Utility of hematological and inflammatory biomarkers in predicting recovery in critical Covid-19 patients: Our experience in the largest Covid-19 treating center in Lebanon

Background

COVID-19 pandemic has led to a catastrophic shortage of ICU beds. This has resulted in the need to identify patients that can be discharged early before full clinical recovery. We designed this study to determine if in changes routine tests like CBCD and CRP can be a useful complement to clinical status when deciding to discharge patients from ICU.

Methods

This retrospective study was conducted in Rafic Hariri University Hospital. Levels of biomarkers measured at admission (T1) and within 3 days of outcome (T2) were collected and ratios (T2/T1) were calculated. The Odds Ratios of association between the changes in these biomarkers and outcome were estimated. Multivariate analysis and AUC for the performance of these biomarkers were also conducted.

Results

We found on multivariate analysis that reduction in counts of lymphocyte and platelets and elevation in counts of neutrophils and level of CRP (T2/T1 ratio > 1) are strongly associated with mortality with respective ORs estimated at 6.74, 3.26, 5.65 and 4.34 [p-values < 0.001]. AUCs were found to lie in a range of 0.68 to 0.81 indicating fair to good performance. Other factors found to impact survival were AKI, AF and ACS [p-values < 0.01]. In contrast to other studies, risk factors didn’t show an association with survival when adjusted for effects of complications and changes in biomarker levels.

Conclusions

Our results confirm that inexpensive tests like lymphocyte count and CRP can be reliably used to follow COVID-19 patients in ICU and to support the decision to discharge patients.

Integrated enhanced cognitive behavioural (I-CBTE) therapy significantly improves effectiveness of inpatient treatment of anorexia nervosa in real life settings

BACKGROUND

Inpatient treatment of anorexia nervosa can be lifesaving but is associated with high rates of relapse and poor outcomes. To address this, the Oxford service has adapted the enhanced cognitive behavioural treatment (CBTE) model, first developed for inpatients in Italy to a UK national health service (NHS) setting. In this study, we compared the outcomes from treatment as usual (TAU), integrated CBTE (I-CBTE), and alternative treatment models in routine UK clinical practice.

METHODS

This is a longitudinal cohort study, using routinely collected data between 2017 and 2020 involving all adults with anorexia nervosa admitted to specialist units from a large geographical area in England covering a total population of 3.5 million. We compared TAU with (1) I-CBTE (13 weeks inpatient CBTE, restoration to a healthy weight, combined with 7 weeks day treatment followed by 20 weeks of outpatient CBTE; (2) standalone inpatient CBTE (due to insufficient resources since the pandemic; and (3) 6-8 weeks admission with partial weight restoration as crisis management. Primary outcome measures (min. 1 year after discharge from hospital) were defined as: (1) good outcome: Body Mass Index (BMI) > 19.5 and no abnormal eating or compensatory behaviours; (2) poor outcome: BMI < 19.5 and/or ongoing eating disorder behaviours; (3) readmission; or (4) deceased. Secondary outcomes were BMI on discharge, and length of stay.

RESULTS

212 patients were admitted to 15 specialist units in the UK depending on bed availability. The mean age was 28.9 (18-60) years, mean admission BMI was 14.1 (10-18.3), 80% were voluntary. At minimum 1-year follow up after discharge, 70% of patients receiving I-CBTE and 29% standalone inpatient CBTE maintained good outcomes, in contrast with < 5% TAU and crisis management admission. Readmission rates of I-CBTE were 14.3% vs ~ 50% (χ² < 0.0001) in the other groups. The main predictors of good outcome were reaching healthy BMI by discharge, I-CBTE and voluntary status. Age, psychiatric comorbidity and length of stay did not predict outcomes. BMI on discharge and length of stay were significantly better in the CBTE groups than in TAU.

CONCLUSIONS

Our main finding is that in a real-life setting, I-CBTE has superior short- and minimum 1 year outcomes as compared with alternative inpatient treatment models. Dissemination of I-CBTE across the care pathway has the potential to transform outcomes of inpatient treatment for this high-risk patient population and reduce personal and societal costs.

Association between quality of sleep and screen time during the COVID-19 outbreak among adolescents in the United Arab Emirates

The COVID-19 pandemic had a major impact on people of all ages. Adolescents' exposure to online learning is linked to excessive screen time on digital devices, which leads to poor sleep quality. This study aimed to investigate the association between screen time on different electronic devices and sleep quality among adolescents in the United Arab Emirates. This study was based on a self-reported questionnaire, which was administered online to school-aged adolescents (aged 12-19 years). The multicomponent questionnaire collected information on sociodemographic characteristics, sleep quality using the Pittsburgh Sleep Quality Index (PSQI), and screen time (minutes) on TV, TV-connected devices, laptops, smartphones, and tablets on weekdays, weeknight, and weekends using the Screen Time Questionnaire (STQ). Univariate and multivariate analyses were used to identify factors correlated with poor sleep quality. A total of 1720 adolescents were recruited from private and public schools (mean age 14.6 ± 1.97 years). The mean PSQI score was 8.09 ± 3.37, and 74.3% of participants reported poor sleep (cutoff score >5). Mean scores were highest for the sleep latency (1.85 ± 0.97) and sleep disturbance (1.56 ± 0.62) domains. The highest STQ score was observed for smartphones, with a median screen time of 420 min on weekdays and 300 min on weekends. Screen time related to smartphones on weekends (p = 0.003) and increased screen time in bed (p < 0.001) were significantly associated with poor sleep. Our results confirmed the correlation between sleep and screen time in adolescents. The results may inform educational polices that target screen time and sleep among adolescents during and after the COVID-19 pandemic.

Memory, neurogenic protein and oxidative deficits of frontal cortex following chlorpyrifos/dichlorvos exposure in rats

Objective: The use of xenobiotics to boost agricultural productivity has led to toxic chemicals exposure including organophosphates, causing adverse health outcomes including behavioral and neuronal impairments. This study aimed to evaluate the memory indices, possible oxidative and cholinesterase outturnson the frontal cortices of rats exposed to organophosphates.Methodology: Thirty-two Wistar rats were grouped into four. They received 1ml/kg of Normal, 8.8 mg/kg dichlorvos, 14.9 mg/kg chlopyrifos, and 8.8 mg/kg dichlorvos plus 14.9mg/kg chlorpyrifos respectively. They had training trials in the Y Maze paradigm then spatial working memory assessment. They were euthanized 24hours following exposure and tissues excised for analysis.Results: A marked reduction in metabolic markers, Acetylcholine Esterase (AChE) activity, spatial memory indices and proliferative neuron marker (Ki67) were observed. Also, increase in oxidative stress markers in the frontal cortices of the organophosphates exposed rats.Conclusion: The findings demonstrated neurotoxic effects of organophosphates in rats.

Safety and Efficacy of Elective Switch from Nilotinib to Imatinib in Newly Diagnosed Chronic Phase Chronic Myeloid Leukemia

The treatment of newly diagnosed chronic phase chronic myeloid leukemia (CML) with nilotinib has resulted in a higher rate of major molecular (MMR) and complete cytogenetic response (CCyR) at 12 months compared to imatinib but at a higher cumulative cost and increased risk of serious adverse events. To maintain long-term efficacy and minimize both toxicity and costs, we aimed at evaluating in a prospective single-center trial the efficacy and safety of a response-directed switch from nilotinib to imatinib after 12 months in patients newly diagnosed with chronic phase CML. Thirteen adult patients were enrolled. Twelve patients started on nilotinib 300 mg twice daily. Eleven patients completed one year of nilotinib and were switched to imatinib 400 mg daily as per protocol. At 3 months, all patients achieved a complete hematologic response, with 7 (58%) patients had early molecular response. At 12 months, all patients achieved CCyR, of whom 5 (42%) and 4 (33%) patients achieved MMR and MR4.5, respectively. Three (27%) patients switched back to nilotinib after 18, 24, and 51 months respectively: 1 patient because of loss of CCyR after 18 months, and 2 patients because of imatinib intolerance. At last follow-up, all patients (n = 12) were alive and in MMR, 6 (50%) of them in continuous MR4.5. These findings suggest that response directed switch from nilotinib to imatinib at 12 months is capable of maintaining long-term response, with manageable side effects. This approach warrants further exploration with larger prospective trials. Clinical trial registration: Clinicaltrials.gov identifier: NCT01316250, https://clinicaltrials.gov/ct2/results?cond=&term=NCT01316250&cntry=&state=&city=&dist=. 

Microbial Evaluation of Some Syrups in Syrian Pharmacies

Microbial contamination of syrups can bring clinical hazards to patients as well as physical and chemical changes in the product.

Aims

Studying the influence of the war on the Syrian pharmaceutical industry from a microbiological point of view by assessing the microbiological quality of syrup samples taken from Syrian pharmacies.

Methodology

Fifty different syrups from 29 different companies having various manufacture dates were collected during validity period between 9-2019 and 6-2021 in Aleppo, Syria. Membrane filtration technique was performed to quantify microbial contamination of the collected syrup samples. This involved passing the samples through filter nitrocellulose membrane disks with a pore size of 0.45 μm then transferring the filter disks alongside any collected microorganisms into Tryptone Soya Agar, Sabouraud Dextrose agar, Xylose lysine Deoxycholate agar and Eosin Methylene Blue agar plates. Colonies observed on these plates were counted and the number of viable microbes in the original sample was expressed as colony forming units per milliliter (CFU/mL). Investigation of Escherichia coli in all syrup samples and Salmonella in herbal syrup samples was also performed.

Results

This study revealed that 28 syrups (56%) had no growth of either bacterial or fungal colonies; 33 syrups (66%) had no growth of bacterial colonies; 43 syrups (86%) had no growth of fungal colonies. On the other hand, 7 syrups (14%) exceeded the pharmacopoeial limit for bacterial growth and 6 syrups (12%) exceeded that for fungal growth. Furthermore, 5 syrup samples (10%) were on the high permissible limits for bacterial contamination and none for fungal contamination.

All syrups were free from E. coli and all herbal syrups were free from Salmonella. Taken together, out of the fifty syrups examined 13 syrups (26%) exceeded the pharmacopoeial limits and therefore pharmacopoeial accepted syrups constitute a percentage of (74%).

Conclusion

Although the majority of samples tested showed compliance with the pharmacopoeial limits of microbiological contamination, the small proportion of syrups in the Syrian market exceeding the pharmacopoeial limit is still concerning and reveals the implications of post-war conditions on the quality of manufacturing in the Syrian pharmaceutical industry. That said, it remained within the proper limits compared to studies conducted in other countries in similar situations.

This study, therefore, highlights the need to apply the Good Manufacturing Practice (GMP) rules more strictly in order to limit microbiological contamination in pharmaceutical syrups to ensure the quality of products and safety of users. We suggest that further quality control studies are conducted on a larger scale and repeated more frequently.

Risk, demand, capacity and outcomes in adult specialist eating disorder services in South-East of England before and since COVID-19

AIMS AND METHOD

This is a longitudinal cohort study describing the demand, capacity and outcomes of adult specialist eating disorder in-patient services covering a population of 3.5 million in a South-East England provider collaborative before and since the COVID-19 pandemic, between July 2018 and March 2021.

RESULTS

There were 351 referrals for admission; 97% were female, 95% had a diagnosis of anorexia nervosa and 19% had a body mass index (BMI) <13. Referrals have increased by 21% since the start of pandemic, coinciding with reduced capacity. Waiting times have increased from 33 to 46 days. There were significant differences in outcomes between providers. A novel, integrated enhanced cognitive behaviour theapy treatment model showed a 25% reduction in length of stay and improved BMI on discharge (50% v. 16% BMI >19), compared with traditional eclectic in-patient treatment.

CLINICAL IMPLICATIONS

Integrated enhanced cognitive behaviour theapy reduced length of stay and improved outcomes, and can offer more effective use of healthcare resources.

community pharmacists’ experiences and beliefs towards providing pharmacy services to deaf and hard of hearing patients: a mixed-method study in Riyadh, Saudi Arabia

Introduction

Provision of pharmacy services to patients requires the pharmacist to well communicate with the patients. Research has shown that healthcare providers, including community pharmacists, face many challenges while providing services to deaf and hard-of-hearing patients (DHOH).

Aim

To investigate community pharmacists’ experiences and beliefs about providing pharmacy services to DHOH in Riyadh, Saudi Arabia.

Methods

This was a sequential explanatory mixed-method study involving a survey and semi-structured interviews. At first, a web-based, self-administered survey was disseminated to community pharmacists in Riyadh, Saudi Arabia during the period October to November 2020. The survey was disseminated through the official twitter account of Saudi Pharmaceutical Society. Two reminders were sent. It was made clear that the survey targeted community pharmacists working in Riyadh city. To calculate an appropriate sample size, according to Hair et al, the general rule to have a minimum sample size would be five observations per variable (5:1), and an acceptable sample size would be ten observations per variable (10:1). In this survey, there are 16 items, and hence the acceptable sample size was 160 participants. The semi-structured telephone-based interviews were conducted with a purposive sample of survey respondents to gather in-depth information on experiences, beliefs, and barriers about providing pharmacy services to DHOH. The interviews were conducted until saturation occurred. Survey data was analysed using Statistical Package for Social Sciences (SPSS version 24), and the semi-structured interviews were analysed by Framework analysis.

Results

A total of 175 community pharmacists completed the survey. The majority were: male (84.6%), aged between 25 to 35 years (74.9%). Of the respondents, 32.2% and 29.1% had experience in community pharmacy of 1-5 and 6-10 years, respectively. The number of DHOH patients the pharmacists met during the past 6 months were as follows: 68 (38.9%) pharmacists met 1-2 patients, 71 (40.6%) %) pharmacists met 3-4 patients, and 19 (11%) %) pharmacists met ≥ 5 patients. The provided services included: prescription medications (by 82.9%), counselling on prescription medications (by 56.6%), OTC medication dispensing (by 4.3%), and counselling on OTC medications (by 52.6%). Forty participants (22.8%) reported their awareness of the basics of Saudi sign language (SSL). Of the participants, 101 (57.7%) believed that they have handled communication barriers appropriately, while 61(35%) acknowledged unmanageable communication barriers. Among the main barriers identified were the lack of knowledge of the basics of SSL. (70.9%) and the inability to recognize disability (52.6%). The semi-structured interviews further explored pharmacists’ experiences and views on providing such a service. Of the main themes emerged were: (1) Experience; interviewees preferred written communication with DHOH patients regardless of their literacy level, while spontaneous hand gesturing was the least preferred method of communication, and they also acknowledged that their roles in providing services, to the DHOH, need to be improved (2) Beliefs; interviewees believed that awareness of the basics of SSL is important to ensure safe medication use. The barriers emerged from the interview were classified as pharmacist-related, system-related, and patient-related.

Conclusion

To our knowledge, this is the first study of its kind to be conducted in Saudi Arabia. The study highlighted that when providing pharmacy services to DHOH patients, community pharmacists encountered multiple barriers. These barriers need to be addressed for better support and provision of pharmacy services to DHOH. Further studies with large sample size, are warranted to better understand the situation.

References

(1) Hair J, Black W, Babin B, Anderson R. Multivariate data analysis. 7th ed. Harlow: Pearson Education Limited; 2014

(2) Scheier DB. Barriers to health care for people with hearing loss: a review of the literature. J N Y State Nurses Assoc. 2009 Mar 22;40(1):4-11.

(3) Ferguson MC, Shan L. Survey evaluation of pharmacy practice involving deaf patients. Journal of pharmacy practice. 2016 Oct;29(5):461-6.

257 Comparing Practice Testing to Restudying in the Dissecting Room: An Experimental Study

Aim

Medical students employ many strategies for learning, most commonly restudying. However, evidence suggests that restudying is not as effective as other strategies, namely practice testing. Different studies have compared restudying to practice testing on a variety of subjects. Few studies have assessed the effect of practice testing in anatomy courses. To the best of the authors' knowledge, no studies have investigated practice testing in the dissecting room (DR). In this study, we aim to measure the effect of practice testing in a DR setting, as compared to restudying.

Method

Second-year medical students learning the cardiovascular system were included in the study. Two groups were randomly selected to participate in practice tests taken at the end of DR sessions. The other two groups were asked to restudy the material. At the end of the four-week course, all students took a 15 points multiple-choice exam on learned material. Authors of practice tests were blind to the final exam content and vice versa.

Results

One hundred eight students participated in the study. Fifty-three students were in the practice testing group, and 55 were in the restudying group. The practice testing group performed significantly better than the restudying group (p = .008), with a mean of 8.57 +/- 2.3 for the practice testing group and 7.27 +/- 2.6 for the restudying group.

Conclusions

Practice testing significantly improved retention of Anatomy. We recommend that practice testing is implemented regularly at the end of DR sessions to enhance the learning experience.

259 Effect of Telegram Videos on Anatomy Education Among 2nd Year Medical Students, University of Khartoum, 2021

Aim

COVID-19 had major effect on the health and medical education. In order to oblige with the social distancing and quarantine, universities shifted to online learning. This study aimed to assess the effect of online education on anatomy DR (dissection room) teaching by the use of telegram software.

Method

This was a cross-sectional, prospective interventional study, which was carried out among 2nd year medical students in University of Khartoum. Students undertook initial tests on the heart and anterior abdominal wall modules. Telegram videos, prepared by the author, on the anatomy of the heart and the anterior abdominal wall were distributed to students. Students took a second test after watching the videos. A total number of 41 students attended heart sessions and 40 students attended the anterior abdominal wall sessions were included.

Results

The pre-test mean score for the heart and abdomen modules were 4.56 ± 2.335 and 6.15 ± 2.94, respectively. The post-tests means were 9.98 ± 2.877 and 8.95 ± 3.14, respectively. 90% and 75% of the students were satisfied with these videos, respectively.

Conclusions

This study revealed that Telegram videos as a method of online teaching had a positive effect on the students' performance, which was evidenced by the significant improvement in student's scores after watching the videos. Additionally, most of the students were satisfied with the videos and give positive feedback.

255 An Audit on the Knowledge of Junior Doctors About DKA at a Local Hospital, Khartoum, Sudan

Aim

DKA is the most common cause of death in pediatric patients with insulin-dependent diabetes mellitus (IDDM). Junior doctors have a significant role in the management of those patients. We conducted this audit to assess and improve the knowledge of house officers about the characteristic features and management of DKA.

Method

The audit was conducted in Alshuhada hospital, Khartoum. It consisted of two cycles (2019–2021). A 14 items questionnaire based on Sudan Diabetes Mellitus guidelines 2011 was used for the assessment. All house officers in the department of pediatrics were involved in this study. Teaching sessions were used as an intervention in the first cycle, while poster presentations and teaching sessions were used in the second cycle.

Results

Nine house officers participated in the first cycle, while seven house officers were involved during the second cycle. The correct choice of initial fluid correction was selected by 55.5%, 88.8%, and 100% of the house officers before the first cycle, after the first cycle, and after the second cycle, respectively. The figures for the initial management of cerebral edema also rose from 33.3% to 66.7% after the first cycle and reached 100% after the second cycle. The percentage of house officers who identified Investigations needed in suspected cases of DKA improved with each cycle, from 66% to 77% in the first cycle and increased to 100% after the second cycle.

Conclusions

Teaching sessions and posters helped to improve the knowledge of the House officers about the diagnosis and management of DKA.

Test-Retest Data for the Assessment of Breast MRI Radiomic Feature Repeatability

Background

Radiomic features extracted from breast MRI have potential for diagnostic, prognostic, and predictive purposes. However, before they can be used as biomarkers in clinical decision support systems, features need to be repeatable and reproducible.

Objective

Identify repeatable radiomics features within breast tissue on prospectively collected MRI exams through multiple test–retest measurements.

Study Type

Prospective.

Population

11 healthy female volunteers.

Field Strength/Sequence

1.5 T; MRI exams, comprising T2‐weighted turbo spin‐echo (T2W) sequence, native T1‐weighted turbo gradient‐echo (T1W) sequence, diffusion‐weighted imaging (DWI) sequence using b‐values 0/150/800, and corresponding derived ADC maps.

Assessment

18 MRI exams (three test–retest settings, repeated on 2 days) per healthy volunteer were examined on an identical scanner using a fixed clinical breast protocol. For each scan, 91 features were extracted from the 3D manually segmented right breast using Pyradiomics, before and after image preprocessing. Image preprocessing consisted of 1) bias field correction (BFC); 2) z‐score normalization with and without BFC; 3) grayscale discretization using 32 and 64 bins with and without BFC; and 4) z‐score normalization + grayscale discretization using 32 and 64 bins with and without BFC.

Statistical Tests

Features' repeatability was assessed using concordance correlation coefficient(CCC) for each pair, i.e. each MRI was compared to each of the remaining 17 MRI with a cut‐off value of CCC > 0.90.

Results

Images without preprocessing produced the highest number of repeatable features for both T1W sequence and ADC maps with 15 of 91 (16.5%) and 8 of 91 (8.8%) repeatable features, respectively. Preprocessed images produced between 4 of 91 (4.4%) and 14 of 91 (15.4%), and 6 of 91 (6.6%) and 7 of 91 (7.7%) repeatable features, respectively for T1W and ADC maps. Z‐score normalization produced highest number of repeatable features, 26 of 91 (28.6%) in T2W sequences, in these images, no preprocessing produced 11 of 91 (12.1%) repeatable features.

Data Conclusion

Radiomic features extracted from T1W, T2W sequences and ADC maps from breast MRI exams showed a varying number of repeatable features, depending on the sequence. Effects of different preprocessing procedures on repeatability of features were different for each sequence.

Level of Evidence

2

Technical Efficacy Stage

1

Duration of Medical Treatment of Benign Prostatic Hyperplasia: Impact on Urodynamics and Post-Prostatectomy Outcome

OBJECTIVES

The aim of this study was to assess whether the duration of preoperative benign prostatic hyperplasia (BPH) medication would affect the pressure flow study (PFS) parameters and the outcome of prostate surgery or not.

MATERIAL AND METHODS

A retrospective study involving patients with LUTS/BPH aged 50 years or older who were compliant with BPH medications. PFS was performed prior to prostate surgery to determine BOO degree and detrusor overactivity. The efficacy of prostate surgery was determined at 3 and 6 months after surgery using the I-PSS, QOL index, Q-max, and PVR. Patients were categorized into group A, who received treatment for 12 months or less, and group B, who received the treatment for 12 months or more. The categorization starts once the patient prefers surgical intervention.

RESULTS

A total of 114 patients were enrolled, 50 in group A and 64 patients in group B. The mean duration, in months, of medical treatment was 9.52 ± 2.24 and 22.50 ± 4.35 in group A and group B, respectively. Pdet@Qmax is significantly (p = 0.02) higher in patients of group B (63.85 ± 11.34 vs. 94.75 ± 19.53). The detrusor overactivity amplitude is slightly higher in group A (36.42 ± 37.27 vs. 16.42 ± 28.38) (p = 0.3). The mean I-PSS, Q-max, and PVR at 1, 3, and 6 months were comparable between the groups.

CONCLUSION

After 24 months of BPH medical treatment, no profound PFS changes that may affect the decision of prostate surgery were observed. Patients who completed 24 months of medical treatment were safe as regards to detrusor muscle contractility with no urge to undergo prostate surgery earlier.

Massive hematemesis and melena stool: A case report of unusual manifestation of Cow's milk protein intolerance

Cow’s milk protein intolerance (CMPI) is a common condition that causes gastrointestinal bleeding in the first year of life. It is the most common cause of chronic blood loss and anemia; however, severe massive hematemesis is an uncommon condition. Herein, we present a case of severe massive hematemesis with melena stool in a six-month-old boy with cow’s milk protein intolerance. In this case, we described management used in poor developing countries.

Inorganic nitrate attenuates endothelial dysfunction consequent to systemic inflammation

Introduction

Chronic cardiovascular diseases are characterised by low-grade systemic inflammation and attenuated nitric oxide (NO) bioavailability resulting in endothelial dysfunction. Inorganic nitrate augments NO bioavailability and improves markers of vascular dysfunction in patients with cardiovascular risk factors. However, the exact mechanism of this effect is uncertain.

Purpose

To determine whether inorganic nitrate supplementation alters systemic inflammation-induced endothelial dysfunction.

Methods

62 healthy male volunteers were randomised 1:1 to receive ∼8–10 mmol of dietary inorganic nitrate in beetroot juice or nitrate-free beetroot juice (placebo) once daily for 6 days. Measures of brachial artery flow-mediated dilatation (FMD), brachial blood pressure (BP), pulse wave analysis and carotid-femoral pulse wave velocity (PWV) by Vicorder were taken prior to and at 8 hours after a typhoid vaccine (to induce mild systemic inflammation). Plasma, urine and saliva samples were also collected. Clinicaltrials.gov: NCT02715635.

Results

Baseline characteristics were similar between the two groups. Inorganic nitrate significantly elevated plasma nitrite (placebo = Δ0.02±0.5 μM, inorganic nitrate = Δ0.63±1.2 μM; p=0.01) and nitrate levels (p&lt;0.0001) compared to placebo. There were significant increases in urine nitrite (p&lt;0.0001) and nitrate (p&lt;0.0001) in addition to salivary nitrite (p&lt;0.0001) and nitrate (p&lt;0.0001) compared to placebo. After 8 hours, typhoid vaccine induced an increase in circulating white cells (placebo = Δ3.34±3.37x109/L, inorganic nitrate = Δ2.9±2.78x109/L; p=0.58) that was similar in in both arms. However, there was a significant reduction in the FMD response in the placebo group at 8-hours post vaccine; an effect that was absent in volunteers treated with inorganic nitrate (placebo = Δ−1.33±1.53%, inorganic nitrate = Δ−0.07±1.84%, p=0.005). Importantly, there were no statistically significant differences in baseline vessel diameter (p=0.78), time to peak diameter in response to flow (p=0.87) and peak shear rate (p=0.57) between the groups. When comparing change from baseline to 8 hours after the vaccine, there were no significant differences in brachial systolic BP (p=0.12), central systolic BP (p=0.12) and PWV (p=0.60) between groups, but a significant reduction in brachial diastolic BP in the inorganic nitrate group (p=0.048).

Conclusions

Inflammation-induced endothelial dysfunction was prevented in those receiving dietary inorganic nitrate suggesting that elevating circulating nitrite and delivering NO to the blood vessel wall, through dietary approaches may offer potential therapeutic benefit in those cardiovascular diseases which typically exhibit low grade inflammation and deficiencies in bioavailable NO.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): British Heart Foundation

Incidental Delayed Diagnosis of Isolated Diffuse Ganglioneuromatosis Caused the Death of a 6-Year-Old Boy: Case Report

Intestinal diffuse ganglioneuromatosis is a rare, benign, neoplastic condition characterized by disseminated proliferation of neural elements. It has an established association with several systemic disorders including: multiple endocrine neoplasia IIB (MEN IIB) and von Recklinghausen's disease. However, isolated GNs are very rare and sporadic. We report a case of a 6-year-old patient was referred to the emergency department due to a colon perforation during endoscopy. He then underwent sigmoidectomy and the pathologic studies revealed prominent signs of diffuse ganglioneuromatosis. Unfortunately, the patient died the day after because of the late diagnosis and treatment. Such presentation emphasizes the importance of considering diffuse ganglioneuromatosis, among other causes, in patients with intractable GI symptoms despite medical treatment.

280 The Use of Telemedicine in Plastics Surgery During COVID-19: A Single-Centre Correlation Study with Patient Reported Outcome Measures

Aim

With enforcement of social distancing measures during the COVID-19 pandemic, face-to-face patient contact was shifted to telemedicine consultations. There is limited evidence evaluating patient experience of follow-ups and expectations into quality metrics. Our aim was to perform a service evaluation by prospectively evaluating the management and outcomes of plastic surgery patients.

Method

Patients were consecutively assessed over the COVID-19 lockdown period, from March to May 2020. They ranged from urgent cancer cases to burns and trauma. We used a questionnaire to evaluate initial treatment, wound care, complications, and overall service. A validated health-related quality of life (HRQL) survey was used to assess the impact of injury or wound on lifestyle and we also assessed patient enablement. Correlation analysis determined relationships between outcomes, service evaluations and HRQL variables.

Results

77 patients were consecutively treated in our unit, of which 46 completed the questionnaire. 42.2% used multimedia as mode of follow-up, including smart phones for messages and videocalls, and trust e-mails. There was a 3-fold increase in number of infections for non-face-to-face consultations, with a correlation significance of 0.043. We found no correlation between age and wound complication rates. 72.7% of patients found overall service very good or excellent. Although overall service satisfaction was similar for multimedia use and face-to-face consultations (p = 0.02), less patients were confident looking after their wound without face-to-face follow-ups.

Conclusions

COVID-19 has brought upon an unprecedented change in practice in our department. Implementing multimedia use and educating patients on wound care can significantly improve efficiency and service provision.

1255 Crowdedness and Consequences of Long Waiting Time in Public and Private Health Centers Among Patients in Khartoum State, Sudan - 2016

Aim

Waiting time (WT) reflects quality of services delivered by Primary health care level. Long waiting time is due to various causes, among which crowdedness is a main cause. This prolonged time has negative impacts on PHC services utilization as well as patients’ outcomes. The aim of this study is to measure the total WT, assess the crowdedness in PHC centers, and to determine the possible consequences of this long waiting time.

Method

Descriptive cross sectional– health institution-based study done in 40 Health centres across Khartoum state using randomized multi-stage sampling. Patients, doctors and lab technicians were interviewed using three different pre-tested structured questionnaires.

Results

A total of 477 patients were included in the study. The average waiting time was found to be 168 minutes. Crowdedness was one of the main causes of delay in waiting time. The lab was the most perceived crowded service (74.4% of the respondents). This long WT had health consequences on patients, ranging from backache, joint pain, and headaches to hypoglycemic symptoms. These symptoms affected patients' willingness to return to the same center. 36.4% of the affected patients were unwilling to revisit the same center.

Conclusions

WT in this study is longer compared to studies from other countries. Crowdedness is one of the main causes of long WT. Due to this prolonged time, patients experienced physical symptoms. It also affected their future attitude regarding PHC centers utilization. There is a need to understand the underlying causes of this issue and address them appropriately.

Impact of COVID-19 pandemic on lower urinary tract symptoms in patients with benign prostatic hyperplasia and predictors of urine retention in such patients

Objectives

We assess the effect of coronavirus disease 2019 (COVID‐19) on lower urinary tract symptoms (LUTS) of patients with benign prostatic hyperplasia (BPH). Moreover, we delineate risk factors for urine retention in such patients.

Methods

All COVID‐19 infected males were expeditiously evaluated. All enrolled patients were assessed using the International Prostate Symptom Score (IPSS), uroflowmetry, and pelvi‐abdominal ultrasonography for prostate volume and postvoiding residual urine (PVR) estimation.

Results

Fifty patients, who were diagnosed with BPH, were enrolled. The mean age (±SD) was 62.64 ± 7.69. In the pre‐ and post‐COVID‐19 group, the mean (±SD) IPSS was 13.42 ± 4.32 and 26.62 ± 5.77, respectively (P < .001), while PVR was 90.40 ± 32.75 and 185.42 ± 73.42, respectively (P < .001), and maximum flow rate was 14.40 ± 2.75 and 10.74 ± 3.43, respectively (P < .004). After infection with COVID‐19, 13 (26%) patients were managed by urethral catheter fixation owing to urine retention. On bivariate analysis, age, diabetes, large prostate on digital rectal examination, alpha‐blocker monotherapy, microscopic hematuria, positive urine culture, and pre‐COVID‐19 IPSS were significantly correlated with urine retention (P < .001, P = .01, P < .001, P = .06, P < .001, P = .04, and P < .001, respectively). On multivariate analysis, age, pre‐COVID‐19 IPSS, and positive urine culture were the independent predictors of urine retention (P = .05, P < .001, and P = .01, respectively).

Conclusion

LUTS in BPH patients were significantly affected by COVID‐19. COVID‐19 increases IPSS leading to a change in the treatment modality of BPH. On multivariate analysis, age, pre‐COVID‐19 IPSS, and positive urine culture were the independent predictors of urine retention post COVID‐19 infection.

Seasonal bias in global ocean color observations

In this study, we identify a seasonal bias in the ocean color satellite-derived remote sensing reflectances (Rrs(λ);sr-1) at the ocean color validation site, Marine Optical BuoY. The seasonal bias in Rrs(λ) is present to varying degrees in all ocean color satellites examined, including the Visible Infrared Imaging Radiometer Suite, Sea-Viewing Wide Field-of-View Sensor, and Moderate Resolution Imaging Spectrometer. The relative bias in Rrs has spectral dependence. Products derived from Rrs(λ) are affected by the bias to varying degrees, with particulate backscattering varying up to 50% over a year, chlorophyll varying up to 25% over a year, and absorption from phytoplankton or dissolved material varying by up to 15%. The propagation of Rrs(λ) bias into derived products is broadly confirmed on regional and global scales using Argo floats and data from the cloud-aerosol lidar with orthogonal polarization instrument aboard the cloud-aerosol lidar and infrared pathfinder satellite. The artifactual seasonality in ocean color is prominent in areas of low biomass (i.e., subtropical gyres) and is not easily discerned in areas of high biomass. While we have eliminated several candidates that could cause the biases in Rrs(λ), there are still outstanding questions regarding potential contributions from atmospheric corrections. Specifically, we provide evidence that the aquatic bidirectional reflectance distribution function may in part cause the observed seasonal bias, but this does not preclude an additional effect of the aerosol estimation. Our investigation highlights the contributions that atmospheric correction schemes can make in introducing biases in Rrs(λ), and we recommend more simulations to discern these influence Rrs(λ) biases. Community efforts are needed to find the root cause of the seasonal bias because all past, present, and future data are, or will be, affected until a solution is implemented.

The efficacy and safety of a nurse-led electrical cardioversion service for atrial fibrillation over a two-year time period

Funding Acknowledgements

Type of funding sources: None.

Background & Purpose

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide, with a significant impact on morbidity, mortality and utilisation of healthcare resources. Electrical direct-current cardioversion (DCCV) is offered to patients with ongoing symptoms despite medical management. In this study we aim to evaluate the safety and efficacy of a specialised nurse-led DCCV cardioversion service. 

Methods

This was a retrospective cohort study analysing the outcome of patients presenting with atrial fibrillation or flutter, who were subsequently referred for a nurse-led DCCV procedure between August 2017 and December 2019. 

Results

Analysis included a total of 341 patients (mean age = 68.37; STDV = 10.96) who presented with either atrial fibrillation (N = 267; 78.30%) or atrial flutter (N = 74; 21.70%). Approximately 30% of patients were female (N = 101); and 70% were male (N = 240). Of the 341 patients who underwent DCCV, 299 were successfully cardioverted (87.68%), whilst 42 patients remained in AF (12.32%). Of those patients successfully cardioverted, 167 remained in sinus rhythm after 6 weeks (55.85%); 93 patients reverted back to AF (31.10%). 38 patients were lost to follow up (12.71%). Of all 341 patients who underwent DCCV, only 24 patients were admitted to hospital during the subsequent 3 month period (7.04%). Of these admissions, 11 were due to persistent AF (45.83%), and 13 were due to other non-related reasons (54.17%). Importantly, no patients were admitted as a direct complication of the DCCV procedure. 

Using a Chi-squared analysis, we found a significant difference in cardioversion success rates between patients presenting with atrial flutter (97% success rate) versus those in atrial fibrillation (85% success rate) (χ2 = 8.089; p = 0.004; α&lt;0.05). We did not find a significant difference in cardioversion success rates between males and females (χ2 = 1.651; p = 0.199; α&lt;0.05); nor did we witness a significant impact from the presence of ischaemic heart disease (χ2 = 1.545; p = 0.214; α&lt;0.05) or hypertension (χ2 = 2.075; p = 0.150; α&lt;0.05). Similarly, we found negligible impact of LV ejection fraction (χ2 = 1.494; p = 0.684; α&lt;0.05) or LA size (χ2 = 1.310; p = 0.727; α&lt;0.05) upon cardioversion success rates.  We witnessed a dramatic improvement in DC cardioversion success rates in patients taking antiarrhythmic medication in preference to a rate control strategy alone (χ2 = 11.825; p = 0.008; α&lt;0.05). 

Conclusion

Overall, data gathered from this study provides positive evidence to support the use of a nurse-led DCCV service. In addition to obtaining very successful cardioversion rates, we found low remission rates, with a very low hospital readmission rate for AF related issues after successful DCCV.

Changing susceptibility pattern of Neisseria Gonorrhoeae: A threat to management of sexually transmitted infections - Case series

Gonorrhoea is a sexually transmitted infection (STI) that increases the risk of infection with human immunodeficiency virus (HIV) and causes infertility and urethral stricture. We describe three cases of sexually active men, otherwise stable, who presented with a history of painful micturition and creamy white, urethral discharge. A clinical diagnosis of gonococcal urethritis was made and confirmed by microscopy, culture and 16SrRNA. Antimicrobial susceptibility revealed resistance to all the antimicrobial agents tested including ceftriaxone. A dual therapy was initiated using ceftriaxone and azithromycin, but at a higher dose for the patient with multi-drug resistant (MDR) Neisseria gonorrhoeae. Patients did well and were followed up for 5 months. Contact tracing was done for their sexual partners. While it is also important for healthcare workers to familiarize themselves with current treatment guidelines for gonococcal urethritis, the place of clinical laboratory in the management of STIs, with molecular techniques and the need for surveillance for MDR Neisseria gonorrhoeae cannot be overemphasized.

Cystic fibrosis and coeliac disease: a case report of an unusual association

Coeliac disease (CD) and cystic fibrosis (CF) are well known as the most common causes of chronic intestinal malabsorption in childhood. The coexistence of coeliac disease with cystic fibrosis is uncommon. Here, we describe the case of cystic fibrosis in a patient diagnosed with coeliac disease who failed to respond clinically to a gluten-free diet and had persistent steatorrhea and failure to thrive.

388 Detection of Cytomegalovirus Infection in Infants with Biliary Atresia: A Meta-analysis

Introduction

Biliary atresia (BA) is the most common indication of liver transplantation in children. Several reports attributed BA to both prenatal and perinatal aetiologies, including a viral infection-induced auto-immune response that targets the bile ducts. Cytomegalovirus (CMV) remains the most common virus being linked to BA. This meta-analysis estimates to what extent CMV infection is detected in patients with BA.

Method

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases of MEDLINE/PubMed, WHO-Virtual Health Library (VHL), ScienceDirect, and Google Scholar were used for the systematic search. Random effects model was used to estimate the pooled prevalence estimate with the corresponding 95% confidence interval (CI) using StatsDirect statistical software.

Results

A total of 13 studies (covering 419 patients) that fulfilled the eligibility criteria were included in the meta-analysis. The pooled overall prevalence of CMV infection in patients with BA was 24.5% (95% CI 11.9 %– 33.9%).

Conclusions

The available data demonstrate that the detection of CMV infection is common in infants with BA. There is still a need for large studies with appropriate controls to examine various aspects of the association between CMV infection and BA.

An unusual case of chronic abdominal pain: an association between Celiac disease and Crohn's disease

Inflammatory bowel diseases (IBD) and Celiac disease (CeD) are immune-mediated gastrointestinal diseases with incompletely understood etiology. Both diseases show a multifactorial origin with a complex interplay between genetic, environmental factors, and some components of the commensal microbiota. The coexistence of celiac disease with Crohn's disease is rarely reported in the literature. Here, we report a case of a 13-year-old Syrian male who presented with a history of abdominal pain, anorexia and pallor. CeD and Crohn's disease was documented on gastrointestinal endoscopy and histological study. The patient was treated with a gluten-free, low fiber, high caloric diet, and a course of oral corticosteroids with an improvement in growth rate and abdominal pain.

Validation of the Arabic linguistic version of the International Consultation on Incontinence Questionnaire-overactive bladder (ICIQ-OAB)

Background

Overactive bladder (OAB) is a health burden that needs an Arabic assessment tool. The idea is to validate the Arabic version of the International Consultation on Incontinence Questionnaire-overactive bladder (ICIQ-OAB).

Methods

A multicenter cross-sectional study carried out between March 2019 and February 2020. The translated ICIQ-OAB was used to assess the 227 patients. The enrolled patients were 112 complaining of symptoms suggestive of OAB, 115 healthy without LUTS symptoms. Additionally, patients with and without BOO symptoms were included. The reliability assessment of the internal consistency was done using Cronbach’s α test. With the aid of Spearman’s correlation coefficient (r), the interdomain associations were assessed. The Mann–Whitney test was used to assess the discrimination validity.

Results

A high internal consistency between the mean scores of women with and those without OAB as well as BOO groups, Cronbach’s alpha value was 0.82. A strong correlation obviates among whole ICIQ domains in OAB set (P ≤ 0.001). Equally, a high correlation exists among each domain in the BOO group, and Cronbach’s alpha value was 0.82. In comparison with control, highly significant scores exist for all ICIQ-OAB domains and entire points in the BOO as well as OAB sets (P < 0.001). The ICIQ-OAB was found to have good discriminant validity.

Conclusion

A formulated and approved ICIQ-OAB -Arabic release is a value tool for addressing OAB symptom complex. The easy questionnaire will be a useful tool in grading the bother symptoms in Arabic speaking inhabitant.

Particulate Backscattering in the Global Ocean: A Comparison of Independent Assessments

How well do we know the particulate backscattering coefficient (b_bp) in the global ocean? Satellite lidar b_bp has never been validated globally and few studies have compared lidar b_bp to b_bp derived from reflectances (via ocean color) or in situ observations. Here, we validate lidar b_bp with autonomous biogeochemical Argo floats using a decorrelation analysis to identify relevant spatiotemporal matchup scales inspired by geographical variability in the Rossby radius of deformation. We compare lidar, float, and ocean color b_bp at the same locations and times to assess performance. Lidar b_bp outperforms ocean color, with a median percent error of 18% compared to 24% in the best case and a relative bias of -11% compared to -21%, respectively. Phytoplankton carbon calculated from ocean color and lidar exhibits basin-scale differences that can reach ±50%.

An unusual case of seizures in a 5-year-old Syrian female with abdominal tuberculosis: an isoniazid therapeutic dose side effect

Isoniazid (INH) is highly bactericidal against replicating tubercule bacilli and is involved in all antituberculous chemotherapeutic regimens. Several neurological adverse effects, following both therapeutic and overdose use of INH, have been reported in adults in the literature. Here, we present a case of a 5-year-old girl with intestinal Tuberculosis, who developed hemiclonic seizure as a side effect of INH therapeutic dose after 2 weeks of tuberculosis therapy.

Detection of cardiac allograft vasculopathy by multi-layer left ventricular longitudinal strain in heart transplant recipients

Cardiac allograft vasculopathy (CAV) is an obliterative and diffuse type of coronaropathy that develops in the transplanted human heart, representing a major cause of graft failure and mortality. Nowadays the gold standard for the diagnosis of CAV is coronary angiography (CA). Non-invasive CAV detection, especially in the early stages of the disease, is still challenging. Our study aimed to investigate the role of speckle tracking echocardiography (STE), in particular three-layer STE, in predicting CAV at early stages, and if other traditional echocardiographic, clinical or biochemical parameters could relate to CAV. The study population was composed of a total of 33 heart transplanted patients, divided accordingly to the presence or absence of CAV (12 CAV+ , 22 CAV-). All subjects underwent a complete transthoracic echocardiographic examination on the same day of the CA, and all conventional parameters of myocardial function were obtained, including strain values assessed by STE. Strain values were significantly reduced in presence of CAV, at each myocardial layer but in particular the endocardial-epicardial gradient (- 4.15 ± 1.6 vs - 1.7 ± 0.4% < .0001) that was also highly predictive of CAV (AUC at ROC curve 0.97). Among diastolic parameters, the E wave deceleration time (DT) and the mean E/e' ratio were strongly positively associated with CAV. In our population, left ventricular global longitudinal strain (GLS), layer-specific GLS and the endocardial-epicardial LS gradient, E wave DT and E/e' ratio were the best independent non-invasive predictors of CAV.

An unusual cause of recurrent pediatric vomiting (an extraluminal pyloric duplication cystic): A case report

Vomiting is a common symptom of a multitude of diseases in children. It is usually part of benign illness and can occur at any age. Recurrent vomiting can be a symptom of life-threatening medical or surgical emergencies. It can be rarely caused by an extraluminal pyloric duplication cyst. Early recognition is essential for preventing delays in management and potential complications.

Here we report a case of an extraluminal pyloric duplication presenting as progressive gastric outlet obstruction cyst in a 14-month-old Syrian boy. The diagnosis was made through abdominal ultrasound, gastrointestinal endoscopy and abdominal computed tomography scan.

Influence of the photoinitiating system on the properties of photopolymerized methylmethacrylate: the role of the ketyl radical in type II photoinitiators

The photopolymerization of methylmethacrylate using different initiating systems strongly affects its glass transition temperature and dispersity.

Genetic profiling of CAH Egyptian children: rapid guide to clinical interpretation of common mutations

OBJECTIVES

The prevalence of CAH in Egypt is reported to be ten times more than that of the worldwide prevalence. The study aimed at genetic screening of children diagnosed with 21-alpha hydroxylase deficiency congenital adrenal hyperplasia (21OHD-CAH). In addition, the study offers a rapid and easy guide for clinical reporting of common mutations for endocrinologists.

METHODS

A cohort of 174 unrelated Egyptian children with 21OHD-CAH were screened for 11 common CYP21A2 gene mutations using a strip hybridization assay, and then, bioinformatics analysis was done to report the pathogenicity of the common mutations for clinical classification.

RESULTS

The most common mutations were I2 splice and p.Q318X. Deletions/conversions comprised 45.9% of the cohort, whereas 7.4% of the cases were negative for all mutations. The least positively detected point mutations were p.P453S, cluster E6, p.R483P, and p.L307FS, which were detected in fewer than 5% of cases.

CONCLUSION

Strip hybridization assay is a rapid screening tool for the diagnosis of CAH. The authors hypothesized an easy and rapid scheme for clinical interpretation of the strip results to gain the highest value of the strip in diagnosis.

An Environmental Scan and Evaluation of Home Dialysis Quality Indicators Currently Used in Canada

Background

Quality indicators are important tools to measure and ultimately improve the quality of care provided. Performance measurement may be particularly helpful to grow disciplines that are underutilized and cost-effective, such as home dialysis (peritoneal dialysis and home hemodialysis).

Objective

To identify and catalog home dialysis quality indicators currently used in Canada, as well as to evaluate these indicators as a starting point for future collaboration and standardization of quality indicators across Canada.

Design

An environmental scan of quality indicators from provincial organizations, quality organizations, and stakeholders.

Setting

Sixteen-member pan-Canadian panel with expertise in both nephrology and quality improvement.

Patients

Our environmental scan included indicators relevant to patients on home dialysis.

Measurements

We classified existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.

Methods

To evaluate the indicators, a 6-person subcommittee conducted a modified version of the Delphi consensus technique based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for further examination. We rated items from 1 to 9 on 6 domains (1-3 does not meet criteria to 7-9 meets criteria) as well as a global final rating (1-3 unnecessary to 7-9 necessary) to distinguish high-quality from low-quality indicators.

Results

Overall, we identified 40 quality indicators across 7 provinces, with 22 (55%) rated as "necessary" to distinguish high quality from poor quality care. Ten indicators were measured by more than 1 province, and 5 of these indicators were rated as necessary (home dialysis prevalence, home dialysis incidence, anemia target achievement, rates of peritonitis associated with peritoneal dialysis, and home dialysis attrition). None of these indicators captured the IOM domains of timely, patient-centered, or equitable care.

Limitations

The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals.

Conclusions

These results provide Canadian home dialysis programs with a starting point on how to measure quality of care along with the current gaps. This work is an initial and necessary step toward future collaboration and standardization of quality indicators across Canada, so that home dialysis programs can access a smaller number of highly rated balanced indicators to motivate and support patient-centered quality improvement initiatives.

Microbiome of the Middle Meatus in HIV

BACKGROUND

Infection with Human Immunodeficiency Virus (HIV) leads to immune dysfunction with increased risk of developing varied infections including opportunistic infections. It may be that a change in the microbial community of HIV patients could be contributory to their development of rhinosinusitis. However, the normal sinonasal microbiome in HIV is yet to be thoroughly studied.

OBJECTIVE

To determine the bacteria in the middle meatus of HIV infected adults without features of rhinosinusitis.

METHODS

Middle meatal swab specimens were collected under endoscopic guidance from 141 HIV infected patients with no sign and symptoms of rhinosinusitis. Specimen were sent for microscopy and culture. 141 HIV negative individuals were used as controls.

RESULTS

Fourty eight point nine (48.9%) of swab specimen had bacteria isolated in the patients. Thirty-nine (56.5%) specimen yielded aerobes consisting of Staphylococcus epidermidis, Staphylococcocus aureus and Streptococcus; while thirty (43.5%) specimen yielded anaerobes consisting of Bacteroids and Peptostreptococcus. Staphylococcus epidermidis was the most frequently isolated bacteria. In the control group, forty-two (29.8%) of cultures were positive for bacteria. There was statistically significant difference in the bacteria isoltes (P=0.001) CONCLUSION: Bacteria isolated were similar to those isolated from the HIV negative control however there were greater number of isolates in the subjects.

Personalised management of Chronic Obstructive Pulmonary Disease (COPD): Malaysian consensus algorithm for appropriate use of inhaled corticosteroid (ICS) in COPD patients

BACKGROUND

Regarding the long-term safety issues with the use of inhaled corticosteroids (ICS) and the clinical predominance of dual bronchodilators in enhancing treatment outcomes in chronic obstructive pulmonary disease (COPD), ICS is no longer a "preferred therapy" according to the Global Initiative for Chronic Obstructive Lung Disease except on top of a dual bronchodilator. This has necessitated a change in the current therapy for many COPD patients.

OBJECTIVE

To determine a standardised algorithm to reassess and personalise the treatment COPD patients based on the available evidence.

METHODS

A consensus statement was agreed upon by a panel of pulmonologists in from 11 institutes in Malaysia whose members formed this consensus group.

RESULTS

According to the consensus, which was unanimously adopted, all COPD patients who are currently receiving an ICS-based treatment should be reassessed based on the presence of co-existence of asthma or high eosinophil counts and frequency of moderate or severe exacerbations in the previous 12 months. When that the patients meet any of the aforementioned criteria, then the patient can continue taking ICS-based therapy. However, if the patients do not meet the criteria, then the treatment of patients need to be personalised based on whether the patient is currently receiving long-acting beta-agonists (LABA)/ICS or triple therapy.

CONCLUSION

A flowchart of the consensus providing a guidance to Malaysian clinicians was elucidated based on evidences and international guidelines that identifies the right patients who should receive inhaled corticosteroids and enable to switch non ICS based therapies in patients less likely to benefit from such treatments.

320-multidetector cardiac computed tomography in the evaluation of conotruncal anomalies

Background

Multi-detector computed tomography (MDCT) has become an effective tool in the assessment of congenital heart disease in infants and children.

Purpose

To evaluate the role of 320-row MDCT in the assessment of conotruncal anomalies and compare it with echocardiography (echo) considering the operative and/or catheter findings as the gold standard.

Methods

The studied group included 50 patients having conotruncal anomalies. All patients were evaluated with 320-row MDCT angiography. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MDCT and echo were calculated. The patient effective dose was reported.

Results

The overall sensitivity, specificity, accuracy, PPV and NPV for MDCT angiography in assessment of various abnormalities in patients with conotruncal anomalies were 98.97%, 100%, 99.75%, 100% and 99.67% for MDCT angiography. Sensitivity, specificity, PPV and NPV of MDCT angiography were 97.87%, 100%, 100% and 99.04% and 99.49%, 100%, 100% &99.86% for the detection of intracardiac defects and extracardiac vascular anomalies respectively. The mean absorbed radiation dose was 63.63 mGy-Cm per scan and the mean effective dose was 1.56±0.47 mSv.

Conclusion

320-MDCT angiography offers an excellent diagnostic procedure in the preoperative evaluation of the complex anatomy of the conotruncal anomalies.

Funding Acknowledgement

Type of funding source: None

[Present-day policy of surgical treatment for type A acute aortic dissection]

A surgical intervention for type A acute aortic dissection is the only effective method of treatment making it possible to prevent the development of life-threatening complications and to attain clinical recovery of the patient. Supracoronary replacement of the ascending aorta and the proximal portion of the aortic arch is considered to be the classical and most commonly used method of an open operative intervention. On the one hand, it is technically the simplest and shortest operation, and on the other, this surgical technique is often accompanied by long-term proximal and distal complications, and first of all those caused by a persistent false lumen. The accumulated surgical experience and contemporary operative techniques, as well as advances of intensive therapy in treatment of type A acute aortic dissection make it possible to currently perform more extensive primary resections in order to improve the remote results. Total aortic arch replacement, including the use of the 'frozen elephant trunk' technique leads to fast thrombosis of the false lumen, preventing progression of the disease of the thoracic aorta and promoting its positive remodelling. The article describes the perioperative therapeutic policy accepted and pursued in our medical facility, also presenting the authors' opinion on the role and place of the 'frozen elephant trunk' technique in rendering medical care for patients with type A acute aortic dissection.