Genetic diversity of the chemical composition and pod production of Prosopis juliflora trees grown in Saudi Arabia.

This investigation was conducted to evaluate pod and chemical component traits and the genetic diversity of Prosopis juliflora genotypes at two locations. The selected locations were in the middle (Qassim region) and western (Jeddah region) areas, representing two agro-climatic zones of Saudi Arabia. The measured pod characteristics included production, weight, length, filling period, and chemical composition. A wide range of variations in pod yield and chemical traits were observed in the different agro-climatic regions. The results revealed that the mean values ranged from 9.5 kg tree-1 (Jeddah) to 14.2 kg tree-1 (Qassim) for pod yield, 3.1 g pod-1 (Qassim) to 3.7 g pod-1 (Jeddah) for pod weight, and 14.8 cm (Qassim) to 16.6 cm (Jiddah) for pod length. The results of genetic diversity indicated that Prosopis genotypes in each location were distributed in three different clusters in the two regions at 60 Euclidean distances. The principal component analysis (PCA) showed that the two components (PC1 and PC2) explained 25.03 % and 20.03 % of the overall variance, respectively, which is over 45 % of the variability. The heatmap revealed that genotypes Q20, Q21, and Q24 at the Qassim location and genotypes J1, J6, and J7 at the Jiddah location exhibited positive and significant correlations with pod yield. It can be concluded that superior Prosopis genotypes (Q20, Q21, Q24, J1, J6, and J7) were identified with good traits (pod yield, pod-filling period, and protein %) in each location and may be used in the future for the selection of elite genotypes.

Time Spent on Medical Round Activities, Distance Walked, and Time-Motion in the General Medicine Department at Hamad General Hospital in Qatar.

Background The daily morning round is a routine activity performed by medical teams. During the morning round, updates on the patient's clinical condition, new laboratory results, and other test results are reviewed and discussed between team members, the patient, and at times the family. Completing these tasks takes time. The design of the patient location differs between hospitals, and significant distance between patients can considerably affect round times. This study assesses physicians' time spent on clinical activities, the distance traveled, and the time they spend walking between patients during daily morning rounds to identify better reorganization methods to reduce wasted time. Methodology The survey was self-administered and had no intervention needing ethical approval. The research team's leader engaged two observers (a general practitioner from another department and a general internal medicine department case manager) to collect the data. The general practitioner was a medical graduate doctor, while the bed manager was not a medical college graduate. They observed 10 rounds over 10 non-consecutive days from July 1 to July 30, 2022. They recorded daily activities during the daily morning round, including time spent with patients, family conversations, bedside education, medication, social issues, and the time and distance required to move from patient to patient and from one location to location. The informal conversations about age, work history, and other small talk were recorded and converted into quantitative data. In each round, records were given to a statistician for rechecking. Subsequently, the records were imported into a Microsoft Excel spreadsheet for further statistical analysis. For continuous variables, the data were summarized as mean, median, and standard deviation. For categorical variables, the data were summarized as counts or proportions. Results On average, the duration of the daily morning round was 161.7 ± 17.3 minutes. The average number of patients seen by the general internal medicine round team was 14. The median patient encounter time per patient was 14 minutes (11-19 minutes), with an average of 12 minutes. An average of 8.6 employees participated in the 10-day rounds. The physician spent 41.2% of the time in direct contact with the patient during the morning round, 11.4% in maintaining electronic medical records, and 18.20% in bedside teaching. Additionally, 7.1% of the round time was spent because of interruptions by clinical and non-clinical staff other than team members or family members who were not in the room. Furthermore, a team member walked an average of 763 ± 54.5 m (667-872 m) per round, costing 35.7 minutes (22.1%) of the total round time. Conclusions The daily morning round time was significantly longer compared with the reported round times. Relocating patient beds to a common location reduced the rounding time by 22.30%. Disruption, teaching, and medical instruction must also be considered and shortened to reduce the morning round time.

Protein-losing enteropathy as the first presentation of systemic lupus erythematosus: A case report from Sudan.

Key Clinical Message: In low- and middle-income countries, protein-losing enteropathy is a diagnosis of exclusion. SLE should be on the list of differential diagnoses of protein-losing enteropathy, especially if the patient had a long history of GI symptoms and ascites. Abstract: Protein-losing enteropathy can rarely be the initial presentation of systemic lupus erythematosus (SLE). Protein-losing enteropathy is a diagnosis of exclusion in low- and middle-income countries. Protein-losing enteropathy in SLE should be in the list of differential diagnosis of unexplained ascites, especially if patient had long history of gastrointestinal symptoms. We present a case of 33 years old male with long standing gastrointestinal symptoms and diarrhea attributed previously to irritable bowel syndrome. Presented with progressive abdominal distension, and diagnosed with ascites. Workup for him showed leucopenia, thrombocytopenia, hypoalbumenemia, elevated inflammatory markers (ESR 30, CRP 6.6), high cholesterol level (306 mg/dL), normal renal profile and normal urine analysis. Ascitic tab pale yellow with SAAG 0.9 and positive for adenosine deaminase (66 u/L) sugesstive for tuberculous peritonitis although quantitative PCR and geneXpert for MBT was negative. Antituberculous treatment was started and his condition deteriorated, immediately antituberculous was withdrawal. Further tests revealed positive serology for ANA (1:320 speckled pattern) with positive anti-RNP/Sm, positive anti-Sm antibodies. Complements level were normal. He started immunosuppressive therapy (prednisolone 10 mg/day, hydroxychloroquine 400 mg/day, azathioprine 100 mg/day). In addition, his condition is improved Diagnosis was made as SLE with Protein-losing enteropathy based on hypoalbumenemia (with exclusion of renal loss of protein), ascites, hypercholesrtolemia and exclusions of other mimics as explained later. As well as positive response to immunosuppressive medications. Our patient diagnosed clinically as SLE with protein-losing enteropathy. Protein-losing enteropathy in SLE is challenging in diagnosis because of its rarity as well as limitations in its diagnostic tests.

Consequences of COVID-19 Among Adult HIV Patients Versus Non-HIV Patients: Two-Year Data From the Primary Isolation Centre in Sudan.

Background The COVID-19 pandemic remains to have a global impact despite the great efforts in prevention. Controversy persists regarding the outcomes of SARS-CoV-2 among HIV patients versus non-HIV individuals. Objective This study aimed to assess the impact of COVID-19 among adult patients with HIV versus non-HIV in the chief isolation centre in Khartoum state, Sudan. Methods This is an analytical cross-sectional, comparative single-centre study conducted at the Chief Sudanese Coronavirus Isolation Centre in Khartoum from March 2020 to July 2022. Data were analysed using SPSS V.26 (IBM Corp., Armonk, USA). Results This study included 99 participants. The overall age mean was 50±1 years old, with a male predominance of 66.7% (n=66). 9.1% (n=9) of the participants were HIV cases, 33.3% of whom were newly diagnosed. The majority, 77.8%, reported poor adherence to anti-retroviral therapy. The most common complications included acute respiratory failure (ARF) and multiple organ failure, 20.2% and 17.2%, respectively. The overall complications were higher among HIV cases than non-HIV cases; however, statistically insignificant (p>0.05 ), except for acute respiratory failure (p<0.05). 48.5% of participants were admitted to the intensive care unit (ICU), with slightly higher rates among HIV cases; however, this was statistically insignificant (p=0.656). Regarding the outcome, 36.4% (n=36) recovered and were discharged. Although a higher mortality rate was reported among HIV cases compared to non-HIV cases (55% vs 40%), it was statistically insignificant (p=0.238). Conclusion The mortality and morbidity percent proportion among HIV patients with superimposed COVID-19 infection was higher than in non-HIV patients but statistically insignificant aside from ARF. Consequently, this category of patients, to a large extent, should not be considered highly susceptible to adverse outcomes when infected with COVID-19; however, ARF should be closely monitored for.

Scenarios to Improve the Patient Experience Time in a Tertiary Academic Hospital Using Simulation.

Background Shortening the patient experience time (PET) in the emergency department (ED) improves patient quality and satisfaction and reduces mortality and morbidity. Worldwide, the PET target in the ED is ≤ 6 hours; however, the PET awaiting admission to inpatient Medicine at Hamad General Hospital (HGH) in the Qatar State, through ED is currently 15.3±6.4 (mean ± SD) hours. Aim Identify solutions to reduce the PET duration at HGH-ED to the international target. Method A cohort study was done using the Discrete-event simulation (DES) model, utilizing a commercial simulation software package (Process Model Inc., Utah, version 5.2.0). One-year data, January 1, 2019 - December 30, 2019, was analyzed and found to follow seven subprocesses. The duration of each subprocess was recorded, and the average time was calculated. A computer simulation scheme was developed for all the subprocesses of the actual PET duration. The simulated PET was validated, and scenarios were proposed and assessed for each subprocess separately and in combination, A constructed simulatory design using an iterative process involving a construction model. This model starts with the logical organization of submitted tasks based on their cycle times. A subject-matter expert interview was conducted to determine the appropriateness and frequency of actions. The duration of each activity in the considered process was defined using a triangular distribution. Results The actual PET duration for the Medical Department was 15.3±6.4 (mean + SD) hours. The three most prolonged PET subprocess durations were in the referral to internal medicine, the decision to admit, and finding a free bed; these represent 17.9%, 53.8%, and 16.7% of the PET, respectively. Adding two physicians to each shift, which shortens the subprocess of the decision to admit, reduced the PET duration by 27.5%. Moreover, creating a new admitting team (unit) that takes care of new patients admitted to the ED reduced PET duration by another 12.5%. Combining these two scenarios reduced the average PET duration to only 10.2±0.5 hours. In addition to these scenarios, the PET can be further decreased to six hours by increasing the number of inpatient beds. Conclusions The simulated scenarios indicated that restructuring the medical teams, adding two physicians to each shift, and creating an admissions team dedicated to the ED would reduce the total PET duration to 10.2 hours, Furthermore, PET's further reduction to six hours is predictable by increasing the bed number.

Redistribution of Doctors and Decentralization of Clinics Improved Utilization of Services, Demand, and Capacity of Hamad Medical Corporation's Staff Clinic.

BACKGROUND:  The Staff Medical Clinic (SMC) of the Hamad Medical Corporation (HMC) serves the staff members who require healthcare services, but in a crowded environment, the SMC can only meet 75% of that demand. Overcrowding reduces productivity and service quality and increases waiting time. Furthermore, overcrowding in healthcare facilities decreases the experience and satisfaction of patients and healthcare providers. AIM: The main objective of this study was to use simulation modeling to evaluate interventions that could improve SMC waiting time and efficiency. METHOD:  Eighteen months of data on SMC patient flow, staffing, and clinical sessions were collected (January 2018 to June 2019). The patient's journey through the SMC was modeled as a series of processes with assigned durations defined mathematically using the appropriate probability distribution. A simulation flow model was developed considering the locations of the staff and nearby main hospital facilities. An intervention was proposed and evaluated through a simulation. The intervention involved redistributing 25% of the SMC staff into three main satellite clinics located at the facilities where most of the SMC patients came.  Results: The proposed intervention decreased crowding by 37%, reduced staffing requirements by 28%, and increased the number of patient slots by 22%, resulting in a net increase in the number of patients served by an average of 1250 monthly, without the need for hiring new additional staffing. CONCLUSION:  Redistribution of the available medical staff to three new satellite clinics reduces workload pressure at all sites and increases clinic capacity without additional costs.

Management of osteoporosis in patients with chronic kidney disease.

Patients with CKD have a 4-fivefold higher rate of fractures. The incidence of fractures increases with deterioration of kidney function. The process of skeletal changes in CKD patients is characterized by compromised bone strength because of deterioration of bone quantity and/or quality. The fractures lead to a deleterious effect on the quality of life and higher mortality in patients with CKD. The pathogenesis of bone loss and fracture is complex and multi-factorial. Renal osteodystrophy, uremic milieu, drugs, and systemic diseases that lead to renal failure all contribute to bone damage in CKD patients. There is no consensus on the optimal diagnostic method of compromised bone assessment in patients with CKD. Bone quantity and mass can be assessed by dual-energy x-ray absorptiometry (DXA) or quantitative computed tomography (QCT). Bone quality on the other side can be assessed by non-invasive methods such as trabecular bone score (TBS), high-resolution bone imaging methods, and invasive bone biopsy. Bone turnover markers can reflect bone remodeling, but some of them are retained by kidneys. Understanding the mechanism of bone loss is pivotal in preventing fracture in patients with CKD. Several non-pharmacological and therapeutic interventions have been reported to improve bone health. Controlling laboratory abnormalities of CKD-MBD is crucial. Anti-resorptive therapies are effective in improving BMD and reducing fracture risk, but there are uncertainties about safety and efficacy especially in advanced CKD patients. Accepting the prevalent of low bone turnover in patients with advanced CKD, the osteo-anabolics are possibly promising. Parathyroidectomy should be considered a last resort for intractable cases of renal hyperparathyroidism. There is a wide unacceptable gap in osteoporosis management in patients with CKD. This article is focusing on the updated management of CKD-MBD and osteoporosis in CKD patients. Chronic kidney disease deteriorates bone quality and quantity. The mechanism of bone loss mainly determines pharmacological treatment. DXA and QCT provide information about bone quantity, but assessing bone quality, by TBS, high-resolution bone imaging, invasive bone biopsy, and bone turnover markers, can guide us about the mechanism of bone loss.

Varicella-Zoster Virus (VZV) Meningitis in an Immunocompetent Adult after BNT162b2 mRNA COVID-19 Vaccination: A Case Report.

We present, to our knowledge, the second case report of a 46-year old female who developed varicella-zoster virus (VZV) meningitis after BNT162b2 mRNA COVID-19 vaccination. The patient is immunocompetent and has no known predisposing risk factors for developing VZV meningitis. The patient received acyclovir therapy and subsequently had a complete recovery. We describe possible mechanisms of VZV meningitis after mRNA COVID-19 vaccination.

Incidental hepatitis B virus in Sudanese patients and relative risk factors: Why more screening is needed in primary care?

Background: Hepatitis B virus (HBV) is considered one of the most paternally transmissible viruses. Therefore, education about its risk factors and transmission is vital in decreasing the prevalence of the disease burden in Sudan. The aim of the present study was to investigate the relative risk factors of HBV and its impact on the society. Materials And Methods: A facility-based, descriptive, cross-sectional study was conducted among those who were incidentally detected with HBV surface antigen (HbsAg) and their contact family members by ICT and enzyme-linked immunosorbent assay (ELISA) in Tropical Diseases Teaching Hospital, Omdurman locality, Khartoum state, Sudan. Results: The study recruited 112 participants, among whom 63 individuals incidentally attended for screening for HBV and this led to contact tracing of 49 individuals (contact relative group). Among 63 patients of the incidental group, there were 83.9% males and 16.1% females. In the contact tracing group consisting of 49 individuals, there were 83.3% males and 16.7% females (odds ratio [OR] = 1.375, 95% confidence interval [CI] = 0.14-13.6; P = 0.000). All the participants were screened for HBsAg. HBV was found to have a significant association with male gender (OR = 1.375, 95% CI = 0.14-13.6; P = 0.000), marital status (OR = 627.084, 95% CI = 48-8195; P = 0.000), working as police officers (OR = 524.2, 95% CI = 43.5-6314; P = 0.000), residing in Khartoum (OR = 520.173, 95% CI = 43-6290; P = 0.000), being illiterate (OR = 558.4, 95% CI = 47.7-6544.7; P = 0.000), vaccination status (OR = 625.4, 95% CI = 48.9-7996.3; P = 0.000), and with some concomitant diseases (OR = 559.193, 95% CI = 47.7-6561.5; P = 0.000). Conclusion: The HBV is still considered a very critical, highly infectious disease; therefore, primary care physicians have an important role in the investigation, prevention, and health education, in order to prevent the viral spread.

The COVID-19 pandemic and E-learning: challenges and opportunities from the perspective of students and instructors.

The spread of COVID-19 poses a threat to humanity, as this pandemic has forced many global activities to close, including educational activities. To reduce the spread of the virus, education institutions have been forced to switch to e-learning using available educational platforms, despite the challenges facing this sudden transformation. In order to further explore the potentials challenges facing learning activities, the focus of this study is on e-learning from students' and instructor's perspectives on using and implementing e-learning systems in a public university during the COVID-19 pandemic. The study targets the society that includes students and teaching staff in the Information Technology (IT) faculty at the University of Benghazi. The descriptive-analytical approach was applied and the results were analyzed by statistical methods. Two types of questionnaires were designed and distributed, i.e., the student questionnaire and the instructor questionnaire. Four dimensions have been highlighted to reach the expected results, i.e., the extent of using e-learning during the COVID-19 pandemic, advantages, disadvantages and obstacles of implementing E-learning in the IT faculty. By analyzing the results, we achieved encouraging results that throw light on some of the issues, challenges and advantages of using e-learning systems instead of traditional education in higher education in general and during emergency periods.

Severity of Illness in Persons Infected With the SARS-CoV-2 Delta Variant vs Beta Variant in Qatar.

Importance: The Delta variant is now the predominant circulating SARS-CoV-2 strain worldwide. Severity of illness in persons infected with the SARS-CoV-2 Delta variant compared with the Beta variant is not known. Objective: To directly compare clinical outcomes in persons infected with the SARS-CoV-2 Delta variant vs those infected with the Beta variant in Qatar. Design, Setting, and Participants: This retrospective cohort study used data from the national COVID-19 database in Qatar, which includes information on all individuals who were ever tested for SARS-CoV-2 using a reverse transcriptase-polymerase chain reaction test and all individuals who received any SARS-CoV-2 vaccine in Qatar. Among persons with confirmed SARS-CoV-2 infection between March 22 and July 7, 2021, those infected with the Delta variant were identified and were propensity score matched with control individuals infected with the Beta variant. The variants were ascertained by variant genotyping of the positive samples. Exposures: SARS-CoV-2 infection with the Delta or Beta variant. Main Outcomes and Measures: The main outcomes were admission to the hospital, admission to the intensive care unit, use of supplemental oxygen, use of high-flow oxygen, receipt of mechanical ventilation, or death among those infected with the Delta or Beta variant overall and stratified by vaccination status. Results: Among 1427 persons infected with the Delta variant (252 [55.9%] male; median age, 34 years [IQR, 17-43 years]) and 5353 persons infected with the Beta variant (233 [51.7%] male; median age, 34 years [IQR, 17-45 years]), 451 propensity score-matched pairs were identified. Persons infected with the Delta variant were more likely to be hospitalized (27.3% [95% CI, 23.2%-31.6%] vs 20.0% [95% CI, 16.4-24.0]; P = .01) or to have mild-moderate or severe-critical disease outcomes (27.9% [95% CI, 23.8%-32.3%] vs 20.2% [95% CI, 16.6%-24.2%]; P = .01) compared with persons infected with the Beta variant. Infection with the Delta variant was independently associated with higher odds of experiencing any adverse outcome (adjusted odds ratio [aOR], 2.53; 95% CI, 1.72-3.72). Compared with being unvaccinated, being vaccinated with a second dose more than 3 months before infection was associated with lower odds of any adverse outcome among persons infected with the Delta variant (aOR, 0.11; 95% CI, 0.04-0.26) and among those infected with the Beta variant (aOR, 0.22; 95% CI, 0.05-0.98). Protection was similar among those who received a second vaccine dose less than 3 months before infection, but having received only a single dose was not associated with a lower odds of any severe outcome among those infected with the Delta variant (aOR, 1.12; 95% CI, 0.41-3.06) or those infected with the Beta variant (aOR, 0.74; 95% CI, 0.20-2.72). Conclusions and Relevance: In this cohort study of persons with COVID-19 in Qatar, infection with the SARS-CoV-2 Delta variant was associated with more severe disease than was infection with the Beta variant. Being unvaccinated was associated with greater odds of severe-critical disease.

Redo Heart Double-Lung Transplant in a Previous Double-Lung Transplant Recipient With Pneumonectomy: A Case Report.

Placing a new donor lung into a postpneumonectomy pleural space has many potential surgical challenges. We report the technical challenges we faced in a case of a 42-year-old man who had initially undergone a double-lung transplant for idiopathic pulmonary arterial hypertension. Unfortunately, his left transplanted lung failed, which required a left pneumonectomy. Eight years later, his remaining right lung failed. He was evaluated and deemed suitable for retransplant. Our report presents the first successful redo heart double-lung transplant surgery preceded by pneumonectomy. There were significant technical intraoperative challenges; however, the procedure was performed successfully with an uneventful postoperative course and follow-up.

Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis.

BACKGROUND: Preoperative anemia is a common comorbidity that often necessitates allogeneic blood transfusion (ABT). As there is a risk associated with blood transfusions, preoperative intravenous iron (IV) has been proposed to increase the hemoglobin to reduce perioperative transfusion; however, randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive. Consequently, a meta-analysis that pools these studies may provide new and clinically useful information. METHODS/DESIGN: Databases of MEDLINE, EMBASE, EBM Reviews; Cochrane-controlled trial registry; Scopus; registries of health technology assessment and clinical trials; Web of Science; ProQuest Dissertations and Theses; Clinicaltrials.gov; and Conference Proceedings Citation Index-Science (CPCI-S) were searched. Also, we screened all the retrieved reference lists. SELECTION CRITERIA: Titles and abstracts were screened for relevance (i.e., relevant, irrelevant, or potentially relevant). Then, we screened full texts of those citations identified as potentially applicable. RESULTS: Our search found 3195 citations and ten RCTs (1039 participants) that met our inclusion criteria. Preoperative IV iron supplementation significantly decreases ABT by 16% (risk ratio (RR): 0.84, 95% confidence interval [CI]: 0.71, 0.99, p = 0.04). In addition, preoperatively, hemoglobin levels increased after receiving IV iron (mean difference [MD] between the study groups: 7.15 g/L, 95% CI: 2.26, 12.04 g/L, p = 0.004) and at follow-up > 4 weeks postoperatively (MD: 6.46 g/L, 95% CI: 3.10, 9.81, p = 0.0002). Iron injection was not associated with increased incidence of non-serious or serious adverse effects across groups (RR: 1.13, 95% CI: 0.78, 1.65, p = 0.52) and (RR: 0.96, 95% CI: 0.44, 2.10, p = 0.92) respectively. CONCLUSIONS: With moderate certainty, due to the high risk of bias in some studies in one or two domains, we found intravenous iron supplementation is associated with a significant decrease in the blood transfusions rate, and modest hemoglobin concentrations rise when injected pre-surgery compared with placebo or oral iron supplementation. However, further full-scale randomized controlled trials with robust methodology are required. In particular, the safety, quality of life, and cost-effectiveness of different intravenous iron preparations require further evaluation.

Risk Factors of Inpatients Mortality of Visceral Leishmaniasis, Khartoum State, Sudan.

BACKGROUND: Visceral leishmaniasis (VL) is one of the common infections in Sudan and can be associated with an increase in morbidity and mortality. The aim of this study was to assess the risk factors associated with mortality and morbidity with VL. MATERIALS AND METHODS: This is a cross-sectional hospital-based study that recruited 150 patients with VL from two centers in Khartoum. Secondary data were extracted from the patient records, and data were analyzed using SPSS version 24.0. RESULTS: The study included 2.5% of infants, 39.4% children, and 58% of adults. Male represents 77.3% of the cohort, and total mortality was 16%. Among the death reported 12.5% in infants, 16.7% were children, and 70.8% were in adults. Laboratory parameters significantly associated with mortality in univariate analysis were low white cell count, low platelets, high creatinine, and high liver enzymes. While risk factors such as infant, male, acquired infection from Eastern Sudan or White Nile, weight loss, morbid diseases, and concomitant bacterial infections were also associated with significant mortality in univariate analysis. Importantly, logistic regression analysis revealed significant association with infant (P = 0.02), concomitant bacterial infections (P = 0.003), comorbid disease (P = 0.001), low total blood cell count (P = 0.018), low platelets (P = 0.013), and high aspartate transaminase/alanine aminotransferase (P = 0.013). CONCLUSION: Health education and awareness are needed in terms of prevention and control, especially with high mortality seen in the infant. Treatment of underlying co-morbid diseases and bacterial infections are important to enhance survival. Patients with Leishmania are vulnerable; therefore, regular routine blood tests are an essential part of management to manage complications such as renal, hepatic failure, or severe anemia.

Predictors of hospital mortality after surgery for ischemic mitral regurgitation: the Toronto General Hospital experience.

BACKGROUND: The benefit of mitral valve repair (MVr) over replacement in patients with severe ischemic mitral regurgitation (IMR) is still controversial. We report our early postoperative outcomes of repair versus replacement. METHODS: Data were collected for patients undergoing first-time mitral valve surgery for severe IMR between 1990 and 2009 (n = 393). Patients who underwent combined procedures for papillary muscle rupture, post-infarction ventricular septal defect, endocarditis, or any previous cardiac surgery were excluded. Preoperative demographics, operative variables, and hospital outcomes were analyzed, and multivariable regression analysis was employed to identify independent predictors of hospital mortality. RESULTS: Valve repair was performed in 42% (n = 164) of patients and replacement in 58% (n = 229). Patients who underwent replacement were older and had a higher prevalence of unstable angina, New York Heart Association Class IV symptoms, preoperative cardiogenic shock, preoperative myocardial infarction, peripheral vascular disease, renal failure, and urgent or emergency surgery (all p < .05). Unadjusted hospital mortality was higher in patients undergoing valve replacement (13% vs. 5%; p = .01). Valve repair was associated with a lower prevalence of postoperative low cardiac output syndrome. Multivariable analysis revealed that age, urgency of operation, and preoperative left ventricular (LV) function were independent predictors of hospital mortality. Importantly, MVr versus replacement was not an independent predictor of hospital mortality. CONCLUSION: Our data did not suggest an early survival benefit to MVr over replacement for IMR. However, age, LV dysfunction, and the need for urgent surgery were independently associated with hospital mortality.

The co-infection of Buruli ulcer and cutaneous leishmaniasis in Sudanese patient: An association by choice or by chance?

Buruli ulcer and cutaneous leishmaniasis both have the similar cutaneous clinical presentation. Therefore, relying on clinical diagnosis can be challenging. We present a case of 45 years old woman diagnosed with cutaneous leishmaniasis, confirmed by skin biopsy. She received different modalities of anti-leishmanial treatment (fluconazole 450mg daily for 4 weeks, sodium stibogluconate (SSG) followed by thermal therapy, SSG/IV 20mg/kg for 30 days combined with paromomycin 15mg/kg IM for 17 days). These treatments were associated with partial improvement of the ulcer and failure of healing. A second biopsy demonstrated the presence of Mycobacterium ulcerans and hence the diagnosis of Buruli ulcer as a cause of the delayed healing of the ulcer. M. ulcerans releases a toxin known as mycolactone, which decreases immune system function and results in tissue death. M. ulcerans, is regarded as the third most prevalent Mycobacterium after M. tuberculosis and M. leprae. Treatment with streptomycin intramuscular injections 1g daily and rifampicin 600mg daily for 8 weeks was associated with complete healing of the ulcer. To our knowledge, this is the first report that describes the co-infection of Buruli ulcer and cutaneous leishmaniasis in Sudan.

Acceleration-induced acute type A aortic dissection in the sky: 10-year follow-up.

Acute aortic dissection is uncommon, but can turn into a fatal disease if not managed quickly. A 49-year-old male fighter pilot presented to us after sudden excruciating chest pain during a flight at the moment of an acute spiral down action. A contrast-enhanced computed tomography angiography showed Stanford type A aortic dissection that required surgical ascending aorta and hemiarch replacement with uneventful postoperative recovery and 10-year follow-up. Here, we presented the first report of a previously healthy pilot developed acute aortic dissection in the sky. Physicians should be aware of such a case that might happen more common with rapid aviation progress.

What is a clinically meaningful survival benefit in refractory metastatic colorectal cancer?

Assessment of the clinical benefit of cancer treatments can be highly subjective, influenced by both perspective and context. Such assessments are required in regulatory and policy decision-making, but consistency between jurisdictions is often lacking. Clear and consistent standards for determining when a treatment offers a meaningful benefit, relative to the current standard of care, can help to address issues of equity and transparency in health technology assessment. For metastatic colorectal cancer (mcrc), no standardized Canadian definition of clinically meaningful benefit has yet been proposed. Colorectal Cancer Canada therefore convened a group of medical oncologists expert in colorectal cancer to review the literature about clinical significance. The resulting consensus is intended to apply to any therapeutic agent being considered in the setting of chemotherapy-refractory mcrc. It was agreed that overall survival is the appropriate measure of clinical efficacy in chemorefractory mcrc. As quantitative targets for efficacy, an improvement of 2 months or more in median overall survival or a hazard ratio for survival of 0.75 or lower (or both) are proposed as the threshold for clinically meaningful benefit. That threshold could be influenced by a treatment's effect on quality of life. Treatment toxicity is also relevant to the assessment of clinical benefit in this setting, specifically when significant differences in treatment tolerability are evident.

Association between Helicobacter pylori gastritis and dental diseases: A cross-sectional, hospital-based study in Eastern Saudi Arabia.

BACKGROUND: There is inconsistent evidence about the association between Helicobacter pylori (H. pylori) and dental diseases with possible effect of environmental factors. The aims of the study were to assess (1) the association between gastric and oral H. pylori colonization and (2) the association between oral colonization of H. pylori and dental diseases. METHODS: A cross-sectional study was conducted in King Fahad University hospital in Khobar, Eastern Saudi Arabia in 2017. Patients admitted to the Endoscopy Unit were recruited and clinically examined for plaque, decayed teeth (D), filled teeth (F), missing teeth (M), periodontal pocket depth (PPD), attachment loss (AL), and gingival bleeding in addition to assessing their age, gender, education, tooth brushing, flossing, and tobacco use with a questionnaire. Pooled dental plaque samples were collected and analyzed using nested polymerase chain reaction PCR to detect oral H. pylori. Gastroscopy was used to extract biopsies to assess gastritis and the presence of gastric H. pylori using Giemsa stain. Regression analysis was used to assess differences between patients with and without gastritis, oral H. pylori and gastric H. pylori in the percentage of sites with gingival bleeding, PPD, CAL, D, M, and F with adjustment for confounders. RESULTS: One hundred twenty patients were included. Most of them brushed daily (82.6%) and had university education (45.7%). Of these, 34.2% had gastric H. pylori and 5% had oral H. pylori. No significant association was observed between the percentage of sites with gingival bleeding, mean PPD, AL, F, and either gastritis, the presence of oral or gastric H. pylori. Patients with gastritis had significantly higher number of D and M than patients without gastritis (P = 0.03). CONCLUSIONS: In this study, the presence of gastric and oral H. pylori in patients with good oral hygiene and moderate socioeconomic status is not significantly associated with periodontal diseases. Patients with gastritis tend to have a higher number of decayed and missing teeth.