Surgical versus medical management of patients with primary hyperaldosteronism and indeterminate adrenal vein sampling: A 10-year experience of the Cleveland Clinic.

In patients with primary hyperaldosteronism (PA), adrenal vein sampling (AVS) can identify patients suitable for unilateral adrenalectomy. However, in AVS with an indeterminate aldosterone-to-cortisol lateralization (ACL) ratio of 3.0-4.0, clinical guidance is unclear. The authors screened all patients undergoing AVS at the Cleveland Clinic from October 2010 to January 2021 and identified 18 patients with indeterminate ACL results. Ten underwent adrenalectomy and eight continued medical management. The surgical group was younger (58.5 vs. 68 years, p = .17), and more likely to have a unilateral imaging adrenal abnormality (90% vs. 38%, p = .043) and a lower contralateral suppression index (0.63 vs. 1.1, p = .14). Post-treatment, the surgical group had a significant reduction in diastolic blood pressure (-5.5 mmHg, p = .043) and aldosterone (4.40 vs. 35.80 ng/mL, p = .035) and required fewer anti-hypertensive medications (2 vs. 3, p = .015). These findings may support the benefit of adrenalectomy in a select group of patients with indeterminate ACL.

Diversity, Equity, and Inclusion in Endocrinology: A Survey and Vision for the Future.

OBJECTIVE: The Diversity, Equity, and Inclusion (DEI) committee of the American Association of Clinical Endocrinology (AACE) performed a survey whose aim was to explore characteristics of our membership, members' definitions, perceptions, and experiences with DEI in the endocrinology community, and future directions for the organization in this arena. METHODS: A cross-sectional study was conducted consisting of an anonymous, self-administered online questionnaire that captured members' demographic and professional data and assessed their responses to questions about DEI in the endocrinology community. The questionnaire was sent to all AACE members (n=4,079) during May and June 2021. A descriptive analysis was performed, and variables were cross-tabulated to find significant associations. RESULTS: Four hundred thirty members completed the survey (response rate, 10.5%). Respondents considered a wide array of demographic variables in their definition of diversity, and most perceived the endocrine community to be diverse. Almost half of respondents reported discrimination in their workplace, with women being more likely to report it. Respondents prioritized addressing health care inequities, providing a mentorship program, and providing educational material and resources about DEI as the highest priorities for the organization in this space. CONCLUSION: AACE DEI survey data revealed a diverse AACE membership. Member perspectives will aid in creating a roadmap to broaden DEI among the greater endocrine community.

Attitudes of Physicians in Jordan Towards Non-Disclosure of Health Information.

OBJECTIVES: This report aims to investigate the attitudes of physicians in Jordan towards non-disclosure of health information among physicians, with a focus on those who are 'always truthful' and those who are not. METHODS: The report is based on the second subset of data from a cross-sectional study-conducted between January and August 2016-of the truth disclosure practices among and attitudes of physicians in Jordan. The sample consisted of 240 physicians selected from four major hospitals by stratified random sampling and invited to complete a self-administered questionnaire regarding truth disclosure attitudes. The attitudes of physicians who were 'always truthful' were compared with those who were not. RESULTS: A total of 164 physicians (response rate: 68%) completed the questionnaire. Of these, 17 (10%) were 'always truthful', while the remaining 144 (90%) were not. Physicians who were 'always truthful' were more likely to indicate that non-disclosure is 'unethical' (77% versus 39%; P = 0.009). Moreover, physicians who were 'always truthful' were more likely to disagree that non-disclosure is beneficial for the physical and psychological health of patients (82% versus 55%; P = 0.03). Most of the surveyed physicians agreed that all patients have the right to know their diagnosis, most patients prefer to know their diagnosis and the introduction of legislation to enforce disclosure would positively affect medical practice in Jordan. CONCLUSION: The differential attitudes of physicians who were 'always truthful' and those who were 'not always truthful' suggests a rationale behind independent non-disclosure; namely, that non-disclosure is ethically justifiable and beneficial for the physical and psychological health of patients.

Tobacco Research in the Eastern Mediterranean Region: A Scoping Review of Published Studies from Seven Countries.

While surveillance on a global scale has been showing a decline in tobacco smoking in the past decade, rates in the Eastern Mediterranean Region (EMR) remained stable with some countries showing rising trends. This study aimed to analyze the landscape of tobacco research in the EMR, present data on publication trends, and identify research gaps and opportunities to guide future tobacco research in the region. We conducted a scoping review of tobacco research in seven countries from January 2000 to December 2013. Three hundred and forty eight studies were identified, the majority of which were published in international journals and in English language. There was an increase in publications over time, with a significant positive linear trend (p = 0.03). Descriptive cross-sectional and case-control studies were the most common study designs (67.0%), and only 8% were longitudinal studies. Papers that reported, in part or solely, on waterpipe tobacco smoking (WTS) constituted 25.6% of the total publication pool. Tobacco consumption was treated as an exposure variable in half of the papers and mostly in relation to cancer and cardiovascular diseases, as an outcome measure in 37.7%, and as a confounding variable in 14.7% of the papers. Studies that examined associations of tobacco with other behaviors (5.3%) were lacking. The scarcity of high-evidence tobacco research in the EMR, together with the relatively deficient data on WTS and associations with other factors warrant the need for discussions on research priority setting and guidance on funding allocations in the region.

Internal Medicine Residents and the Practice of Defensive Medicine: A Pilot Study Across Three Internal Medicine Residency Programs.

Background Defensive medicine is becoming increasingly prevalent in the United States and is estimated to cost billions of dollars in excess healthcare spending. There is evidence that the practice of defensive medicine starts early in the medical career. Defensive medicine has been investigated among residents in high medico-legal risk specialties, but there is a paucity of information on its prevalence among internal medicine residents. Objective  To examine the prevalence and patterns of defensive medical practices among internal medicine residents. Methods We conducted an online survey among the residents of three internal medicine residency programs in the 2018-2019 academic cycle. We invited all internal medicine residents within the selected programs to participate through email and asked them to complete an electronic survey assessing defensive medical practices. Results A total of 49 out of 143 residents participated in the study (response rate: 34.3%); 55% (n = 27) of the residents who participated considered the risk of being sued during residency to be low, compared to 40.8% (n = 20) who considered it to be moderate and 4.1% (n = 2) who considered it to be high. Defensive medical practices were found to be widely prevalent (40.0-91.3%) among internal medicine residents across all three clinical training stages. Assurance defensive practices were more common than avoidance practices. Conclusion Defensive medical practices, especially of the assurance type, were widely prevalent among our sample of internal medicine residents.

Thyroid Storm-induced Severe Dilated Cardiomyopathy and Ventricular Tachycardia.

Thyroid storm is an extreme form of hyperthyroidism associated with a high mortality rate. Heart failure is considered the leading cause of mortality in patients with thyroid storm, though the underlying cardiac pathology is unclear. Approximately 6% of patients with thyroid storm have heart failure symptoms as the initial presenting complaint. Roughly, one-third of these patients develop dilated cardiomyopathy (DCM). In this report, we present a case of cardiogenic pulmonary edema and sustained ventricular tachycardia in a patient with hyperthyroidism presenting with thyroid storm.

Life-threatening hemoptysis following mitral valvuloplasty for rheumatic mitral stenosis.

BACKGROUND: Massive hemoptysis is a rare complication of rheumatic mitral valve stenosis. Its recurrence following successful initial treatment of the stenosis has not, to our knowledge, been described. CASE REPORT: We describe a 58-year-old African American woman with a history of balloon valvuloplasty for the treatment of severe rheumatic mitral valve stenosis who presented to our institution with massive life-threatening hemoptysis due to recurrent mitral valve stenosis. Repeat balloon valvuloplasty was complicated postoperatively by severe mitral regurgitation and the patient expired from refractory cardiopulmonary collapse not amenable to further intervention. CONCLUSION: Life-threatening hemoptysis is a medical emergency requiring rapid source identification and treatment of the underlying etiology. A high degree of suspicion should be maintained for recurrence of mitral valve stenosis in patients presenting with life-threatening hemoptysis and risk factors of rheumatic heart disease, regardless of previous surgical management or unilateral chest x-ray signs.

Truth Disclosure Practices of Physicians in Jordan.

Disclosure of health information is a sensitive matter, particularly in the context of serious illness. In conservative societies-those which predominate in the developing world-direct truth disclosure undoubtedly presents an ethical conundrum to the modern physician. The aim of this study is to explore the truth disclosure practices of physicians in Jordan, a developing country. In this descriptive, cross-sectional study, 240 physicians were initially selected by stratified random sampling. The sample was drawn from four major hospitals in Amman, Jordan. A closed-ended questionnaire was distributed and completed by self-report. A total of 164 physicians completed the questionnaire. Thirty-seven physicians (23 per cent) usually withheld the diagnosis of "serious illness" from patients, while 127 physicians (77 per cent) usually divulged the information directly. Among the latter, 108 physicians (86 per cent) made exceptions to their disclosure policy. Specialists were more likely to withhold health information (p = 0.04998). Non-disclosure was primarily motivated by request from the patient's family (seventy-one participants, 54 per cent). In twenty cases (15 per cent), non-disclosure was undertaken independently. In conclusion, most respondents opt to disclose the truth; however, the vast majority of these respondents make exceptions. Instances of non-disclosure are primarily motivated by sociocultural constructs.

Factors Associated with Depression and Anxiety Symptoms Among Medical Students in Bahrain.

OBJECTIVES: Medical training can be a stressful experience and may negatively impact mental health for some students. The purpose of this study was to identify the prevalence of depressive and anxiety symptoms among medical students in one international medical university in the Kingdom of Bahrain and to determine associations between these symptoms, the students' characteristics, and their satisfaction with life. METHODS: This is a cross sectional study using a self-administered questionnaire, distributed to 350 enrolled medical students. We used Beck's Depression Inventory (BDI-II) and Beck's Anxiety Inventory (BAI) instruments to assess depressive and anxiety symptoms. The Satisfaction With Life Scale (SWLS) was used to measure global cognitive judgments of one's life satisfaction. Sociodemographic details including social background and academic information were also documented. RESULTS: Forty percent (n = 124) of the participants had depressive symptoms, of which 18.9% (n = 58) met the criteria for mild, 13% (n = 40) for moderate, and 8.5% (n = 26) for severe depressive symptoms. Depressive symptoms were associated with Arab ethnicity (χ 2 = 5.66, p = .017), female gender (χ 2 = 3.97, p = .046), relationship with peers (p < .001), year of study (χ 2 = 13.68, p = .008), and academic performance (p < 0.001). Anxiety symptoms were present in 51% (n = 158) of students. Anxiety symptoms were associated with female gender (χ 2 = 11.35, p < 0.001), year of study (χ 2 = 10.28, p = .036), and academic performance (χ 2 = 14.97, p = .002). CONCLUSION: The prevalence of depressive and anxiety symptoms among medical students was high. Medical universities in the Middle East may need to allocate more resources into monitoring and early detection of medical student distress. Medical education providers are encouraged to provide adequate pastoral and psychological support for medical students, including culturally appropriate self-care programs within the curriculum.

Cancer Research in the Arab World: A review of publications from seven countries between 2000-2013.

This review aimed to examine trends in cancer research in the Arab world and identify existing research gaps. A search of the MEDLINE® database (National Library of Medicine, Bethesda, Maryland, USA) was undertaken for all cancer-related publications published between January 2000 and December 2013 from seven countries, including Bahrain, Kuwait, Iraq, Lebanon, Morocco, Palestine and Sudan. A total of 1,773 articles were identified, with a significant increase in yearly publications over time (P <0.005). Only 30.6% of the publications included subjects over the age of 50 years old. There was a dearth of cross-sectional/correlational studies (8.8%), randomised controlled trials (2.4%) and systematic reviews/meta-analyses (1.3%). Research exploring cancer associations mainly considered social and structural determinants of health (27.1%), followed by behavioural risk factors (14.1%), particularly tobacco use. Overall, more cancer research is needed in the Arab world, particularly analytical studies with high-quality evidence and those focusing on older age groups and associations with physical activity and diet.

Tobacco Smoke Exposure Reduces Paraoxonase Activity in a Murine Model.

AIM: To demonstrate a direct inhibitory effect of cigarette smoke exposure on paraoxonase 1 activity in a murine in vivo model. METHODS: At 8 weeks old, we randomized 10 C57/bl6 mice to an environment consisting of either filtered air or cigarette smoke for 6 months. Smoke exposure (7 hours per day, 5 days per week) was standardized using a model TE-10 smoking machine and adjusted to maintain constant sidestream and mainstream smoke. After 6 months of exposure, we assessed differences in lung air space, cholesterol, lipid, and lipoprotein profiles, as well as paraoxonase activity in mice exposed to cigarette smoke extract compared to unexposed control mice. RESULTS: Cigarette smoke exposure by the protocol used was sufficient to result in pathologic changes in lung architecture consistent with emphysema. Specifically, we observed that mice exposed to cigarette smoke had a significantly higher mean linear chord length compared to animals that were exposed to filtered air (p<0.02). Despite this exposure, no differences in total HDL-cholesterol levels or HDL-cholesterol sub-fractions (i.e. HDL2 and HDL3 fractions) were noted between smoke-exposed and unexposed animals (p=1.00, 0.6, and 0.4, respectively). Notably, mean HDL-cholesterol levels were identical between groups (92.8 vs 92.8 mg/dL, p=1.0). Paraoxonase activity, however, was markedly reduced in mice exposed to cigarette smoke compared to those who were not exposed (102, SD=9.6 vs 144, SD=4.1 units of activity, respectively, p=0.002). CONCLUSION: In this murine model, tobacco smoke exposure directly inhibits paraoxonase activity independently of HDL-cholesterol levels rather than indirectly via reduction in HDL-cholesterol levels.

The lifestyle habits and wellbeing of physicians in Bahrain: a cross-sectional study.

BACKGROUND: Lifestyle habits of physicians are of paramount importance both because they influence the physician's own health and because these habits have been shown to affect patients' care. There is limited information on physician health and lifestyle habits in Bahrain. METHODS: In a cross-sectional study design, an anonymous self-administered questionnaire that assesses wellbeing and lifestyle habits was distributed to a random sample of 175 out of 320 primary health care physicians in Bahrain. Descriptive analyses were performed, and the variables were cross-tabulated using SPSS version 20.0. RESULTS: 152 physicians agreed to participate in the study. Respondents were 67.1% female with a mean age of 45 (SD = 10). The majority were of Bahraini nationality. The most prevalent reported health conditions were hyperlipidaemia (25.5%), hypertension (20.3%), and diabetes (11.0%). Only 29.6% of physicians reported performing ≥ 30 min of exercise in a usual week. Of physicians exercising ≥ 30 min weekly, only 13% exercised ≥ 5 days weekly. 98.0% report never drinking, 1.3% report previously drinking, and 0.7% report drinking less than once weekly. The average body mass index (BMI) was 27.8 (SD = 5), with 39% of physicians being overweight and 33% obese. BMI was directly associated with sleep time (P0.027, r(2) = 0.034), age (P < 0.01, r(2) = 0.179), male gender (P = 0.031, r(2) = 0.054), and a known diagnosis of hypertension (P = 0.007, r(2) = 0.079) or hyperlipidaemia (P = 0.008, r(2) = 0.088). CONCLUSIONS: There is a clear pattern of unfavourable lifestyle habits and obesity among primary health care physicians in Bahrain. We encourage institutions and public health sectors to be more proactive in assisting physicians to attain healthier lifestyles.

Prevalence of tobacco smoking among health-care physicians in Bahrain.

BACKGROUND: There is a clear shift in smoking habits among the Middle Eastern population with a recent and alarming increase in the prevalence of waterpipe (shisha) smoking. This phenomenon has not yet been studied sufficiently across the physician population. Therefore, we set out to establish the smoking status of primary healthcare physicians in the kingdom of Bahrain. METHODS: A self-administered questionnaire was distributed to a random sample of 175 out of the total 320 primary care physicians. Descriptive analysis was performed on all data and associations between variables were tested using Fishers Exact t test with statistical significance set as P-value < 0.05. RESULTS: One hundred and fifty two physicians agreed to participate in the study. Sixty seven percent of physicians were females and the mean (SD) age was 45 (10) years. The majority of the physicians were married (93%) and of Bahraini nationality (76%). Ever-smokers were 11% of the population while current smokers corresponded to 8.6%. Waterpipe was the most common method of tobacco smoking followed by cigarettes. Among male physicians, the prevalence of current 'waterpipe only' smokers was 12%, followed by 4% and 2% corresponding to 'cigarette only' smokers and both, respectively. There were only three female smokers in the population, two 'waterpipe only' smokers and one cigar smoker. Of those who smoked waterpipe (n = 9; 6%), 33% smoked daily, 44% smoked weekly and 22% smoked at least once a month. Current smoking status was associated with male gender (P < 0.001) and showed a male to female smoking ratio of (10:1). CONCLUSION: Waterpipe smoking rates exceeded cigarette smoking among the population of physicians in Bahrain. Prevalence of smoking remains unacceptably high among male physicians. Assessment of physicians' knowledge of the harmful effects of waterpipe tobacco smoking is warranted to plan future interventions.

Beliefs and perceptions toward quitting waterpipe smoking among cafe waterpipe tobacco smokers in Bahrain.

INTRODUCTION: There is a rising prevalence of waterpipe smoking worldwide, but still a paucity of information on perceptions toward quitting waterpipe use. We set out to establish the beliefs and perceptions of café waterpipe smokers toward quitting waterpipe smoking in the Kingdom of Bahrain. METHODS: A cross-sectional study. A random sample of 20 of 91 cafés serving waterpipe tobacco in Bahrain was taken. A questionnaire was administered in each café to 20 participants aged 18 and above. RESULTS: Three hundred eighty participants completed questionnaires from waterpipe smokers. Eighty-four percent of participants were Bahraini and 71% had a university degree. Mean age was 28.9 years. Average age of waterpipe smoking initiation was 20.3 years. The majority of waterpipe users chose flavored tobacco. Sixty-one percent smoked waterpipe tobacco daily with a mean smoking time of 2.6hr/day. Seventy-two percent considered waterpipe tobacco as harmful as or more harmful than cigarettes, but 67% considered cigarettes as more addictive. Eighty-two percent stated that they could quit waterpipe at any time, but only 40% were interested in quitting. Interest in quitting smoking was related to 4 variables: a physician mentioning the need to quit smoking, being non-Bahraini, having a family with a hostile attitude toward waterpipe smoking, and not considering oneself "hooked" on waterpipe tobacco. CONCLUSIONS: Waterpipe smokers in Bahrain cafés are frequent and high users. Health professionals must consider waterpipe smoking in all consultations and health promotion messages. A partnership between health professionals and disapproving members of families may be an effective strategy in encouraging waterpipe smokers to quit.