Diagnostic waste: whose responsibility?

Waste management is notably absent from current discussions about efforts to improve access to diagnostics in low-and middle-income Countries (LMICs). Yet an increase in testing will inevitably lead to an increase in diagnostic waste, especially since many of the diagnostic tests designed for use in LMICs are single-use point-of-care tests. Diagnostic waste poses a threat to both human and environmental health. In this commentary we draw on our experience of diagnostic waste management in Sierra Leone and review current evidence on: the volume and impact of diagnostic waste in LMICs, existing health-care waste management capacity in LMICs, established national and international policies for improving health-care waste management, and opportunities for strengthening policy in this area. We argue that questions of safe disposal for diagnostics should not be an afterthought, only posed once questions of access have already been addressed. Moreover, responsibility for safe disposal of diagnostic waste should not fall solely on national health systems by default. Instead, consideration of the end-life of diagnostic products must be fully integrated into the diagnostic access agenda and greater pressure should be placed on manufacturers to take responsibility for the full life-cycle of their products.

Higher education strategy in digital transformation.

Digital transformation in the global higher education industry determines the future roadmap to a sustainable education management strategy. This research paper aims to develop a qualitative model that advocates how digital transformation as a propelling force could be used to build competitive advantages for universities. Building competitive advantage is a relative, evolving, and important concept in strategy formulation. In recent years, specifically in the education industry, the notion of building competitive advantage is challenged by global phenomena such as digital transformation globalization, information exchange, digitization and social media in most of the global industries. These phenomena have collectively made the process of building competitive advantage rapidly changing, short-term and contextual. These findings aid the evolution of strategic management practices in universities by providing empirical insights in determining the impactful changes and their connection to evolutionary learning. It also stresses the importance of using the developed model as a decision support system to generate, regulate and retain student experience and expectations. This research paper provides first-hand insight into the impactful changes affecting universities' vision and how they can turn these changes to their advantages and set a road map to design-develop models to integrate and regulate these essential changes in their strategies using evolution learning mechanism and digital transformation strategy.

A sustainable University: Digital Transformation and Beyond.

Universities focus on digital transformation strategy to stay competitive in global education, staying competitive is taking on quite a different meaning in the 21st century - it includes the long-term implications of Covid-19 - the interaction of politics and economics, the emergence of China as a superpower, the end of neoliberalism, the emergence of distributed autonomous organisations particularly in the area of research and education. The impact of sustainable digital transformation in universities could be perceived as system and systematic. When the intangible but impactful influence is identified/recognized as a system, an applicable conceptual model could become designable and implementable. Conceptual models of digital transformation are vital to universities and business schools to gain sustainability amid rapid technological changes. However, there is paucity of practical, implementable and simple digital transformational models combining technologies, system and educational phenomena. This theoretical gap is sizeable, impactful and non-ignorable. To fulfil this gap, this paper critically examines the need and the association between sustainable digital transformation and its impact in the universities, using an innovative qualitative grounded theory approach which uses three distinct coding procedures namely open, axial and selective followed by transcribing qualitative data. The researchers have proposed a conceptual model for sustainable digital transformation, new propositions by critically reviewing the latest but multiple cases on (a) sustainability (b) digital transformation (c) green technologies and (d) implementable approaches in the education industry/universities. How fast universities could develop dependable business models to cater for the rapid changes amid globalization of education has become an important issue. If the universities can explore a scientific approach to the design-developing conceptual model, then it becomes straightforward for the academic leaders to implement digital transformation process effectively without resource burnouts. The adoption sustainability in digital transformation/information technology is remaining an underdeveloped area. There is a need to develop an innovative architectural design (blueprint) to stimulate sustainable practice, reporting mechanism and its leadership implication. Once universities recognize the digital transformational capabilities, then they could transform into operational effectiveness, which is vital to their business sustainability. This research study points to the effectiveness of using a sustainable blueprint while designing, developing and implementing digital transformation projects in universities. Also, this paper developed numerous value propositions for green implementation of digital transformation as new research studies/potential studies.

Vasodilators for primary Raynaud's phenomenon.

BACKGROUND: Numerous agents have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered to be the drugs of choice, evidence of the effects of alternative pharmacological treatments is limited. This is an update of a review first published in 2008. OBJECTIVES: To assess the effects of drugs with vasodilator effects on primary Raynaud's phenomenon as determined by frequency, severity, and duration of vasospastic attacks; quality of life; adverse events; and Raynauds Condition Score. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trial register to November 16, 2020. SELECTION CRITERIA: We included randomized controlled trials evaluating effects of oral, intravenous, and topical formulations of any drug with vasodilator effects on subjective symptoms, severity scores, and radiological outcomes in primary Raynaud's phenomenon. Treatment with calcium channel blockers was not assessed in this review, nor were these agents compared. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, assessed studies using the Cochrane "Risk of bias" tool, and extracted study data. Outcomes of interest included frequency, severity, and duration of attacks; quality of life (QoL); adverse events (AEs); and the Raynaud Condition Score (RCS). We assessed the certainty of the evidence using GRADE. MAIN RESULTS: We identified seven new studies for this update. In total, we included 15 studies involving 635 participants. These studies compared different vasodilators to placebo. Individual studies used different methods and measures to report different outcomes. Angiotensin-converting enzyme (ACE) inhibitors Combining data from three studies revealed a possible small increase in the frequency of attacks per week after treatment (captopril or enalapril) compared to placebo (mean difference [MD] 0.79, 95% confidence interval [CI] 0.43 to 1.17; low-certainty evidence). There was no evidence of a difference between groups in severity of attacks (MD -0.17, 95% CI -4.66 to 4.31; 34 participants, 2 studies; low-certainty evidence); duration of attacks (MD 0.54, 95% CI -2.42 to 1.34; 14 participants, 1 study; low-certainty evidence); or AEs (risk ratio [RR] 1.35, 95% CI 0.67 to 2.73; 46 participants, 3 studies; low-certainty evidence). QoL and RCS were not reported. Alpha blockers Two studies used alpha blockers (buflomedil or moxisylyte). We were unable to combine data due to the way results were presented. Buflomedil probably reduced the frequency of attacks compared to placebo (MD -8.82, 95% CI -11.04 to -6.60; 31 participants, 1 study; moderate-certainty evidence) and may improve severity scores (MD -0.41, 95% CI -0.62 to -0.30; moderate-certainty evidence). With moxisylyte, investigators reported fewer attacks (P < 0.02), less severe symptoms (P < 0.01), and shorter duration of attacks, but the clinical relevance of these results is unclear. No evidence of a difference in AEs between buflomedil and placebo groups was noted (RR 1.41, 95% CI 0.27 to 7.28; 31 participants, 1 study; moderate-certainty evidence). More AEs were observed in participants in the moxisylyte group than in the placebo group. Prostaglandin/prostacyclin analogues One study compared beraprost versus placebo. There was no evidence of benefit for frequency (MD 2.00, 95% CI -0.35 to 4.35; 118 participants, low-certainty evidence) or severity (MD -0.06, 95% CI -0.34 to 0.22; 118 participants, low-certainty evidence) of attacks. Overall, more AEs were noted in the beraprost group (RR 1.59, 95% CI 1.05 to 2.42; 125 participants; low-certainty evidence). This study did not report on duration of attacks, QoL, or RCS. Thromboxane synthase inhibitors One study compared a thromboxane synthase inhibitor (dazoxiben) versus placebo. There was no evidence of benefit for frequency of attacks (MD 0.8, 95% CI -1.81 to 3.41; 6 participants; very low-certainty evidence). Adverse events were not reported in subgroup analyses of participants with primary Raynaud's phenomenon, and the study did not report on duration of attacks, severity of symptoms, QoL, or RCS. Selective serotonin reuptake inhibitors One study compared ketanserin with placebo. There may be a slight reduction in the number of attacks per week with ketanserin compared to placebo (MD -14.0, 95% CI -27.72 to -0.28; 41 participants; very low-certainty evidence) and reduced severity score (MD -133.00, 95% CI -162.40 to -103.60; 41 participants; very low-certainty evidence). There was no evidence that ketanserin reduced the duration of attacks (MD -4.00, 95% CI -14.82 to 6.82; 41 participants; very low-certainty evidence), or that AEs were increased in either group (RR 1.54, 95% CI 0.89 to 2.65; 41 participants; very low-certainty evidence). This study did not report on QoL or RCS. Nitrate/nitrate derivatives Four studies compared topical treatments of nitroglycerin or glyceryl trinitrate versus placebo, each reporting on limited outcomes. Meta-analysis demonstrated no evidence of effect on frequency of attacks per week (MD -1.57, 95% CI -4.31 to 1.17; 86 participants, 2 studies; very low-certainty evidence). We were unable to pool any data for the remaining outcomes. Phosphodiesterase inhibitors Three studies compared phosphodiesterase inhibitors (vardenafil, cilostazol or PF-00489791) to an equivalent placebo. Results showed no evidence of a difference in frequency of attacks (standardized MD [SMD] -0.05, 95% CI -6.71 to 6.61; 111 participants, 2 studies; low-certainty evidence), severity of attacks (MD -0.03, 95% CI -1.04 to 0.97; 111 participants, 2 studies; very low-certainty evidence), duration of attacks (MD -1.60, 95% CI -7.51 to 4.31; 73 participants, 1 study; low-certainty evidence), or RCS (SMD -0.8, 95% CI -1.74 to 0.13; 79 participants, 2 studies; low-certainty evidence). Study authors reported that 35% of participants on cilostazol complained of headaches, which were not reported in the placebo group. PF-00489791 caused 34 of 54 participants to experience AEs versus 43 of 102 participants receiving placebo (RR 1.49). Headache was most common, affecting 14 participants (PF-00489791) versus nine participants (placebo). AUTHORS' CONCLUSIONS: The included studies investigated several different vasodilators (topical and oral) for treatment of primary Raynaud's phenomenon. Small sample sizes, limited data, and variability in outcome reporting yielded evidence of very low to moderate certainty. Evidence is insufficient to support the use of vasodilators and suggests that vasodilator use may even worsen disease.

Participant Retention in a Randomized Clinical Trial in an Outbreak Setting: Lessons From the Sierra Leone Trial to Introduce a Vaccine Against Ebola (STRIVE).

Clinical Trials Registration: ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].

Mobilization of the outer cavernous membrane decreases bleeding and improves resection in spheno-clinoidal meningiomas without cavernous sinus extension: A randomized controlled trial.

OBJECTIVE: The aim of this study was to determine whether adding mobilization of the outer cavernous sinus membrane as a part of the approach, in large spheno-clinoidal meningiomas without cavernous sinus extension, would reduce bleeding and increase the extent of resection. METHODS:: This prospective randomized controlled trial was held between February 2016 and April 2017 at Cairo University Hospitals. The study recruited 94 patients with spheno-clinoidal meningiomas without cavernous sinus involvement. Patients were randomly assigned (by a computer based randomization system) into two groups; the treatment group, in which the patients received mobilization of the outer layer of the lateral wall of the cavernous sinus, prior to opening of the dura; and, the control group, in which the patients were operated by a direct opening of the dura without cavernous sinus dissection. The primary outcome of this study was the difference in the amount of blood lost during surgery between both groups of patients. The secondary outcome variables were the estimated blood loss (EBL) calculated according to Mercurelli's formula, the extent of tumor resection and the amount of blood transfused. RESULTS:: The amount of blood loss and estimated blood loss (EBL) were significantly less in the "with mobilization group" with the P value being 0.00 and 0.013, respectively. Additionally, the amount of residual tumor was compared between both the groups and it showed that the group of patients who have received mobilization of the outer cavernous sinus membrane had a higher rate of radical resection as expressed by a lower volume of residual tumor (P value 0.005). CONCLUSION:: In large spheno-clinoidal meningiomas without cavernous sinus involvement, routine mobilization of the outer cavernous sinus membrane reduces bleeding. This helps in a better visualization of cranial nerves in a relatively avascular field as it enables the performance of neurovascular dissection in an earlier phase of surgery. It also enables a more radical resection.

Rare k-mer DNA: Identification of sequence motifs and prediction of CpG island and promoter.

Empirical analysis on k-mer DNA has been proven as an effective tool in finding unique patterns in DNA sequences which can lead to the discovery of potential sequence motifs. In an extensive study of empirical k-mer DNA on hundreds of organisms, the researchers found unique multi-modal k-mer spectra occur in the genomes of organisms from the tetrapod clade only which includes all mammals. The multi-modality is caused by the formation of the two lowest modes where k-mers under them are referred as the rare k-mers. The suppression of the two lowest modes (or the rare k-mers) can be attributed to the CG dinucleotide inclusions in them. Apart from that, the rare k-mers are selectively distributed in certain genomic features of CpG Island (CGI), promoter, 5' UTR, and exon. We correlated the rare k-mers with hundreds of annotated features using several bioinformatic tools, performed further intrinsic rare k-mer analyses within the correlated features, and modeled the elucidated rare k-mer clustering feature into a classifier to predict the correlated CGI and promoter features. Our correlation results show that rare k-mers are highly associated with several annotated features of CGI, promoter, 5' UTR, and open chromatin regions. Our intrinsic results show that rare k-mers have several unique topological, compositional, and clustering properties in CGI and promoter features. Finally, the performances of our RWC (rare-word clustering) method in predicting the CGI and promoter features are ranked among the top three, in eight of the CGI and promoter evaluations, among eight of the benchmarked datasets.

Honey based therapy for the management of a recalcitrant diabetic foot ulcer.

OBJECTIVE: Diabetic foot ulcers are usually treated at hospital podiatry clinics and not at primary care level. We report an alternative approach using honey based therapy in the successful management of diabetic foot ulcer at primary health care level. METHODS: The case is discussed in relation to various modalities targeting diabetic foot ulceration in the literature. RESULT: A 65 years old female-Egyptian diabetic patient presented with a neuropathic plantar ulcer of 10 × 5 cm post-thermal burn following the use of a hot water bottle. The patient was treated with strict offloading using a pair of crutches, debridement of necrotic tissue using a sharp scalpel and commercial honey applied daily and covered with a glycerin based dressing. The honey dressing was changed daily along with strict offloading and by week 16 the ulcer completely healed. CONCLUSION: Treatment of diabetic foot ulcer is possible at primary care level.

Comparative Analysis of Coronal Sealing Materials in Endodontics: Exploring Non-Eugenol Zinc Oxide-Based versus Glass-Ionomer Cement Systems.

The proper closure of the access cavity between appointments during endodontic treatment is paramount and relies on temporary fillings. This systematic review evaluates the effectiveness of zinc oxide-based materials and glass-ionomer cement (GIC) as temporary coronal sealers after root canal treatment in extracted human teeth. Three databases were searched to identify randomized clinical trials that examined the sealing properties of various temporary sealing materials using dyes or stains as indicators. A total of seven in vitro studies that fulfilled the eligibility criteria were critically analyzed. These indicated significant variations in the relative sealing ability of the coronal breach of endodontically treated teeth, either by zinc oxide or GIC-based materials. While GIC-based material (e.g., Fuji IX and Fuji II) exhibited superior sealing of single-rooted teeth, zinc oxide-based material (e.g., Cavit, Coltosol, Caviton) also showed promising attributes. Resin-modified GIC formulations displayed enhanced physical properties, yet challenges related to adhesive failure and shrinkage during polymerization were observed. Zinc oxide-based materials have demonstrated superior coronal sealing effectiveness over certain GIC in controlled settings. Their premixed nature ensures consistent application and hygroscopic properties improve cavity sealing. However, the focus on dye penetration tests for microleakage in vitro may not fully represent the risk of bacterial infiltration. Thus, in vivo studies are crucial for validating these findings in clinical contexts.

Next-Generation Sequencing (NGS) and Third-Generation Sequencing (TGS) for the Diagnosis of Thalassemia.

Thalassemia is one of the most heterogeneous diseases, with more than a thousand mutation types recorded worldwide. Molecular diagnosis of thalassemia by conventional PCR-based DNA analysis is time- and resource-consuming owing to the phenotype variability, disease complexity, and molecular diagnostic test limitations. Moreover, genetic counseling must be backed-up by an extensive diagnosis of the thalassemia-causing phenotype and the possible genetic modifiers. Data coming from advanced molecular techniques such as targeted sequencing by next-generation sequencing (NGS) and third-generation sequencing (TGS) are more appropriate and valuable for DNA analysis of thalassemia. While NGS is superior at variant calling to TGS thanks to its lower error rates, the longer reads nature of the TGS permits haplotype-phasing that is superior for variant discovery on the homologous genes and CNV calling. The emergence of many cutting-edge machine learning-based bioinformatics tools has improved the accuracy of variant and CNV calling. Constant improvement of these sequencing and bioinformatics will enable precise thalassemia detections, especially for the CNV and the homologous HBA and HBG genes. In conclusion, laboratory transiting from conventional DNA analysis to NGS or TGS and following the guidelines towards a single assay will contribute to a better diagnostics approach of thalassemia.

Microbial biodiversity in the throats of pulmonary tuberculosis patients and tuberculin skin test (TST) positive and negative healthy individuals in Malaysia.

The purpose of this study was to investigate the composition of throat microbiota in pulmonary tuberculosis patients (PTB) in comparison to healthy tuberculin skin test positive (TSTp) and negative (TSTn) individuals. Throat swabs samples were collected, and the microbiota was characterized. Richer operational taxonomic units (OTUs) were present in PTB group, compared to TSTp and TSTn. Regarding alpha diversity analysis there was a higher community diversity in TSTn compared to TSTp. Beta diversity analysis showed different species composition in TSTp compared to TSTn and PTB. There was higher presence of Firmicutes in PTB and TSTn compared to TSTp group at phylum level. At the genus level, Leuconostoc and Enterococcus were higher in TSTn compared to TSTp and Pediococcus, Chryseobacterium, Bifidobacterium, Butyrivibrio, and Bulleidia were higher in PTB compared to TSTn. Streptococcus was higher in TSTn compared to PTB and Lactobacillus in PTB compared to TSTp. At species level, Streptococcus sobrinus and Bulleidia moorei were higher in PTB compared to TSTn individuals, while Lactobacillus salivarius was higher in PTB compared to TSTp. The differences in the microbiome composition could influence the resistance/susceptibility to Mtb infection.

Nurse-led theory-based educational intervention improves glycemic and metabolic parameters in South Asian patients with type II diabetes: a randomized controlled trial.

OBJECTIVE: This study assessed whether a structured nurse-led diabetes educational program underpinned by the theories of the health belief model, change in locus of control, and patient empowerment is effective in improving glycemic and metabolic parameters among South Asians with type II diabetes compared to regular outpatient care. METHODS: This was a parallel-group randomized trial in South Asian adult patients with type II diabetes living in Qatar. 460 subjects were randomized to a nurse-led, group-based diabetes educational program (n = 230) or to usual care (n = 230). The primary outcome was the improvement in HbA1c and other metabolic parameters, including lipid profile, albumin/creatinine ratio, blood pressure, and body mass index. Patients in the intervention group were invited to attend four 2-h sessions of self-efficacy improvement education once weekly. Outcomes were assessed at baseline and 12 months later. An intention-to-treat analysis was performed using repeated measures ANOVA (analysis of variance) for each of the clinical outcome variables. RESULTS: After 12 months, 290 patients completed the study. Subjects in the intervention group had statistically significant improvements in HbA1c (-0.55 %, p = 0.012), fasting blood sugar (-16.6 mg/dl, p = 0.022), albumin/creatinine ratio (-3.09, p < 0.001), and HDL cholesterol (+6.08 mg/dl, p < 0.0001). CONCLUSION: The inclusion of South Asian patients with type II diabetes in a structured, theory-based diabetes educational program that is led by nurses improves glycemic and metabolic parameters after 12 months.

The efficacy and safety of natural honey on the healing of foot ulcers: a case series.

UNLABELLED: This clinical observation investigated the efficacy, cost-effectiveness, and acceptability of natural honey on the healing of a variety of chronic foot ulcers at the primary care level. MATERIALS AND METHODS: A total of 12 patients with foot ulcers utilizing natural honey as an effective alternative to more expensive, advanced wound products were followed. Cases were referred to Umgwailinah Primary Health Care Center, Doha, Qatar from different health centers and from Hamad General Hospital, Doha, Qatar. There were also self-referred cases. After rinsing the site with normal saline, natural honey was applied and the wound was covered by glycerin-impregnated gauze (Adaptic Non-Adhering Dressing, Systagenix, San Antonio, TX) to prevent the absorption of honey into the cotton gauze and away from the wound site. Patients were followed on a daily basis for an average of 4 weeks. RESULTS: All ulcers healed with no contractures or scars with a mean healing time of 3 weeks. There was a 75% reduction in the dressing budget of the health center and a high level of satisfaction among both health professionals and patients. Patients' pain levels were reduced significantly after using natural honey, as evidenced by the use of the Visual Analog Scale. CONCLUSION: The use of natural honey in the management of chronic foot ulcers proved to be efficacious, cost-effective, and acceptable by both clinicians and patients.

Culturally sensitive patient-centred educational programme for self-management of type 2 diabetes: a randomized controlled trial.

OBJECTIVE: To assess the effectiveness of a culturally sensitive, structured education programme (CSSEP) on biomedical, knowledge, attitude and practice measures among Arabs with type two diabetes. RESEARCH DESIGNS AND METHODS: A total of 430 patients with type II diabetes mellitus living in Doha, Qatar were enrolled in the study. They were randomized to either intervention (n = 215) or a control group (n = 215). A baseline and one-year interval levels of biomedical variables including HbA1C, lipid profile, urine for microalbuminuria; in addition to knowledge, attitude and practice (KAP) scores were prospectively measured. The intervention was based on theory of empowerment, health belief models and was culturally sensitive in relation to language (Arabic), food habits and health beliefs. It consisted of four educational sessions for each group of patients (10-20 patients per session), lasting for 3-4 h. The first session discussed diabetes pathophysiology and complications; while the second session discussed healthy life style incorporating the Idaho plate method; and the third session dealt with exercise benefits and goal setting and the fourth session concentrated enhancing attitude and practice using counselling techniques. Outcomes were assessed at base line and 12 months after intervention. RESULTS: After 12 months participation in the intervention was shown to have led to a statistically significant reduction in HbA1C in the (CSSEP) group (-0.55 mmol/L, P = 0.012), fasting blood sugar (-0.92 mmol/L, P = 0.022), body mass index (1.70, P = 0.001) and albumin/creatinine ratio (-3.09, P < 0.0001) but not in the control group. The intervention group also had improvement in Diabetes knowledge (5.9%, P < 0.0001), attitude (6.56%, P < 0.0001), and practice (6.52%, P = 0.0001). CONCLUSION: This study demonstrates the effectiveness of culturally sensitive, structured, group-based diabetes education in enhancing biomedical and behavioural outcomes in Diabetic patients.

Status of complementary and alternative medicine in the curricula of health colleges in Saudi Arabia.

OBJECTIVES: To assess the status of complementary and alternative medicine (CAM) education in health colleges in Saudi Arabia. METHODS: A cross sectional descriptive study was conducted including all medical, dentistry, pharmacy, nursing, allied medical science, and health colleges in Saudi Arabia. A semi- structured questionnaire was designed to collect information covering CAM tracks, courses and contents in the college's curricula, available postgraduates programs, continuing medical education activities, number of colleges staff members specialized or interested in CAM. RESULTS: Out of 110 health colleges in Saudi Arabia, 90 (81.1%) participated in the survey. There is no CAM specialized track or postgraduate education in any health college. Eleven (12.2%) colleges are teaching CAM courses in their curricula. Fifteen (16.7%) colleges are teaching topics related to CAM in different study subjects. Five (5.6%) colleges conducted continuing medical education (CME) activities related to CAM. Among faculty members, there are only 16 CAM specialists working in 7 colleges and 84 interested staff members, working in 20 colleges. Colleges of pharmacy are more interested in CAM education compared to other colleges with 42.9% (6/14) of them have CAM courses in their curricula, (p=0.006). Also, they have more faculty CAM specialists (p=0.026) compared to other colleges. CONCLUSION: There is a low and diverse attention given to CAM in medical education in Saudi Arabia. There is a need for a national plan to review health colleges curricula to prepare health care providers for the integration of evidenced based CAM practices.