Online medical education in Egypt during the COVID-19 pandemic: a nationwide assessment of medical students' usage and perceptions.

BACKGROUND: The coronavirus (COVID-19) pandemic required a transformation of medical education in Egypt. Public health measures necessitated a rapid shift from traditional face to face lectures to largely online platforms following campus closures. The aim of this study is to characterize medical student use and perception of online medical education in Egypt as well as exploring the efficacy of different e-learning modalities. Additionally, many barriers and opportunities as perceived by students are reviewed to inform future educational improvements. METHODS: A 29-item online survey was created on google forms and distributed by social media to medical students across 26 Egyptian medical schools. The survey was administered from August 20th, 2021, to September 5th, 2021. The survey consisted of a mixture of questions style. The medical students were asked about their experiences with online medical education during the COVID-19 pandemic as well as medical students' anxiety, perceived academic performance, and obstacles related to online education. RESULTS: Of the 4935 responses collected, 43.4% (n = 2140) of respondents were women; 56.6% (n = 2795) were men. Medical students from private medical schools were 13.0% (n = 644), whereas 87.0% (n = 4291) were from public medical schools. 54.6% of students reported that online education is not as effective as face-to-face education. There was a significant rise in hours spent by medical students on online medical education compared to before COVID-19 pandemic. More than half of students (63%) agreed that online recorded video tutorials (e.g., YouTube) were the most effective form of online medical education. CONCLUSION: The shift to online education has significantly impacted medical students in Egypt. Medical students reported various limitations and challenges of online medical education, which must be addressed considering the potential benefits of online platforms over traditional face to face learning. The results of this nationwide study provide a framework for potential areas to implement change to improve the accessibility and structure of online medical education in Egypt.

"Anosmia" the mysterious collateral damage of COVID-19.

COVID-19 pandemic spreads worldwide, with more than 100 million positive cases and more than 2 million deaths. From the beginning of the COVID-19 pandemic, several otolaryngologists described many cases of a sudden loss of smell (anosmia) associated with the disease with or without additional symptoms. Anosmia is often the first and sometimes the only sign in the asymptomatic carriers of COVID-19. Still, this disorder is underestimated, and it is not life-threatening. However, it significantly decreases the quality of life. This olfactory dysfunction continues in several cases even after the nasopharyngeal swab was negative. The occurrence of anosmia can be used as a screening tool for COVID-19 patients and can be used to identify these patients to accomplish the isolation and tracking procedures. In this review, we highlighted the possible mechanisms of anosmia in COVID-19 patients, major pathologies and features of anosmia, implications of anosmia in early diagnosis of COVID-19, evaluation of the smell function during COVID-19, and management and treatment options of COVID-19 anosmia.

Dapagliflozin attenuates diabetic cardiomyopathy through erythropoietin up-regulation of AKT/JAK/MAPK pathways in streptozotocin-induced diabetic rats.

PURPOSE: This study was designed to investigate the mechanism of Dapagliflozin (Dapa) cardioprotection against diabetic cardiomyopathy (DCM). Structural and functional changes in the heart as well as decrease of erythropoietin (EPO) levels were reported in DCM. EPO simultaneously activates three pathways: the Janus-activated kinase-signal transducer and activator of transcription (JAK2/STAT5), phosphatidylinositol-3-kinase-Akt (PI3K/Akt), and extracellular signal-related kinase (ERK/MAPK) cascades, that result in proliferation and differentiation of cardiac cells. METHODS AND RESULTS: DCM was induced by a high fat diet for 10 weeks followed by administration of streptozotocin. After confirmation of diabetes, rats were divided randomly to 5 groups: Group 1; normal control group, Group 2; untreated diabetic group and Groups (3-5); diabetic groups received Dapa daily (0.75 mg, 1.5 or 3 mg/Kg, p.o) respectively for a month. At the end of the experiment, full anaesthesia was induced in all rats using ether inhalation and ECG was recorded. Blood samples were collected then rats were sacrificed and their heart were dissected out and processed for biochemical and histopathological studies. Untreated diabetic rats showed abnormal ECG pattern, elevation of serum cardiac enzymes, decrease EPO levels, downregulation of P-Akt, P-JAK2 and pMAPK pathways, abnormal histological structure of the heart and increase immunostaining intensity of P53 and TNF α in the cardiomyocytes. Dapa in a dose dependent manner attenuated the alterations in the previously mentioned parameters. CONCLUSION: The cardioprotective effect of Dapa could be mediated by increasing EPO levels and activation of P-Akt, P-JAK2 and pMAPK signalling cascades which in turn decrease apoptosis.

Usability of Telemedicine in Physical Therapy Rehabilitation: Systematic review.

BACKGROUND: The term 'Telemedicine' was coined in the 1970s to imply 'healing at a distance. Physical therapy rehabilitation (PTR) focuses on the re-institution of function in bodily strength and movement. Covid-19 has created a challenge in one-on-one PTR sessions due to social distancing, which requires the minimization of all non-essential physical contact. Most outpatient services in PTR have had to be staggered and minimized to increase adherence to social distancing requirements and flatten the pandemic's curve. Telemedicine is applicable in PTR in several ways, including guided therapy sessions, and remote monitoring of patient progress through videoconferencing. Telemedicine allows patients to access PTR from the comfort of their homes, which minimizes travel costs and general strain on the body. Although it has been encumbered by various challenges, telemedicine could revolutionize the delivery of PTR while also increasing access to essential healthcare services. OBJECTIVE: Purpose: Covering the main aspects of telemedicine usability in physical therapy rehabilitation, that encourage using of the telemedicine in physical therapy in the world regions not covered by, especially the Middle East. METHODS: Method: A systematic search in libgen.is, jmir.org, wiley.com, sagepub.com, and scholar.google.com. was performed using the search terms: Telemedicine; asynchronous telemedicine; synchronous telemedicine; Covid-19; rehabilitation medicine; physical therapy rehabilitation; videoconferencing; Medicaid programs; telehealth; and HIPAA. Papers published up to Oct. 22nd, 2020, in English, were included. RESULTS: Telemedicine is cost-effective for physical therapy Rehabilitation particularly in pandemic like COVID19, also it's time and human resources saving especially with hands-off skills rehabilitation. CONCLUSIONS: Telemedicine is a revolutionary aspect of medicine that has seen an unexpected uptake following the Covid-19 pandemic. While people formerly preferred live sessions for PTR, the convenience of telemedicine is increasingly emerging. The various advantages, including reduced cost implications, reduced waiting time, and reduction of non-essential travel to obtain therapy have increased the preference for telemedicine. [9] The WHO recognizes the importance of Telemedicine, and conducted a regional and global survey to analyze its viability. At the onset of global lockdown due to Covid-19, the APTA expressed the need for physiotherapists to utilize telemedicine as an alternative for efficient PTR delivery within the bounds of social recommendations for curve-flattening. Telemedicine in PTR has various advantages including cost reduction, the convenience of access, reduction of long waiting lists among others for the patient. [10] PTR can also be availed to areas that are too remote to have a full-fledged PTR center. Through the utilization of nurse aides and other social support systems, therapists can effectively conduct therapy sessions through videoconferencing. Laws governing the adoption and use of telemedicine for PTR include the HIPAA and other DPL, which regulate the extent to which therapists can collect, use, and store data collected during online therapy sessions. Therapists need to obtain verifiable consent from the patient before commencement.

Comparison of MOLLI, shMOLLLI, and SASHA in discrimination between health and disease and relationship with histologically derived collagen volume fraction.

Aims: To determine the bioequivalence of several T1 mapping sequences in myocardial characterization of diffuse myocardial fibrosis. Methods and results: We performed an intra-individual sequence comparison of three types of T1 mapping sequences [MOdified Look-Locker Inversion recovery (MOLLI), Shortened MOdified Look-Locker Inversion recovery ((sh)MOLLI), and SAturation recovery single-SHot Acquisition (SASHA)]. We employed two model diseases of diffuse interstitial fibrosis [patients with non-ischaemic dilated cardiomyopathy (NIDCM), n = 32] and aortic stenosis [(AS), n = 25)]. Twenty-six healthy individuals served as controls. Relationship with collagen volume fraction (CVF) was assessed using endomyocardial biopsies (EMB) intraoperatively in 12 AS patients. T2 mapping (GraSE) was also performed. Myocardial native T1 with MOLLI and shMOLLI showed, firstly, an excellent discriminatory accuracy between health and disease [area under the curves (P-value): 0.94 (0.88-0.99); 0.87 (0.79-0.94); 0.61 (0.49-0.72)], secondly, relationship between histological CVF [native T1 MOLLI vs. shMOLLI vs. SASHA: r = 0.582 (P = 0.027), r = 0.524 (P = 0.046), r = 0.443 (P = 0.150)], and thirdly, with native T2 [r = 0.628(P < 0.001), r = 0.459 (P = 0.003), r = 0.211 (P = 0.083)]. The respective relationships for extracellular volume fraction with CVF [r = 0.489 (P = 0.044), r = 0.417 (0.071), r = 0.353 (P = 0.287)] were significant for MOLLI, but not other sequences. In AS patients, native T2 was significantly higher compared to controls, and associated with levels of C-reactive protein and troponin. Conclusion: T1 mapping sequences differ in their bioequivalence for discrimination between health and disease as well as associations with diffuse myocardial fibrosis.

Strategies to attenuate micro-vascular obstruction during P-PCI: the randomized reperfusion facilitated by local adjunctive therapy in ST-elevation myocardial infarction trial.

BACKGROUND: Microvascular obstruction (MVO) following primary percutaneous coronary intervention (PPCI) treatment of ST-segment elevation myocardial infarction (STEMI) contributes to infarct expansion, left ventricular (LV) remodelling, and worse clinical outcomes. The REFLO-STEMI trial tested whether intra-coronary (IC) high-dose adenosine or sodium nitroprusside (SNP) reduce infarct size and/or MVO determined by cardiac magnetic resonance (CMR). METHODS AND RESULTS: REFLO-STEMI, a prospective, open-label, multi-centre trial with blinded endpoints, randomized (1:1:1) 247 STEMI patients with single vessel disease presenting within 6 h of symptom onset to IC adenosine (2-3 mg total) or SNP (500 µg total) immediately following thrombectomy and again following stenting, or to standard PPCI. The primary endpoint was infarct size % LV mass (%LVM) on CMR undertaken 24-96 h after PPCI (n = 197). Clinical follow-up was to 6 months. There was no significant difference in infarct size (%LVM, median, interquartile range, IQR) between adenosine (10.1, 4.7-16.2), SNP (10.0, 4.2-15.8), and control (8.3, 1.9-14.0), P = 0.062 and P = 0.160, respectively, vs. CONTROL: MVO (% LVM, median, IQR) was similar across groups (1.0, 0.0-3.7, P = 0.205 and 0.6, 0.0-2.4, P = 0.244 for adenosine and SNP, respectively, vs. control 0.3, 0.0-2.8). On per-protocol analysis, infarct size (%LV mass, 12.0 vs. 8.3, P = 0.031), major adverse cardiac events (hazard ratio, HR, 5.39 [1.18-24.60], P = 0.04) at 30 days and 6 months (HR 6.53 [1.46-29.2], P = 0.01) were increased and ejection fraction reduced (42.5 ± 7.2% vs. 45.7 ± 8.0%, P = 0.027) in adenosine-treated patients compared with control. CONCLUSIONS: High-dose IC adenosine and SNP during PPCI did not reduce infarct size or MVO measured by CMR. Furthermore, adenosine may adversely affect mid-term clinical outcome. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01747174; https://clinicaltrials.gov/ct2/show/NCT01747174.

The REFLO-STEMI trial comparing intracoronary adenosine, sodium nitroprusside and standard therapy for the attenuation of infarct size and microvascular obstruction during primary percutaneous coronary intervention: study protocol for a randomised controlled trial.

BACKGROUND: Microvascular obstruction (MVO) secondary to ischaemic-reperfusion injury is an important but underappreciated determinant of short- and longer-term outcome following percutaneous coronary intervention (PCI) treatment of ST-elevation myocardial infarction (STEMI). Several small studies have demonstrated a reduction in the degree of MVO utilising a variety of vasoactive agents, with adenosine and sodium nitroprusside (SNP) being most evaluated. However, the evidence base remains weak as the trials have had variable endpoints, differing drug doses and delivery. As such, the results regarding benefit are conflicting. METHODS: The REperfusion Facilitated by LOcal adjunctive therapy in STEMI (REFLO-STEMI) trial is a multicentre, prospective, randomised, controlled, open label, study with blinded endpoint analysis: Patients presenting within 6 h of onset of STEMI and undergoing planned primary PCI (P-PCI) with TIMI 0/1 flow in the infarct-related artery (IRA) and no significant bystander coronary artery disease on angiography, are randomised into one of three groups: PCI with adjunctive pharmacotherapy (intracoronary adenosine or SNP) or control (standard PCI). All receive Bivalirudin anticoagulation and thrombus aspiration. The primary outcome is infarct size (IS) (determined as a percentage of total left ventricular mass) measured by cardiac magnetic resonance imaging (CMRI) undertaken at 48 to 72 h post P-PCI. Secondary outcome measures include MVO (hypoenhancement within infarct core) on CMRI, angiographic markers of microvascular perfusion and MACE during 1-month follow-up. The study aims to recruit 240 patients (powered at 80% to detect a 5% absolute reduction in IS). DISCUSSION: The REFLO-STEMI study has been designed to address the weaknesses of previous trials, which have collectively failed to demonstrate whether adjunctive pharmacotherapy with adenosine and/or SNP can reduce measures of myocardial injury (infarct size and MVO) and improve clinical outcome, despite good basic evidence that they have the potential to attenuate this process. The REFLO-STEMI study will be the most scientifically robust trial to date evaluating whether adjunctive therapy (intracoronary adenosine or SNP following thrombus aspiration) reduces CMRI measured IS and MVO in patients undergoing P-PCI within 6 h of onset of STEMI. TRIAL REGISTRATION: Trial registered 20th November 2012: ClinicalTrials.gov Identifier NCT01747174.

Standardization of T1 measurements with MOLLI in differentiation between health and disease--the ConSept study.

BACKGROUND: T1 imaging based on pixel-wise quantification of longitudinal relaxation has the potential to differentiate between normal and abnormal myocardium. The accuracy of T1 measurement has not been established nor systematically tested in the presence of health and disease. METHODS: Intra-observer, inter-observer and inter-study reproducibility of T1 imaging was assessed in subjects with left ventricular hypertrophy (LVH, n = 25) or dilated cardiomyopathy (DCM, n = 43). Thirty-eight subjects with low-pretest likelihood of cardiomyopathy served as a control group. T1 values were acquired in a single mid-ventricular short axis slice using modified Look-Locker imaging prior and after the application of gadolinium contrast at 1.5 and 3 T. Analysis was performed with regions of interest (ROI) placed conservatively within the septum or to include the whole short axis (SAX) myocardium. RESULTS: Intra-observer, inter-observer and inter-study repeated measurements within the septum showed smaller mean differences and narrower 95% confidence intervals than repeated short axis ROI measurements. Native T1 values were higher in septal ROIs compared with SAX values at both field strengths (1.5 T: 976 ± 37 vs. 952 ± 41, p < 0.01; 3 T: 1108 ± 67 vs. 1087 ± 60, p < 0.01). Native T1 values revealed significant mean differences between controls and patients with LVH for both septal (1.5 T: 26 ± 9, p < 0.01; 3 T: 50 ± 13, p < 0.01) and SAX ROIs (1.5 T: 19 ± 11, p < 0.05; 3 T: 47 ± 19, p < 0.05) with greater differences observed at 3 T versus 1.5 T field strength. Native T1 values revealed significant mean differences between controls and patients with DCM for septal ROI (1.5 T: 29 ± 15, p < 0.05; 3 T: 55 ± 16, p < 0.01) at both 1.5 T and 3 T, but only for SAX ROIs at 3 T (49 ± 17, p < 0.01). There were no significant differences in post-contrast T1 values or partition coefficient (λ) between controls and patients. CONCLUSION: Conservative septal ROI T1 measurement is a robust technique with excellent intra-observer, inter-observer and inter-study reproducibility for native and post-contrast T1 value and partition coefficient measurements. Moreover, native septal T1 values reveal the greatest difference between normal and abnormal myocardium, which is independent of geometrical alterations of cardiac chamber and wall thickness. We propose the use of native T1 measurements using conservative septal technique as the standardized approach to distinguish health from disease assuming diffuse myocardial involvement.