Diagnosing osteomyelitis in diabetic foot by diffusion-weighted imaging and dynamic contrast material-enhanced magnetic resonance imaging: a systematic review and meta-analysis.

AIM: To evaluate the diagnostic performance of diffusion-weighted imaging (DWI) and dynamic contrast enhanced (DCE), for diagnosing osteomyelitis in the diabetic foot. MATERIALS AND METHODS: A thorough search was carried out to identify suitable studies published up to September 2023. The quality of the studies involved was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). The diagnostic sensitivity and specificity of each imaging modality/method for each specific cut point were summarized. The summary receiver operating characteristic (SROC) curve was calculated using bivariate mixed effects models. RESULTS: Five studies investigating 187 patients and 234 bone lesions with 110 diagnosed osteomyelitis were enrolled. Four studies used DWI (172 lesions), three studies used DCE techniques (140 lesions) and two studies presented results of conventional MRI (66 lesions). The sensitivity ranges using conventional MRI, DWI and DCE were 65%-100%, 65%-100% and 64%-100%, respectively. The specificity ranges were 50%-61%, 56%-95%, and 66%-93%, respectively. The SROC curve of DWI and DCE was 0.89 (95% CI, 0.86-0.92) and 0.90 (95% CI, 0.87-0.92), respectively. CONCLUSION: Combining DWI and DCE methods, alongside conventional MRI, can improve the reliability and accuracy of diabetic foot osteomyelitis diagnosis. However, the study recognizes result variability due to varying protocols and emphasizes the need for well-designed studies with standardized approaches. To optimize diagnostic performance, the study recommends considering low ADC values, Ktrans or rapid wash-in rate from DCE such as iAUC60, along with using large ROIs that cover the entire lesion while excluding normal bone marrow.

Omicron COVID-19 Case Estimates Based on Previous SARS-CoV-2 Wastewater Load, Regional Municipality of Peel, Ontario, Canada.

We determined correlations between SARS-CoV-2 load in untreated water and COVID-19 cases and patient hospitalizations before the Omicron variant (September 2020-November 2021) at 2 wastewater treatment plants in the Regional Municipality of Peel, Ontario, Canada. Using pre-Omicron correlations, we estimated incident COVID-19 cases during Omicron outbreaks (November 2021-June 2022). The strongest correlation between wastewater SARS-CoV-2 load and COVID-19 cases occurred 1 day after sampling (r = 0.911). The strongest correlation between wastewater load and COVID-19 patient hospitalizations occurred 4 days after sampling (r = 0.819). At the peak of the Omicron BA.2 outbreak in April 2022, reported COVID-19 cases were underestimated 19-fold because of changes in clinical testing. Wastewater data provided information for local decision-making and are a useful component of COVID-19 surveillance systems.

Inorganic Compounds as Remineralizing Fillers in Dental Restorative Materials: Narrative Review.

Secondary caries is one of the leading causes of resin-based dental restoration failure. It is initiated at the interface of an existing restoration and the restored tooth surface. It is mainly caused by an imbalance between two processes of mineral loss (demineralization) and mineral gain (remineralization). A plethora of evidence has explored incorporating several bioactive compounds into resin-based materials to prevent bacterial biofilm attachment and the onset of the disease. In this review, the most recent advances in the design of remineralizing compounds and their functionalization to different resin-based materials' formulations were overviewed. Inorganic compounds, such as nano-sized amorphous calcium phosphate (NACP), calcium fluoride (CaF2), bioactive glass (BAG), hydroxyapatite (HA), fluorapatite (FA), and boron nitride (BN), displayed promising results concerning remineralization, and direct and indirect impact on biofilm growth. The effects of these compounds varied based on these compounds' structure, the incorporated amount or percentage, and the intended clinical application. The remineralizing effects were presented as direct effects, such as an increase in the mineral content of the dental tissue, or indirect effects, such as an increase in the pH around the material. In some of the reported investigations, inorganic remineralizing compounds were combined with other bioactive agents, such as quaternary ammonium compounds (QACs), to maximize the remineralization outcomes and the antibacterial action against the cariogenic biofilms. The reviewed literature was mainly based on laboratory studies, highlighting the need to shift more toward testing the performance of these remineralizing compounds in clinical settings.

Asthma patients in Saudi Arabia - preferences, health beliefs and experiences that shape asthma management.

Objectives: The aim of this study was to explore the experience of Saudi participants in managing their asthma and their perspectives about using future pharmacy-based services for asthma management. METHODS: Semi-structured interviews were conducted with adult Saudis with asthma or those who were a carer of a child with asthma. Participants were recruited from medical practices and community centres in Riyadh, Saudi Arabia. Verbatim transcribed interviews were inductively analysed using thematic analysis. RESULTS: Twenty-three Saudi participants with asthma or caring for those with asthma took part in interviews which lasted on average for 25 min. Most participants did not have well-controlled asthma. Thematic analyses of the interview transcripts highlighted four key emergent themes: participants experience of asthma, participants' beliefs and perceptions about health and medicines, perception of health professionals and advocacy and social support. Many participants expressed an emotional burden in their lived experience of asthma. Lack of self-management skills were evident in participants' reluctance to make decisions in emergency situations. Some participants had strong beliefs about using herbal medicines rather than western medicines. Using social media or consulting with their family members with asthma was a common preference, rather than consulting healthcare professionals. Participants' were rather unclear about pharmacy asthma care services and reported not having experienced such services in their pharmacies. CONCLUSION: Inadequate self-management behaviours may affect the level of asthma control in people with asthma in Saudi Arabia. Improved primary care models with extensive focus on asthma education are needed to relieve the over-reliance on tertiary care help-seeking models that are currently the norm. Current evidence-based information also needs to be prepared in patient friendly formats and disseminated widely. Community pharmacists would need to be trained and skilled inpatient engagement and would have to win the public trust for viable asthma services provision.

A child with unique skin pattern: A case report of Tinea imbricata.

This paper reports a case of Tinea imbricata in a young Orang Asli boy which was noted during his admission for severe symptomatic anemia. Upon discharge, he was started on syrup Griseofulvin 10mg/kg daily and Whitfield cream for 4 weeks. The Department of Orang Asli Development (JAKOA) and the local Health Clinic were contacted before discharge to facilitate patient's follow-up and monitoring. Outbreaks of Tinea imbricata among the Orang Asli have been known to happen from time to time. Although this dermatophyte infection is rare in the urban population, transmission among travelers has been reported. This case report highlights its unique presentation and treatment approach.

Exposure to heavy metals and the risk of osteopenia or osteoporosis: a systematic review and meta-analysis.

The relationship between heavy metal exposure and risk of osteopenia or osteoporosis has biological plausibility, yet it remains inconclusive; therefore, we conducted a systematic review and meta-analysis to evaluate the associations between exposure to heavy metals (i.e., cadmium, lead, and mercury) and the risk of osteopenia or osteoporosis. Databases of MEDLINE, Embase, Scopus, and Web of Science were searched through November 2019, to identify studies that evaluated the relationship between exposure to cadmium, lead, and mercury and risk of osteopenia or osteoporosis in adults. Fourteen eligible studies were included. Effect sizes expressed as pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated using weighted random-effect models. Exposure to cadmium (OR = 1.35; 95% CI: 1.17 to 1.56; P ≤ 0.001) and lead (OR = 1.15; 95% CI: 1.00 to 1.32; P = 0.05) was associated with an increased risk of osteopenia or osteoporosis, unlike mercury. Subgroup analyses showed cadmium exposure increased the risk of osteopenia or osteoporosis in older (> 65 yrs.; OR = 1.43; 95%CI: 1.08 to 1.88, P = 0.01) compared with younger (18-65 yrs.; OR = 1.24; 95% CI: 1.02 to 1.52, P = 0.03) adults. Also, lead exposure increased the risk in men (OR = 1.55; 95% CI: 1.15 to 2.09, P = 0.007) unlike in women. By contrast to urinary levels, blood (OR = 1.26; 95% CI: 1.08 to 1.47, P = 0.003) and dietary (OR = 1.46; 95% CI: 1.28 to 1.67, P < 0.001) levels of cadmium were associated with an increased risk of osteopenia or osteoporosis. Exposure to cadmium and lead may be associated with an increased risk of osteopenia or osteoporosis, although high heterogeneity was detected.

Solitary circumscribed neuroma of the glans penis. An unusual finding.

Palisaded encapsulated neuroma is a rare, benign neural tumor. The involvement of the glans penis is rare; few cases have been reported. We present a 52-year-old man with a five-month course of a solitary painless lesion of the glans penis. Full excision of the nodule was performed. Histopathological and immunohistochemical analyses and examination was consistent with a palisaded encapsulated neuroma. We describe one of a few existing cases of this kind of tumor in the glans penis.

Health consumer engagement in developing novel preventive health community pharmacy roles in cardiovascular disease in Saudi Arabia: A qualitative analysis.

INTRODUCTION: Cardiovascular diseases (CVD) are one of key leading causes of mortality worldwide. Both modifiable and non-modifiable risk factors contribute to the development of CVD. Modifiable risk factors such as smoking, unhealthy diets and lack of exercise are increasing in prevalence in Saudi Arabia but may be mitigated using pharmacological and non-pharmacological approaches. Thus, identifying, assessing and managing these modifiable risks at an early stage is essential. Pharmacists are highly accessible primary health professionals and can play a crucial role in screening and managing these risk factors in collaboration with primary care physicians. There is currently no research in Saudi Arabia exploring the views of health consumers with CVD risk factors regarding their preferences for or willingness to engage with community pharmacy CVD preventive health services. OBJECTIVES: To explore the perceptions of health consumers about current and feasible future services by pharmacists with a specific focus on CVD risk screening and management in Saudi Arabia. METHODS: Semi-structured interviews were conducted with consumers with at least one modifiable CVD risk factor. The interviews were audio-recorded, transcribed verbatim, translated into English and then thematically analysed. RESULTS: A total of 25 individuals, most of whom were Saudi (88%) and women (65%), participated in face to face interviews. Five main themes emerged from the analysis of consumers' responses. 1. Perception of pharmacists' role, the pharmacists' main role was perceived as medication supply. 2. Trust and satisfaction with current service, most participants appeared to have low trust in pharmacists. 3. Preferences for future pharmacy services, most participants were willing to engage in future pharmacy delivered CVD preventive health services, provided there was stringent regulation and oversight of the quality of such services. 4. Viability of new pharmacy services was raised with promotion of such services to the public, collaboration with other health professionals, financial incentivization and motivational rewards thought of as essential ingredient to ensure service feasibility. 5. Health beliefs and help seeking behaviours of consumers were diverse and low health literacy was evident; it was thought that pharmacists can help in these matters by educating and advocating for such consumers. Overall, the data suggested that clinical, communication and professional skills need to be enhanced among Saudi pharmacists to enable them to provide optimal patient cantered services. CONCLUSION: Health consumers participants were willing to participate and utilise CVD risk screening and management pharmacy-based services, when offered, provided their concerns are addressed. Therefore, in light of the burden of CVD disease in the country, development, implementation and evaluation of pharmacist provided CVD risk screening and management should be undertaken.

Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019.

BACKGROUND: Sepsis syndrome is an emerging healthcare problem, especially in critically ill patients, regardless whether it's community- or hospital-acquired sepsis. This study evaluates the characteristics of these patients, in addition to the type, source, and outcome of sepsis and septic shock, in a university tertiary hospital in Palestine. It also studies the most common organisms encountered in these patients. MATERIALS AND METHODS: This is retrospective observational chart review study of all adult admissions to the intensive care unit over a period of 2 years. The presence of sepsis and septic shock was assessed and documented based on the Third International Consensus Definitions (Sepsis-3). Data regarding demographics, severity, comorbidities, source of infection, microbiology, length of stay, and outcomes (dead/alive at discharge from ICU) were recorded. RESULTS: A total number of 174 patients were included. The mean age was 57.4 years, with cardiovascular diseases and diabetes being the leading comorbidities encountered in them. Respiratory infections were the most common site of sepsis, found in around 71% of patients, followed by urinary tract infections. More than 70% of cases were due to hospital-acquired infections (HAIs). Acinetobacter species were the most common gram-negative organisms encountered, while Enterococcus was the most common gram-positive organisms. Around 54% of patients had multidrug-resistant organisms. The average length of stay in the ICU was 8 days. The average mortality rate was 39.7%, which is higher among septic shock patients. CONCLUSION: Both sepsis and septic shock carry high morbidity and mortality rates, and they are very frequent among critically ill patients. Special care and developing management bundles are crucial in controlling and preventing this threat. HOW TO CITE THIS ARTICLE: Rabee HA, Tanbour R, Nazzal Z, Hamshari Y, Habash Y, Anaya A, et al. Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019. Indian J Crit Care Med 2020;24(7):551-556.

Topical corticosteroids in clinical practice.

Topical corticosteroids are common medications prescribed for skin problems encountered in the primary care or dermatology clinic settings. As skin conditions comprise of around 20% of cases seen in primary care, this article written to guide readers, especially non-dermatologists on the appropriate potency of topical corticosteroids to be chosen for skin problems of patients and to list the side effects both local and systemic.

Bisleuconothines B-D, Modified Eburnane-Aspidosperma Bisindole Alkaloids from Leuconotis griffithii.

Three new bisindole alkaloids, bisleuconothines B-D (1-3), were isolated from the bark of Leuconotis griffithii. Their structures were elucidated by 1D and 2D NMR spectroscopy and DFT calculations. Bisleuconothine B (1) is the first monoterpene indole alkaloid dimer featuring bridges between both C-16-C-10' and C-2-O-C-9'. All compounds were deemed noncytotoxic (IC50 > 10 µM) when tested against A549 human lung adenocarcinoma cells.

Perspectives and experiences of patients with type 2 diabetes observing the Ramadan fast.

INTRODUCTION: Diabetes is a common chronic disease among Australians. Culturally and linguistically diverse groups are observed to have higher prevalence rates of diabetes. Continuing management needs adherence to medication and diet regimens. Religious practices such as fasting can affect diabetes management and medication use. Pharmacists as medication specialists have a significant role in helping people observing religious practices such as the Ramadan fast, which involves month-long absolute abstinence from food during daylight hours, to maintain good control over their condition. OBJECTIVE: This study investigated the perspective of patients with type 2 diabetes (T2D) who undertake the fast of Ramadan, to understand their experiences, health-related needs and service preferences regarding diabetes management. METHODS: A qualitative, exploratory design was used in this study. Data collection comprised the conduct of semi-structured interviews with a purposive convenient sample of patients in areas of ethnic diversity in Sydney, using a standardised interview guide. Interview data were transcribed verbatim and thematically analysed. RESULTS: Twenty-five semi-structured interviews (68% males) among a heterogeneous sample of fasting T2D patients were conducted. Themes emerging from analysis of transcripts included issues relating to sociocultural pressure for T2D patients to fast; lack of awareness about the role of pharmacists and, most importantly, the need to train pharmacists in cultural sensitivity and clinical implications thereof. CONCLUSIONS: Community awareness about the role of the pharmacists in assisting medication use and adjustment during fasting periods should be enhanced. Furthermore, community pharmacists need to be trained about the unique religious and sociocultural issues of patients with diabetes opting to observe spiritual rituals such as the Ramadan fast. Clinical education in this area should up-skill pharmacists to inculcate self-management behaviours in fasting T2D patients.

Higher dietary diversity score is associated with obesity: a case-control study.

OBJECTIVE: The present study was carried out to compare dietary diversity score (DDS) among overweight, obese, and normal-weight adults. STUDY DESIGN: This case-control study was conducted with a total of 200 cases (100 participants with obesity and 100 participants with overweight) and 300 controls (normal weight) matched by socio-economic status (SES), older than 18 years. METHODS: Dietary intakes were assessed using a self-administered Food Frequency Questionnaire. Data regarding physical activity and sociodemographic variables were gathered. DDS was computed based on the scoring of the five food groups emphasized in the United States Department of Agriculture Food Guide Pyramid. Anthropometric measurements were measured, and the body mass index and waist-to-hip ratio were calculated. RESULTS: The mean ± standard deviation of DDS was higher in participants with obesity (5.65 ± 1.32) than that in overweight participants (5.23 ± 1.23), while the lowest score was reported among normal-weight individuals (4.97 ± 1.42) (P < 0.001). The odds of obesity increased with each unit increase in DDS (odds ratio [OR]: 1.46; 95% confidence interval [CI]: 1.22, 1.74). However, the association became slightly weaker after adjusting for potential confounding factors (OR: 1.34; 95% CI: 1.07, 1.68). CONCLUSION: It was concluded that there was a significant positive association between DDS and obesity. However, additional investigations are warranted.

Calofolic acids A-F, chromanones from the bark of Calophyllum scriblitifolium with vasorelaxation activity.

Vasorelaxation activity guided separation of the methanol extract of Calophyllum scriblitifolium bark led to the isolation of 6 chromanones (calofolic acids A-F, 1-6). Their structures were elucidated by 1D and 2D NMR spectroscopy, and their absolute configurations were investigated by a combination of CD spectroscopy and DFT calculation. All isolated chromanones showed dose-dependent vasorelaxation activity on isolated rat aorta.

Suitability of hair type for dermatophytes perforation and differential diagnosis of T. mentagrophytes from T. verrucosum.

Most of the dermatophyte species have the ability to perforate hair structure and consume its contents of keratin through secretion of keratinase enzyme. Two clinical isolated species of dermatophytes were diagnosed as Trichophyton mentagrophytes var. granulosum and Trichophyton verrucosum. To determine the perforation ability, the isolated fungi were incubated with the hair of four different animals (rabbit, rat, cow and cat) and human hairs with three different colours (black, albino and bleached yellow) for different periods. Variable perforating ability of T. mentagrophytes was shown in rat hair and all types of human hair after 15 days, while other mammalian hairs exhibited resistance to this fungal activity. On the other hand, T. verrucosum was revealed a slow perforating ability, which needed a long time (60 days) for most of tested hairs. Perforation of human black hair could be considered a diagnostic test for differentiation between T. mentagrophytes and T. verrucosum. In conclusion, the treated or untreated human hair was considered more suitable to use as a source of keratin for the growth of dermatophytes than animal hairs. The human black hair was a best type of hair to use in the perforating test for differentiation between T. mentagrophytes and T. verrucosum.

Infective endocarditis in patients on haemodialysis - possible strategies for prevention.

BACKGROUND AND AIMS: Infective endocarditis is an important cause of morbidity and mortality in patients receiving haemodialysis for established renal failure. We carried out a prospective audit of patients developing infective endocarditis in a single renal unit. METHODS AND RESULTS: From 1 January 2000 to 31 December 2013, we collected data on all cases of endocarditis occurring in patients receiving haemodialysis at Monklands Hospital, Airdrie. Twenty-nine patients developed endocarditis during our audit period. Twenty-three (79.3%) of the patients had pre-existing cardiac valve abnormalities such as regurgitation or calcification. Staphylococcus aureus was the most common microorganism cultured from the blood of 22 patients (75.9%). MRSA bacteraemia was identified in eight of these patients and all eight patients died during that first presentation. Different strategies were introduced within the unit during the audit period aiming to reduce the rate of bacteraemia. Since 2011, a successful strategy has been introduced under the auspices of the Scottish Patient Safety Programme. This led to our Staph aureus bacteraemia rate related to non-tunnelled venous catheters going from an average of 15 days between episodes to having had no episodes between 2 December 2011 and the end of the study period (760 days). This also appears to have had a positive impact on reducing the rate of endocarditis. CONCLUSION: Infective endocarditis remains a devastating consequence of bacteraemia in patients receiving haemodialysis. An effective strategy aimed at reducing the rate of bacteraemia appears to have a similar effect on the rate of endocarditis.

Platelet-cancer interactions.

Platelets play a crucial role in the pathophysiological processes of hemostasis and thrombosis. Increasing evidence indicates that they fulfill much broader roles in balancing health and disease. The presence of tumor cells affects platelets both numerically, through a wide variety of mediators and cytokines, or functionally through tumor cell-induced platelet activation, the first step toward cancer-induced thrombosis. This induction results from signaling events through the different platelet receptors, or may be cytokine-mediated. Reciprocally, upon activation, the platelets will release a myriad of growth factors from their dense and α-granules and peroxisomes; these will directly impact tumor growth, tethering, and spread. A similar cross-talk is initiated between tumor microvesicles stimulating the platelets and platelet microparticles, promoting both thrombosis and tumor growth. A vicious loop of activation thereafter takes place. Platelets directly and indirectly promote tumor growth, and enable a molecular mimicry coating the malignant growth and allowing metastasizing cells to escape T-cell-mediated immunity and natural killer cell surveillance. Breaking this vicious activation loop with nonspecific platelet inhibitors, such as aspirin, or by targeting specific sites on the activation cascade may offer a mean to reduce both the risks of development and progression of cancer and the risk of thrombosis.

Primary repair with no flaps for lower lip defects (30-80 %) after cancer excision.

Reconstruction of the lip is a necessary procedure when lip tumors are excised. Although many good techniques have been described, they often have disadvantages such as necrosis and extensive suture lines. In our approach, we aim to minimize the suture line and avoid tissue necrosis for medium-sized lip defects (30-80 %). This is a surgical technique report from a single center. After tumor resection, we made a bilateral 15 mm horizontal skin and mucosa incision from the angles of the lip to the lateral sides. The mucosa and skin were dissected from the underlying muscle, and the muscle was cut approximately 15 mm on each side. The lip defect was then closed and sutured in four layers. Finally, the released mucosa was sutured to the corner of the incised skin. We followed the patients for 36 months and found that their speech intelligibility, sensation, mobility, and aesthetic satisfaction were preserved. The scars were also less pronounced compared to flaps, and there were no signs of edema or drooling. In conclusion, our technique offers many advantages for moderate defects of lower lip tumors. By avoiding the use of flaps, we eliminate the complications associated with flap surgery while achieving aesthetically satisfactory results. However, further evaluation by other surgeons is necessary to fully examine the technique's benefits.

System dynamics simulation for evaluating implementation strategies of genomic sequencing: tutorial and conceptual model.

INTRODUCTION: Precision Medicine (PM), especially in oncology, involve diagnostic and complex treatment pathways that are based on genomic features. To conduct evaluation and decision analysis for PM, advanced modeling techniques are needed due to its complexity. Although System Dynamics (SD) has strong modeling power, it has not been widely used in PM and individualized treatment. AREAS COVERED: We explained SD tools using examples in cancer context and the rationale behind using SD for genomic testing and personalized oncology. We compared SD with other Dynamic Simulation Modelling (DSM) methods and listed SD's advantages. We developed a conceptual model using Causal Loop Diagram (CLD) for strategic decision-making in Whole Genome Sequencing (WGS) implementation. EXPERT OPINION: The paper demonstrates that SD is well-suited for health policy evaluation challenges and has useful tools for modeling precision oncology and genomic testing. SD's system-oriented modeling captures dynamic and complex interactions within systems using feedback loops. SD models are simple to implement, utilize less data and computational resources, and conduct both exploratory and explanatory analyses over time. If the targeted system has complex interactions and many components, deals with lack of data, and requires interpretability and clinicians' input, SD offers attractive advantages for modeling and evaluating scenarios.