Clinical presentation and management of methanol poisoning outbreaks in Riyadh, Saudi Arabia: a retrospective analysis.

BACKGROUND: Acute methanol intoxication, whether unintentional or deliberate, necessitates prompt intervention to prevent severe morbidity and mortality. Homemade alcoholic beverages are a frequent source of such poisoning. This retrospective analysis examined two outbreaks of methanol intoxication in Saudi Arabia. It investigated the clinical presentation, implemented management strategies, and any lasting complications (sequelae) associated with these cases. The aim was to assess the potential impact of different treatment modalities and the timeliness of their initiation on patient outcomes. METHODS: This was a retrospective case series of methanol poisoning cases which presented to the adult emergency department (ED) at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. There were two separate outbreaks in the city, the first one was from September 1 to September 10, 2020 and the second one was from May 14 to May 20, 2021. Electronic charts were reviewed, and data were extracted to previously prepared data extraction sheets. RESULT: From the 22 patients who arrived in the ED alive, the most common complaints were nausea or vomiting followed by altered level of consciousness. About 9% from the patient were hypotensive, 36% were tachycardic, 41% were tachypneic and 4% were having SpO2 < 94%. Brain CT was abnormal in 6 patients. Vision impairment was the most common sequalae of methanol poisoning (7 out of 12 patients who were assessed by ophthalmologist, 58%). When the patients were divided based on severity (mild, moderate, severe), nausea or vomiting and loss of consciousness were the most common complaints among the moderate group while loss of consciousness predominated in the severe group. Two patients presented with low blood pressure and were in the sever group. The severe group had a mean Glasgow Coma Scale (GCS) of 8. Most of the patients in the severity groups underwent the same management apart from those who died or deposited. Eight patients in the severe group had to be intubated. CONCLUSION: This study demonstrates the multifaceted clinical presentation of methanol poisoning, culminating in a 17.4% mortality rate. Notably, our findings emphasize the critical role of prompt diagnosis and swift initiation of combined fomepizole therapy and hemodialysis in mitigating mortality and minimizing the potential for chronic visual sequelae associated with methanol poisoning.

kdr mutations and deltamethrin resistance in house flies in Abu Dhabi, UAE.

BACKGROUND: The house fly, Musca domestica, is a significant carrier of diseases that can impact public health. Repeated use of pyrethroid insecticides may act as a selection pressure for mutations and amino acid substitutions in the house fly voltage-sensitive sodium channel (VSSC), which ultimately confers resistance. The objectives of this study were to determine the presence of knockdown resistance (kdr) mutations using molecular tools and to set up a CDC bottle bioassay specific for house flies in the United Arab Emirates (UAE) to screen for deltamethrin resistance. METHODS: Adult flies were collected from 19 locations in Abu Dhabi, UAE, and DNA was extracted, followed by PCR amplification of specific alleles (PASA) and conventional PCR using several primers to amplify regions of the VSSC gene. Sanger sequencing was performed on PCR products. We also designed primers that detect four kdr mutations using complementary DNA (cDNA) in reverse transcriptase (RT)-PCR followed by Sanger sequencing. Additionally, a CDC bottle bioassay was set up for detecting deltamethrin resistance in adult house flies. RESULTS: In PASA, the primers successfully amplified the target bands (480, 280 and 200 bp). The kdr allele was found in flies collected from 18 of the 19 locations, at the highest and lowest prevalence of 46.9% and 9.4%, respectively. Resistant homozygous (RR) insects constituted 5.0% of the tested populations, and heterozygous (RS) insects accounted for 36.5%. The RR genotype was prevalent in house flies collected at 10 of 19 sampling locations. House fly populations were mostly in Hardy-Weinberg equilibrium, except in three locations. In addition to verifying the presence of the previously identified kdr mutation L1014F, in this study we detected two kdr mutations, L1014H and T929I, that have not previously been reported in the UAE. Also, for the first time in the UAE, a CDC bottle bioassay for deltamethrin resistance was used, which found that 60 min and 4.5 µg/ml were the diagnostic time and dose, respectively. Using this assay, we detected deltamethrin resistance in house flies from two of 16 locations, with a resistance level of 12.5%. CONCLUSIONS: Using DNA sequencing, we confirmed the presence of a known kdr mutation and uncovered two new kdr mutations in house flies from Abu Dhabi. Additionally, we detected deltamethrin resistance in these flies using a CDC bottle bioassay. Further research is recommended to comprehensively identify more kdr mutations in UAE house fly populations and assess their impacts on control strategies.

Virome diversity of Hyalomma dromedarii ticks collected from camels in the United Arab Emirates.

Background and Aim: Viruses are important components of the microbiome of ticks. Ticks are capable of transmitting several serious viral diseases to humans and animals. Hitherto, the composition of viral communities in Hyalomma dromedarii ticks associated with camels in the United Arab Emirates (UAE) remains unexplored. This study aimed to characterize the RNA virome diversity in male and female H. dromedarii ticks collected from camels in Al Ain, UAE. Materials and Methods: We collected ticks, extracted, and sequenced RNA, using Illumina (NovaSeq 6000) and Oxford Nanopore (MinION). Results: From the total generated sequencing reads, 180,559 (~0.35%) and 197,801 (~0.34%) reads were identified as virus-related reads in male and female tick samples, respectively. Taxonomic assignment of the viral sequencing reads was accomplished based on bioinformatic analyses. Further, viral reads were classified into 39 viral families. Poxiviridae, Phycodnaviridae, Phenuiviridae, Mimiviridae, and Polydnaviridae were the most abundant families in the tick viromes. Notably, we assembled the genomes of three RNA viruses, which were placed by phylogenetic analyses in clades that included the Bole tick virus. Conclusion: Overall, this study attempts to elucidate the RNA virome of ticks associated with camels in the UAE and the results obtained from this study improve the knowledge of the diversity of viruses in H. dromedarii ticks.

Can't find the antidote: A root cause analysis.

Background: In a series of cases that came to be recognized as a national methanol outbreak, an incident of delay in allocation and treatment with the antidote fomepizole is described with aim of sharing a learning experience. Method: A team of 16 members was formed to conduct a Root Cause Analysis (RCA), which included multiple individual interviews with the stakeholders and inspection visits to the area. Results: Root causes: The restocking process was unclear and inconsistent and specifically lacked a restocking policy for antidotes, inappropriate labeling and area design, and a sound-alike between fomepizole and omeprazole. Contributing factors included: unsuitable restocking practice and lack of training in using the pharmaceutical electronic inventory system. Corrective actions were recommended and implemented. Conclusion: Management of antidotes in large healthcare systems requires a team effort to ensure appropriate and timely availability in emergency poisoning cases. This RCA identified important areas for improvement that could be insightful to other institutions in preventing similar vulnerabilities and is unique in describing the details of system improvements that can have a large impact on patient safety.

Assessing Temporal Changes in Microbial Communities in Hyalomma dromedarii Collected From Camels in the UAE Using High-Throughput Sequencing.

Ticks (Acari) are ectoparasites of animals that harbor communities of microbes of importance to animal and human health. Microbial communities associated with ticks exhibit temporal patterns of variation in their composition, with different genera dominating at different times of the year. In this study, molecular tools were used to assess the composition of the microbial communities associated with Hyalomma dromdarii. Adult ticks were collected every month for 1 year from 25 camels in the UAE. A total of 12 DNA pools were prepared (one pool for each month). We monitored the microbiota of ticks using high-throughput sequencing of the V3-V4 region of the bacterial 16S rRNA gene. A total of 614 operational taxonomic units were produced through de novo clustering and belonged to 17 phyla, 30 classes, 46 orders, 118 families, and 222 genera. Fifteen bacterial families were found to be the most abundant. The dominant bacterial communities associated with H. dromedarii belonged to the genera Staphylococcus, Bacillus, Francisella, and Corynebacterium, which were reported with high relative abundance from all months. No significant correlation occurred between the abundance of microbial families or genera in H. dromedarii ticks and the ambient temperature. Our findings revealed, for the first time in the UAE, temporal fluctuations of microbial communities in H. dromedarii ticks and provided key insights on the interaction between different microbial groups. Moreover, our results contribute to the current understanding of disease development and allow more investigations for potentially pathogenic microbiota.

Microbial composition in Hyalomma anatolicum collected from livestock in the United Arab Emirates using next-generation sequencing.

BACKGROUND: Hyalomma anatolicum is a widely distributed tick species that acts as a vector transmitting tick-borne pathogens (TBPs) in livestock. Such pathogens affect the health of livestock and consequently reduce their productivity. Knowledge about the microbial communities (pathogens and endosymbionts) of ticks in the United Arab Emirates (UAE) is scarce. Therefore, the aim of the present study was to quantify microbial diversity in H. anatolicum using next-generation sequencing (NGS) technology. METHODS: Hyalomma anatolicum ticks were collected from livestock in the emirates of Abu Dhabi, Dubai and Sharjah in the UAE during 2019. DNA was extracted from 175 male ticks sampled from livestock (n = 78) and subjected to NGS. The 16S rRNA gene was analyzed using the Illumina MiSeq platform to determine the bacterial communities. Principal coordinates analysis (PCA) was performed to identify patterns of diversity in the bacterial communities. RESULTS: Twenty-six bacterial families with high relative abundance were identified, of which the most common were Staphylococcaceae, Francisellaceae, Corynebacteriaceae, Enterobacteriaceae, Moraxellaceae, Bacillaceae, Halomonadaceae, Xanthomonadaceae, Pseudomonadaceae, Enterococcaceae, Actinomycetaceae and Streptococcaceae. The diversity of the microbial communities in terms of richness and evenness was different at the three study locations, with the PCA showing clear clusters separating the microbial communities in ticks collected at Abu Dhabi, Dubai, and Sharjah. The presence of bacterial families harboring pathogenic genera showed that H. anatolicum could pose a potential threat to livestock and food security in the UAE. CONCLUSIONS: The study is the first to document important data on the microbial communities associated with H. anatolicum in the UAE. This knowledge will facilitate a better understanding of the distribution pattern of microbes in livestock ticks in the UAE and, ultimately, will aid in deciphering the relationships between microbes and in the exploration of potential factors towards developing effective management strategies.

Prevalence, Distribution, and Molecular Record of Four Hard Ticks from Livestock in the United Arab Emirates.

Ticks are important arthropod vectors that serve as reservoirs of pathogens. Rapid urbanization and changes in animal breeding practices could be causing a rise in tick burden on animals. Studies on tick distribution on livestock and tick molecular diversity from the United Arab Emirates (UAE) are limited. The aim of this study was to (i) provide molecular and morphological identification of tick species, (ii) compare tick infestation between different hosts, (iii) compare tick infestation in relation to the sex of the host, and (iv) assess the prevalence of tick species on hosts. A total of 5950 ticks were collected from camels (4803 ticks), cows (651 ticks), goats (219 ticks), and sheep (277 ticks). Ticks were identified based on morphological characters at the species level using taxonomic keys. In addition, Polymerase Chain Reaction (PCR) amplification of the cytochrome oxidase subunit 1 (cox1) and 16S rRNA mitochondrial genes was used to identify ticks. Four species were confirmed based on molecular and morphological characterization, namely, Hyalomma dromedarii, Hyalomma anatolicum, Rhipicephalus sanguineus, and Amblyomma lepidum. Hyalomma dromedarii (94.3%) was the most abundant species, followed by H. anatolicum (32.8%). Camels were heavily infested (94%) with ticks as compared to cows (38%), sheep (37%), and goats (14%). Widespread occurrence of these four tick species in the UAE poses a risk of spreading tick-borne pathogens wherever the conditions of infection prevail.

Spontaneous Coronary Artery Dissection with Sudden Cardiac Arrest in a Female Patient During Her Postpartum Period: A Case Report and Review.

BACKGROUND Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction, and the literature is undecided on the etiology, predisposing factors, and susceptible populations involved. SCAD is a disease that is under-recognized, underdiagnosed, and mainly affects young women of reproductive age. It has the highest incidence in the third trimester and postpartum period. CASE REPORT We present a case of a 29-year-old woman who was brought by family members to our Emergency Department (ED) in Riyadh, Saudi Arabia with sudden cardiac arrest due to SCAD in the right coronary artery 13 days after normal spontaneous vaginal delivery. The patient was brought in with no cardiopulmonary resuscitation for 20 min. She was resuscitated successfully in the ED. Her initial rhythm was ventricular fibrillation (VF). Point-of-care ultrasound (PoCUS) was performed during pulse checks, which revealed no signs of right ventricular strain nor signs of deep vein thrombosis (DVT). After that, she underwent primary percutaneous coronary intervention, which confirmed the diagnosis of right coronary artery dissection. The patient was successfully managed and discharged from the hospital after 18 days. She was independent and in good health after 4 months of follow-up. CONCLUSIONS A high index of suspicion, familiarity with predisposing factors for SCAD, and PoCUS may play a critical role in detecting and managing SCAD patients.

Four Tick-Borne Microorganisms and Their Prevalence in Hyalomma Ticks Collected from Livestock in United Arab Emirates.

Ticks and associated tick-borne diseases in livestock remain a major threat to the health of animals and people worldwide. However, in the United Arab Emirates (UAE), very few studies have been conducted on tick-borne microorganisms thus far. The purpose of this cross-sectional DNA-based study was to assess the presence and prevalence of tick-borne Francisella sp., Rickettsia sp., and piroplasmids in ticks infesting livestock, and to estimate their infection rates. A total of 562 tick samples were collected from camels, cows, sheep, and goats in the Emirates of Abu Dhabi, Dubai, and Sharjah from 24 locations. DNA was extracted from ticks and PCR was conducted. We found that Hyalomma dromedarii ticks collected from camels had Francisella sp. (5.81%) and SFG Rickettsia (1.36%), which was 99% similar to Candidatus Rickettsia andeanae and uncultured Rickettsia sp. In addition, Hyalomma anatolicum ticks collected from cows were found to be positive for Theileria annulata (4.55%), whereas H. anatolicum collected from goats were positive for Theileria ovis (10%). The widespread abundance of Francisella of unknown pathogenicity and the presence of Rickettsia are a matter of concern. The discovery of T. ovis from relatively few samples from goats indicates the overall need for more surveillance. Increasing sampling efforts over a wider geographical range within the UAE could reveal the true extent of tick-borne diseases in livestock. Moreover, achieving successful tick-borne disease control requires more research and targeted studies evaluating the pathogenicity and infection rates of many microbial species.

Ticks and Tick-Borne Diseases of Livestock in the Middle East and North Africa: A Review.

Ticks are important vectors of an array of viral, bacterial and protozoan pathogens resulting in a wide range of animal and human diseases. There is limited information in the literature about tick species in the Middle East and North Africa (MENA) countries, even though they have suitable climate and vegetation for ticks and their hosts. We reviewed the occurrence of tick species and the pathogens they transmit from the MENA on published papers from 1901-2020. We found taxonomic records of 55 tick species infesting livestock representing the following eight genera: Ornithodoros, Otobius, Amblyomma, Dermacentor, Haemaphysalis, Hyalomma, Ixodes, and Rhipicephalus. In addition, 15 pathogens were recorded causing diseases of significance, with Crimean-Congo hemorrhagic fever, theileriosis, babesiosis and anaplasmosis being widely distributed diseases in the region. In recent decades, there has been increasing trends in disease occurrence and movement associated with global movement of humans and global trade of animals. We suggest that disease control and prevention could be achieved effectively through good integration between public health, veterinary medicine and animal management, and ecological approaches. We recommend further research in the areas of tick ecology and tick born-disease transmission. Furthermore, we suggest evaluation and improvement of disease control policies in the region.

Exploring human-animal host interactions and emergence of COVID-19: Evolutionary and ecological dynamics.

The novel coronavirus disease (COVID-19) that emerged in December 2019 had caused substantial morbidity and mortality at the global level within few months. It affected economies, stopped travel, and isolated individuals and populations around the world. Wildlife, especially bats, serve as reservoirs of coronaviruses from which the variant Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) emerged that causes COVID-19. In this review, we describe the current knowledge on COVID-19 and the significance of wildlife hosts in its emergence. Mammalian and avian coronaviruses have diverse host ranges with distinct lineages of coronaviruses. Recombination and reassortments occur more frequently in mixed-animal markets where diverse viral genotypes intermingle. Human coronaviruses have evolved through gene gains and losses primarily in interfaces where wildlife and humans come in frequent contact. There is a gap in our understanding of bats as reservoirs of coronaviruses and there is a misconception that bats periodically transmit coronaviruses to humans. Future research should investigate bat viral diversity and loads at interfaces between humans and bats. Furthermore, there is an urgent need to evaluate viral strains circulating in mixed animal markets, where the coronaviruses circulated before becoming adapted to humans. We propose and discuss a management intervention plan for COVID-19 and raise questions on the suitability of current containment plans. We anticipate that more virulent coronaviruses could emerge unless proper measures are taken to limit interactions between diverse wildlife and humans in wild animal markets.

Microbial communities associated with the camel tick, Hyalomma dromedarii: 16S rRNA gene-based analysis.

Hyalomma dromedarii is an important blood-feeding ectoparasite that affects the health of camels. We assessed the profile of bacterial communities associated with H. dromedarii collected from camels in the eastern part of the UAE in 2010 and 2019. A total of 100 partially engorged female ticks were taken from tick samples collected from camels (n = 100; 50/year) and subjected to DNA extraction and sequencing. The 16S rRNA gene was amplified from genomic DNA and sequenced using Illumina MiSeq platform to elucidate the bacterial communities. Principle Coordinates Analysis (PCoA) was conducted to determine patterns of diversity in bacterial communities. In 2010 and 2019, we obtained 899,574 and 781,452 read counts and these formed 371 and 191 operational taxonomic units (OTUs, clustered at 97% similarity), respectively. In both years, twenty-five bacterial families with high relative abundance were detected and the following were the most common: Moraxellaceae, Enterobacteriaceae, Staphylococcaceae, Bacillaceae, Corynebacteriaceae, Flavobacteriaceae, Francisellaceae, Muribaculaceae, Neisseriaceae, and Pseudomonadaceae. Francisellaceae and Enterobacteriaceae coexist in H. dromedarii and we suggest that they thrive under similar conditions and microbial interactions inside the host. Comparisons of diversity indicated that microbial communities differed in terms of richness and evenness between 2010 and 2019, with higher richness but lower evenness in communities in 2010. Principle coordinates analyses showed clear clusters separating microbial communities in 2010 and 2019. The differences in communities suggested that the repertoire of microbial communities have shifted. In particular, the significant increase in dominance of Francisella and the presence of bacterial families containing pathogenic genera shows that H. dromedarii poses a serious health risk to camels and people who interact with them. Thus, it may be wise to introduce active surveillance of key genera that constitute a health hazard in the livestock industry to protect livestock and people.

The genome of pest Rhynchophorus ferrugineus reveals gene families important at the plant-beetle interface.

The red palm weevil, Rhynchophorus ferrugineus, infests palm plantations, leading to large financial losses and soil erosion. Pest-host interactions are poorly understood in R. ferrugineus, but the analysis of genetic diversity and pest origins will help advance efforts to eradicate this pest. We sequenced the genome of R. ferrugineus using a combination of paired-end Illumina sequencing (150 bp), Oxford Nanopore long reads, 10X Genomics and synteny analysis to produce an assembly with a scaffold N50 of ~60 Mb. Structural variations showed duplication of detoxifying and insecticide resistance genes (e.g., glutathione S-transferase, P450, Rdl). Furthermore, the evolution of gene families identified those under positive selection including one glycosyl hydrolase (GH16) gene family, which appears to result from horizontal gene transfer. This genome will be a valuable resource to understand insect evolution and behavior and to allow the genetic modification of key genes that will help control this pest.

Population Dynamics of Hyalomma dromedarii on Camels in the United Arab Emirates.

Hyalomma dromedarii is the most important tick species infesting camels in the Middle East. So far, there are no studies on the population dynamics of H. dromedarii ticks on camels in the United Arab Emirates (UAE). Thus, the current study was performed: (1) to assess H. dromedarii population dynamics under common camel breeding and management practices in the study area, (2) to evaluate H. dromedarii life stage changes and sex ratio over time, and (3) to measure parasitological indicators of H. dromedarii infestation. We conducted monthly on-site tick visual counts and collection from camels in Al Ain, UAE, over 12 months. Our results show that the infestation prevalence was very high during the whole study period, with a mean of 94.33%. The maximum infestation intensity occurred in June, while the minimum occurred in January. Overall, H. dromedarii ticks were found on camels during the entire year in spite of monthly applications of an acaricide. This study reveals that H. dromedarii has a very high prevalence and continuous presence on camels in the UAE regardless of the weather fluctuations and acaricide applications and showed the need for an effective control strategy.

Prevalence, distribution on host's body, and chemical control of camel ticks Hyalomma dromedarii in the United Arab Emirates.

BACKGROUND AND AIM: Camel farming remains a part of the culture of the Arabian Peninsula although modern methods have greatly increased camel densities in the entire region. In the United Arab Emirates (UAE), camel production is threatened by tick parasitism. However, no study has considered assessing the magnitude of the problem in the UAE. We conducted a study evaluating tick richness, abundance, and spatial distribution of ticks on camels in farms near Al Ain, UAE. In addition, we conducted a survey of farm owners to determine the control methods used to eliminate camel ticks. MATERIALS AND METHODS: Tick counts were made on 502 camels (Camelus dromedarius). For each examined animal, visual counts of ticks were made on the entire body segregating the counts by head, neck, forelegs, hump, abdomen, back legs, and tail area. In addition, a total of 70 camel owners from the study area were randomly selected and surveyed about the tick control methods. RESULTS: Hyalomma dromedarii was the only species found during the study. The prevalence of ticks was 98% among the sampled animals. The mean intensity (tick load) was 25.8±2.4 ticks/host and the maximum number of ticks per animal was 102. Ticks were found in five vicinities that are on the border with Oman. The highest number of ticks on the body of the camel occurred on the tail area followed by the abdomen. Cypermethrin was the most commonly used acaricide (46.9%). CONCLUSION: The high abundance of ticks reported in this study calls for the establishment of a good management strategy. In addition, finding ticks in vicinities in the UAE that are on the border with Oman suggests a cross-border movement between the two countries. Therefore, studying this movement is important to understand its role in the global circulation of some H. dromedarii tick-borne diseases and the movement of acaricide resistance alleles among tick populations.

A Case of Status Epilepticus and Transient Stress Cardiomyopathy Associated with Smoking the Synthetic Psychoactive Cannabinoid, UR-144.

BACKGROUND Synthetic cannabinoids have a higher affinity for the cannabinoid receptors CB1 and CB2 than natural cannabinoids. Their use can be associated with cardiovascular disease and neurological complications. A case is reported of status epilepticus and stress cardiomyopathy following the recreational use of the synthetic cannabinoid, UR-144. CASE REPORT A 19-year-old woman presented to the emergency department in status epilepticus after smoking the synthetic cannabinoid known as 'space'. Recurring seizure activity was controlled after three hours. On hospital day 3, the patient developed severe biventricular failure. Cardiac magnetic resonance imaging (MRI) confirmed the diagnosis of stress cardiomyopathy. A comprehensive urine drug screen was performed using gas chromatography-mass spectrometry (GC-MS), which was positive for UR-144, or (1-pentyl-1H-indol-3-yl)(2,2,3,3-tetramethylcyclopropyl)-methanone, and negative for all other illicit recreational drugs. The patient improved at one week following admission, with a left ventricular ejection fraction (LVEF) of 40%. She was discharged home on hospital day 10. CONCLUSIONS The use of the synthetic cannabinoid, UR-144, may be associated with prolonged status epilepticus and stress cardiomyopathy. Physicians should be aware of these potentially lethal complications associated with the recreational use of this and other illicit synthetic cannabinoids.

Coxiella-like endosymbiont in argasid ticks (Ornithodoros muesebecki) from a Socotra Cormorant colony in Umm Al Quwain, United Arab Emirates.

Coxiella burnetii is a pathogen causing Q fever in domestic animals and humans. Seabirds have been implicated as possible reservoirs of this bacterium in the Arabian Gulf and in the Western Indian Ocean. Recently, Coxiella species closely related to C. burnetii was detected from ticks collected from oil rigs used as roosting areas by Socotra Cormorants (Phalacrocorax nigrogularis) in the western Arabian Gulf. We collected ticks from the largest breeding colony of Socotra Cormorants in the United Arab Emirates on the eastern extreme of the species' breeding range to determine the prevalence of C. burnetii and evaluate its role as a wild reservoir. All ticks were identified as Ornithodoros muesebecki and genomic DNA was extracted from larval and nymph/adult tick pools. Multiplex PCR tests were performed targeting three C. burnetii specific genes. C. burnetii was not detected although a Coxiella-like endosymbiont was identified that was closely related to Coxiella symbionts from Ornithodoros capensis ticks. Because domestic and wild ungulates are the primary source of C. burnetii, we suggest that the presence of free-ranging, native and non-native ungulates in some off-shore islands in the Arabian Gulf could disseminate C. burnetii to seabirds. More comprehensive studies on seabird colonies are needed to better understand the diversity and prevalence of Coxiella symbionts and to establish if C. burnetii is endemic on some of these islands.

Critically appraising noninferiority randomized controlled trials: a primer for emergency physicians.

Noninferiority (NI) trials aim to show that a new treatment or drug is not inferior to a standard, accepted treatment. The rapid proliferation of NI trials within the literature makes it imperative for emergency physicians to be able to read, interpret, and appraise critically this type of research study. Using several emergency medicine examples from the recent literature, this article outlines the key differences between traditional, superiority randomized controlled trials and NI trials. We summarize four important points that an emergency physician should consider when critically appraising an NI trial: 1) Does the new treatment have tangible benefits over the standard treatment? 2) Was the choice of the NI margin appropriate? 3) Was the effect of the standard treatment preserved? Does the trial have assay sensitivity? and 4) What type of analysis strategy was employed: intention-to-treat (ITT) or per protocol (PP)?