Radical reform of the undergraduate medical education program in a developing country: the Egyptian experience.

Medical educators are in a continuous quest to close the gap between the needs of medical practice and the rising expectations of the communities in their countries. During the past two decades, competency-based medical education has been evolving as an appealing strategy to close this gap. In 2017, the Egyptian medical education authorities mandated all medical schools to change their curricula to comply with revised national academic reference standards, which changed from outcome-based to competency-based. In parallel, they also changed the timeline of all medical programs for six years of studentship and one-year internship to five years and two years, respectively. This substantial reform involved the assessment of the existing situation, an awareness campaign for the proposed changes and an extensive national faculty development program. Monitoring the implementation of this substantial reform was performed through surveys, field visits and meetings with students, teaching staff and program directors. In addition to the expected challenges, the COVID-19-associated restrictions presented a significant further challenge during the implementation of this reform. This article presents the rationale for and steps of this reform, the challenges faced and how they were addressed.

Vitamin D Supplementation and T Cell Regulation in Preterm Infants: A Randomized Controlled Trial.

The objective of this study was to evaluate the effect of 2 different doses of vitamin D on the expression of T regulatory cells (Treg) in premature infants. A double-blind randomized controlled trial was conducted on preterm infants born with gestational age between 28 and 33 weeks. Subjects were randomly assigned to receive 400 or 800 IU/day of vitamin D3 when they achieved 100 mL/kg of enteral feeds. Percentage increase in Treg cell counts were measured by flow cytometry at enrollment, and after 1 and 4 weeks of oral vitamin D supplementation at the allotted doses in both groups. Short-term morbidity and mortality outcomes were also assessed. A total of 40 infants were enrolled, 20 in each group. The change in Treg count (%) was significantly less in the low-dose vitamin D3 supplementation group after 1 week (1.9 ±â€Š5.5 vs 60 ±â€Š5.6, P = 0.0005) and after 4 weeks (1.8 ±â€Š5.7 vs 73.7 ±â€Š5.6, P = 0.0028). The 2 groups did not differ in anthropometric measurements, duration of oxygen and respiratory support, and mortality. Length of hospital stay was longer in the low-dose group (24.9 ±â€Š5.14 vs 22 ±â€Š3.49, P = 0.04). Oral vitamin D supplementation has a dose and time dependent effect on percentage of Treg in infants born prematurely. The 800 IU dose of vitamin D3 did not have apparent short-term side effects. Larger studies are needed to explore the effect of vitamin D3 dosing on length of hospital stay.

Effect of packed red blood cell transfusion on IL-8 and sICAM-1 in premature neonates at different postnatal ages.

BACKGROUND: Transfusion-related immunomodulation (TRIM) has been described in adults; however, its existence in neonates is not confirmed. The generation of TRIM is attributed to increased concentrations of IL-8, sICAM-1 and other pro-inflammatory cytokines. This study aimed to monitor changes in IL-8, sICAM-1 as markers for TRIM in premature infants at different postnatal ages. METHODS: Preterm infants with a gestational age between 28 and 32 weeks who were receiving PRBC transfusion during the first 28 days of life were included in the study. Infants were stratified into two groups according to their postnatal age: Group 1 with postnatal ages of (0-14) days and Group 2 of (15-28) days. The concentrations of IL-8 and sICAM-1 were measured by enzyme-linked immunosorbent assay (ELISA) before transfusion, 6 h after the end of transfusion and in the donor's PRBCs bag immediately before infusion into the baby. RESULTS: IL-8 concentration in the PRBCs bags correlated with post-transfusion level in Group 2 (r = 0.59, p = 0.002) but not in Group 1 (r = 0.39, p = 0.06). sICAM-1 concentration in the bag correlated with infants'concentrations in neither group. In Group 1, pre-transfusion concentrations of both cytokines (IL-8 and sICAM-1) did not correlate whereas post-transfusion concentrations did correlate (r = -0.09, p = 0.68 and r = 0.4, p = 0.05 respectively). In Group 2, the concentrations of both cytokines did not correlate with each other during pre-transfusion (r = 0.11, p = 0.58) as well as post-transfusion (r = 0.12, p = 0.56). There was no significant increase in either cytokines after transfusion in each group. CONCLUSION: This study showed positive correlation between IL-8 concentration in the transfusion bag and post transfusion in Group 2 infants which could be attributed to passive transmission from the bags. This study does not support an immune modulatory effect for packed RBC in preterm infants.

Role of mean platelet volume and ischemia modified albumin in evaluation of oxidative stress and its association with postnatal complications in infants of diabetic mothers.

Gestational diabetes mellitus (GDM) is accompanied by increased oxidative stress, causing many complications to pregnant women and their newborns. We aimed to determine cord blood levels of mean platelet volume (MPV) and ischemia modified albumin (IMA) as a reflection of oxidative stress in babies born to mothers suffering from GDM. Eighty pregnant women were enrolled in the study. They were divided into two groups: 40 with GDM and 40 healthy matched controls. Each group included twenty giving birth by normal vaginal delivery (NVD) and twenty by cesarean section (C.S). The MPV and the IMA levels were measured. Complete physical examination of babies was done at birth and follow up at age of one week. Comparison between infants of diabetic mothers and of healthy mothers showed statistically significant difference in the levels of MPV (p < .001) and IMA (p = .001). Also, there was a statistically significant difference in MPV (p < .001) and IMA (p = .005) between diabetic females who gave birth by NVD and C.S. ROC curve analysis showed that IMA and MPV variables were related to the postnatal outcomes. MPV and IMA are useful markers of the potential oxidative stress in infants of diabetic mothers and of postnatal complications.

Emerging antimicrobial resistance in early and late-onset neonatal sepsis.

BACKGROUND: Compared to developed countries, the use of antimicrobials in Egypt is less regulated and is available over the counter without the need for prescriptions. The impact of such policy on antimicrobial resistance has not been studied. This study aimed to determine the prevalence of early and late onset sepsis, and the frequency of antimicrobial resistance in a major referral neonatal intensive care unit (NICU). METHODS: The study included all neonates admitted to the NICU over a 12-month period. Prospectively collected clinical and laboratory data were retrieved, including blood cultures and endotracheal aspirate cultures if performed. RESULTS: A total of 953 neonates were admitted, of them 314 neonates were diagnosed with sepsis; 123 with early onset sepsis (EOS) and 191 with late onset sepsis (LOS). A total of 388 blood cultures were obtained, with 166 positive results. Total endotracheal aspirate samples were 127; of them 79 were culture-positive. The most frequently isolated organisms in blood were Klebsiella pneumoniae (42%) and Coagulase negative staphylococcus (19%) whereas in endotracheal cultures were Klebsiella pneumoniae (41%) and Pseudomonas aeruginosa (19%). Gram negative organisms were most resistant to ampicillins (100%), cephalosporins (93%-100%) and piperacillin-tazobactam (99%) with less resistance to aminoglycosides (36%-52%). Gram positive isolates were least resistant to vancomycin (18%). Multidrug resistance was detected in 92 (38%) cultures, mainly among gram negative isolates (78/92). CONCLUSIONS: Antibiotic resistance constitutes a challenge to the management of neonatal sepsis in Egypt. Resistance was predominant in both early and late onset sepsis. This study supports the need to implement policies that prohibits the non-prescription community use of antibiotics.

Applicability and efficacy of a model for prevention of perinatal transmission of hepatitis B virus infection: single center study in Egypt.

AIM: To identify possible maternal risk factors for hepatitis B virus (HBV) acquisition and assess the efficacy of immunoprophylaxis given to infants born to hepatitis B virus surface antigen (HBsAg) positive mothers. METHODS: Screening of 2000 pregnant females was carried out using rapid test and confirmed by enzyme immunoassay. A questionnaire consisting of 20 questions about the possible risk factors for acquisition of HBV infection was filled for every pregnant HBsAg positive female in addition to at least 2 pregnant HBsAg negative females for each positive case. Infants of HBsAg positive women were offered passive and active immunoprophylaxis within the 1st 48 h after birth, in addition to 2nd and 3rd doses of HBV vaccine after 1 and 6 mo respectively. Infants were tested for HBsAg and hepatitis B surface antibodies (HBsAb) at six months of age. RESULTS: HBsAg was confirmed positive in 1.2% of tested pregnant women. Risk factors significantly associated with HBV positivity were; history of injections (OR = 5.65), history of seeking medical advice in a clinic (OR = 7.02), history of hospitalization (OR = 6.82), history of surgery (OR = 4) and family history of hepatitis (OR = 3.89) (P < 0.05). Dropout rate was 28% for HBsAg women whose rapid test was not confirmed and could not be reached to provide immunoprophylaxis for thier newborns. Immunoprophylaxis failure was detected in only one newborn (3.7%) who tested positive for HBsAg at 6 mo of age; and vaccine failure (seronegative to HBsAb after 4 doses of the vaccine) was detected in another one (3.7%). The success rate of the immunoprophylaxis regimen was 92.6%. CONCLUSION: This pilot study shows that a successful national program for prevention of perinatal transmission of HBV needs to be preceded by an awareness campaign to avoid a high dropout rate.

Thrombopoietin level is increased in the serum of asphyxiated neonates: a prospective controlled study.

BACKGROUND: Thrombopoietin (TPO) is a growth factor that controls platelet production. Despite the known association of chronic hypoxia and acute asphyxia with hematologic changes, TPO had not been studied in neonatal asphyxia. OBJECTIVE: To assess TPO concentrations in the serum of asphyxiated and nonasphyxiated neonates, and examine any correlation with the severity of asphyxia. DESIGN/METHODS: This prospective study was carried out on 32 asphyxiated neonates and 30 control subjects admitted at Cairo University Medical Center. Asphyxia was defined if two of the following were found: (1) Apgar score /=-10 and (3) clinical evidence of perinatal asphyxia. Encephalopathy was classified clinically according to Sarnat's stages during the first day of life. Platelet count and TPO level (pg/ml) were measured at 1st, 3rd and 7th day of life. RESULTS: : TPO measured on the first day of life did not differ between cases and controls (900.2+/-526.4 vs 726.6+/-441.9 pg/ml, p=0.2). It increased on the 3rd day of life and was significantly higher in asphyxiated infants compared to controls (1291.4+/-627.9 vs 885.5+/-400.3 pg/ml, respectively; p=0.004). This difference remained significant in a logistic regression model controlling for birth weight, sex and mode of delivery (regression coefficient=476.9+/-146.8; p=0.002). In asphyxiated infants (n=32), encephalopathy was classified as mild (n=17), moderate (n=10) and severe (n=5). TPO correlated with the degree of clinical severity on the 7th day of life (r=0.59, p=0.003). TPO did not differ between survivors (n=24) and nonsurvivors (n=8) within the asphyxia group (1197.1+/-596.8 vs 1613.1+/-605.9 pg/ml; p=0.09). Platelet counts correlated negatively with TPO measured on day 1 (r=-0.415; p=0.02), day 3 (r=-0.64; p=0.001) and day 7 (r=-0.562; p=0.007). CONCLUSIONS: TPO increased and correlated with severity of asphyxia at 3 and 7 days of life. It correlated negatively with the platelet count at all times.

The Egypt National Perinatal/Neonatal Mortality Study 2000.

OBJECTIVES: To estimate stillbirth, perinatal (PMR) and neonatal mortality rates (NMR) in Egypt and to assign main causes of death. STUDY DESIGN: Data were collected from a representative sample of women who gave birth from 17,521 households which were included in the Egypt Demographic and Health Survey (EDHS) 2000. Comparisons were made between three systems for classifying causes of death. RESULTS: The NMR was 25 per 1000 live births (17 early and eight late). Half the deaths occurred in the first two days of life. Neonatal causes of death were pre-maturity (39%), asphyxia (18%), infections (7%), congenital malformation (6%) and unclassified (29%). The PMR was 34 per 1000 births, mainly attributed to: asphyxia (44%) and prematurity (21%). The revised Wigglesworth classification agreed well with the physicians except the panel attributed more deaths to infections (20%). The WHO verbal autopsy algorithm left 48% of deaths unclassified. CONCLUSIONS: Infant mortality in Egypt is showing an epidemiological transition with a significant decrease in mortality, resulting in a disproportionate percentage of deaths in the first week of life. Infant mortality in Egypt declined 64% from 124 per 1000 between 1974 and 1978 to 44 per 1000 between 1995 and 1999, the decline being greatest among older infants; 55% of all infant deaths occurred during the neonatal period. The neonatal mortality rate in this study was estimated to be 25 per 1000 live births.