EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) SHORT VERSION.

OBJECTIVE: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendations were produced, including assigning levels of evidence (LoE) and grading of recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement of the summary and recommendation for each question (using a 5-point Likert scale), which was approved in the case of a level of agreement of greater than 75 %. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1), the remaining 9 questions achieved broad agreement with an assigned LoE of 4 and a weak GRADE recommendation (question 2), three achieved an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8) and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION.

AIMS: To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). METHODS: We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS: One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION: These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.

Invasive aspergillosis of the central nervous system in immunocompetent patients in Saudi Arabia: Case series and review of the literature.

OBJECTIVE: Invasive aspergillosis of the central nervous system in immunocompetent patients is a rare disease. We present in this study three cases that were treated in our centre and reviewed the results of similar studies from Saudi Arabia. METHODS: We retrospectively reviewed all cases of invasive aspergillosis of the central nervous system (CNS) that were treated in our hospital in the last 10 years. We also reviewed the literature for any similar series published from Saudi Arabia. RESULTS: We had three cases treated in our centre and we also found three similar case series in the literature. Total number of cases, including our series was 28, age range from 17 to 66, 10 men and 18 women. The source of infection was nasal sinuses in all cases. Initial presentations were variable and included headache (80% of cases), proptosis or diplopia (50% of cases), seizures (20% of cases), cranial nerve palsies (18% of cases) and acute deterioration in level of consciousness (18% of cases). All patients underwent surgery followed by long course of antifungal treatment. Clinical outcome was reported as cured or no recurrence in 13 cases (47%). CONCLUSIONS: Invasive aspergillosis of CNS is a rare disease in immunocompetent patients. Despite treatment prognosis remains unfavourable in many cases.

General public knowledge, perceptions and practice towards pharmaceutical drug advertisements in the Western region of KSA.

This study aims to examine general public knowledge and behavior toward pharmaceutical advertisements in the Western part of KSA. A cross sectional convenience sampling technique was used in this study. A total of 1445 valid questionnaires were received and analyzed using SPSS version 16 at alpha value of 0.05. Majority of respondents were aware of different types of drugs to be advertised and drug advertisements should seek approval from the health authorities. Television and Internet showed the highest effect on consumers. Almost half of the participants preferred an advertised drug over non-advertised one. Most of the respondents indicated that the quality of frequently advertised drugs is not better than those prescribed by the doctors. Majority of participants had positive beliefs toward advertised drugs concerning their role in education and spreading of awareness among the public. Pharmaceutical advertisements harm the doctor-patient relationship as evidenced by one-third of the investigated sample. Moreover, majority of the participants mentioned that they would consult another doctor or even change the current doctor if he/she refused to prescribe an advertised medication. Results of this study could be used to develop awareness programs for the general public and try to enforce the regulations and policies to protect the general public and patients from the business oriented pharmaceutical companies and drug suppliers.

Can absence of cardiac activity on point-of-care echocardiography predict death in out-of-hospital cardiac arrest? A systematic review and meta-analysis.

AIM: The purpose of this systematic review and meta-analysis was to evaluate the accuracy of the absence of cardiac motion on point-of-care echocardiography (PCE) in predicting termination of resuscitation (TOR), short-term death (STD), and long-term death (LTD), in adult patients with cardiac arrest of all etiologies in out-of-hospital and emergency department setting. METHODS: A systematic review and meta-analysis was conducted based on PRISMA guidelines. A literature search in Medline, EMBASE, Cochrane, WHO registry, and ClinicalTrials.gov was performed from inspection to August 2022. Risk of bias was evaluated using QUADAS-2 tool. Meta-analysis was divided into medical cardiac arrest (MCA) and traumatic cardiac arrest (TCA). Sensitivity and specificity were calculated using bivariate random-effects, and heterogeneity was analyzed using I2 statistic. RESULTS: A total of 27 studies (3657 patients) were included in systematic review. There was a substantial variation in methodologies across the studies, with notable difference in inclusion criteria, PCE timing, and cardiac activity definition. In MCA (15 studies, 2239 patients), the absence of cardiac activity on PCE had a sensitivity of 72% [95% CI 62-80%] and specificity of 80% [95% CI 58-92%] to predict LTD. Although the low numbers of studies in TCA preluded meta-analysis, all patients who lacked cardiac activity on PCE eventually died. CONCLUSIONS: The absence of cardiac motion on PCE for MCA predicts higher likelihood of death but does not have sufficient accuracy to be used as a stand-alone tool to terminate resuscitation. In TCA, the absence of cardiac activity is associated with 100% mortality rate, but low number of patients requires further studies to validate this finding. Future work would benefit from a standardized protocol for PCE timing and agreement on cardiac activity definition.

Assessing left ventricular systolic function by emergency physician using point of care echocardiography compared to expert: systematic review and meta-analysis.

Assessing left ventricular systolic function (LVSF) by echocardiography assists in the diagnosis and management of a diverse range of patients presenting to the emergency department (ED). We evaluated the agreement between ED-based clinician sonographers and apriori-defined expert sonographers. We conducted a systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched Medline, EMBASE, Cochrane, ClinicalTrials.gov, TRIP and Google Scholar for eligible studies from inception to February 2021. Risk of bias was evaluated using Quality Assessment Tool for Diagnostic Accuracy Studies-2 tool. The level of agreement between clinician and expert sonographers was measured using kappa, sensitivity, specificity, positive and negative likelihood ratio statistics using random-effects models. Twelve studies were included (1131 patients, 1229 scans and 159 clinician sonographers). Significant heterogeneity was identified in patient selection, methods of assessment of LVSF, reference standards and statistical methods for assessing agreement. The overall quality of studies was low, with most being small, single centre convenience samples. A meta-analysis including seven studies (786 scans) where visual estimation method was used by clinician sonographers demonstrated simple Kappa of 0.68 [95% confidence interval (CI), 0.57-0.79], and sensitivity, specificity, positive and negative likelihood ratio of 89% (95% CI, 80-94%), 85% (95% CI, 80-89%), 5.98 (95% CI, 4.13-8.68) and 0.13 (95% CI, 0.06-0.24), respectively, between clinician sonographer and expert sonographer for normal/abnormal LVSF. The weighted kappa for five studies (429 scans) was 0.70 (95% CI, 0.61-0.80) for normal/reduced/severely reduced LVSF. There is substantial agreement between ED-based clinician sonographers and expert sonographers for assessing LVSF using visual estimation and ranking it as normal/reduced, or normal/reduced/severely reduced, in patients presenting to ED.

Synthesis of tolyl guanidine as copper corrosion inhibitor with a complementary study on electrochemical and in silico evaluation.

A rapid and new synthetic route for N,N'-di-o-tolyl guanidine (DTG) synthesis from cheap materials is reported. The performance of DTG as an excellent inhibitor for delaying copper (Cu) corrosion with an efficiency higher than 98% at 20 × 10-6 M in an acidic solution was investigated via electrochemical measurements. These measurements included PDP, EFM, and EIS spectroscopy. The experimental data indicated that DTG has an efficient inhibiting effect on the corrosion of Cu in acidic media.The DTG was adsorbed on to the Cu surface via chemical adsorption and followed the Langmuir route. The PDP measurements revealed that DTG acted as a mixed inhibitor. Furthermore, EIS data showed that the DTG adsorbed through the metal/electrolyte interface. This resulted in forming a DTG protective layer on the Cu surface, thereby impeding the dissolution of Cu in the acidic solution. The corrosive solution containing the DTG inhibitor after immersion of the Cu specimen for 48 h, which promoted the formation of a complex between the Cu cation and DTG, was investigated via ultraviolet/visible spectroscopy. In addition, the formation of a DTG protective layer on the Cu surface was confirmed via scanning electron microscopy and atomic force microscopy analysis of the Cu surface morphology. Moreover, the active centers for interaction with the Cu surface in an acidic solution were investigated via in silico evaluation of DTG.

Novel cationic aryl bithiophene/terthiophene derivatives as corrosion inhibitors by chemical, electrochemical and surface investigations.

Two novel bithienyl fluorobenzamidine derivatives namely, 4-([2,2':5',2''-terthiophen]-5-yl)-2-fluorobenzamidine hydrochloride salt (MA-1615), 5'-(4-amidino-3-fluorophenyl)-[2,2'-bithiophene]-5-carboxamidine dihydrochloride salt (MA-1740) were synthesized, characterized and their corrosion inhibition properties were evaluated by electrochemical methods for carbon steel (C-steel) in 1 M HCl. Experimental investigations revealed that the inhibition effectiveness of the investigated inhibitors (INHs) by the Tafel polarization method followed the order: MA-1740 (96.9%) > MA-1615 (95.6%), demonstrating higher efficiency than inhibitors of similar structure reported in the literature. The investigated bithiophene derivatives exhibit mixed-type corrosion inhibition characteristics by blocking the active sites on the surface of C-steel. EIS study revealed that the INHs behave as interface-type corrosion inhibitors. UV-Visible spectrometric measurements confirmed a complex formation between the Fe2+ cation released during the corrosion reactions and inhibitor molecules.

A Case of Spinal Epidural Abscess Presenting with Horner Syndrome.

A spinal epidural abscess (SEA) is an uncommon disease, but it is associated with significant morbidity. SEA can be promoted by multiple risk factors. Moreover, the diagnosis of SEA usually requires the presence of a classic triad of back pain, fever, and neurological deficit, hence, the difficulty in making the diagnosis if presented otherwise. Horner syndrome (HS) is an uncommon presentation in association with SEA. Even though nonsurgical versus surgical management of SEA is still controversial, the literature review indicates a preference for surgical decompression as a treatment for SEA presenting with neurological compromise, followed by long-term antimicrobial therapy. The rapidity of making the diagnosis and the initiation of appropriate treatment determine the outcome. We present a case of a 23-year-old male with no past medical history. The patient arrived at the Hamad General Hospital emergency department (ED) with severe upper back pain radiating to his left shoulder, which progressed to numbness and weakness of the left upper limb and spastic paraplegia. A left HS was revealed in a further neurological examination. However, the diagnosis of a spinal epidural abscess (SEA) was made after a left posterolateral epidural abscess extending from C5/6-T2/3 with associated cord compression and edema was revealed on an MRI scan. The patient then underwent a left C7, T1 hemilaminectomy and received antibiotics followed by admission to the rehabilitation unit. Staph. aureus was reported in culture microbiology results. Unfortunately, motor power recovery after the surgery was not significant. Although it is difficult to diagnose SEA, it is crucial to suspect it in the presence of a neurological deficit regardless of the presence or absence of predisposing factors. Nevertheless, HS is not a relatively common finding in association with SEA. In this case report, we have a young patient with SEA who presented with left HS, upper back pain, and progressive neurological deficit in the absence of identifiable risk factors.

Can COVID-19 Cause Flare-Ups of Acute Hepatitis B? An Atypical Presentation of COVID-19 with Acute Hepatitis B.

We report a case of fulminant liver failure in a patient with acute active hepatitis B infection who was found to have COVID-19 without lung involvement. A 24-year-old male was brought by ambulance service to Hamad General Hospital, Emergency Department (ED), in Doha on April 8, 2020, with chief complaints of fever and cough for 3 days. Upon initial evaluation, the patient was febrile (39.4°C), jaundiced, and disoriented regarding time, place, and person, with an unremarkable past medical history. Initial blood tests showed severely elevated urea, creatinine, transaminases, and ammonium in addition to an impaired coagulation profile consistent with fulminant liver failure. A swab was taken for COVID-19 PCR testing and found to be positive. Serological tests revealed hepatitis B surface antigen positivity and other serology indicating acute hepatitis B. Initial X-ray and repeat chest X-rays did not show lung infiltrates. On the 6th day after admission, the patient developed fixed dilated pupils, with brain edema on CT; cardiac arrest occurred on the 10th day after admission, and the patient died. Although it is still largely unclear, HBV0-activated sudden-onset strong cytotoxic T lymphocyte response and enhanced viral replication and/or retention of the viral capsid in infected hepatocytes may cause the pathogenesis of FH. These pathophysiological events cause extensive hepatocyte apoptosis and necrosis, which results in deadly severe liver failure. Our findings support that the liver damage occurring in COVID-19 is caused by an impaired innate immune system rather than by direct cell damage caused by SARS-CoV-2. We think that more consideration should be given to the presence of acute hepatitis B, especially in COVID-19 patients.

Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum after upper gastrointestinal endoscopy.

Upper gastrointestinal (GI) endoscopies are performed for several reasons. The overuse of endoscopy has negative effects on the quality of healthcare and pressurises endoscopy services. It also results in the complications. These complications include pneumoperitoneum, pneumomediastinum and subcutaneous pneumomediastinum. However, it is worth noting that these complications rarely occur during endoscopy of the upper GI tract. These complications, when they occur, indicate perforation of the retroperitoneal space or peritoneal cavity. In this article, we discuss a case of pneumoperitoneum, pneumomediastinum and subcutaneous emphysema after upper GI endoscopy.

Rare Complications of Seizures in End-Stage Renal Disease: A Case Report.

Patients with chronic kidney disease (CKD) that progresses to end-stage renal disease (ESRD) typically present with uremic symptoms. CKD causes renal osteodystrophy, which leads to disturbances in mineral and bone metabolism. Pathological bone fractures after seizures activity has been reported in literature. In this study, we present what we consider the first case of combined bilateral femoral neck fractures, bilateral temporomandibular joint dislocations, and right shoulder anterior fracture dislocation in a patient who had a seizure activity due to electrolyte imbalance resulting from ESRD. The patient is a 36-year-old man with CKD that progressed to ESRD. Joint dislocations and bone fractures are rare complications of seizures activity. Diagnosis is usually delayed due to the low prevalence of these complications after seizures. Clinicians should always bear in mind that ESRD places patients at high risk of these rare complications.

Experience of Snakebite Envenomation by a Desert Viper in Qatar.

Crotaline and elapid snakebites are reported all over the world as well as in the Middle East and other countries around this region. However, data regarding snakebites and their treatment in Qatar are limited. This review paper is going to investigate the presentation and treatment of snakebite in Qatar. A good assessment helps to decide on the management of the snakebites envenomation. Antivenom and conservative management are the mainstays of treatment for crotaline snakebite. Point-of-care ultrasound (POCUS) has been suggested to do early diagnosis and treatment of soft tissue problems, such as edema and compartment syndrome, after a snakebite. The supporting data are not sufficient regarding the efficiency of POCUS in diagnosing the extent and severity of tissue involvement and its ultimate effect on the outcome. Further research is suggested in this case. Systemic complications, such as bleeding diathesis, can be managed by administering clotting factors and platelets.

Hydroxyethylcellulose used as an eco-friendly inhibitor for 1018 c-steel corrosion in 3.5% NaCl solution.

The inhibition effect of hydroxyethylcellulose (HEC) on 1018 c-steel corrosion in 3.5% NaCl solution was investigated by using potentiodynamic polarization, electrochemical frequency modulation (EFM) and electrochemical impedance spectroscopy (EIS) techniques. The potentiodynamic polarization studies suggested that HEC acts as a mixed-type inhibitor. Data obtained from EIS were analyzed to model the corrosion inhibition process through equivalent circuit. Results obtained from EFM technique were shown to be in agreement with potentiodynamic and EIS techniques. The adsorption behavior of HEC on steel surface follows the Langmuir adsorption isotherm. Thermodynamic parameter (ΔG°(ads)) and activation parameters (Ea(*), ΔH(*) and ΔS(*)) were calculated to investigate mechanism of inhibition. Scanning electron microscopy (SEM) and energy dispersive X-ray (EDX) analysis system were performed to characterize the film formed on the metal surface. DMol(3) quantum chemical calculations were performed to support the adsorption mechanism with the structure of HEC molecule.

Chitosan as a green inhibitor for copper corrosion in acidic medium.

The behavior of copper in 0.5 M HCl acid containing different concentrations of chitosan has been studied by weight loss, potentiodynamic polarization, electrochemical impedance spectroscopy (EIS) and electrochemical frequency modulation (EFM) measurements. Potentiodynamic polarization measurements show that the chitosan acts essentially as a mixed-type inhibitor. EFM can be used as a rapid and non destructive technique for corrosion rate measurements without prior knowledge of Tafel constants. The results of EIS indicate that the value of CPEs tends to decrease and both charge transfer resistance and inhibition efficiency tend to increase by increasing the inhibitor concentration. The investigated inhibitor has shown good inhibition efficiency in 0.5 M HCl. The adsorption of inhibitor on the copper surface obeys Langmuir's isotherm. Metal surface characterization was performed using scanning electron microscope (SEM) and Fourier transform infrared spectroscopy (FT-IR). Also, the relationship between quantum chemical calculations and experimental inhibition efficiency of the inhibitor was discussed.

The influence of consumers' preferences and perceptions of oral solid dosage forms on their treatment.

BACKGROUND: Beyond the direct pharmacological effect of medicines, preferences and perceptions toward a particular oral solid dosage form (OSDF) play a crucial role in recovery and may reduce adherence to the prescribed treatment. OBJECTIVES: This study conducted to investigate the most preferred OSDF and the degree to which swallowing solid medication is an issue, to assess perceptions of the therapeutic benefits of the OSDF, and to find predictors of the most preferred OSDF. METHOD: A cross-sectional study, through convenience sample method, was conducted to survey consumers visiting community pharmacies in Baghdad, Iraq. Data was collected by self-administered and pre-piloted questionnaires, and analyzed using Statistical Package for Social Science. Multiple logistic regression analysis and Chi-square tests were used at alpha level = 0.05. RESULTS: A total of 1,000 questionnaire were included in the analysis. Of all respondents, 52.9 % preferred capsule among other OSDF and this preference varied significantly with a number of socio-demographic factors. Ease of swallowing solid medication was the main issue which resulted in preferences for a particular form. A negative perception of the therapeutic benefits of the OSDF was found among 89.1 % of the consumers. Multiple logistic regression analysis indicated that gender, ease of swallowing, and perceptions of the therapeutic benefits of the OSDF were significant predictors of capsule preferences. CONCLUSIONS: Given the fact that consumers are the end users of medicines and their preferences may influence response to the treatment, efforts are worthwhile by the prescribers and medicines' manufactures to understand consumers' preferences of a particular dosage form in order to achieve successful therapy outcomes.

Perceptions among general medical practitioners toward implementation of medication reconciliation program for patients discharged from hospitals in Penang, Malaysia.

OBJECTIVE: This study aims to explore the perceptions of general practitioners (GPs) from the state of Penang toward the feasibility of implementing the medication reconciliation program in Malaysia. METHODS: A cross-sectional descriptive study using a validated, self-completed anonymous 18-item questionnaire was undertaken over a period of 2 months in 2010. The study was conducted in the state of Penang, Malaysia. A letter consisting of survey questionnaires and prepaid return envelope were mailed to 429 GPs identified from the Private Medical Practice Control Department Registry. RESULTS: A total of 86 responses were received with response rate of 20.1%. Majority (90.1%) of the respondents agreed that medication reconciliation can be a feasible strategy to improve medication safety, and 97.7% confirmed that having an accurate up-to-date list of the patient's previous medication will be useful in the rational prescribing process. However, about half (56.9%) of them felt that standardization of the medication reconciliation process in all clinics will be difficult to achieve. Three quarters (73.2%) of the respondents believed that the involvement of GPs alone is insufficient, and 74.5% agreed that this program should be expanded to community pharmacy setting. More than 90% of the respondents agreed upon the medication reconciliation card proposed by the researchers. CONCLUSIONS: General practitioners in Penang are generally in favor of the implementation of medication reconciliation program in their practice. Because medication reconciliation has been shown to reduce many medicine-related problems, it is thus worth considering the feasibility of nationwide implementation of such program.

Public knowledge and attitudes towards antibiotic usage: a cross-sectional study among the general public in the state of Penang, Malaysia.

INTRODUCTION: Public knowledge and attitudes towards antibiotics play a vital role in the success of the treatment process. This study aimed to assess public knowledge and attitudes toward antibiotic usage which could serve as baseline data for future studies within a government hospital setting in Malaysia. METHODOLOGY: A self-administered cross-sectional survey involving 408 respondents was conducted using a validated questionnaire at an outpatient pharmacy department in Penang Hospital, Malaysia, from February to March 2009. RESULTS: Nearly 55% of the respondents had a moderate level of knowledge. Three quarters of the respondents (76.7%) could correctly identify that antibiotics are indicated for the treatment of bacterial infections. However, 67.2% incorrectly thought that antibiotics are also used to treat viral infections. About 59.1% of the respondents were aware of antibiotic resistance phenomena in relation to overuse of antibiotics. With regard to attitudes, 38% believed that taking antibiotics when having cold symptoms could help them to recover faster, while 47.3% expected antibiotics to be prescribed for common cold symptoms. Age, race and educational level were among the demographic characteristics significantly associated with knowledge and attitudes toward antibiotic use. Poor level of knowledge was found in less than one-third of the respondents whereas more than one-third of the respondents wrongly self-medicate themselves with antibiotics once they have a cold. CONCLUSION: Educational interventions are needed to promote prudent use of antibiotics among the public.

Social pharmacy as a field of study: the needs and challenges in global pharmacy education.

The practice of pharmacy and, consequently, pharmacy curricula have undergone significant changes over the past years in response to a rapidly changing economic, political, and social environment. Within this context, the pharmacist's role had expanded to include more direct interaction with the public in terms of the provision of health information and advice on the safe and rational use of medications. To carry out these roles effectively, pharmacists need to be well prepared on how to deal with patients' behavior and psychology. The understanding of patient sociobehavioral aspects in the medication use process is paramount to achieving optimal clinical and humanistic outcomes from therapy. The concept of behavioral sciences and health psychology are embedded as the fundamental concepts in the field of social pharmacy, and thus it is imperative that this should be taught and nurtured to future pharmacy practitioners. Based on the growing needs for future pharmacists to be exposed to issues in social pharmacy, many pharmacy schools around the world have adopted this subject to be part of their standard curriculum. In this commentary, a discussion of the needs of social pharmacy courses in pharmacy curriculum will be addressed in the context of both developed and developing countries.