Electronic cigarette vapor disrupts key metabolic pathways in human lung epithelial cells.

The steady increase in the use of electronic cigarettes (ECs) has reached an epidemic level, increasing mortality and morbidity, mainly due to pulmonary toxicity. Several mechanisms are involved in EC-induced toxicity, including oxidative stress and increased inflammation. Concurrently, the integrity of cellular metabolism is essential for cellular homeostasis and mitigation of toxic insults. However, the effects of EC on cellular metabolism remain largely unknown. In this study, we investigated the metabolic changes induced by EC in human lung epithelial cells (A549) using an untargeted metabolomics approach. A549 cells were exposed to increasing EC vapor extract concentrations, and cell viability, oxidative stress, and metabolomic changes were assessed. Our findings show that ECs induce cell death and increase oxidative stress in a concentration-dependent manner. Metabolomic studies demonstrated that ECs induce unique metabolic changes in key cellular metabolic pathways. Our results revealed that exposure to ECs induced clear segregation in metabolic responses which is driven significantly by number of essential metabolites such as aminoacids, fatty acids, glutathione, and pyruvate. Interstingly, our metabolomics results showed that each concentration of ECs induced unqiues pattern of metabolic changes, suggesting the complexity of ECs induced cytotoxcity. Disrupted metabolites were linked to essential cellular pathways, such as fatty acid biosynthesis, as well as glutathione, pyruvate, nicotinate and nicotinamide, and amino acid metabolisms. These results highlight the potential adverse effects of ECs on cellular metabolism and emphasize the need for further research to fully understand the long-term consequences of EC use. Overall, this study demonstrates that ECs not only induce cell death and oxidative stress but also disrupt cellular metabolism in A549 lung epithelial cells.

Analyzing pesticides and metal(loid)s in imported tobacco to Saudi Arabia and risk assessment of inhalation exposure to certain metals.

Exposure to toxic chemicals through smoked tobacco is a significant global public health issue due to their genotoxic and carcinogenic properties. The study aims to (1) measure Arsenic (As), Cadmium (Cd), Cobalt (Co), Chromium (Cr), Mercury (Hg), Nickle (Ni), lead (Pb), and 407 pesticides in tobacco commercialized in Saudi Arabia; and (2) evaluate human health risks associated with smoking tobacco. Thus, we analyzed 60 tobacco samples per brand from eight of the most popular tobacco brands in the Saudi market. The analyzed tobacco contained significant concentrations of toxic metal (loid)s and banned pesticides. Twenty-three out of 407 pesticide residues were found, with an average concentration of 0.004-1.155 µg/g. Average concentrations of As, Cd, Co, Cr, Hg, Ni, and Pb for all brands were 0.16, 0.57, 0.75, 1.36, 1.94, 0.01, and 0.37 µg/g, respectively. The risk assessment indicated that high cancer risks are associated with exposure to As, Cd, Cr, and Ni, while lower risks are associated with Pb. Additionally, the potential cancer risk estimated for Cr was higher than other toxic elements. The cumulative cancer risks (95%) under three different cases for all brands were greater than the permissible limits (=10-4). The chances of getting cancer through inhalation of particulate As, Cd, Cr, Ni, and Pb was 4 in 10 000 cases in the best case scenario (1 cigarette per day). Therefore, metal content in cigarette tobacco should be reduced to improve public health.HIGHLIGHTSAll tested brands contained banned pesticide residues except for brand C.Tobacco samples contained significant concentrations of toxic metal(loid)s.A high risk of developing cancer is associated with exposure to As, Cd, Cr, and Ni, while a lower risk is associated with exposure to Pb.

Children's rates of COVID-19 vaccination as reported by parents, vaccine hesitancy, and determinants of COVID-19 vaccine uptake among children: a multi-country study from the Eastern Mediterranean Region.

BACKGROUND: Huge efforts are being made to control the spread and impacts of the coronavirus pandemic using vaccines. However, willingness to be vaccinated depends on factors beyond the availability of vaccines. The aim of this study was three-folded: to assess children's rates of COVID-19 Vaccination as reported by parents, to explore parents' attitudes towards children's COVID-19 vaccination, and to examine the factors associated with parents' hesitancy towards children's vaccination in several countries in the Eastern Mediterranean Region (EMR). METHODS: This study utilized a cross-sectional descriptive design. A sample of 3744 parents from eight countries, namely, Iraq, Jordan, Kuwait, Lebanon, Palestine, Qatar, Saudi Arabia (KSA), and the United Arab Emirates (UAE), was conveniently approached and surveyed using Google forms from November to December 2021. The participants have responded to a 42-item questionnaire pertaining to socio-demographics, children vaccination status, knowledge about COVID-19 vaccines, and attitudes towards vaccinating children and the vaccine itself. The Statistical Package for Social Sciences (SPSS- IBM, Chicago, IL, USA) was used to analyze the data. A cross-tabulation analysis using the chi-square test was employed to assess significant differences between categorical variables and a backward Wald stepwise binary logistic regression analysis was performed to assess the independent effect of each factor after controlling for potential confounders. RESULTS: The prevalence of vaccinated children against COVID-19 was 32% as reported by the parents. Concerning parents' attitudes towards vaccines safety, about one third of participants (32.5%) believe that all vaccines are not safe. In the regression analysis, children's vaccination was significantly correlated with parents' age, education, occupation, parents' previous COVID-19 infection, and their vaccination status. Participants aged ≥50 years and those aged 40-50 years had an odds ratio of 17.9 (OR = 17.9, CI: 11.16-28.97) and 13.2 (OR = 13.2, CI: 8.42-20.88); respectively, for vaccinating their children compared to those aged 18-29 years. Parents who had COVID-19 vaccine were about five folds more likely to vaccinate their children compared with parents who did not receive the vaccine (OR = 4.9, CI: 3.12-7.70). The prevalence of children's vaccination in the participating Arab countries is still not promising. CONCLUSION: To encourage parents, vaccinate their children against COVID-19, Arab governments should strategize accordingly. Reassurance of the efficacy and effectiveness of the vaccine should target the general population using educational campaigns, social media, and official TV and radio channels.

Effect of Helmet Noninvasive Ventilation vs Usual Respiratory Support on Mortality Among Patients With Acute Hypoxemic Respiratory Failure Due to COVID-19: The HELMET-COVID Randomized Clinical Trial.

Importance: Helmet noninvasive ventilation has been used in patients with COVID-19 with the premise that helmet interface is more effective than mask interface in delivering prolonged treatments with high positive airway pressure, but data about its effectiveness are limited. Objective: To evaluate whether helmet noninvasive ventilation compared with usual respiratory support reduces mortality in patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia. Design, Setting, and Participants: This was a multicenter, pragmatic, randomized clinical trial that was conducted in 8 sites in Saudi Arabia and Kuwait between February 8, 2021, and November 16, 2021. Adult patients with acute hypoxemic respiratory failure (n = 320) due to suspected or confirmed COVID-19 were included. The final follow-up date for the primary outcome was December 14, 2021. Interventions: Patients were randomized to receive helmet noninvasive ventilation (n = 159) or usual respiratory support (n = 161), which included mask noninvasive ventilation, high-flow nasal oxygen, and standard oxygen. Main Outcomes and Measures: The primary outcome was 28-day all-cause mortality. There were 12 prespecified secondary outcomes, including endotracheal intubation, barotrauma, skin pressure injury, and serious adverse events. Results: Among 322 patients who were randomized, 320 were included in the primary analysis, all of whom completed the trial. Median age was 58 years, and 187 were men (58.4%). Within 28 days, 43 of 159 patients (27.0%) died in the helmet noninvasive ventilation group compared with 42 of 161 (26.1%) in the usual respiratory support group (risk difference, 1.0% [95% CI, -8.7% to 10.6%]; relative risk, 1.04 [95% CI, 0.72-1.49]; P = .85). Within 28 days, 75 of 159 patients (47.2%) required endotracheal intubation in the helmet noninvasive ventilation group compared with 81 of 161 (50.3%) in the usual respiratory support group (risk difference, -3.1% [95% CI, -14.1% to 7.8%]; relative risk, 0.94 [95% CI, 0.75-1.17]). There were no significant differences between the 2 groups in any of the prespecified secondary end points. Barotrauma occurred in 30 of 159 patients (18.9%) in the helmet noninvasive ventilation group and 25 of 161 (15.5%) in the usual respiratory support group. Skin pressure injury occurred in 5 of 159 patients (3.1%) in the helmet noninvasive ventilation group and 10 of 161 (6.2%) in the usual respiratory support group. There were 2 serious adverse events in the helmet noninvasive ventilation group and 1 in the usual respiratory support group. Conclusions and Relevance: Results of this study suggest that helmet noninvasive ventilation did not significantly reduce 28-day mortality compared with usual respiratory support among patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia. However, interpretation of the findings is limited by imprecision in the effect estimate, which does not exclude potentially clinically important benefit or harm. Trial Registration: ClinicalTrials.gov Identifier: NCT04477668.

Reporting of Adverse Drug Reactions in Primary Care Settings in Kuwait: A Comparative Study of Physicians and Pharmacists.

OBJECTIVE: To investigate and compare knowledge, attitudes, and practices regarding pharmacovigilance (PV) and the reporting of adverse drug reactions (ADR) among physicians and pharmacists in primary care settings. SUBJECTS AND METHODS: A cross-sectional study was conducted, in which a validated self-administered questionnaire was distributed to 386 physicians and 197 pharmacists in 38 primary care clinics in Kuwait. Categorical variables were described using numbers and percentages. The Pearson χ2 test, Fisher exact test, and Mann-Whitney U test were used as appropriate. p < 0.05 was considered statistically significant. RESULTS: Of the 583 questionnaires distributed, 485 were completed (by 318 physicians and 167 pharmacists), giving an overall response rate of 83.2%. A total of 52.8% (n = 256) and 70.5% (n = 341) of the study participants were knowledgeable about the definitions of PV and ADR, respectively, with pharmacists demonstrating significantly better knowledge of PV (n = 105/167 vs. 151/318, i.e., 62.9 vs. 47.5%; p < 0.001) and purpose (n = 123/167 vs. 177/318, i.e., 74.1 vs. 55.7%; p < 0.001). However, the majority (n = 434/485; 89.4%) were not aware of an ADR reporting system in Kuwait. Almost every participant (n = 474/485; 97.7%) thought it was necessary to report ADR. However, significantly fewer physicians than pharmacists (n = 248/318 vs. 147/167, i.e., 78.0 vs. 88.0%; p < 0.01) believed that ADR reporting was a professional obligation. Only 27.8% (n = 133/485) had reported ADR, with pharmacists having reported significantly fewer than physicians (n = 35/167 vs. 98/318, i.e., 21.7 vs. 30.8%; p = 0.036). CONCLUSIONS: This study indicated that the attitude was positive but there was suboptimal knowledge and poor practice among primary care physicians and pharmacists with regard to ADR reporting. Targeted training about ADR reporting while ensuring a robust regulatory framework would encourage ADR reporting practices in the primary health care setting in Kuwait.

Noninvasive Ventilation in Critically Ill Patients With Severe Acute Respiratory Infections.

BACKGROUND: The objective of this study was to evaluate the association between noninvasive ventilation (NIV) compared with invasive ventilation and mortality in subjects with severe acute respiratory infection. METHODS: This was a retrospective multi-center study of subjects with severe acute respiratory infection treated with ventilatory support between September 2012 and June 2018. We compared the 90-d mortality of subjects managed initially with NIV (NIV group) with those managed with invasive ventilation only (invasive ventilation group), adjusting by propensity score. RESULTS: Of 383 subjects, 189 (49%) were in the NIV group and 194 (51%) were in the invasive ventilation group. Of the subjects initially treated with NIV, 117 (62%) were eventually intubated. Crude 90-d mortality was lower in the NIV group versus the invasive ventilation group (42 [22.2%] vs 77 [39.7%]; P < .001). After propensity score adjustment, NIV was associated with lower 90-d mortality than invasive ventilation (odds ratio 0.54, 95% CI 0.38-0.76; P < .001). The association of NIV with mortality compared with invasive ventilation was not different across the studied subgroups. CONCLUSIONS: In subjects with severe acute respiratory infection and acute respiratory failure, NIV was commonly used. NIV was associated with a lower 90-d mortality. The observed high failure rate suggests the need for further research to optimize patient selection and facilitate early recognition of NIV failure.

A new distribution record of Arnold's Gecko, Pristurusminimus (Arnold, 1977) (Squamata, Sphaerodactylidae), in Saudi Arabia.

Reptiles are considered an important element of Saudi Arabia's wildlife to be conserved as a priority. However, the status and distribution of the Kingdom's reptile fauna is not well understood, thus hindering the conservation initiatives. Better understanding of the taxonomy and distribution of the Kingdom's reptile fauna is important for implementing effective conservation measures. Here, we provide the new distribution record of Pristurusminimus (Arnold, 1977; common name, Arnold's Gecko) from southern Saudi Arabia. The species was recorded from the Uruq Bani Ma'arid Protected Area (UBM) of southern Saudi Arabia. Four individuals were captured from different survey sites across the UBM and their species identification was confirmed through a mixture of physical and genetic examination. These results increase the number of species from the Pristurus genus to five for Saudi Arabia and improve the understanding of the Kingdom's reptile fauna and its distribution.

The effect of various washing methods on pesticide residues, toxic and essential elements removal in rice.

This study examined the effects of various treatments on removing pesticide residues and toxic elements in rice. In parallel, nutritional elements, magnesium (Mg), potassium (K), and phosphorous (P), were measured to investigate the effect of these washing treatments on the nutritional value of rice. A naturally contaminated rice sample containing five widespread used pesticides (azoxystrobin, buprofezin, carbendazim, and propiconazole) and toxic elements, arsenic (As), cadmium (Cd), and essential elements, was washed using several washing agents, including boiling water, 5% sodium bicarbonate (baking soda), 5% acetic acid (vinegar), 5% citric acid, and 5% sodium chloride (salt). The washing method was chosen based on its availability and widespread usage; soaking for 10 min was assumed to be reasonable. Our results showed that using 5% acetic acid significantly reduced azoxystrobin by 63%, buprofezin by 70%, carbendazim by 75%, and propiconazole by 61%. However, As and Cd were significantly reduced in sodium chloride by 57% and 32%, respectively. Furthermore, a significant reduction in essential nutrient elements was found in Mg (42%), K (37%), and P (23%) when rice was treated with 5% citric acid. Overall, washing agents reduced analytes in the following manners pesticides, toxic elements, and essential elements when using acetic acid, sodium chloride, and citric acid separately.

Characterisation of engineered titanium dioxide nanoparticles in selected food.

Titanium dioxide (TiO2), an E171 manufacturer-made food additive, is extensively utilised as a colourant in drug and a food products. Some studies showed that most of confectionary and food items contain inexplicable particles. The aim of this article is to determine the size and structure of TiO2 nanoparticles in different food products. Ten food samples, including coffee cream, white chocolate concentrate, frosting, gum, yoghurt candy, hard candies and chewy candies, were investigated for this purpose. The crystalline structure and particle size of TiO2 were determined by Powder X-ray Diffraction (PXRD) and Transmission Electron Microscopy (TEM). TEM images revealed that a few of the extracted nanoparticles had a rod-like shape, but most were spherical. Also, the size of the TiO2 particle had a wide distribution between 12 and 450 nm. Thus, to avoid human health risk, crucial factors such as size, and shape should be considered and regulated by food authorities.

Long-term outcomes of patients with COVID-19 treated with helmet noninvasive ventilation or usual respiratory support: follow-up study of the Helmet-COVID randomized clinical trial.

PURPOSE: To evaluate whether helmet noninvasive ventilation compared to usual respiratory support reduces 180-day mortality and improves health-related quality of life (HRQoL) in patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia. METHODS: This is a pre-planned follow-up study of the Helmet-COVID trial. In this multicenter, randomized clinical trial, adults with acute hypoxemic respiratory failure (n = 320) due to coronavirus disease 2019 (COVID-19) were randomized to receive helmet noninvasive ventilation or usual respiratory support. The modified intention-to-treat population consisted of all enrolled patients except three who were lost at follow-up. The study outcomes were 180-day mortality, EuroQoL (EQ)-5D-5L index values, and EQ-visual analog scale (EQ-VAS). In the modified intention-to-treat analysis, non-survivors were assigned a value of 0 for EQ-5D-5L and EQ-VAS. RESULTS: Within 180 days, 63/159 patients (39.6%) died in the helmet noninvasive ventilation group compared to 65/158 patients (41.1%) in the usual respiratory support group (risk difference - 1.5% (95% confidence interval [CI] - 12.3, 9.3, p = 0.78). In the modified intention-to-treat analysis, patients in the helmet noninvasive ventilation and the usual respiratory support groups did not differ in EQ-5D-5L index values (median 0.68 [IQR 0.00, 1.00], compared to 0.67 [IQR 0.00, 1.00], median difference 0.00 [95% CI - 0.32, 0.32; p = 0.91]) or EQ-VAS scores (median 70 [IQR 0, 93], compared to 70 [IQR 0, 90], median difference 0.00 (95% CI - 31.92, 31.92; p = 0.55). CONCLUSIONS: Helmet noninvasive ventilation did not reduce 180-day mortality or improve HRQoL compared to usual respiratory support among patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia.

Impact of a national collaborative project to improve the care of mechanically ventilated patients.

This prospective quasi-experimental study from the NASAM (National Approach to Standardize and Improve Mechanical Ventilation) collaborative assessed the impact of evidence-based practices including subglottic suctioning, daily assessment for spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), head of bed elevation, and avoidance of neuromuscular blockers unless otherwise indicated. The study outcomes included VAE (primary) and intensive care unit (ICU) mortality. Changes in daily care process measures and outcomes were evaluated using repeated measures mixed modeling. The results were reported as incident rate ratio (IRR) for each additional month with 95% confidence interval (CI). A comprehensive program that included education on evidence-based practices for optimal care of mechanically ventilated patients with real-time benchmarking of daily care process measures to drive improvement in forty-two ICUs from 26 hospitals in Saudi Arabia (>27,000 days of observation). Compliance with subglottic suctioning, SAT and SBT increased monthly during the project by 3.5%, 2.1% and 1.9%, respectively (IRR 1.035, 95%CI 1.007-1.064, p = 0.0148; 1.021, 95% CI 1.010-1.032, p = 0.0003; and 1.019, 95%CI 1.009-1.029, p = 0.0001, respectively). The use of neuromuscular blockers decreased monthly by 2.5% (IRR 0.975, 95%CI 0.953-0.998, p = 0.0341). The compliance with head of bed elevation was high at baseline and did not change over time. Based on data for 83153 ventilator days, VAE rate was 15.2/1000 ventilator day (95%CI 12.6-18.1) at baseline and did not change during the project (IRR 1.019, 95%CI 0.985-1.053, p = 0.2812). Based on data for 8523 patients; the mortality was 30.4% (95%CI 27.4-33.6) at baseline, and decreased monthly during the project by 1.6% (IRR 0.984, 95%CI 0.973-0.996, p = 0.0067). A national quality improvement collaborative was associated with improvements in daily care processes. These changes were associated with a reduction in mortality but not VAEs. Registration The study is registered in clinicaltrials.gov (NCT03790150).

Cross-cultural adaptation and validation of the Arabic version of the upper extremity functional index.

PURPOSE: The purpose of this study was to translate and cross-culturally adapt the UEFI into Modern Standard Arabic language and to examine its psychometric properties among patients with upper extremity musculoskeletal disorders. MATERIALS AND METHODS: Translation and cross-cultural adaptation were done following Beaton's guidelines. Internal consistency, test-retest reliability, measurement error and floor and ceiling effects for the Arabic UEFI were tested among 109 patients with upper extremity musculoskeletal disorders. Construct validity of the Arabic UEFI was also examined. RESULTS: Translation and cross-cultural adaptation processes were generally smooth with no major issues. The Arabic UEFI was considered appropriate and comprehensible by the participants. Internal consistency for Arabic UEFI was adequate (Cronbach's alpha = 0.96). Test-retest reliability for Arabic UEFI was excellent with ICC2,1=0.92. Measurement error was acceptable with a standard error of measurement of 5.5 and minimal detectable change of 12.8 points. Arabic UEFI shows no floor or ceiling effects. The results supported the majority of the construct validity predefined hypotheses (78%) supporting the construct validity of Arabic UEFI as a measure of upper extremity function. CONCLUSION: The Arabic UEFI is an appropriate, valid and reliable outcome measure for Arabic-speaking patients with upper extremity musculoskeletal disorders.Implication for Rehabilitation:The Arabic UEFI is an acceptable, clear and comprehensible outcome measure.The Arabic UEFI has excellent internal consistency, test-retest reliability, and acceptable measurement error with no floor and ceiling effects.The Arabic UEFI is a valid measure of upper extremity activity limitation.

Helmet noninvasive ventilation for COVID-19 patients (Helmet-COVID): statistical analysis plan for a randomized controlled trial.

BACKGROUND: Noninvasive respiratory support is frequently needed for patients with acute hypoxemic respiratory failure due to coronavirus disease 19 (COVID-19). Helmet noninvasive ventilation has multiple advantages over other oxygen support modalities but data about effectiveness are limited. METHODS: In this multicenter randomized trial of helmet noninvasive ventilation for COVID-19 patients, 320 adult ICU patients (aged ≥14 years or as per local standards) with suspected or confirmed COVID-19 and acute hypoxemic respiratory failure (ratio of arterial oxygen partial pressure to fraction of inspired oxygen < 200 despite supplemental oxygen with a partial/non-rebreathing mask at a flow rate of 10 L/min or higher) will be randomized to helmet noninvasive ventilation with usual care or usual care alone, which may include mask noninvasive ventilation, high-flow nasal oxygen, or standard oxygen therapy. The primary outcome is death from any cause within 28 days after randomization. The trial has 80% power to detect a 15% absolute risk reduction in 28-day mortality from 40 to 25%. The primary outcome will be compared between the helmet and usual care group in the intention-to-treat using the chi-square test. Results will be reported as relative risk  and 95% confidence interval. The first patient was enrolled on February 8, 2021. As of August 1, 2021, 252 patients have been enrolled from 7 centers in Saudi Arabia and Kuwait. DISCUSSION: We developed a detailed statistical analysis plan to guide the analysis of the Helmet-COVID trial, which is expected to conclude enrollment in November 2021. TRIAL REGISTRATION: ClinicalTrials.gov NCT04477668 . Registered on July 20, 2020.

Helmet Non-Invasive Ventilation for COVID-19 Patients (Helmet-COVID): study protocol for a multicentre randomised controlled trial.

INTRODUCTION: Non-invasive ventilation (NIV) delivered by helmet has been used for respiratory support of patients with acute hypoxaemic respiratory failure due to COVID-19 pneumonia. The aim of this study was to compare helmet NIV with usual care versus usual care alone to reduce mortality. METHODS AND ANALYSIS: This is a multicentre, pragmatic, parallel randomised controlled trial that compares helmet NIV with usual care to usual care alone in a 1:1 ratio. A total of 320 patients will be enrolled in this study. The primary outcome is 28-day all-cause mortality. The primary outcome will be compared between the two study groups in the intention-to-treat and per-protocol cohorts. An interim analysis will be conducted for both safety and effectiveness. ETHICS AND DISSEMINATION: Approvals are obtained from the institutional review boards of each participating institution. Our findings will be published in peer-reviewed journals and presented at relevant conferences and meetings. TRIAL REGISTRATION NUMBER: NCT04477668.

Efficacy of patient discharge instructions: A pointer toward caregiver friendly communication methods from pediatric emergency personnel.

BACKGROUND: Discharge instructions are vital in postemergency patient care to help the caregiver understand the diagnosis and identify symptoms which require prompt readmission. In general, oral or written instructions are provided on discharge. However, there is a dearth of information on the efficacy of discharge instructions provided by physicians in KSA. OBJECTIVES: To evaluate the efficacy of discharge instructions for postpediatrics emergency visit. MATERIALS AND METHODS: This observational cross-sectional survey conducted in the Department of Paediatric Emergency at King Abdul Aziz Medical City, Riyadh, KSA, included 173 literate adult caregivers who had given their consent. Those who had been on admission earlier and been discharged from the emergency department were excluded. Demographic data and variables like knowledge of medicine and treatment follow-up were collected using a structured questionnaire and analyzed using SPSS version 16. RESULTS: Verbal only, written only, or both verbal and written discharge instructions were provided. Written and verbal instructions, when provided together, were the most effective modes of communication with caregivers. The majority of the respondents were unaware of the follow-up plan (64.16%), unable to identify problems that would necessitate a follow-up (58.96%), and unable to identify the signs and symptoms that would require a revisit (62.43%) irrespective of the mode of instruction. However, more attention is necessary because of the 34.68% of the subjects who left the hospital without discharge instructions. CONCLUSIONS: Instructions given both verbally and in writing were observed to be more effective than verbal only or written only. The effectiveness of discharge instructions was highly influenced by the level of education of the caregivers. Improved caregiver friendly methods of communication from the pediatric emergency health-care team are necessary for the delivery of discharge instructions.

New synonyms of two Arabian ants of the genus Monomorium Mayr, 1855 (Hymenoptera, Formicidae).

Synonymy of two Arabian Monomorium Mayr, 1855 species is proposed: Monomoriumexiguum Forel, 1894 = Monomoriumdesertorum Collingwood & Agosti, 1996, syn. n.; Monomoriumsubopacum Smith, 1858 = Monomoriummintiribe Collingwood & Agosti, 1996, syn. n. A lectotype for Monomoriumvenustum Smith, 1858 is designated. Information on nesting habits of Monomoriumexiguum and Monomoriumvenustum in the Kingdom of Saudi Arabia are provided for the first time. Recently collected records for Monomoriumexiguum, Monomoriumsubopacum, and Monomoriumvenustum from the Kingdom of Saudi Arabia and United Arab Emirates are listed.

Clinical aspects and outcomes of 70 patients with Middle East respiratory syndrome coronavirus infection: a single-center experience in Saudi Arabia.

OBJECTIVES: To report the experience with Middle East respiratory syndrome coronavirus (MERS-CoV) infection at a single center in Saudi Arabia. METHODS: Cases of laboratory-confirmed MERS-CoV occurring from October 1, 2012 to May 31, 2014 were reviewed retrospectively. Information sources included medical files, infection control outbreak investigations, and the preventive medicine database of MERS-CoV-infected patients. Data were collected on clinical and epidemiological aspects and outcomes. RESULTS: Seventy consecutive patients were included. Patients were mostly of older age (median 62 years), male (46, 65.7%), and had healthcare acquisition of infection (39, 55.7%). Fever (43, 61.4%), dyspnea (42, 60%), and cough (38, 54.3%) were the most common symptoms. The majority developed pneumonia (63, 90%) and required intensive care (49, 70%). Infection commonly occurred in clusters. Independent risk factors for severe infection requiring intensive care included concomitant infections (odds ratio (OR) 14.13, 95% confidence interval (CI) 1.58-126.09; p=0.018) and low albumin (OR 6.31, 95% CI 1.24-31.90; p=0.026). Mortality was high (42, 60%), and age ≥65 years was associated with increased mortality (OR 4.39, 95% CI 2.13-9.05; p<0.001). CONCLUSIONS: MERS-CoV can cause severe infection requiring intensive care and has a high mortality. Concomitant infections and low albumin were found to be predictors of severe infection, while age ≥65 years was the only predictor of increased mortality.