RESUMEN
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.
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COVID-19 , Educación de Pregrado en Medicina , Educación Médica , Humanos , Países en Desarrollo , EgiptoRESUMEN
OBJECTIVE: Amplitude integrated electroencephalography (aEEG) has been used in neonates in various clinical and research applications. We hypothesized that an abnormal aEEG score could be used as a predictor of short-term adverse outcome. METHODS: Very low birth weight infants were enrolled in a prospective observational cohort study. Two channel 12-hour continuous aEEG recordings were performed within 48 h of life and at 1 week of age. Recordings were classified as abnormal if they correspond to a 2 point difference in score. Short-term adverse outcome was defined as either death or Bayley scales ≤ 70 at 4 months corrected age. RESULTS: One hundred infants were enrolled. Their average gestational age was 27.9 ± 2.6 weeks and average birth weight was 997 ± 299 gram. Fifteen enrolled infants died, one was withdrawn, 29 lost to follow up, and 55 examined at 4 months. Those with adverse outcome had significantly increased percentages of abnormal EEG at 1 week of life (31% vs. 8%), severe intraventricular hemorrhage (IVH) (27% vs. 4.5%), intubation in the delivery room (45% vs. 16%), and increased average days of mechanical ventilation (16 days vs. 4 days). Combining abnormal aEEG at 1 week of life to severe IVH on early head ultrasound increased the sensitivity of ultrasound to detect short-term adverse outcome from 27% to 50%. CONCLUSION: aEEG is feasible in premature infants and when its data at 1 week of life are combined with early head ultrasound, sensitivity for detecting short-term adverse outcomes was increased.
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Asfixia Neonatal/diagnóstico , Electroencefalografía/métodos , Recién Nacido de muy Bajo Peso/fisiología , Asfixia Neonatal/fisiopatología , Femenino , Estudios de Seguimiento , Edad Gestacional , Humanos , Recién Nacido , Masculino , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Sensibilidad y Especificidad , Factores de TiempoRESUMEN
A random sample of 457 neonates was prospectively studied in order to identify the incidence, common types, and risk factors for arrhythmias in the neonatal intensive care unit (NICU). A 12-lead EKG was studied in all neonates (n = 457). A total of 139 Holter studies was done in every fourth baby with a normal EKG (n = 100) and in all babies with an abnormal EKG (n = 39). Of the 100 infants who were thought to be arrhythmia-free by EKG, nine infants demonstrated an arrhythmia on Holter studies. When we correlated screening results with maternal, obstetrical, and neonatal risk factors; arrhythmias were significantly associated with male gender, more mature gestational age, lower glucose levels, maternal smoking, high umbilical artery lines, and the use of the nebulized beta-2 adrenergic treatment, whereas umbilical venous lines and dopamine infusion did not relate to arrhythmia. We conclude that arrhythmias are more common in the NICU than in the general neonatal population. Compared to Holter monitoring, the sensitivity of the EKG was only 89%.
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Arritmias Cardíacas/epidemiología , Cuidado Intensivo Neonatal/estadística & datos numéricos , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatología , Egipto/epidemiología , Electrocardiografía Ambulatoria , Femenino , Estudios de Seguimiento , Frecuencia Cardíaca/fisiología , Humanos , Incidencia , Recién Nacido , Masculino , Pronóstico , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Rates of sepsis exceeding 50% in a neonatal intensive care unit (NICU) in Cairo, Egypt, were not controlled by routine antimicrobial therapy. We investigated these conditions in September 2001. METHODS: Case series and retrospective cohort studies were conducted on 2 groups of NICU infants admitted to an academic medical center between February 12 and July 31, 2001. Observation of clinical practices led us to culture in-use intravenous (i.v.) fluids and medications. We monitored rates of i.v. fluid contamination, clinical sepsis and mortality after interventions to establish new procedures for handling and disposal of i.v. fluids, infection control training and improved clinical laboratory capacity. RESULTS: Among infants in the retrospective cohort group, 88 (77%) of 115 had clinical sepsis, and 59 (51%) died. In the case series group, we documented the time of initial positive blood culture; 21 (64%) of 33 were septic <24 hours after birth. Klebsiella pneumoniae accounted for 24 (73%) of 33 isolates; 14 (58%) of 24 were extended spectrum beta-lactamase-producing and aminoglycoside-resistant. On admission, all neonates received glucose-containing i.v. fluids; i.v. bottles (500 mL) were divided among multiple infants. The i.v. fluids were prepared at the bedside; poor hand hygiene and poor adherence to aseptic techniques were observed. K. pneumoniae was isolated from 13 (65%) of 20 in-use glucose-containing i.v. fluids. Fluid contamination, sepsis and mortality rates declined significantly after intervention. CONCLUSION: Extrinsically contaminated i.v. fluids resulted in sepsis and deaths. Standard infection control precautions significantly improve mortality and sepsis rates and are prerequisites for safe NICU care.
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Contaminación de Medicamentos , Unidades de Cuidado Intensivo Neonatal , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/aislamiento & purificación , Sepsis/epidemiología , Antibacterianos/farmacología , Sangre/microbiología , Medios de Cultivo , Farmacorresistencia Bacteriana , Egipto/epidemiología , Glucosa , Humanos , Recién Nacido , Control de Infecciones , Infusiones Intravenosas , Infecciones por Klebsiella/microbiología , Infecciones por Klebsiella/mortalidad , Klebsiella pneumoniae/efectos de los fármacos , Sepsis/microbiología , Sepsis/mortalidad , Soluciones/administración & dosificaciónRESUMEN
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 =3 at 1 minute or =6 at 5 minutes, (2) umbilical cord arterial pH =7.2 combined with base deficit >/=-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.
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Asfixia Neonatal/diagnóstico , Asfixia Neonatal/mortalidad , Trombopoyetina/sangre , Puntaje de Apgar , Asfixia Neonatal/sangre , Biomarcadores/sangre , Estudios de Casos y Controles , Cuidados Críticos/normas , Cuidados Críticos/tendencias , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Recién Nacido , Unidades de Cuidado Intensivo Neonatal , Modelos Logísticos , Masculino , Probabilidad , Pronóstico , Estudios Prospectivos , Valores de Referencia , Medición de Riesgo , Sensibilidad y Especificidad , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Trombopoyetina/metabolismoRESUMEN
BACKGROUND: Because the therapeutic options for managing infections in neonates in developing countries are often limited, innovative approaches to preventing infections are needed. Topical therapy with skin barrier-enhancing products may be an effective strategy for improving neonatal outcomes, particularly among preterm, low birth weight infants whose skin barrier is temporarily but critically compromised as a result of immaturity. METHODS: We tested the impact of topical application of sunflower seed oil 3 times daily to preterm infants <34 weeks gestational age at the Kasr El-Aini neonatal intensive care unit at Cairo University on skin condition, rates of nosocomial infections and mortality. RESULTS: Treatment with sunflower seed oil (n = 51) resulted in a significant improvement in skin condition (P = 0.037) and a highly significant reduction in the incidence of nosocomial infections (adjusted incidence ratio, 0.46; 95% confidence interval, 0.26-0.81; P = 0.007) compared with infants not receiving topical prophylaxis (n = 52). There were no reported adverse events as a result of topical therapy. CONCLUSIONS: Given the low cost (approximately .20 dollars for a course of therapy) and technologic simplicity of the intervention and the effect size observed in this study, a clinical trial with increased numbers of subjects is indicated to evaluate the potential of topical therapy to reduce infections and save newborn lives in developing countries.
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Infecciones Bacterianas/prevención & control , Infección Hospitalaria/prevención & control , Países en Desarrollo , Recien Nacido Prematuro , Aceites de Plantas/uso terapéutico , Administración Tópica , Esquema de Medicación , Costos de los Medicamentos , Femenino , Helianthus/química , Humanos , Recién Nacido , Enfermedades del Recién Nacido , Masculino , Excipientes Farmacéuticos , Aceites de Plantas/administración & dosificación , Aceites de Plantas/farmacología , Aceite de GirasolRESUMEN
The purpose of this study was to evaluate the feasibility of the use oral ibuprofen suspension (OIS) in the treatment of patent ductus arteriosus (PDA) in premature infants. Premature infants (= 35 weeks) age 2 to 7 days who suffered from respiratory distress and had been diagnosed with PDA were included in this study. Color Doppler echocardiography (ECHO) was used to measure the internal ductal diameter, pressure gradient, and the ratio of left atrial to aortic root diameters (La/Ao). Infants were randomly assigned to one of two groups: group I received three doses of intravenous (IV) indomethacin (0.2 mg/kg at 12-hour intervals) and group O received an initial dose of OIS (10 mg/kg), followed by two doses of 5 mg/kg each, after 24 and 48 hours. A follow-up ECHO was done after treatment by the same pediatric cardiologist who was blinded to the assignment of the study groups. Changes in blood platelet count, hematocrit, blood urea nitrogen, and creatinine were compared between groups. In total, 78 premature infants were screened: 21 had been diagnosed with PDA. Infants in group I (n = 9) and group O (n = 12) did not differ in birthweight (1884 +/- 485 versus 1521 +/- 398 g [mean +/- SD]; P = 0.13), gestational age (32.9 +/- 1.6 versus 31.2 +/- 2.5 weeks; P = 0.07), internal diameter of PDA (2.3 +/- 0.5 versus 2.1 +/- 0.5 mm; P = 0.34), pressure gradient across PDA (12.83 +/- 6.46 versus 11.11 +/- 4.5 mm Hg; P = 0.48), and La/Ao ratio (1.26 +/- 0.21 versus 1.17 +/- 0.12; P = 0.25). Closure of PDA was achieved in 78% (seven of nine) of infants in group I and in 83% (10 of 12) of infants in group O. Comparisons of laboratory changes following treatment in group I and group O were as follows: decrease in hematocrit (-6.5 +/- 6.6 versus -1.2 +/- 4.2; P = 0.04) and in platelet count (-54 +/- 67 versus -1 +/- 53 x 10 (3)/muL; P = 0.24), and increase in blood urea nitrogen (16.4 +/- 16.4 versus 2.1 +/- 17.4 mg/dL; P = 0.06) and serum creatinine (0.12 +/- 0.22 versus -0.06 +/- 0.19 mg/dL; P = 0.13). Two infants in group I had severe pulmonary hemorrhage, whereas there were none in the group O. Oral ibuprofen could be an easy-to-administer and efficacious alternative in the treatment of PDA.