from the Essential Services for Health in Ethiopia (ESHE) Project and assesses its effect on the coverage of six child health practices associated with reducing child mortality. The ESHE Project was designed to contribute to reducing high child mortality rates at scale among 14.5 million people through the 'three pillars' approach. This approach aimed to (i) strengthen health systems, (ii) improve health workers' performance, and (iii) engage the community. The intervention was designed with national and subnational stakeholders' input. To measure the Project's effect on the coverage of child health practices, we used a quasi-experimental design, with representative household survey data from the three most populous regions of Ethiopia, collected at the 2003-2004 baseline and 2008 endline surveys of the Project. Adifference-in-differences analysis model detected an absolute effect of the ESHE intervention of 8.4% points for DTP3 coverage (p=0.007), 12.9% points for measles vaccination coverage (p<0.001), 12.6% points for latrines (p=0.002), and 9.8% points for vitamin A supplementation (p<0.001) across the ESHE-intervention districts (woredas) compared to all non-ESHE districts of the same three regions. Improvements in the use of modern family planning methods and exclusive breastfeeding were not significant. Important regional variations are discussed. ESHE was one of several partners of the Ministry of Health whose combined efforts led to accelerated progress in the coverage of child health practices.

Effect of the health extension program and other accessibility factors on care-seeking behaviors for common childhood illnesses in rural Ethiopia.

BACKGROUND: In January 2011, Health Extension Workers (HEWs) of Ethiopia's Health Extension Program (HEP) began providing pneumonia case management for children less than five years of age through the integrated Community Case Management (iCCM) strategy. OBJECTIVE: To report the effect of HEP, following the introduction of iCCM, and other accessibility factors on care-seeking behaviors for common childhood illnesses (acute respiratory infection [ARI], diarrhea, and fever). METHODS: Three possible care-seeking outcomes for childhood illnesses were considered: not seeking appropriate care, seeking care from HEP sources, or seeking care from other appropriate sources. The baseline care-seeking outcomes from the Ethiopian Demographic and Health Survey, 2011, were compared with the care-seeking outcomes in a follow-up iCCM survey in December 2012. The effects of the HEP intensity and other factors on care-seeking outcomes were estimated using regression analyses. RESULTS: Appropriate care-seeking for children with acute respiratory infection, ARI, diarrhea, or fever increased two-fold, from 19% at baseline to 38% at follow-up, mainly due to an increase in seeking care for common child- hood illnesses from HEWs. Higher intensity of the HEP and other accessibility factors were associated with higher care-seeking for childhood illnesses from HEP sources. CONCLUSION: Incorporating iCCM within the HEP service package significantly improved the appropriate care-seeking behaviors for childhood illnesses in rural Ethiopia.

Effectiveness of supportive supervision on the consistency of integrated community cases management skills of the health extension workers in 113 districts of Ethiopia.

BACKGROUND: Consistency in the adherence to integrated Community Case Management (iCCM) protocols for common childhood illnesses provided by Ethiopia's Health Extension Program (HEP) frontline workers. One approach is to provide regular clinical mentoring to the frontline health workers of the HEP at their health posts (HP) through supportive supervision (SS) following the initial training. OBJECTIVE: To Assess the effectiveness of visits to improve the consistency of iCCM skills (CoS) of the HEWs in 113 districts in Ethiopia. METHODS: We analyzed data from 3,909 supportive supervision visits between January 2011 and June 2013 in 113 districts in Ethiopia. From case assessment registers, a health post was classified as consistent in managing pneumonia, malaria, or diarrhea cases if the disease classification, treatment, and follow-up of the last two cases managed at the health posts were consistent with the protocol. We used regression models to assess the effects of SS on CoS. RESULTS: All HPs (2,368) received at least one supportive supervision visit, 41% received two, and 15% received more than two. During the observation period, HP management consistency in pneumonia, malaria, and diarrhea increased by 3.0, 2.7 and 4.4-fold, respectively. After controlling for secular trend and other factors, significant dose-response relationships were observed between number of SS visits and CoS indicators. CONCLUSIONS: The SS visits following the initial training were effective in improving the CoS.

Effect of performance review and clinical mentoring meetings (PRCMM) on recording of community case management by health extension workers in Ethiopia.

BACKGROUND: The Performance Review and Clinical Mentoring Meeting (PRCMM) is an approach to improve and sustain Health Extension Worker (HEW) skills and performance in integrated Community Case Management (iCCM). OBJECTIVE: To compare HEW performance in recording case management before and after they participated in PRCMM. METHODS: We conducted a historical cohort analysis of iCCM case records between September 2010 and December 2012 from 622 randomly selected health posts representing 31 intervention woredas (districts) of Amhara, Oromia and Southern Nations Nationalities and Peoples' Regions. We used longitudinal regression analysis comparing the trend in the consistency of the classification with the assessment, treatment and follow-up date as well as caseload in the periods before and after PRCMM, with 5511 and 7901 case records, respectively. RESULTS: Overall consistency improved after PRCMM for all common classifications as follows: pneumonia (54.1% [95% CI: 47.7%-60.5%] vs. 78.2% [73.9%-82.5%]), malaria (50.8% [42.9%-58.7%] vs. 78.9% [73.4%- 84.4%]), and diarrhea (33.7% [27.9%-39.5%] vs. 70.0% [64.7%-75.3%]). This improvement was consistently observed comparing the six months before and the six months after PRCMM in all the common classifications except for malaria where the improvement observed during the first three post-PRCMM months disappeared during the fifth and sixth months. Caseload increased significantly after PRCMM (6.6 [95% CI: 5.9-7.3] vs. 9.2 [8.5-9.9] cases/health post/month). CONCLUSION: PRCMM seemed to improve iCCM performance of HEWs and should be integrated within the PHC system and given about every six months, at least at first, to sustain improvement.

Association of transportation noise with cardiovascular diseases.

This comprehensive article delves into the intricate and multifaceted issue of noise pollution, shedding light on its diverse sources, profound health implications, and the economic burden it imposes on societies. Noise pollution is an increasingly prevalent environmental challenge, impacting millions of people worldwide, often without their full awareness of its adverse effects. Drawing from a wealth of scientific research, the article underscores the well-established links between noise pollution and a spectrum of health issues, including cardiovascular diseases, sleep disturbances, and psychological stress. While exploring the sources and consequences of noise pollution, the article highlights the urgent need for a holistic and collaborative approach to mitigate its impact. This entails a combination of regulatory measures, technological innovations, urban planning strategies, and public education campaigns. It is increasingly evident that the detrimental effects of noise pollution extend beyond physical health, encompassing mental and social well-being. The article also addresses the synergistic relationship between noise pollution and other environmental stressors, emphasizing the importance of considering noise in conjunction with factors like air pollution and access to green spaces. It examines the potential of green spaces to mitigate the effects of noise pollution and enhance overall health.

Commotio cordis in non-sports-related injury: A scoping review.

Commotio cordis is a rare but life-threatening condition characterized by sudden cardiac arrest resulting from a blunt chest impact. While commotio cordis has traditionally been associated with sports-related activities, a significant proportion of cases occur in non-sport-related settings, such as assaults, motor vehicle accidents (MVAs), and daily activities. This critical review examines the epidemiology, clinical characteristics, and outcomes of non-sports-related commotio cordis cases, highlighting the need for increased awareness and improved management in these contexts. The review analyzes existing literature, drawing attention to the demographics of non-sports-related cases, which predominantly affect adolescents and young adults, with males being the primary demographic. In contrast to sport-related cases, non-sports-related commotio cordis cases exhibit a wider age range and a higher proportion of female subjects. Mortality rates are significantly higher in non-sports-related commotio cordis cases, largely due to lower rates of cardiopulmonary resuscitation (CPR), limited access to automated external defibrillators (AEDs), and delayed initiation of resuscitative efforts compared to sport-related incidents. This underscores the critical importance of increasing awareness and preparedness in non-sport-related settings. To mitigate the risks associated with non-sports-related commotio cordis, efforts should focus on early recognition of the condition, timely administration of CPR, and the widespread availability and accessibility of AEDs in various environments. Enhanced awareness and education can potentially lead to a reduction in mortality and improved outcomes for individuals affected by commotio cordis outside of sports-related activities. In conclusion, commotio cordis is not exclusive to sports and presents a significant health risk in non-sport-related scenarios. This review emphasizes the urgent need for increased awareness, preparedness, and resuscitation measures in non-sports contexts to address the higher mortality associated with these cases.

Iraqi experts consensus on the management of relapsing remitting multiple sclerosis in adults.

OBJECTIVE: In Iraq, a lack of evidence-based management protocols for diagnosing, treating, and managing multiple sclerosis (MS) poses risks of suboptimal outcomes and clinical practice variability and potential harm to the patients. This study aimed to develop consensus recommendations regarding the diagnosis and management of MS in Iraq, specifically focusing on treatment-naïve patients, suboptimal responders, and women of childbearing age during preconception, pregnancy planning, and lactation.A survey was conducted to collect feedback from a panel of ten key opinion leaders (KOLs), who evaluated and discussed the statements to determine agreement levels. The mini-Delphi method was employed to establish a consensus on the management recommendations, and a meeting was held to analyze the responses and ensure that the recommendations were based on current evidence and followed a consensus-driven approach. RESULTS: The Revised McDonald Criteria is recommended for MS diagnosis, which includes evidence of dissemination of disease characteristics in space and time. Disease activity and progression can be monitored using relapses, MRI activity, and short-term disability progression. Experts suggest initiating treatment at diagnosis using higher efficacy medications, such as cladribine, ocrelizumab, natalizumab, or rituximab, for patients with high disease activity after careful risk stratification. Injectable interferon preparations have a tolerable risk profile but have drawbacks, such as the route and frequency of administration. Overall, disease-modifying therapies (DMTs) have shown efficacy in reducing relapse rates and short-term disability. CONCLUSION: This article presents expert panel recommendations for managing MS in Iraq, taking into account international guidelines, medication updates, and local resources. However, practical questions remain regarding the real-world use of disease-modifying therapies (DMTs). Personalizing treatment based on disease severity, prognosis, and individual risk factors while adhering to guidelines is crucial. A collaborative approach between healthcare providers and patients, considering individual preferences, is vital for achieving treatment goals.

Cardiac Manifestations in Inherited Metabolic Diseases.

Inherited metabolic diseases (IMDs) stem from genetic defects affecting enzyme function within specific metabolic pathways, collectively constituting rare conditions with an incidence of less than 1/100,000 births. While IMDs typically manifest with multisystemic symptoms, cardiac manifestations are common, notably hypertrophic cardiomyopathy. Additionally, they can lead to dilated or restrictive cardiomyopathy, as well as noncompacted left ventricular cardiomyopathy. Rhythm disturbances such as atrioventricular conduction abnormalities, Wolff-Parkinson-White syndrome, and ventricular arrhythmias, along with valvular pathologies and ischemic coronary issues, are also prevalent. This study aims to provide a narrative review of IMDs associated with cardiac involvement, delineating the specific cardiac manifestations of each disorder alongside systemic symptoms pivotal for diagnosis.

Multiorgan Involvement of Dormant Uveal Melanoma Micrometastases in Postmortem Tissue From Patients Without Coexisting Macrometastases.

OBJECTIVES: Almost half of all patients diagnosed with uveal melanoma will die of metastatic disease. This has been attributed to early seeding of micrometastases. We investigate the presence, density, organ involvement, and characteristics of micrometastases of uveal melanoma in tissue obtained at autopsy of patients with and without coexisting macrometastases. METHODS: Patients diagnosed with primary uveal melanoma at a national referral center between 1960 and 2020 (n = 4,282) were cross-referenced with autopsy registers at nearby hospitals. Eleven patients were included. Formalin-fixed, paraffin-embedded tissue samples obtained during autopsy were examined with routine histology, immunohistochemistry, and immunomagnetic separation. RESULTS: Micrometastases were detected in 5 of 5 patients with and in 5 of 6 patients without coexisting macrometastases. Micrometastases were identified in several sites, including lungs, kidneys, myocardium, and bone marrow. Their highest density per mm2 of tissue was seen in the liver. Of 11 examined patients, 2 had at least 1 BAP-1-positive metastasis. All micrometastases had immune cell infiltrates and no or very low proliferative activity. CONCLUSIONS: We demonstrate multiorgan involvement of apparently dormant micrometastases in patients with uveal melanoma. This suggests that micrometastases are present in nearly all patients diagnosed with primary uveal melanoma, regardless of coexisting macrometastases.

Molar Pregnancy with Co-Existing Viable Fetus Delivered Preterm at 24 Weeks Gestation: A Case Report.

Introduction and Importance: It is unusual and challenging to have a molar pregnancy and a viable fetus at the same time. Bleeding per vagina, anemia, hyperemesis gravidarum, hypertension, thyrotoxicosis, and uterine enlargement disproportionate to uterine age are common clinical presentations that should alert the clinician to this uncommon illness. Pregnancy of a hydatidiform mole with a coexistent live fetus in most cases is a complete molar pregnancy. Partial molar pregnancy with fetus is rare and almost always ends in miscarriage due to triploid fetus. Case Presentation: In this case study, we present a 19-year-old woman who presented with acute vaginal bleeding and pelvic discomfort. Transabdominal ultrasound revealed fetal heart rate and identified the fetus at 24 weeks gestation. A large heterogeneous and complex cystic mass was found in the fundus, which was diagnosed as an abnormal placenta with a strong suspicion of molar pregnancy. The cervix was dilated by 4 cm at the time of hospital admission and four hours later, she gave birth to a healthy female fetus. The placenta emerged along with the membrane and abundant grape-like cystic tissue. Clinical Discussion: A case study showed a coexisting live fetus that was 24 weeks gestational age and had a partial hydatidiform mole, along with severe vaginal bleeding and uterine contraction. A partial mole was identified through histology analysis of the placenta. Conclusion: Maternal b-HCG levels fell to undetectable levels one month after birth without treatment. She was doing well and a follow-up six months later revealed no evidence of retained tissue or recurrence.

Cost of Acute Malnutrition Treatment Using a Simplified or Standard Protocol in Diffa, Niger.

Evidence on the cost of acute malnutrition treatment, particularly with regards to simplified approaches, is limited. The objective of this study was to determine the cost of acute malnutrition treatment and how it is influenced by treatment protocol and programme size. We conducted a costing study in Kabléwa and N'Guigmi, Diffa region, where children with acute malnutrition aged 6-59 months were treated either with a standard or simplified protocol, respectively. Cost data were collected from accountancy records and through key informant interviews. Programme data were extracted from health centre records. In Kabléwa, where 355 children were treated, the cost per child treated was USD 187.3 (95% CI: USD 171.4; USD 203.2). In N'Guigmi, where 889 children were treated, the cost per child treated was USD 110.2 (95% CI: USD 100.0; USD 120.3). Treatment of moderate acute malnutrition was cheaper than treatment of severe acute malnutrition. In a modelled scenario sensitivity analysis with an equal number of children in both areas, the difference in costs between the two locations was reduced from USD 77 to USD 11. Our study highlighted the significant impact of programme size and coverage on treatment costs, that cost can differ significantly between neighbouring locations, and that it can be reduced by using a simplified protocol.