Management of Infective Endocarditis and Tibioperoneal Mycotic Aneurysm Following COVID-19 Infection.

Introduction: Infective endocarditis and mycotic tibioperoneal aneurysms are rare complications of COVID-19 infection. Medical therapy may not always be sufficient to reduce the high morbidity and mortality associated with these cardiovascular complications. Surgical treatment may need to be considered in such patients. Report: A 56 year old male patient with diabetes, hypertension, and hyperlipidaemia developed severe pneumonia from COVID-19 infection. He was admitted to the intensive care unit (ICU) at another facility where he was ventilated for a period of six weeks. Blood culture isolated coagulase-negative Staphylococcus and an echocardiogram showed a 1.4 × 1.5 cm mitral valve vegetation. He was treated for a period of 12 weeks with various antibiotic combinations including meropenem, levofloxacin, and teicoplanin with no improvement. On presentation at the current centre, he complained of painful right calf swelling. Computed tomography angiography showed a 7 cm right tibioperoneal trunk aneurysm. He underwent lung and cardiac assessment, following which it was decided to proceed with one stage synchronous surgery. Cardiac surgery was started through a median sternotomy and Guiraudon transeptal approach, with mitral valve replacement using a bioprosthesis (Edwards Magna, size 29). This was immediately followed by a medial lower limb approach with ligation of the aneurysm, followed by arterial reconstruction using a reversed saphenous vein graft from the superficial femoral artery to the posterior tibial artery. He was placed on intravenous vancomycin and ceftriaxone for a period of six weeks. He was discharged home after day 31 on 75 mg aspirin daily. At six month follow up, he was symptom free with a palpable posterior tibial pulse. Discussion: Increased awareness and close surveillance are necessary for patients with severe COVID-19 infection. In those who develop unusual cardiovascular complications, one stage cardiac and vascular surgery may be feasible, as described in this case.

Prognostic factors for failed Pavlik harness treatment in infants with developmental dysplasia of the hip: a retrospective cohort study.

PURPOSE: Pavlik harness treatment is the most common treatment in newborns diagnosed with developmental dysplasia of the hip (DDH). The success rates and predictors for failure have been debated over the last decade. In this study, we explored our treatment failure rate and potential prognostic factors that could predict the failure of Pavlik harness (PH) treatment in patients with DDH. METHODS: Two hundred and sixty-five patients were treated with PH based on the Graf hip types of classification. Age, gender, first born status, family history, foot deformity, plagiocephaly, breech presentation, hip abduction, hip stability, Graf hip type, Galeazzi sign, bilateralism, and femoral nerve palsy were tested as predictors for failure in multivariate logistic regression mode. Success and failure were determined by the normalization of the hip based on the Graf hip classification. RESULTS: The failure rate of patients treated with Pavlik harness was 16.6% which is within the reported range of failure rate. The mean age of patients who were successfully treated was 6.73 weeks in comparison to 8.84 weeks for those who failed. Age, plagiocephaly, hip instability, Graf classification, and the development of femoral nerve palsy were found to be predictors for failure of PH treatment upon univariate analysis only. However, only the presence of Galeazzi sign, hip instability, high grades of Graf hip classification, and the development of femoral nerve palsy proved to be independent predictors for failed PH treatment upon multivariate logistic regression analysis. CONCLUSIONS: Pavlik harness treatment is a successful treatment with an average success of 83.4%. Several independent predictors for failure of PH treatment have been identified. These include a positive Galeazzi sign, a frankly dislocated hip, Graf types III and IV, and the development of femoral nerve palsy.

Real-world experience and long-term evaluation of tofacitinib in refractory alopecia areata: A prospective, open-label, single-center study in Asian Arab population.

Tofacitinib is a pan-janus kinase inhibitor (JAK) which has been tested off-label in alopecia areata (AA) with promising results. However, evidence of tofacitinib in real-life setting is still poor. We evaluated long-term efficacy and safety of tofacitinib for refractory AA. This is a prospective, open-label, observational, single-center cohort study conducted between January 2018 and December 2020. Primary end-point was the percent change in Severity of Alopecia Tool (SALT) at the basal visit and at the most recent follow-up visit. Three categories of treatment response were analyzed. Data on 47 participants of Arab-Asian heritage were analyzed. A complete and partial regrowth was observed in 18 patients (41.86%) and 11 patients (25.58%), respectively. In 12 patients (27.9%), no response was obtained. Most of the non-responders belonged to the alopecia universalis group (66.67%). No statistical differences were observed in rates of regrowth between pediatric and adult individuals (p = 0.52), nor between women and men. Significant differences in the average duration of tofacitinib treatment were obtained among the three categories of regrowth (p < 0.003), notably duration of AA did not impact the clinical regrowth (p = 0.62). To the best of our knowledge, this is the first prospective, observational, long-term study using tofacitinib in refractory AA. Rates of regrowth and side effects are analogous to previous works. Length of tofacinitib therapy should last for 12 months before considering any discontinuation or change, since early cessation can lead to treatment failures or incomplete regrowth. Maintenance therapy after complete regrowth has demonstrated to be safe and effective to prevent recurrences of hair loss.

Barriers to nurse-patient communication in primary healthcare centers in Bahrain: Patient perspective.

Objectives: Effective and efficient communication is a core element in healthcare systems, especially between healthcare providers and patients. This study aimed to identify communication barriers between nurses and patients in primary healthcare centers in Bahrain. Methods: This is a cross-sectional study conducted across primary healthcare centers in Bahrain. Four hundred and two patients were recruited using convenience sampling. A self-administered questionnaire comprising 29 items on communication barriers was used. Results: A total of 402 patients consented to participate. The majority of participants reported the following statements had large effects on communication: "shortage in the number of nurses compared to the large number of patients" (254/401, 63.3%), "lack of desire of nurse to communicate with patients" (246/402, 61.2%), and "negative attitude of the nurse toward the patient" (238/401, 59.4%). Further, "difference in language between nurses and patients," "lack of self-confidence by nurses," and "nurses overwhelmed by work" were ranked as top three statements with a significant influence on communication between nurses and patients. Conclusions: Communication between healthcare providers and patients is pivotal for an optimal healthcare service. Based on the findings of this study and the literature, we recommend formal training of health care workers in improving communication skills and including this not only in medical curriculum but also in the form of continuing medical education (CMEs).

Evidence based treatment for developmental dysplasia of the hip in children under 6 months of age. Systematic review and exploratory analysis.

INTRODUCTION: Developmental dysplasia of the hip (DDH) is a common paediatric orthopaedic condition that attracts a substantive amount of controversy. The treatments vary because of the wide spectrum of the condition and the age of children at presentation. Although conservative and surgical treatments exist; it is widely accepted that conservative treatment is the first line of treatment in the first 6 months of life. Several devices have been proposed as the treatment of choice; however, to the best of our knowledge these have not been critically appraised. Therefore, we conducted this review. METHODS: A modified Cochrane method was followed with a preplanned detailed research protocol that was developed to guide all aspects of the review. Treatment failure of the devices was chosen as the primary outcome. Secondary outcomes included femoral nerve palsy (FNP), avascular necrosis of the femoral head (AVN), residual dysplasia, skin problems, failure of subsequent surgical treatment, compliance and tolerance issues. Results are reported according to the PRISMA guidelines. RESULTS: A total of 30 studies were included in the review comparing 5 devices (The Pavlik harness, the Von Rosen splint, the Tubingen brace, the Frejka pillow, and the Aberdeen splint). The devices were compared in terms of success rate, AVN rate and residual dysplasia. The von Rosen splint has been shown to be superior to other devices in term of success rates and residual dysplasia (Χ2: P < 0.05). CONCLUSION: The review findings should be interpreted with caution as there are substantive flaws in the literature and a randomized control trail is warranted to confirm the best device to treat DDH. This is feasible given the magnitude of the problem, the clear diagnostic criteria and the treatment options.

Antioxidant status in acute asthmatic attack in children.

OBJECTIVES: To determine the oxidant - antioxidant imbalance in asthmatic children, by measuring the levels of malondialdehyde (MDA) as an oxidant marker of lipid peroxidation as well as antioxidant compounds like vitamin C, vitamin E and uric acid and to investigate whether their concentrations are associated with more severe asthma. METHODS: This case controlled prospective study was conducted on 219 children aged 1-12 years, attending Basra Maternity and Children Hospital. Included were 98 asthmatic children during acute attack and 121 nonasthmatic, apparently healthy children. Serum malondialdehyde (MDA) as an oxidant marker of lipid peroxidation, and vitamin C, vitamin E and uric acid (as antioxidants) were estimated in asthmatic children during acute attack and compared with non-asthmatic children. RESULTS: Asthmatic children during exacerbation of their asthma have significant lower serum levels of antioxidant compounds like vitamin C, vitamin E and uric acid (p < 0.001) and significantly high malondialdehyde as compared with the controls. MDA was significantly elevated (P < 0.001), while that of vitamin C, vitamin E and uric acid were significantly decreased with increasing severity of asthmatic attack (P < 0.001). A significant negative correlation between MDA with vitamin C (P < 0.05, r = - 0.44) was observed in severe asthmatic attacks. CONCLUSION: Asthmatic patients during acute attack suffer a high degree of reactive oxygen species formation causing considerable oxidative stress that is indicated by the high level of oxidants (MDA) and low level of antioxidants.